Every finding on record at Ingleside Manor

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 2 of 6 residents (R28 and R4) reviewed for PIs out of a sample of 19 residents. R28 was admitted to the facility with four (4) Stage 1 PIs. R28 was at risk for further PI development and had significant comorbidities. The facility failed to complete a readmission skin assessment, accurately complete all wound assessments and measurements, notify the provider of changes to the PI, offload pressure, and follow standards of practice during wound care. R28 developed an Unstageable PI which deteriorated to a Stage IV (4) PI with osteomyelitis. R4 was admitted [DATE] without any pre-existing pressure injuries. R4 has developed 4 unstageable pressure injuries and was diagnosed with cellulitis that required IV antibiotics to treat. R4's initial pressure injury care plan was not put in place until 4/2025 and contained few interventions for pressure off-loading. R4 had only two Braden Scales for Pressure Injury Risk conducted since admission, which should have been completed upon readmission from the hospital and at least quarterly. R4 did not receive several wound treatments and missed several weekly wound assessments. The failures to complete readmission skin assessments, notify a provider of PI changes, offload pressure, complete wound treatments as ordered, and follow wound care standards of practice created a finding of immediate jeopardy that began on 5/2/25. NHA A (Nursing Home Administrator) was informed of the immediate jeopardy on 10/1/25 at 5:09 PM. The immediate jeopardy was removed on 10/4/25, however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The NPIAP (National Pressure Injury Advisory Panel) classifies a PI as follows: Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may be associated with Stage 4 pressure ulcers. Unstageable: Obscured full-thickness skin and tissue loss full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation reveals a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the extent of tissue injury, or many resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury. (Unstageable, Stage 3 or Stage 4). The facility's Pressure Injury Prevention Guidelines, undated, indicate in part, as follows: Preventative Skin Care: 1. Inspect skin while providing care, paying close attention to bony prominences; 2. Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. The facility policy, Pressure Injury Risk Assessment, revised March 2020, documents, in part, as follows: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). General Guidelines: Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. The interventions must be based on current, recognized standards of care. The effects of the interventions must be evaluated. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. The facility policy, Prevention of Pressure Injuries, revised April 2020, documents, in part, as follows: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Skin Assessment: Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Reposition resident as indicated on the care plan. Weekly RN (Registered Nurse) assessment and documentation completed. Wound rounds must be completed at a minimum of at least once every 7 days. Measurements and documentation to support treatment, interventions, type of wound must be part of the weekly documentation. MD (Medical Doctor) must be notified of any changes in wound. Mobility/Repositioning: Reposition all resident with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. The facility policy, Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, documents, in part, as follows: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection.Reusable items are cleaned and disinfected or sterilized between residents. The facility's policy, Handwashing/Hand Hygiene, revised August 2019, states in part: This facility considers hand hygiene the primary means to prevent the spread of infections. Wash hands with soap and water for the following situations: When hands are visibly soiled.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .Before and after direct contact with residents; Before handling clean or soiled dressings, gauze pads, etc.; After contact with blood or bodily fluids; After handling used dressings.; After contact with objects in the immediate vicinity of the resident; After removing gloves; Before and after entering isolation precaution settings. The facility policy titled, Purpose and Instructions for the Braden Scale for Pressure Sore Risk, undated, states, in part: Pressure sore risk screening tools assist in wound prevention as they identify those persons who are at risk for pressure ulcer development, from those who are not. The purpose of identifying those at risk is to allow for appropriate use of resources for prevention. Risk Level Risk Score -At Risk 15-18. Suggested interventions have been developed based on risk scores. Interventions should be individualized and include review of the following; -Support surfaces for wheelchair/chair and or bed -Frequent position changes, mobilize and or move your resident -Nutritional interventions -Appropriate skin care routine -Routine skin inspection. Frequency of pressure ulcer assessments [sic] depends on your health care setting: Long-Term Care: -On admission and then weekly for four weeks, and then quarterly -Upon readmission from hospital -With any significant change in health status. The facility policy titled, Wound Care, dated 10/2010, states in part: .Documentation The following information should be recorded in the resident's medical record: 2. The date and time the wound care was given. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size drainage, etc.) obtained when inspecting the wound. 9. If the resident refused the treatment and the reason(s) why. Reporting 1. Notify the supervisor if the resident refuses wound care. 2. Report other information in accordance with facility policy and professional standards of practice. R28 admitted to the facility on [DATE] with diagnoses including but not limited to idiopathic peripheral neuropathy (a type of nerve damage where the underlying cause is unknown), gait instability (unsteady pattern of walking that increases the risks of falls,) and generalized weakness. She is wheelchair bound at baseline but usually does her own transfers and is now unable. On 12/17/24, R28's hospital report documents as follows: Fractured styloid process right radius (fractured thumb) . R28 has had worsening generalized weakness since 11/27/24, she states that her arms and legs feel weak. She normally uses a walker, recently she has been using a wheelchair due to increased weakness. She is wheelchair bound at baseline but usually does her own transfers and is now unable. R28's admission Minimum Data Set (MDS) dated [DATE] indicates R28 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. R28's MDS indicates she is at risk for PI development and was admitted with four (4) Stage 1 PIs. On 12/17/24, a Registered Nurse (RN) completed R28's Weekly Skin Check. Any reddened areas that do not resolve after pressure is reduced: Yes, buttock, back, and bilateral heels Any open ulcers: No On 12/24/25 at 9:59 AM, an RN (Registered Nurse) completed R28's Weekly Skin Check. Any reddened areas that do not resolve after pressure is reduced: No R28's CNA (Certified Nursing Assistant) Kardex, documents the following: Transfers: Hoyer lift (Start Date: 12/20/24) Ambulation: Therapy only (Start Date: 12/18/24) Mobility Devices: Uses wheelchair (Start Date: 12/18/24). Pressure Ulcer/Injury: Start Date: 12/26/24 Avoid shearing resident's skin during positioning, transferring, and turning. Pressure Ulcer/Injury: Start Date: 12/26/24 Conduct a systematic skin inspection with daily cares and bathing activities. *Reposition/offload at least every 2-3 hours and PRN (as needed) for skin protection and comfort. Pressure Ulcer/injury: Start Date: 12/26/25 Keep clean and dry as possible. Minimize skin exposure to moisture. Pressure Ulcer/Injury: Start Date: 7/28/25 EBP (Enhanced Barrier Precautions) due to wound and foley. DON gown and gloves when providing care. R28's comprehensive care plan indicates the following: Problem Start Date: 12/26/24 Pressure ulcer/Injury R28 is at risk for skin breakdown r/t (related to) limited mobility, occasional incontinent of B&B (bowel and bladder), potential for falls. Long Term Target Date 10/18/25: R28's wound will not have s/s (signs/symptoms) of infection. Approach start date: 7/28/25 EBP (Enhanced Barrier Precautions) due to wound and foley. DON (put on) gown and gloves when providing care. Approach Start Date: 12/26/24 Avoid shearing resident's skin during positioning, transferring, and turning. Approach Start Date: 12/26/24 Conduct a systemic skin inspection with daily cares and bathing activities. Reposition/offload at least every 2-3 hours and PRN (as needed) for skin protection and comfort. Approach Start Date: 12/26/24 Keep clean and dry as possible. Minimize skin exposure to moisture. Approach Start Date: 12/26/24 Keep skin lubricated. It is important to note, the care plan documents Reposition/offload at least every 2-3 hours. On 12/30/24, R28 was admitted to the hospital under observation. R28 returned to the facility on [DATE] with diagnoses including, but not limited to, chronic heart failure (heart is not functioning properly) and failure to thrive (a decline resulting in weight loss and weakness). It is important to note the facility did not complete a readmission skin assessment on 1/7/25. Of note, there is no documentation in the hospital that R28 has a PI. On 1/7/25, R28 enrolled in hospice services. Initially, hospice was measuring and assessing R28's PI. It is important to note, the facility had no documentation of R28's weekly PI measurements and assessments for approximately 3 months until requested by Surveyor. The facility obtained requested documentation from hospice after Surveyor requested the PI assessments. On 1/8/25 at 1:00 PM, hospice completed the following Initial PI assessment: Wound Assessment: Boggy, Intact, Purple Location: Heel Deep Tissue Injury Peri-wound: Dry, Intact Drainage: None Measurements: 3.0 x 3.0 cm (centimeters) Margins: Well-defined edges Pressure Injury: Deep Tissue Wound Cleansing: Soap and water Interventions: Air Dry Dressing Status: None On 1/13/25, R28's Braden Assessment (a measure of pressure injury risk) indicates R28 is at risk for PI development. 1/16/25 (Hospice) Wound Assessment: Boggy, Fragile/Friable, Moist, Purple Peri-wound: Dry, Intact Drainage: Small Serosanguineous Measurements: 4.0 x 4.0 cm Margins: Well-defined edges Pressure Injury: Deep Tissue Wound Cleansing: Wound cleanser Foam border (Allevyn/Aquacel/Mepilex/Optifoam) Dressing Status: Clean, dry, intact Dressing change: Done (Note: PI increased in size and now has drainage.) No significant changes in the wound are documented by hospice in weekly assessments from 1/23/25 through 3/5/25. On 3/4/25, R28's Bath Sheet documents No open areas. Note, this is inaccurate. On 3/11/25, R28's Bath Sheet documents No open areas. Note, this is inaccurate. 3/12/25 (Hospice) *Wound Assessment: Black, Dry, Fragile/Friable, Moist, Pink Peri-wound: Boggy, Dry, Intact Drainage: Serosanguinous Measurements: 4.0 x 4.0 cm (centimeters) Topical Wound Treatment: Betadine Dressing: Foam border (Allevyn/Aquacel/Mepilex/Optifoam) Dressing Status: Clean, dry, intact On 3/13/25, R28's Provider visit indicates Reason: Weekly Visit, hospice SKIN-no masses, no rashes, no lesion on exposed skin. On 3/14/25, NP M (Nurse Practitioner) conducted an initial evaluation of R28's PI. Diagnosis that could affect wound healing: Heart failure, generalized weakness, obesity, lower extremity edema, hyperlipidemia, hypertension Physical Examination: Left heel unstageable pressure ulcer measuring 3.0 cm x 5.0 cm with 10% slough and 90% eschar. Small serous drainage. Wound examined, noted to have foul odor and some maceration to periwound. Tx (treatment) plan discussed with hospice. Status: Initial evaluation Plan: Cleanse wound paint with Betadine cover with ABD (dressing) and Kerlix daily Assessment Pressure ulcer of left heel, unstageable: Unstageable pressure ulcer to left heel with primarily eschar and some slough to perimeter of wound. There is a foul odor noted. Treatment plan adjusted for moisture control. Plan of care discussed with hospice nursing and facility nurse as well as patient Adult failure to thrive: Adult failure to thrive-now on hospice care. Unspecified diastolic (congestive) heart failure: No medical management. Hospice following. 2–3+ pitting pedal edema bilaterally. Elevate lower extremities as tolerated throughout the day. On 3/18/25 at 8:05 PM, R28's Progress Notes include the following: Resident seen for initial evaluation in weekly wound rounds with wound NP, NP M, and wound RN per request from hospice RN. (It is important to note, the wound RN is not wound care certified.) 0/10 pain reported. Wound assessment: Unstageable pressure ulcer to left heel with wound bed eschar and some slough to perimeter of wound. Foul odor present. See wound management documentation. Treatment plan adjusted for moisture control. Plan of care discussed with hospice nurse. New wound care orders placed per hospice MD (Medical Doctor). On 3/18/25, R28's Wound Management Detail Report documents as follows: 3.0 x 5.0 cm Stage: Unstageable-Slough and/or Eschar Exudate: Moderate serous Wound odor present: Yes Describe: Foul. Undermining: No Tunneling: *Note, there is no description of the PI wound bed or peri-wound. On 3/21/25 at 11:39 PM, R28's Progress Note documents the following: LVM (left voice mail) for hospice RN requesting PRN (as needed) MS04 (Morphine sulfate) medication) 7.5mg (milligrams) be scheduled nightly; (R28's name) does not complain; but when asked if she has pain, she always says yes. When offered her low-dose narcotic at HS (bedtime) she always accepts. As well her heel could use some help; requested treatment change to include Santyl or SSD (silver sulfadiazine – an antibiotic cream used to prevent and treat infections.) Will call back 3/22. Just found fax from earlier with updated orders for heel incl (including) Silvadene; Matrix updated. On 3/22/25 at 2:10 PM, Just received fax to update MS (Morphine Sulfate) order to schedule daily at bedtime; matrix updated. On 3/26/25 Hospice Notes document in part as follows: Wound Assessment: Brown, Boggy, Eschar, Fragile/Friable, Moist, Painful, Slough (Percentages not indicated) Periwound: Fragile, Moist, Painful, Pink Drainage: Moderate Drainage Description: Brown, Malodorous, Serosanguineous, Yellow Measurements: 5.0 x 3.0 Margins: Well-defined edges Pressure Injury Stage: U (Unstageable) Wound cleansing: Soap and water Topical wound: Betadine, Silvadene Dressing: ABD, Gauze fluff roll (Kerlix) Dressing status: Clean, dry and intact Dressing changed: Done On 4/2/25, R28's Wound Management Detail Report documents as follows: 3.0 x 5.0 Can depth be measured: No - Unstageable - Slough and/or eschar Tissue Type: NECROTIC. On 4/9/25, Hospice notes document as follows: Measurement: 5.0 x 2.0. Unable to determine depth d/t (due to) eschar/necrotic tissue present. Wound Assessment: Brown, Boggy, Eschar, Fragile/Friable, Granulation tissue, Moist Necrotic, Painful 80%eschar 20% yellow slough Periwound: Fragile, Moist Drainage: Moderate Drainage Description: Brown, Malodorous, Tan, Yellow On 4/11/25, NP M completed R28's Wound Care Assessment. Chief Complaint: Evaluation of unstageable pressure ulcer Subjective: Patient seen today for follow-up regarding unstageable pressure ulcer left heel. She was not seen last week due to facility reporting they would be managing her wound however now being requested to follow by hospice. Wound examined today with large eschar demarcating and underlying slough present. There is foul odor. Patient reports moderate amount of pain constantly to that heel. She denies any fevers or chills. Verbal consent obtained today to debride eschar. Area debrided with patient tolerating well. Post debridement with 100% slough to wound bed and significant undermining as noted below. Plan of care adjusted and discussed with patient, nursing, as well as hospice today. Interventions in place: Offloading measures per facility protocol, nutritional support, comfort measures with hospice services in place, weekly wound assessment with treatment plan as directed. Physical Examination: Left heel, unstageable PI measuring 2.5 cm x 4.5 cm with 100% demarcated eschar and moderate serous drainage with foul odor. Eschar removed with surgical debridement performed after verbal consent obtained from patient. There is 100% slough beneath eschar (dead, necrotic tissue). Wound measuring 2.5 cm x 4.5 cm with undermining circumferentially with deepest aspect at 6:00 measuring 3.6 cm. Unable to fully visualize extent of wound bed given depth of undermining. *Status: Declined Plan: Cleanse wound gently/loosely packed with quarter strength Dakin's dampened gauze followed by ABD and Kerlix to be changed daily and as needed. Continue offloading measures. On 4/18/25, NP M completed R28's Wound Care Assessment. Physical Examination: Left heel unstageable pressure ulcer measuring 2.4 cm x 3.3 cm x UTD (undetermined) with 100% slough, with undermining circumferentially with deepest aspect at 6:00 measuring 3.4 cm. Unable to fully visualize extent of wound bed given depth of undermining. Moderate serous drainage. Plan: Cleanse wound gently/loosely packed with quarter strength Dakins dampened gauze followed by ABD and Kerlix to be changed daily and as needed. Continue offloading measures. On 4/25/25, NP M completed R28's Wound Care Assessment. Wound Care Assessment: Left heel unstageable pressure ulcer measuring 2.2 cm x 3.5 cm x 1.0 cm with undermining from 5:00 to 7:00 with deepest aspect measuring 3.5 cm at 6:00. Wound appears to be 20% slough and 80% granulation however unable to fully visualize extent of wound bed given depth of undermining. Moderate serosanguineous drainage. Plan: Cleanse wound gently/loosely packed with quarter strength Dakin's dampened gauze followed by ABD and Kerlix to be changed daily and as needed. Continue offloading measures. On 5/1/25, R28's orders contain the following: Juven with collagen added to orders twice daily. On 5/2/25, NP M completed R28's Wound Care Assessment. Physical Examination: *Left heel Stage 4 pressure ulcer measuring 1.8 cm x 3.2 cm x 0.8 cm with undermining from 5:00 to 7:00 with deepest aspect measuring 3.7 cm at 6:00. Unable to fully visualize wound bed due to depth however visible area of wound bed is 100% granulation and there is moderate amount of serosanguineous drainage. There does appear to be bone probable to undermining area. Moderate serosanguineous drainage. Status: Improved Plan: Cleanse wound gently/loosely packed with quarter strength Dakin's dampened gauze followed by ABD and Kerlix to be changed daily and as needed. Recommending Dakin's be changed to Vashe given granulation tissue present and facility will potentially provide, discussed with ADON (Assistant Director of Nursing). Continue offloading measures. On 5/9/25, RN N documented the following PI assessment for R28: Stage 4 measuring 2.3 x 3.5 x 1.4 undermining circumferentially with deepest aspect at 6 measuring 3.3 cm and 100% granulation with wound bed not well visualized. Moderate serosanguinous drainage noted. On 5/16/25, NP M completed R28's Wound Care Assessment. Physical Examination: Left heel stage 4 pressure ulcer measuring 1.9 cm x 3.0 cm x 1.1 cm with undermining from 4:00 to 7:00 with deepest aspect measuring 3.0 cm at 6:00. Unable to fully visualize wound bed due to depth however visible area of wound bed is 100% granulation and there is moderate amount of serosanguinous drainage. Bone probable to undermining area. Moderate serosanguineous drainage. Status: Stable Plan: Cleanse wound gently/loosely packed with quarter strength Dakin's dampened gauze followed by ABD and Kerlix to be changed daily and as needed. Recommending Dakin's be changed to Vashe given granulation tissue present and facility will potentially provide. On 5/23/25, NP M completed R28's Wound Care Assessment. Wound Care Assessment: Left heel Stage 4 pressure ulcer measuring 2.3 cm x 3.0 cm x 0.5 cm with undermining from 4:00 to 7:00 with deepest aspect measuring 3.4 cm at 6:00. Unable to fully visualize wound bed due to depth however visible area of wound bed is 100% granulation and there is moderate amount of serosanguinous drainage. Bone probable to undermining area. Status: stable Plan: Cleanse wound gently/loosely packed with quarter strength Dakin's dampened gauze followed by ABD and Kerlix to be changed daily and as needed. On 5/30/25, NP M completed R28's Wound Care Assessment. Wound Care Assessment: Left heel Stage 4 pressure ulcer measuring 1.7 cm x 3.0 cm x 1.3 cm with undermining from 4:00 to 7:00 with deepest aspect measuring 3.0 cm at 6:00. Unable to fully visualize wound bed due to depth however visible area of wound bed is 100% granulation and there is moderate amount of serosanguinous drainage. Bone probable to undermining area. Foul odor. Plan: Cleanse wound gently/loosely packed with quarter strength Dakins dampened gauze followed by ABD and kerlix to be changed daily and as needed. Add powdered Flagyl (an antibiotic) to be sprinkled over gauze just packed loosely into the wound for odor control. On 9/26/25, R2's Stage 4 PI to her left heel has not healed. The Wound Management Detail Report documents as follows: 1.9 x 2.4 Irregular wound edges. Surrounding skin: Dark purple or rusty discoloration; Edema; [NAME] or grey pallor It is important to note, on 9/26/25 the facility discovered a new PI to R28's left heel superior (above) the existing Stage 4 PI. The Wound Management Detail Report documents the following: 1.9 x 2.4 Can depth be measured: No Exudate: None Wound odor: None Stage: Unstageable – Deep Tissue Injury Undermining Present: No Sinus tract/tunneling: No Tissue Type: Closed/Resurfaced Wound Edges: Irregular wound edges Skin Surrounding Wound: Dark purple or rusty discoloration; Edema; [NAME] or grey pallor On 9/29/25 at 10:50 AM, Surveyor observed RN N complete R28's dressing changes. RN N stated she has worked as the wound care nurse at the facility since April 2025. Surveyor observed RN N put on a gown and then use hand sanitizer. While standing at the cart, RN N put on a pair of dirty gloves from the keyboard, picked up gauze, sprayed it with Integrity Wound Cleanser and carried this along with other supplies into R28's room. While holding onto the supplies, RN N set a drape on the bed. Surveyor observed R28's heels directly on a pillow and not floated (not wearing boots). Surveyor asked RN N, should R28's heels be floated. RN N stated, R28 usually has the foam boots on while in bed however, she asked CNAs (Certified Nursing Assistants) to leave them off. Surveyor asked RN N, how long have R28's boots been off. RN N stated about 15 minutes. Surveyor asked RN N, should R28's heels be floated. RN N stated, yes. Surveyor observed RN N ask R28 if she is having any pain. R28 stated her pain is at a 5 or 6 and she got pain medication already. Surveyor observed RN N cut the kerlix wrap from R28's ankle to her foot with a scissors she pulled from her pocket. Surveyor observed a new PI actively bleeding above R28's existing Stage 4 PI to her left heel. Surveyor asked RN N about this new PI. RN N stated this new area was discovered on 9/26/25 and it is located above R28's Stage 4 PI. RN N stated, this is a new DTI (Deep Tissue Injury). Surveyor asked RN N, how would you describe the new DTI. RN N stated, depth unable to determine, periwound red, purple, and boggy. RN N stated, R28 has had a longstanding Stage 4 to her left heel as there is bone probable. RN N added, R28 has a history of undermining to the left heel wound with current undermining present from 12:00-2:00. The wound bed is 100% granulation with moderate serosanguinous drainage, and a callous to the periwound. RN N stated, the new DTI will remain Unstageable until it opens. Note, Surveyor observed the new DTI to be actively bleeding during the treatment. At this point during the dressing change, RN N has removed a soiled dressing without removing her gloves, sanitizing her hands and donning new gloves. Surveyor observed RN N apply skin prep around the Stage 4 PI. Surveyor observed RN N use dirty scissors that were in her pocket and used to cut off the old dressing to also cut Medline Calcium Alginate to pack the Stage 4 PI. It is important to note, this is cross contamination; in addition, R28 likely has osteomyelitis per interview with NP M (below). Surveyor observed RN N remove her gloves and don new gloves. Of note, RN N did not sanitize her hands in between glove changes. RN N stated she told staff to wrap the kerlix above and below the resident's ankle, so the dressing does not migrate. Surveyor asked RN N, what is the cause of R28's new PI. RN N stated, she thinks the dressing migrated and moved on that area causing pressure. Surveyor observed RN N apply an ABD and kerlix to R28's foot and ankle, remove her gloves and wash her hands in the bathroom sink, apply tubigrips to R28's bilateral feet, set dirty scissors on a single layer of gauze, take a second piece of gauze, apply hand sanitizer, wipe scissors, and set it on dirty single layer of gauze (permeable and not using a barrier) underneath it. On 9/29/25 at 11:13 AM, Surveyor spoke with RN N. Surveyor asked RN N, where did you have your scissors. RN N stated, I should have had them out of my pocket, obviously they're cleansed from the other patient. Surveyor asked RN N, do you normally use hand sanitizer to disinfect scissors. RN N stated here she does as she does not have Sani Wipes. RN N stated usually she uses the purple Sani Wipes with 2-minute contact time. Surveyor asked RN N, should you have the scissors on a clean solid barrier. RN N stated, Yes, I should have used a drape. Surveyor asked RN N, should you disinfect scissors in between dirty and clean. RN N stated, Yes. Surveyor asked RN N, after you cut the existing kerlix off should you have disinfected the scissors before cutting the Calcium Alginate. RN N stated, Yes. Surveyor asked RN N, when should you change gloves. RN N stated, When going from dirty to clean. Surveyor stated, after removing the existing dressing and before packing the PI should you have removed your gloves, sanitized your hands, and donned new gloves. RN N stated, Yes. On 9/29/25 at 4:12 PM, Surveyor spoke with DON B (Director of Nursing who has been in her role since 9/18/25. Surveyor asked DON B, how often are PIs to be measured and assessed. DON B stated every 7 days. Surveyor asked DON B, on 1/7/25 when R28 readmitted to the facility should staff have completed a readmission skin assessment. DON B stated, yes. Surveyor asked DON B, on 2/27/25 during R28's weekly PI assessment and measurement, should staff have measured R28's PI. DON B stated, yes. Surveyor asked DON B, do you expect staff to float residents' heels. DON B stated, yes. Surveyor asked DON B, do you expect staff to turn and reposition residents that require assistance with turning and repositioning. DON B stated, yes. Surveyor asked DON B, how often do you expect staff to turn and reposition residents. DON B stated every 2 hours. Surveyor asked DON B, where is turning and repositioning documented. DON B stated, turning and repositioning is care planned. DON B added, if a physician wants this ordered, we'll get an order. Surveyor asked DON B, is turning and repositioning documented. DON B stated, if they have an order for it, yes. Surveyor asked DON B, does R28 have an order for turning and repositioning. DON B stated, no, she does not see one. Surveyor asked DON B who discovered R28's PI to her left heel. DON B stated, It looks like on 3/14/25 the NP documented it. Surveyor asked DON B, how often should staff be checking R28's heels. DON B stated, staff should be checking R28's heels during a weekly skin assessment. Surveyor asked DON B, on 4/2/25 when R28's PI is documented as necrotic was a provider notified. DON B stated, no, but they should have been. Surve

Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect the census (48). The facility is not monitoring the temperature of their water heater as part of their control measures for Water Management Program.The August 2025 line list does not include symptom monitoring. Evidenced by:The facility's Legionella Water Management Program policy, dated 9/2022, states, in part: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella.5. The water management program includes the following elements: .e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; .h. A system to monitor control limits and the effectiveness of control measures; .j. Documentation of the program.Per Centers for Disease Control and Prevention (CDC), 3/15/24 documents, in part: .Cold water guidance: Store and circulate cold water at temperatures below 77 F, although Legionella may grow at temperatures as low as 68 F (20 C). Hot water guidance: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation doesn't fall below 120 F (49 C) and recirculate hot water continuously, if possible .The facility's Surveillance for Infections policy, dated September 2017, includes: The infection preventionist will conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 3. Infections that will be included in routine surveillance include those with: a. evidence of transmissibility in a healthcare environment; b. available processes and procedures that prevent or reduce the spread of infection; c. clinically significant morbidity or mortality associated with infection; and d. pathogens associated with serious outbreaks. 4. Infections that may be considered in surveillance include those with limited transmissibility in a healthcare environment; and/or limited prevention strategies. 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible.Data Collection and Recording .4. For targeted surveillance using facility-created tools, follow these guidelines: a. DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form.Example 1Surveyor requested documentation of monitoring of control limits in regard to water management. On 9/29/25 at 1:15 PM, NHA A (Nursing Home Administrator) provided the following documents and stated that temperature testing should be completed at least weekly, but these were the only documents that could be found:*TELS Report indicating temperatures dated 12/6/24: East Shower 109 F (Fahrenheit), East 62 110 F, South 84 111F, [NAME] 24 108 F, North 32 111F, Kitchen 110F*TELS Report indicating temperatures dated 4/7/25: Kitchen 140 F, Laundry 140 F, room [ROOM NUMBER] 110F, Shower room west 120 F, room [ROOM NUMBER] 130 F, room [ROOM NUMBER] 113 F*TELS Report indicating temperatures dated 4/8/25: laundry 120 F, Kitchen 120 F, North hall 108 F, west mixing valve 108 F, east hall 110 F, south hall 113 F*Ingle Living Communities Water Temps, dated 4/8/25: Boiler Rm Mixing Valve Temp--Linen 120, East 110, South 110; Administration Mixing Valve Temp--24 110, Inglenook 108; Mech Rm Mixing Valve Temp-west 108, North 113, Dining room [ROOM NUMBER], kitchen 120 On 9/29/25 at 4:11 PM, Surveyor interviewed IP G (Infection Preventionist) who stated that the 3 documents from April were the only logs found for 2025. IP G stated the locations temped and listed on the documents are not all the areas that should be monitored, and all locations should be monitored weekly for water safety.On 9/30/25 at 12:58 PM, Surveyor interviewed MD E (Maintenance Director) who stated that the water at the boiler needs to be at 140 degrees, but MD E has not done any temperature testing since starting in September and MD E is not aware of any documentation of testing prior to arrival. Example 2The August 2025 Infection Surveillance Log includes the following:*R23 Start date 8/8/25 Levofloxacin (antibiotic) tablet 750mg (milligrams) 1 tablet daily for 4 days. Diagnosis (Dx): sepsis; start date 8/1/25 Bactrim DS tablet 800-160 mg 1 tablet twice a day. Dx: acute cystitis with hematuria (an inflammation of the bladder, typically caused by bacterial infection with bloody noted in the urine)*R4 Start date 8/29/25 amoxicillin (antibiotic) tablet 500 mg 1 tablet for GBS bacteremia suppression twice a day. Dx: bacteremia (bacteria in the bloodstream)*R8 Start date 8/18/25 valacyclovir (antiviral) tablet 1 gram oral three times a day. Dx: Shingles (a viral infection that causes painful rash)*R27 Start date 8/30/15 doxycycline hyclate (antibiotic) capsule 100 mg 1 capsule administer for 7 days for wound infection twice a day. Dx: venous insufficiency*R40 Start date 8/30/25 cefdinir capsule 300 mg once day. Dx: pneumonia (infection in the lungs)*R43 Start date 8/6/25 amoxicillin tablet 875 mg take with food for five days twice a day. Dx: cellulitis (a bacterial skin infection) of left lower limb*R46 Start date 8/9/25 cefuroxime axetil tablet 500 mg 2 tablets Take with food but do not start until blister fluid from top of foot has been collected. Twice a day. Dx: cellulitis*R47 Start date 8/13/25 cephalexin capsule 500 mg take with meals twice a day. Dx: Urinary tract infection*R5 Start date 8/27/25 cefdinir capsule 300 mg twice a day. Dx: urinary tract infection*R59 Start date 7/22/25 cefadroxil capsule 500 mg take 2 capsules by mouth 2 times daily for mealtime for 21 days for cellulitis. Dx: cellulitis; Start date 8/18/25 valacyclovir tablet 1 gram Take 1 tablet by mouth three times daily for 7 days for infection. Dx: ShinglesImportant to note: There was no documentation of symptoms of infection on the surveillance log. Surveyor asked for documentation of symptom surveillance; no further documentation was provided.On 9/25/25 at 9:44 AM, Surveyor interviewed RN H (Registered Nurse) and asked about residents with infection. RN H stated that residents with new symptoms should be monitored with vital signs for 3 days. RN H stated that RN H didn't think there was a 24 hour board at the facility, but that a progress note should be written and information shared in report to the next shift. RN H stated that residents with infection should have a progress note with resident assessment through the course of their antibiotic treatment.On 9/25/25 at 10:03 AM, Surveyor interviewed IP G (Infection Preventionist) and asked about surveillance of infection / symptom monitoring as there were no symptoms noted to be documented on the August 2025 Infection Surveillance Log. IP G stated the line lists that we gave you are not our expectation; we will be rolling out a new program October 1.On 9/30/25 at 3:21 PM, Surveyor interviewed IP G and asked about monitoring of residents on antibiotics. IP G stated that through the course of the antibiotic the resident should have an assessment of vital signs and the body system involved, along with any signs and symptoms of adverse reaction to the antibiotic. IP G stated that symptom surveillance had been a noted issue. On 10/1/25 at 9:50 AM, Surveyor interviewed DON B (Director of Nursing) and asked about surveillance of signs and symptoms of infection. DON B stated yes, signs and symptoms of infection should be monitored. DON B stated that DON B and IP G looked through all of their residents on 9/30/25 and created an up to date line list with symptoms and they would carry on with this process moving forward. Surveyor asked about residents on antibiotics. DON B stated that assessments should be done and documented through the course of the antibiotic. DON B stated it is the facility's plan to educate staff and make sure that this is occurring.

Based on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly, for 3 of 11 supplemental residents (R12, R46, R52) and 2 of 18 sampled residents (R26 & R42). During Resident Council Task, three months of Resident Council Minutes were reviewed to find 3 (R12, R46, R52) residents had voiced concerns regarding facility phone issues. R12 and R42 voiced concerns to Surveyors regarding concerns with no one answering the facility phone. Evidenced by: The facility policy entitled, Ingleside Manor Resident Council Policy and Procedure, dated 5/26/2021, states, in part: . Policy: It is the policy of this facility to support and assist in the formulation of a Resident Council which provides a formal, structured process for communication among residents, staff and administrator. Procedure: . *Within the Resident Council forum, provide the members with the opportunity to express their concerns, contribute ideas, and make recommendations regarding the facility's functions. *A request will be made for formal written responses to all identified concerns and a set deadline for a reply as prior to the next Council Meeting. Resident Council Minutes dated 7/02/2025 include: *R52 questioned if the facility has someone at the front desk to answer the phone. R52 voiced concern with having had an appointment and when appointment was over, she tried calling the facility because her ride back to the facility was not there to pick her up. R52 indicated she called the facility, and someone answered and hung up. R52 called back and no one answered. R52 indicated she called and left a voicemail with ANHA C (Assistant Nursing Home Administrator) and someone else. R52 indicated she was stuck at her appointment. Resident Council Minutes dated 8/08/25 include: *R46 voiced concern with people trying to call the facility and not being able to get a hold of anyone. R46 indicated she has sat up by the nurses' station and observed the phone ringing and no one answering it. On 10/1/25, at 10:05AM, Surveyor interviewed R46 who indicated when she has been out for appointments and has tried calling the facility no one has answered. R46 indicated when the nurse or doctor needed more information from the facility and has tried calling, they as well can't get through. *R12 indicated he has an issue he brought up with ANHA C; R12 had a friend trying to get ahold of him to notify R12 that a friend of theirs was passing. R12 indicated the friend called the facility many times and could not get ahold of R12. R12 indicated he voiced his concern to ANHA C that the phone issue needs to be figured out and someone must be answering the phones. R12 indicated he was told that the facility may get everyone a cell phone to carry on them. R12 voiced that the facility says they will work on these issues but R12 feels the facility does not care about the residents because they have done nothing with the issues. On 10/1/25, at 10:11AM, Surveyor interviewed R12. R12 indicated when he has gone out with family or friends, and he has tried calling the facility to let them know he is running late on getting back to the facility. No one has answered the phone. R12 indicates he is unable to update the facility and worries the facility will put a silver alert out on him. R12 indicates no one answers the phone and there is no way to get the facility a message. R12 indicated the whole building is listed under the same number; when R12's girlfriend calls the facility she gets a busy signal or else the phone doesn't get answered. On 9/30/25, at 3:02PM, Surveyor interviewed R42 who voiced concern with the facility not answering the phone. R42 indicated this morning she had an appointment and could not get anyone to answer her call light, so she tried calling the facility and had gone right down the list of staff by number and no one was answering the phone. R42 indicated she finally got through to AN Q (Admissions Nurse). R42 indicated the phone does not get answered during off hours and the weekends. R42 indicated it scares her because if she can't get anyone to answer her call light or the phone what is she to do. R42 indicated she does not want to have to call 911 but will if she must. On 10/1/25, at 10:00AM, Surveyor interviewed R52 who indicated the facility does not man the phones. R52 indicated she had a problem with a doctor appointment, and she tried calling the facility and no one answered. R52 indicated she did not know who was picking her up from her doctor appointment and tried calling the facility to find out and no one would answer the phone. R52 tried three times then called her daughter. On 10/1/25, at 8:10AM, Surveyor interviewed R26. R26 indicated the facility does not answer the phone. R26 indicated he will call, and no one answers the phone. On 10/1/25, at 4:54PM, Surveyor interviewed ANHA C. Surveyor asked ANHA C if he was aware of issues with the phone not being answered. ANHA C indicated the receptionist had gone into early retirement that caused some gaps and CNAs (Certified Nursing Assistants) have filled in. ANHA C indicated there is a receptionist from 8am-8pm Monday through Friday. ANHA C indicated there are gaps with the recent retirement though and he was aware. ANHA C indicated on the weekends the phone rings to the receptionist and if it is not answered it bounces to the nurse stations. ANHA C indicated if a nurse is not sitting there at the nurse station, the call will go to voice mail. ANHA C indicated the nurses are expected to check voicemail throughout the shift. Surveyor asked ANHA C if he was aware of Resident Council concerns and ANHA C indicated yes, he reviews them monthly. ANHA C indicated he delegates the concerns to where he feels they need to go. Surveyor asked if ANHA C reviewed the July and August Resident Council Minutes regarding resident concerns with the facility phone not being answered. ANHA C indicated he did not see those minutes. ANHA C indicated the facility recently switched the answering system sound board because of the issues with calls not being transferred to people and people could not adequately use the dial by direct. Surveyor asked when this switch took place and ANHA C indicated July. ANHA C indicated he has boxes of phones to disperse to the nurses, he just has not dispersed them yet. Surveyor informed ANHA C that residents have voiced concerns to Surveyors about the phones not being answered while conducting the facility's annual survey.

Based on interview and record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 3 of 4 sampled residents (R51, R6 & R23) and 1 of 1 Supplemental Residents (R69). R51 was admitted to the facility with a surgical wound. R51's wound treatments were not completed as ordered by the physician. R6 had a change of condition and did not have documented assessments through the course of antibiotic treatment. R23 had a change of condition and did not have documented assessments through the course of antibiotic treatment. R69 admitted to the facility on antibiotic for infection and did not have documented assessments through the course of antibiotic treatment. This is evidenced by: The facility policy titled, Wound Care, dated 10/2010, states, in part: . Documentation The following information should be recorded in the resident's medical record:. 2. The date and time the wound care was given. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size drainage, etc.) obtained when inspecting the wound. 9. If the resident refused the treatment and the reason(s) why. Reporting 1. Notify the supervisor if the resident refuses wound care. 2. Report other information in accordance with facility policy and professional standards of practice. Example 1 R51 was admitted to the facility on [DATE], with diagnoses including [NAME] cell carcinoma (Aggressive skin cancer), aftercare following surgery for neoplasm (abnormal tissue growth), neoplasm related pain (acute) (chronic), unspecified severe protein-calorie malnutrition, adult failure to thrive, cognitive communication deficit, and unspecified open wound of left buttock. R51's Minimum Data Set with Assessment Reference Date 9/25/25 indicates R51 has a Brief Interview for Mental Status score of 15 out of 15, indicating R51 is cognitively intact. R51's Physician Orders indicate, in part: WOUND CARE: L. (Left) Thigh – Cleanse with soap and water; pat dry; apply Vaseline Gauze; Cover with ABD; Wrap with ACE bandage. Once A Day. Start Date: 8/15/25. End Date: 8/29/25. Discontinued Order. WOUND CARE: Left Hip/Buttock – Cleanse with soap and water; pat dry; apply Silvadene (or generic equivalent); Pack wound with kerlix; cover with ABD; Secure with Tape. Twice A Day. Start Date: 8/15/25. End Date: 8/19/25. Discontinued Order. WOUND CARE: Left Hip/Buttock – Cleanse with soap and water; pat dry; apply Silvadene (or generic equivalent); Pack wound with kerlix; cover with ABD; Secure with Tape. Twice A Day. R51's Medication Administration Record (MAR) indicates, in part: On 8/15/25, R51 did not receive her wound care according to provider orders for her left hip/buttock wound. The MAR contains the comment: Drug/Item Unavailable. On 8/16/25, R51 did not receive her wound care according to provider orders for her left thigh and left hip/buttock wounds. The MAR contains the comment: pt (patient) load/staffing for her left hip/buttock wound. On 8/24/25, R51 did not receive her wound care according to provider orders for her left thigh and left hip/buttock wound. The MAR contains the comment: not enough time in shift for amount of work to be done for one nurse for the left thigh wound and left hip/buttock wound. On 8/27/25, R51 did not receive her wound care according to provider order for her left thigh and left hip/buttock wounds. R51's Progress Notes indicate, in part:On 8/25/25 at 12:46 PM, a Progress Note is written that states, in part: Writer arrived to start shift to find agency RN 'overwhelmed' stating she wasn't able to get to (R51's Room Number) wound d/t (due to) being short staffed and too many patients. Writer immediately went to change wound and found it w (with) moderate purulent drainage and some bloody discharge. Also observe surgical incisions being wider and wetter than when she first got here. On 10/1/25 at 2:00 PM, Surveyor interviewed DON B (Director of Nursing) and IP G (Infection preventionist). Surveyor asked DON B and IP G if they expect wound care treatments to be completed according to provider orders. DON B indicated, yes, unless the resident refuses, then the refusal should be documented. R51's surgical wound treatments were not completed as ordered by the physician. Example 2 R6 admitted to the facility on [DATE] and has diagnoses that include: acute pyelonephritis-Right sided (an infection of the kidneys); personal history of urinary infections; retention of urine (the inability to completely empty the bladder which can lead to infection) R6's Physician Orders include Sulfamethoxazole-trimethoprim (an antibiotic) 800-160 mg (milligrams) Take 2 tablets by mouth BID (twice a day) for 7 days d/t (due to) MDRO (multi-drug resistant organism) proteus (a bacterium which causes infection) on culture. Start date 7/28/25. During record review Surveyor was unable to locate any assessments or continued monitoring for R6 after having a change in condition with a UTI (urinary tract infection). Surveyor requested documentation related to assessment of symptoms of urinary tract infection through completion of antibiotic treatment. No documentation was provided by the facility. Example 3 R23 admitted to the facility on [DATE] and has diagnoses that include: urinary tract infection; hydronephrosis with renal and ureteral calculous obstruction (a condition where the kidney becomes swollen due to a blockage caused by kidney stones) R23's Physician Orders include Sulfamethoxazole-trimethoprim 800-160 mg Take 1 tablet by mouth 2 times daily at mealtime for 3 days for infection. Start date 6/18/25. During record review Surveyor was unable to locate any assessments or continued monitoring for R23 after having a change in condition with a UTI. Surveyor requested documentation related to assessment of symptoms of urinary tract infection through the completion of antibiotic treatment. No documentation was provided by the facility. Example 4 R69 admitted to the facility on [DATE] and has diagnoses that include: cystitis; chronic kidney disease (a condition in which the kidneys lose their ability to filter waste products) R69's Physician Orders include Cefdinir (antibiotic) 300 mg Take 1 capsule by mouth once daily. Start date 7/18/25. R69's Progress notes include 7/18/25 at 2:36 PM Resident admitted to facility today.foley present and draining clear yellow urine. During record review Surveyor was unable to locate continued assessments or monitoring for a UTI. Surveyor requested documentation related to assessment of symptoms of urinary tract infection through the completion of antibiotic treatment. No documentation was provided by the facility. On 9/30/25 at 3:21 PM, Surveyor interviewed IP G (Infection Preventionist) and asked about monitoring of residents on antibiotics. IP G stated that through the course of the antibiotic the resident should have an assessment of vital signs and the body system involved, along with any signs and symptoms of adverse reaction to the antibiotic. IP G stated that symptom surveillance had been a noted issue. Surveyor asked if R6, R23 and R69 were assessed through the course of their antibiotic treatment. IP G stated no, R6 and R23 needed to have urinary assessments through the course of their antibiotics and that while R69 had an assessment on 7/18/25, assessment would be expected through 7/22/25. On 10/1/25 at 9:50 AM, Surveyor interviewed DON B (Director of Nursing) Surveyor asked about residents on antibiotics. DON B stated that assessments should be done and documented through the course of the antibiotic. DON B stated it is the facility's plan to educate staff and make sure that this is occurring. R6, R23 and R69 did not have documented assessments through the course of their antibiotic treatment.

Based on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 1 of 3 shower room affecting a pattern of residents who use the shower room and 1 (R67) of 19 sampled residents. Surveyor observed the Whirlpool Shower Room (Note just shower) to not be homelike with the following visible repairs needed: Example 1: Opening in floor covered by a loose piece of tile and a board laying over a large open area Example 2: Tiles missing on the wall next to the shower with exposed rusty metal protruding from the wall Example 3: Missing tiles on the shower floor Example 4: Dark substance along the inside right where the shower wall meets the floor. Tiles are broken and worn in this area as well. Example 5: Vent above shower coated with dust; dust is visibly hanging off the vent Example 6: Hairband in shower drain in the tub for one (1) week without being picked up. The shower is not being cleaned. R67's chair rail was in need of repair in R67's room presenting a safety hazard. This is evidenced by: The facility policy, Quality of Life – Homelike Environment, revised May 2017, states, in part: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment On 10/1/25 at 7:45 AM, Surveyors requested ANHA C (Assistant Nursing Home Administrator) and MD E (Maintenance Director) to walk to the shower room with Surveyors. Example 1: Opening in floor covered by a loose piece of tile and a board laying over a large open area Surveyors asked MD E (Maintenance Director) to move the items so Surveyor could see what is located underneath the items. MD E picked up the items off the area to reveal a very large open hole with previously used plumbing. MD E stated, we need to fill this with gravel and concrete. Surveyor asked is this a hazard to residents. ANHA C (Assistant Nursing Home Administrator) stated, yes, it's not secure and carts or a Hoyer could get hooked or bump this with how easy we can lift these items up. Example 2: Tiles missing on the wall next to the shower with exposed rusty metal protruding from the wall Surveyor asked MD E (Maintenance Director) to observe what appears to be rusty metal protruding from the wall. MD E inspected the concern and stated it is rusty metal. MD E stated, he has not seen any order for this in the maintenance system. ANHA C (Assistance Nursing Home Administrator) stated this is the first time he is seeing this. MD E added, we need to repair the wall. Example 3: Missing tiles on the shower floor MD E (Maintenance Director) stated, these tiles need to be repaired. Example 4: Dark substance along the inside right where the shower wall meets the floor. Tiles are broken and worn in this area as well. MD E (Maintenance Director) stated, It needs to be cleaned. Example 5: Vent above shower coated with dust; dust is visibly hanging off the vent MD E (Maintenance Director) and ANHA (Assistant Nursing Home Administrator) stated, the vent is dirty and needs to be cleaned. Example 6: Hairband in shower drain in the tub for one (1) week without being picked up. The shower is not being cleaned. ANHA C (Assistant Nursing Home Administrator) stated, staff need to pick up items on the floor of the shower and it needs to be cleaned. Of note, after Surveyors spoke with ANHA C (Assistant Nursing Home Administrator) and MD E (Maintenance Director) the shower room was closed for repairs. Example 7 R67 admitted to the facility on [DATE] and has diagnoses that include conversion disorder with seizures or convulsions (a mental health condition where a person experiences physical symptoms that cannot be explained by a medical condition. These symptoms include seizures or convulsions) and generalized anxiety disorder. On 9/30/25, at 3:00PM, Surveyor observed behind R67's bed above the headboard, approximately 30 inches above the floor, the wood chair rail was broken presenting a potential injury to the resident with splinters and sharp ends of wood exposed. On 10/1/25, at 7:45AM, Surveyor interviewed MD E (maintenance director) and ANHA C (Assistant Nursing Home Administrator). Surveyor, MD E and ANHA C observed the broken chair rail in R67's room together. Surveyor asked if MD E and ANHA C were aware of the broken chair rail and ANHA C indicated he became aware of it on 9/25/25 when Life Safety brought it to his attention. Surveyor asked MD E and ANHA C if this could cause potential injury to R67 and ANHA C indicated yes. Surveyor expressed safety concerns to MD E and ANHA C and ANHA C agreed it was a safety concern and should not be left as showing. Surveyor asked if there was a work order or a plan to fix and ANHA C indicated the facility will pull the trim off, sand it down, and repaint it. On 10/1/25, at 11:01 AM, Surveyor interviewed R67. R67 indicated she had reported the broken chair rail weeks ago when she moved into that room. R67 expressed concern and indicated everything is always in a shamble here at the facility. R67 stated, My room just looks like it is shambles.

Based on interview and record review, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 5 of 18 residents (R8, R7, R3, R26, R67) reviewed for advanced directives. R8, R7, R3, R26, and R67's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by: The facility's Advance Directives policy, dated 9/2022, states, in part: .Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. Example 1 R8 admitted to the facility on [DATE]. On 9/24/25 at 12:22 PM, during the record review portion of the initial pool process, Surveyor was unable to find documentation of a Power of Attorney for Health Care (POAHC) for R8 or evidence of a discussion with R8 about establishing one. Example 2 R7 admitted to the facility on [DATE]. On 9/24/25 at 3:03 PM, during the record review portion of the initial pool process, Surveyor was unable to find documentation of a POAHC for R7 or evidence of a discussion with R7 about establishing one. On 9/30/25 at 9:02 AM, Surveyor interviewed ANHA C (Assistant Nursing Home Administrator) who indicated that the Social Services Director's last day of work was 9/25/25 and ANHA C was taking those responsibilities at present time. Surveyor asked about advanced directives. ANHA C stated that advanced directives are discussed at time of admission / admission care conference. If the resident hasn't shared POAHC documentation, the process is discussed, and the facility offers to help with the paperwork. Surveyor asked if this discussion is documented. ANHA C stated yes, there should be a progress note from the social worker. Surveyor asked if there was documentation of a POAHC or discussion about creating a POAHC for R7. ANHA C reviewed R7's chart and stated there was no document or note of discussion. ANHA C stated there should have been note of discussion and what decision was made by the resident. Surveyor asked if there was note of discussion for R8, R3, R26, and R67. ANHA C stated that ANHA C would review charts. On 9/30/25 at 9:50 AM, ANHA C stated there was no documentation of discussion of POAHC for R8, R3, R26, and R67 and that there should have been. On 10/1/25 at 9:50 AM, Surveyor interviewed DON B (Director of Nursing) and asked about POAHC. DON B stated yes, there should absolutely be a documented conversation with the resident upon admission and facility should be assisting as needed. Example 3: R3 admitted to the facility on [DATE]. During the recertification survey, Surveyor was unable to locate documentation of a Power of Attorney for Health Care (POAHC) for R3 during record review. Surveyor could not find evidence of a discussion with R3 about establishing a POAHC. Example 4: R26 admitted to the facility on [DATE]. During the recertification survey, Surveyor was unable to locate documentation of a POAHC for R26 during record review. Surveyor could not find evidence of a discussion with R26 about establishing a POAHC. Example 5: R67 admitted to the facility on [DATE]. During the recertification survey, Surveyor was unable to locate documentation of a POAHC for R67 during record review. Surveyor could not find evidence of a discussion with R67 about establishing a POAHC.

Based on interview and record review, the facility did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized for 2 of 5 residents (R9 and R2) reviewed for immunizations.R9 and R2 were not offered pneumococcal vaccination.Evidenced by:The facility's Pneumococcal Vaccine policy, dated 2001, states, in part: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. 2. Routine vaccination consists of the following: a. If the resident has not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose of PCV15, 1 dose of PCV20, or 1 dose PCV21.d. Previously received only PPSV23: 1 dose PCV20, or 1 dose PCV21, at least 1 year after the last PPSV23 dose.4. Provision of information, education, and the VIS (Vaccination Information Statement) are documented in the resident's medical record. 5. The resident (or representative) has the right to refuse vaccines. If refused, the date of and stated reason for the refusal of the vaccine are documented in the resident's medical record.Example 1R9 admitted to the facility on [DATE].R9's Preventive Health Care Report lists Pneumococcal vaccines as follows:*Administration date: 11/20/2017 Type: PPSV23*Administration date: 6/10/2011 Type: PPSV23Per PneumoRecs VaxAdvisor, the U.S. Centers for Disease Control and Prevention's recommendation for R9's age group is to give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23.There is no documentation that R9 was offered a dose of PCV15, PCV20, or PCV21. Example 2R2 admitted to the facility on [DATE].R2's Preventive Health Care Report shows no documentation of Pneumococcal vaccines.Per PneumoRecs VaxAdvisor, the U.S. Centers for Disease Control and Prevention's recommendation for R2's age group is to give one dose of PCV15, PCV20, or PCV21.There is no documentation that R2 was offered PCV15, PCV20, or PCV21.On 9/29/25 at 4:11 PM, Surveyor interviewed IP G (Infection Preventionist) and asked about the facility's guidelines for offering the pneumonia vaccination. IP G stated that PneumoRecs app is used to determine if residents are up to date. Surveyor asked if R9 and R2 were up to date with their pneumonia vaccination. IP G stated no, they were not up to date and should have been offered vaccination at time of admission.

Based on interview and record review, the facility did not identify issues to which quality assessment and assurance activities are necessary or develop and implement appropriate plans of action to correct identified quality deficiencies for 2 of 2 Residents (R28 & R4). The facility has failed to identify key areas of deficient practice and implement action plans to correct these deficient practices or identify areas needing improvement to develop, implement, monitor, and evaluate action plans to achieve specific goals to improve quality of care for Pressure Injury care and prevention.Evidenced by:The facility's Quality Assurance and Performance Improvement (QAPI) Program-Feedback, Data, and Monitoring policy, dated March 2020, states, in part: The QAPI program is based on the collection of information obtained from data, self assessment and systems of feedback. Information is collected, evaluated and monitored by the QAPI committee. 1. Information obtained about the quality of care and services delivered to residents is evaluated and monitored by the QAPI committee in order to identify problems that are high risk, high volume, or problem prone and to guide decisions regarding opportunities for improvement. 2. The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. 3. Systems and tools used to identify, collect and evaluate data from all departments to monitor performance indicators include, but are not limited to the following: a. Self-assessment tools: *ongoing facility assessment *monthly resident census data.b. Data collection tools: *monthly surveillance reports for quality of care indicators. 6. Corrective actions and performance improvement activities are initiated and monitored.The facility's QAPI Plan 2025, dated 7/8/2025, states, in part: .The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions. These include, but are not limited to, customer service, care management. The QA&A (Quality Assessment and Assurance) Committee reports to the executive leadership and Governing Body and is responsible for: . 3. Developing and implementing appropriate plans of action to correct identified quality deficiencies. Performance Improvement Projects (PIP) Overall PIP Plan: Performance Improvement Projects will be a concentrated effort on a particular problem in one area of the nursing center or on a facility-wide basis. They will involve gathering information systematically to clarify issues or problems and intervening for improvements.PIP Determination Process: Areas for improvement are identified by routinely and systematically assessing quality of care and service, and include high risk, high volume and problem prone areas. Consideration will be given to incidence, prevalence, and severity of problems, especially those that affect health outcome.R28 was admitted to the facility with four (4) Stage 1 PI's. R28 was at risk for further PI development and had significant co-morbidities including idiopathic peripheral neuropathy (a type of nerve damage where the underlying cause is unknown), generalized weakness, and a fractured syloid process right radius (thumb). The facility failed to, complete a readmission skin assessment, failed to accurately complete all weekly wound assessments and measurements, failed to notify provider of changes to PI, failed to document turning and repositioning, failed to offload pressure, and failed to follow standards of practice during wound care resulting in cross contamination of R28's PI. R28 developed an Unstageable PI which deteriorated to a Stage IV (4) PI with osteomyelitis.R4 was admitted [DATE] without any pre-existing pressure injuries. Since admission, R4 has developed 4 pressure injuries. The pressure injury on his left heel was first identified 10/25/24 at a stage 2 and progressed to an unstageable pressure injury by 2/3/25. The pressure injury on his right heel was first identified on 10/25/24 at a stage 2 and progressed to an unstageable pressure injury by 10/29/24. The pressure injury on his left lateral foot, or 5th metatarsal was identified 6/13/25 at a stage 2 and progressed to an unstageable pressure injury on 6/27/25 (100% eschar wound bed with undetermined depth). The pressure injury on his left lateral foot was identified 9/15/25 as and unstageable pressure injury. R4 was diagnosed with cellulitis (skin infection) with a source of chronic left lateral malleolus (ankle) and left foot wounds on 6/16/25 that required IV (intravenous) antibiotics to treat. R4 was diagnosed with Group B strep bacteremia (bacterial infection in the blood) and left fifth metatarsal (where foot meets pinky toe) osteomyelitis (infection of the bone) which was treated with IV antibiotics with the only definitive recommended treatment being amputation. R4's initial pressure injury care plan was not put in place until 4/2025 and contained few interventions for pressure reduction/off-loading. R4 only had two Braden Scales for Pressure Injury Risk conducted since admission, which should have been completed upon readmission from the hospital and at least quarterly. R4 did not receive several wound treatments and missed several weekly wound assessments.On 10/1/25 at 2:39 PM, Surveyor interviewed ANHA C (Assistant Nursing Home Administrator) and asked how concerns are identified for QAPI. ANHA C stated through screening grievances, MDS (Minimum Data Set) flags / risks, interdisciplinary team meetings, employee surveys.On 10/1/25 at 4:32 PM, Surveyor interviewed ANHA C and asked if there had been discussion of and/or a PIP (performance improvement plan) initiated in relation to skin/Pressure Injuries. ANHA C stated no, not that I have been aware of. Surveyor asked if ANHA C would be aware of all topics discussed in QAPI. ANHA C stated, yes, he would be aware of all topics from 3/6/25 to present. ANHA C stated that there have been staff meetings with discussion of staff being the eyes (taking note of concerns), but there was no specific discussion of skin/PI. Surveyor asked if ANHA C was aware the facility had 2 residents with pressure injuries, one with a stage IV pressure injury and one with multiple stage 3 pressure injuries, ANHA C stated no. Surveyor asked if this was something that should have been discussed by QAPI. ANHA C stated, yes, ANHA C should have been made aware, and it should have been discussed by QAPI, as this is where the facility is best able to troubleshoot concerns.When adverse resident events are identified, the facility must analyze the cause of the error/event, implement corrective actions to prevent future events, and conduct monitoring to ensure desired outcomes are achieved and sustained, this was not initiated or completed by the facility for pressure injuries despite having residents with multiple pressure injuries that occurred in house or worsened after being admitted to the facility.

Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R28) reviewed for hospice.R28's current hospice plan of care and visit notes were not available to facility staff.The facility did not designate a staff member to coordinate the plan of care with the hospice provider.This is evidenced by: The facility's Hospice Program policy, revised July 2017, states, in part: .9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. 12. Our facility has designated (Name) and (Title) (blank) to coordinate car provided to the resident by our facility staff and the hospice staff. a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. B. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. D. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 14. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident representative, including: a. Palliative goals and objectives; b. Palliative interventions; c. Medical treatment and diagnostic tests. 15. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including, but not limited to: a. Diagnosis; b. Problem list; c. Symptom management (pain, nausea, vomiting, etc.); d. Bowel and bladder care; e. Nutrition and hydration needs; f. Oral health; g. Skin integrity; h. Spiritual, activity and psychosocial needs; and i. Mobility and positioning R28 was re-admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic heart failure (heart is not functioning properly), and failure to thrive (a decline resulting in weight loss and weakness).On 1/7/25 R28 was enrolled in hospice services.The facility did not have record of R28's PI (pressure injury) assessments and measurements. Upon Surveyor's request for the information, the facility contacted hospice to request this documentation.On 9/30/25 at 3:00 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A if there should be a current hospice plan of care and visit notes for R28's PI (pressure injury) assessments from January through March 2025. NHA A stated, yes. Surveyor asked if there should be a current hospice plan of care hospice binder for staff to reference. NHA A stated yes. NHA A stated, the facility was caring for R28's PI but NHA A stated, she can see there is a documentation gap. On 10/1/25 at 11:24 AM, Surveyor spoke with RN Hospice O (Registered Nurse). Surveyor asked RN Hospice O, does R28 have a hospice plan of care. RN Hospice O stated, yes, whenever there is an admission currently living at the facility, the facility will request it and hospice will send it to the facility. RN Hospice O stated the plan of care is always available to ask for. RN Hospice O stated, anytime the facility needs anything they ask me or call our main triage number inquiring to have that done. RN Hospice O indicated the plan of care is always accessible to the facility. Surveyor asked RN Hospice O, does the facility needs to request the plan of care or is it automatically provided. RN Hospice O indicated, she does not know. Surveyor asked RN Hospice O, if she shares visit notes with the facility. RN Hospice O stated, she has access to MatrixCare. RN Hospice O stated, if it's a regular visit and wound care is not involved, she enters the visit into MatrixCare (electronic health record). RN Hospice O stated, if she is completing wound care she will fax the documents to the facility.On 10/1/25 at 11:32 AM, Surveyor asked RN P (Registered Nurse) R28's hospice plan of care. RN P stated, she was unable to locate R28's care plan in the binder on the nurse's station bookshelf and stated that each hospice service is handled differently. Surveyor asked RN P how hospice and the facility communicate. RN P stated, hospice checks in with the RN (Registered Nurse), SW (Social Worker), and CNA's (Certified Nursing Assistants). RN P stated hospice will let us know if they make any changes or notify us of new skin issues. Surveyor asked RN P is there a designated staff member to coordinate the plan of care with hospice? RN P stated no. R28's current hospice plan of care and visit notes were not available to facility staff until after Surveyor requested them and the facility does not have a designate staff member to coordinate with the hospice provider.

Based on observation, interview, and record review, the facility did not provide food that accommodates resident preferences; appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice for 1 of 18 sampled resident's (R19). R19 was known to be a vegetarian and was not given foods of similar nutritive value to replace the meat options on the menu to maintain his assessed protein goals.Evidenced by:R19 was admitted to the facility from the hospital on 6/3/25 with diagnoses of cerebral infarction, type 2 diabetes, and congestive heart failure. His most recent MDS (Minimum Data Set), dated 9/8/25 includes a BIMS (Brief Interview for Mental Status) score of 15, indicating he is cognitively intact. R19 has physician's orders, dated 6/4/25, for a vegetarian diet, no dairy.R19's nutrition care plan states, Problem: Resident has potential for alteration in nutritional status related to diagnoses, medications, fluid balance, diet, intake, physical activity and metabolic demands.Goals: Maintain weight at a healthy range for the Resident without any unwarranted significant weight changes, tolerate physician ordered diet, have personal food and dining preferences met; promote and/or maintain skin integrity, and be without any s/s of any unfavorable nutrition outcome.There is no specific diet or dietary interventions documented on R19's care plan, nor what his likes and dislikes are.On 9/25/25 at 11:49 AM, R19 was observed sitting in the dining room. A dietary aide who was serving food asked R19 what he wanted to eat and stated, I know that you don't like meat. R19 acknowledged this and received a plate containing a baked sweet potato, mashed sweet potatoes, wax beans and peas. At this time, Surveyor asked R19 at his table what his diet was. R19 stated he was a vegetarian and everybody in his family is a vegetarian. R19 stated that he is concerned that he is not getting enough protein. R19 stated he did not like fish, eggs, or dairy but he would eat a peanut butter and jelly sandwich, bean burgers, beans, meat analogs, and tofu. When asked if anybody at the facility had tried to find him replacements for meat, R19 stated, No. When asked if he believed staff would bring him a peanut butter and jelly sandwich if he asked, R19 indicated they would, but had not asked and staff had not brought him any substitutes since he had admitted to the facility.On 9/29/2025 at 2:42 PM, Surveyor interviewed DM S (Dietary Manager). DM S stated that she gets diet info from the admission nurse and they tell her what diets their primary care physician is recommending. DM S stated that at the admission care conference for each resident there is a sheet that she goes through including preferences and finds out what each resident likes and what they don't like and she puts it on their diet ticket. DM S also state that she did not know if R19's protein intake was being monitored or tracked in any way, such as if he was on a supplement or if he had requested any food items outside of mealtime such as a peanut butter sandwich. DM S stated that her cooks know R19 is a vegetarian. When it comes to how to replace the lost protein/meat items for each meal, DM S indicated that she refers to either the dietician or primary care physician in determining what specifically he (R19) needs in terms of protein. DM S indicated that when R19 was first admitted she did look up meat free alternatives but all she could find was a case of hundred burgers. DM S also indicated that when R19 was admitted he was supposed to be short term rehabilitation so some of the food ordering and attention to his dietary needs were did not get immediate attention. Additionally, DM S stated that R19 would not drink a clear supplement because those still had milk-based ingredients, even though they were lactose-free. When asked if there were any plant-based supplements, DM S stated that she was unaware of such supplements. At approximately 3:15 PM, DM S approached Surveyor in the hallway with a plant-based Ensure supplement and stated she did not know such a supplement existed but found one in her kitchen and would offer it to R19.A dietary note by DM S, dated 9/29/25 at 3:34 PM states, Conversation with resident regarding diet and increasing protein and preferences. Upon admission in June, resident stated to me that he does not like eggs. Today, he retracted that statement saying that he will eat hard cooked eggs, egg salad, and the occasional scrambled egg. Offered resident a Plant Based Ensure to try. He said, Well, I am not familiar with that product. Encouraged resident to try it, and I would check back in with him to see if he liked it. Resident hesitant, but agreed. I also discussed meat alternative products with resident. Told resident that I would do some research to see what my supplier carries and then touch base with him tomorrow, 9/30, on those items, and the outcome of the Plant Based Ensure Trial. Note: dietician had recommended Boost Clear, however that contains milk product and resident was not interested. Email sent to nurse practitioner to request an order for the Plant Based Ensure if resident is agreeable to it.On 10/01/2025 at 8:54 AM, Surveyor interviewed DON B (Director of Nursing). DON B stated she was also concerned about R19's protein needs given his vegetarian diet and that his preferences should be met and obtained by the dietary manager. DON B stated that the facility and facility staff should be providing R19 with a protein replacement and that he should not have to ask them for alternatives.On 10/01/2025 at 9:12 AM, Surveyor once again interviewed DM S who stated that she had received the necessary order from the nurse practitioner to get R19 the plant-based ensure. DM S stated that she had just talked to R19 about other foods and R19 replied to bring him a list of possible food options and they could go through them together. DM S stated that she talked to R19 about peanut butter so she added peanut butter toast to his breakfast and made a list of beans for staff to be available to him. DM S stated that she now has a list of things R19 will eat. DM S stated that she should have made these changes when R19 was admitted and stated, What I should have done was asked him about how to fill the protein void when he came in. I didn't know until the next day after he was admitted that he was a vegetarian. DM S stated that she does not have a vegetarian alternative on the menu but will work with providing other protein dense non-meat food items for R19 and other future vegetarians.On 10/1/25 at 3:15 PM, Surveyor observed a Diet Roster list posted on a refrigerator in the main kitchen which stated NO MEAT, EGGS OR DAIRY by R19's name. Next to this list was a Beverage Preferences list and next to R19's name it stated, OJ and milk for breakfast.The facility was aware R19 was a vegetarian but did not establish alternatives and preferences to meet resident needs.

Based on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 1 of 2 medication carts. Surveyor observed medication on top of an unsupervised medication cart in hallway while nurse administered medications to a resident. The medication cart had an expired open bottle of Milk of Magnesia (laxative medication). Evidenced by: The facility policy entitled Administering Medications, dated 4/2019, states, in part: . Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. The facility policy entitled Storage and Expiration Dating of Medications and Biologicals, dated [DATE], states, in part: . Applicability: Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure: . 10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier 11. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guideline with respect to expiration dates for opened medications. Example 1 On [DATE], at 4:06 PM, Surveyor observed MT K (medication tech) leave a stock bottle of Senna Plus, a stock bottle of AREDS (PreserVision), and a medication cup with 1 loose senna plus tablet on top of the medication cart unattended as MT K and Surveyor went into a resident's room to administer medications. The medications on the cart were left unattended for 5 minutes. The medication cart was left in hallway, and the resident's door was closed, with the cart out of sight. On [DATE], at 4:36PM, Surveyor interviewed MT K and asked if the stock bottle of Senna Plus and AREDS, and medication cup with the 1 loose Senna Plus tablet should be left unattended on top of the medication cart. MT K indicated no, it should have been locked in the medication cart. MT K put the 2 bottles and medicine cup with 1 senna plus tablet in the medication cart. On [DATE], at 10:52 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated medications should not be left on top of the medication cart unattended while MT K was administering medications in a resident's room with the door closed. DON B indicated she would expect the medications to be locked in the medication cart while unattended. Example 2 On [DATE] at 8:59 AM, Surveyor observed the [NAME] Hall medication cart with LPN F (Licensed Practical Nurse). Surveyor observed an open bottle of Milk of Magnesia (laxative medication) marked with an expiration date of 7/2025. Surveyor interviewed LPN F regarding the bottle. LPN F stated that the medication was expired and should not be in the medication cart. On [DATE] at 9:50 AM, Surveyor interviewed DON B (Director of Nursing) and asked about expiration dates. DON B stated the nurses and DON check the medication storage room for expiration dates and the nurses should be checking the medications in the cart. DON B stated that this outdated medication should not have been in the medication cart.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 4 errors out of 31 opportunities that affected 2 out of 6 residents (R16 & R54) included in the medication pass task, which resulted in an error rate of 12.9%. R16's ordered Miralax was omitted. R16 received Simethicone without an order and received 2 tablets of Senna Plus and order was for 1 tablet. R54 was to receive 2 tablets of Senna Plus and it was omitted. Evidenced by:The facility policy entitled Medication Errors, dated 9/01/10, states, in part: . Applicability: This section 10.1 sets forth procedures relating to medication errors.Procedure: .4. Administration Errors: . Examples of administration errors include, but are not limited to: .4.4 Dose Error: Community administers to the resident a medication dose that is greater than or less than the amount ordered by the physician/prescriber.4.7 Omission Error: Community fails to administer an ordered dose to the resident.4.11 Unauthorized drug error: Community administers a medication dose not authorized for the resident. The facility policy entitled Administering Medications, dated 4/2019, states, in part: . Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber order. Example 1: R16 admitted to the facility on [DATE] and has diagnoses that include constipation and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone. Common symptoms of hypothyroidism include constipation.). R16's Care Plan dated 7/15/24, states, in part: . Problem: Category: Dehydration/Fluid MaintenanceR16 has constipation episodes.Approach:Approach Start Date: 7/15/24 Administer medications/enemas/suppository. R16's Physician Orders as of 9/30/25 include:-Miralax (polyethylene glycol 3350) powder; 17 grams/dose.Special Instructions: Constipation. Twice a day; 8:00AM 4:00PM. Start Date: 9/08/25. End Date: Open Ended. -Senna Plus (sennosides-docusate sodium) tablet, 8.6-50 mg(milligrams), amount 1 tablet, oral. Special instructions: Constipation Twice a day; 8:00AM, 8:00PM. Start Date- 9/09/25. End Date- Open Ended. Important to note: order is for 1 tablet.Important to note: Physician orders do not include an order for simethicone. R16's MAR (Medication Administration Record) for September 29, 2025, shows:-polyethylene glycol 3350 powder; 17 grams/dose was administered for 4:00PM dose-Senna Plus (sennosides-docusate sodium) tablet; 8.6-50 mg; Amount to administer: 1 tablet; oral, was administered for the 4:00PM dose. Important to note: 2 Senna Plus tablets were administered. On 9/29/25, at 4:00PM, Surveyor observed LPN J (Licensed Practical Nurse) administer to R16 2 Senna Plus tabs and Simethicone 80 mg chew tab. Important to note: Surveyor did not observe LPN J administer R16's Miralax that was ordered for 4:00PM. On 9/30/25, at 10:35AM, Surveyor interviewed DON B (Director of Nursing). Surveyor informed DON B of observation of LPN J administering to R16:-2 senna plus tabs-simethicone 80 mg chew tabSurveyor asked DON B when LPN J administered 2 tablets of senna plus when the order is for 1 tablet would that be a medication error. DON B indicated yes. Surveyor asked when LPN J administered simethicone without an order, would that be considered a medication error. DON B indicated yes. Surveyor asked DON B LPN J omitting Miralax and signing it out on the MAR without administering it, would that be a medication error; DON B indicated yes. DON B indicated she would expect physician orders to be followed. Example 2: R54 admitted to the facility on [DATE] and has diagnoses that include constipation. R54's Physician Orders as of 9/30/25, state, in part: . Start Date: 2/19/24. End Date: Open Ended. Senna Plus (sennosides- docusate sodium) tablet; 8.6-50 mg (milligrams), amount 2 tablets, oral. Twice a day; 8:00AM, 4:00 PM. R54's MAR (medication administration record) for 9/29/25 includes:-Senna Plus (sennosides-docusate sodium) tablet; 8.6-50 mg; Amount to Administer: 2 tablets, oral.Important to note: Order is for 2 tablets. On 9/29/25, 4:06PM, Surveyor observed LPN J (Licensed Practical Nurse) administer Senna Plus 1 tablet to R54. On 9/30/25, at 4:36 PM, Surveyor interviewed DON B (Director of Nursing) and informed her of observation of LPN J administer R54 1 Senna Plus and order is for 2 Senna Plus. Surveyor asked DON B if this is a medication error and DON B indicated yes. DON B indicated she would expect physician orders to be followed.

Based on observation, interview and record review the facility failed to ensure a resident who receives nutrition and hydration and maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 4 residents (R19) reviewed for nutrition.Facility staff were aware R19 was prescribed a vegetarian diet and failed to provide a source of protein on his daily meal trays to accommodate R19's likes. R19 went 3 months without an adequate source of protein provided on his daily meal trays or a supplemental protein source R19 experienced a weight loss of 16%, a severe weight loss, in 3 months. Evidenced by:The National Council on Aging (NCOA) states, The first step in managing diabetes through diet as an older adult is to understand how different nutrients affect blood glucose levels. A balanced blend of high-fiber carbohydrates, lean protein, and healthy fats can help you maintain stable blood sugar levels and prevent dangerous fluctuations.it is recommended older adults consume 1.0-1.2 grams of protein per kilogram of body weight. For example, an older adult who weighs 150 pounds (68 kg) should eat 68-82 grams of protein per day. Aim to spread your protein intake evenly throughout the day with 20-30 grams at mealtimes and 12-15 grams with snacks.The Cleveland Clinic states that sarcopenia is the gradual loss of muscle mass, strength and function. The condition commonly affects the elderly population and is thought to occur due to aging. Sarcopenia can greatly impact quality of life by reducing the ability to perform daily tasks. Risk factors include malnutrition or inadequate protein intake. Sarcopenia can be treated and by increasing protein intake through food or supplements and aiming for 20 to 35 grams of protein in each meal.A 2023 study, titled Association of Dietary Patterns and Sarcopenia in the Elderly Population: A Cross-Sectional Study, states:*Due to the escalation of the reported prevalence in elderly populations, sarcopenia leads to a worse quality of life.* The results of this study showed that vegetarian participants had a higher risk of sarcopenia due to the insufficient protein intake of this dietary pattern.https://pmc.ncbi.nlm.nih.gov/articles/PMC10485369/ The facility's weights procedure policy staters, Residents will be weighed on admission and daily for the first 72 hours following admission. Weights will continue weekly for 4 weeks and monthly there in after or as needed as determined by a physician's order or nursing assessment of need. To assure proper assessment of residents' nutritional status, to monitor for changes in resident's health, to alert staff of potential problems that might be affecting residents health and wellbeing. Additionally, the policy states:*Any weight loss or gain of 5% of residents that are 101 lbs. or greater need to be reported to the physician.*Residents on alternate nutrition or deemed to be assessed at risk will be weighted weekly or as often as the physician or nursing assessment indicates. R19 was admitted to the facility from the hospital on 6/3/25 with diagnoses of cerebral infarction, type 2 diabetes, and congestive heart failure. His most recent MDS (Minimum Data Set), dated 9/8/25 includes a BIMS (Brief Interview for Mental Status) score of 15, indicating he is cognitively intact. R19 has a physician's order, dated 6/4/25, for a vegetarian diet, no dairy.R19's nutrition care plan states, Problem: Resident has potential for alteration in nutritional status related to diagnoses, medications, fluid balance, diet, intake, physical activity and metabolic demands.Goals: Maintain weight at a healthy range for the Resident without any unwarranted significant weight changes, tolerate physician ordered diet, have personal food and dining preferences met; promote and/or maintain skin integrity, and be without any s/s of any unfavorable nutrition outcome. There is no specific diet or dietary interventions documented on R19's care plan.R19's hospital discharge paperwork shows a weight of 228.3 lbs on 6/3/25. Facility records show the following weights:*6/3/25: 228.3 lbs*6/13/25: 206.2 lbs (Of note, this is a 22.1 pound/9.68% weight loss in 10 days, this would be considered a severe weight loss.)*6/22/25: 209.2 lbs*6/23/25: 192.6 lbs (this is a 16.6 pounds/7.93% weight loss in a day)(Of note: R19 lost 35.7 pounds/15.63% of his body weight in 20 days, this is a severe weight loss) A dietary note, dated 6/26/25 and noted by RD T (Registered Dietician) states, Initial Assessment: [AGE] year old male admitted for rehab and cares.confirms his appetite has been adequate since admit. Height: 72 weight: 192.6 pounds (6/23/25). BMI: 26.12 kg/m2 (overweight). Admit weight of 228 lb-questionable, as are 6/21/25 weight of 192.6 lb and 6/23/25 weight above. All other weights since admit showing 202-209 lb-will monitor, though do not believe significant changes have occurred.estimated needs: 1750-2187 kcal/day, 70-88g pro/day, 1ml fluid/kcal. Diet: Vegetarian/no dairy diet.The facility recorded the following additional weights for R19:*7/1/25: 197 lbs*7/29/25: 196.5 lbs*8/5/25: 198 lbs*8/19/25: 198.4 lbs On 9/7/25, R19 tested positive for COVID and was monitored through 9/16/25. A quarterly dietary note by RD T, dated 9/11/25, states, Appetite has been good since admission, 51-100% on average. However, COVID+ currently and intakes decreased because of it.weight: 198.4 lbs (8/19).Recommendations: 1) Ensure Clear (or equivalent) TID (three times a day) due to recent poor oral intakes due to covid infection. Would expect minor weight loss from covid/poor oral intake; however, expect appetite to bounce back once infection clears. Will continue to monitor and advise on changes to nutrition interventions quarterly. It should be noted that facility documentation shows R19 was only offered the supplement on 9/16/25 in which he consumed 1-25%. R19's next and most recent recorded weight at the facility was on 9/19/25 in which R19 weighed 190.2 lbs. Of note, the facility gathers resident food intakes for breakfast, lunch and dinner. Between 6/3/25 and 7/1/25, the facility documented 4 meals: 6/8 breakfast (26-50%), 6/13 dinner (26-50%), 6/20 dinner (46-50%) and 6/21 lunch (26-50%). Additionally, meal intakes were not documented between 7/1 and 7/8, between 7/10 and 7/15, 7/21, between 8/10 and 8/23, 9/7, 9/9, 9/12, 9/14, 9/17, 9/18, and 9/21. On 9/25/2025 at 11:49 AM Surveyor was observing the lunch meal in the dining room. When R19 entered the dining room, a dietary aide plating food stated to R19, I know you don't like meat, so we have sweet potato fries, mashed sweet potatoes, peas, wax beans . R19 then received a plate of a baked sweet potato, mashed sweet potatoes, peas and wax beans. At this time, Surveyor asked R19 at his table what his diet was. R19 stated he was a vegetarian and everybody in his family is a vegetarian. R19 stated that he is concerned that he is not getting enough protein. R19 stated he did not like fish, eggs, or dairy but he would eat a peanut butter and jelly sandwich, bean burgers, beans, meat analogs, and tofu. When asked if anybody at the facility had tried to find him replacements for meat, R19 stated, No. When asked if he believed staff would bring him a peanut butter and jelly sandwich if he asked, R19 indicated they would, but had not asked and staff had not brought him any substitutes since he had admitted to the facility.On 9/29/2025 at 2:42 PM, Surveyor interviewed DM S (Dietary Manager). DM S stated that she gets diet info from the admission nurse and they tell her what diets their primary care physician is recommending. DM S stated that at the admission care conference for each resident there is a sheet that she goes through including preferences and finds out what each resident likes and what they don't like and she puts it on their diet ticket. DM S also state that she did not know if R19's protein intake was being monitored or tracked in any way, such as if he was on a supplement or if he had requested any food items outside of mealtime such as a peanut butter sandwich. DM S stated that her cooks know R19 is a vegetarian. When it comes to how to replace the lost protein/meat items for each meal, DM S indicated that she refers to either the dietician or primary care physician in determining what specifically he (R19) needs in terms of protein. DM S indicated that when R19 was first admitted she did look up meat free alternatives but all she could find was a case of hundred burgers. DM S also indicated that when R19 was admitted he was supposed to be short term rehabilitation so some of the food ordering and attention to his dietary needs did not get immediate attention. Additionally, DM S stated that R19 would not drink a clear supplement because those still had milk-based ingredients, even though they were lactose-free. When asked if there were any plant-based supplements, DM S stated that she was unaware of such supplements. At approximately 3:15 PM, DM S approached Surveyor in the hallway with a plant-based Ensure supplement and stated she did not know such a supplement existed but found one in her kitchen and would offer it to R19.A dietary note by DM S, dated 9/29/25 at 3:34 PM states, Conversation with resident regarding diet and increasing protein and preferences. Upon admission in June, resident stated to me that he does not like eggs. Today, he retracted that statement saying that he will eat hard cooked eggs, egg salad, and the occasional scrambled egg. Offered resident a Plant Based Ensure to try. He said, Well, I am not familiar with that product. Encouraged resident to try it, and I would check back in with him to see if he liked it. Resident hesitant, but agreed. I also discussed meat alternative products with resident. Told resident that I would do some research to see what my supplier carries and then touch base with him tomorrow, 9/30, on those items, and the outcome of the Plant Based Ensure Trial. Note: dietician had recommended Boost Clear, however that contains milk product and resident was not interested. Email sent to nurse practitioner to request an order for the Plant Based Ensure if resident is agreeable to it.On 9/30/25 at 1:30 PM, Surveyor interviewed RD T who stated that when the facility most likely used the hospital weight on 6/3/25 instead of obtaining their own weight and should have gotten weights daily at the facility for 3 days and not waited until 6/13/25 to obtain a second weight. RD T indicated that the weights she had in her system were what Surveyors could see in the facility's EHR (Electronic Health Record). RD T stated that she wouldn't necessarily recommend any protein options for a vegetarian if the resident was eating well and that plenty of protein can be obtained from non-meat items and stated that she did not recommend any replacements for R19, nor was she tracking or monitoring his protein intakes. RD T indicated that being a vegetarian wouldn't be a red flag that a resident is malnourished and that it is more important to look at the intakes. RD T stated that she recommended ensure clear when R19 had COVID but was unaware that he would not take it and did not follow up with him or facility staff to see if he was taking the supplement. RD T stated, I would expect that the dietary manager would determine what a resident would eat and not eat. I try to default to the facility as they are available every day to the residents. RD T indicated that she had not recommended any other supplements for R19 other than the Ensure Clear.On 10/01/2025 at 8:54 AM, Surveyor interviewed DON B (Director of Nursing). DON B stated she was also concerned about R19's protein needs given his vegetarian diet and that his preferences should be met and obtained by the dietary manager. DON B stated that the facility and facility staff should be providing R19 with a protein replacement and that he should not have to ask them for alternatives. DON B also indicated that the facility should be doing weights more frequently for R19 given his steady weight loss.On 10/01/2025 at 9:12 AM, Surveyor interviewed DM S who stated that she had received the necessary order from the nurse practitioner to get R19 the plant-based ensure. DM S stated that she had just talked to R19 about other foods and R19 replied to bring him a list of possible food options and they could go through them together. DM S stated that she talked to R19 about peanut butter so she added peanut butter toast to his breakfast and made a list of beans for staff to be available to him. DM S stated that she now has a list of things R19 will eat. DM S stated that she should have made these changes when R19 was admitted and stated, What I should have done was asked him about how to fill the protein void when he came in. I didn't know until the next day after he was admitted that he was a vegetarian. DM S stated that she does not have a vegetarian alternative on the menu but will work with providing other protein dense non-meat food items for R19 and other future vegetarians.On 10/1/25 at 3:15 PM, Surveyor observed a Diet Roster list posted on a refrigerator in the main kitchen which stated NO MEAT, EGGS OR DAIRY by R19's name. Next to this list was a Beverage Preferences list and next to R19's name it stated, OJ and milk for breakfast.The facility was aware that R19 was a vegetarian but did not care plan or put resident-specific interventions in place to address his preferences, needs for alternatives or any potential supplementation to meet the nutritive needs that had been assessed for him (70-88 grams of protein per day). The facility was not consistently monitoring R19's intakes, did not weigh R19 upon admission and for 10 days thereafter, and did not put any additional weights or interventions into place when R19 had been found to have experienced a 16% weight loss in 3 months.

Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (R42) reviewed for catheter care. Staff attached a dirty leg bag with urine in the bag and the tube after removing R42's catheter bed bag.Evidenced by:The facility policy entitled, Urinary Leg Drainage Bags, dated October 2010, states, in part: . Purpose: The purpose of this procedure is to provide guidelines to decrease the likelihood of nosocomial urinary tract infections associated with the intermittent use of leg drainage bags with foley catheters.General Guidelines: .3. A new sterile drainage bag should be used every time the regular straight drainage tubing is disconnected, and the leg bag is used.6. Do not wash or disinfect leg bags in an attempt to reuse them. R42 admitted to the facility on [DATE] and has diagnoses that include neuromuscular dysfunction of bladder (occurs when there is damage or dysfunction in the nerves or muscles that control bladder function) and urinary incontinence (loss of bladder control).R42's Care Plan, dated 8/07/25, states, in part: . Problem: Category: Indwelling Catheter. Resident requires a suprapubic catheter.Goal: Long Term Goal Target Date: 11/06/25. Resident will have suprapubic catheter care managed appropriately as evidenced by not exhibiting obstruction, signs of infection, dislodgement of catheter, bowel perforation, or trauma.Approach: .Approach Start Date: 8/07/2025. Keep catheter system a closed system as much as possible.Approach Start Date: 8/07/2025. Manipulate tubing as little as possible during care.On 9/24/25, at 1:57PM, Surveyor interviewed R42. R42 expressed concern with catheter care she receives. R42 indicated she has had several urinary tract infections since being at the facility. R42 indicated the facility reuses the catheter bags, and they do not always cleanse them. R42 indicated when the staff reconnect the ends of the catheter tubing they don't always wash the ends. R42 expresses concern that she is afraid she is going to get a urinary tract infection. On 9/29/25, at 8:39AM, Surveyor observed CNA R (certified nursing assistant), and AN Q (Admissions nurse) perform catheter care. AN Q grabbed the old leg bag out of R42's bathroom that had a small amount of urine in the bag and tube. AN Q cleansed the end of leg bag tubing with alcohol wipes. The bed bag was removed from R42, and the leg bag was attached. The bed bag was taken into R42's bathroom and hung-over towel rack with urine noted in the tubing. On 9/29/25, at 9:03AM, Surveyor interviewed AN Q and CNA R and asked how long the bed bags and leg bags are used for before they are replaced with new ones. Both AN Q and CNA R indicated not knowing. Surveyor asked how long has R42's bags been in use, and AN Q and CNA R indicated not knowing. Surveyor asked if the catheter bags should be dated if being reused and AN Q and CNA R indicated not knowing. Surveyor asked what the process is for cleansing the bags before reusing. AN Q indicated they should have water run through them and vinegar if the facility has it. Surveyor asked when you would expect the bags to be cleansed, and AN Q indicated once a day by the night shift. Surveyor repeated to AN Q and asked, the process is the bag gets removed from R42's catheter and hung in the bathroom for the night shift to wash out; the leg bag hanging in the bathroom then gets applied to R42's catheter? AN Q indicated yes. Surveyor asked if the leg bag had been cleansed when it was just applied to R42, and AN Q indicated I don't recall I was alcoholing the end of the leg bag's tubing. Surveyor informed AN Q there was urine still in leg bag and the bottom tube of the leg bag. AN Q indicated it should have been cleansed out and was not. It should not have been applied without being cleansed out.On 9/29/25, at 9:20AM, AN Q returned to Surveyor and indicated he has information on questions that were asked. AN Q indicated if a resident has high sedimentation rates in their urine their catheter bags gets changed out weekly, and if a resident has normal output the catheter bags gets changed monthly. Surveyor asked AN Q how would the cnas know when to change the bags if they are not dated, and AN Q indicated the nurses keep track and hand the new bags out when it is due to be changed. On 9/30/25, at 10:47AM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) who both indicated the expectation for changing catheter bags and urinary leg bags would be to follow the facility's policy.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 48 residents (R42) reviewed for abuse. Facility did not report an abuse allegation involving R42 within the required two hours to the state agency (SA). Evidenced by:The facility policy entitled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 9/2022, states, in part: . Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation:Reporting Allegations to the Administrator and Authorities:1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.3. Immediately is defined as:a. Within two hours of an allegation involving abuse or result in serious bodily injury. R42 was admitted to the facility on [DATE] and has diagnoses that include multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves that results in nerve damage that disrupts communication between the brain and the body.) and major depressive disorder. On 9/25/25, at 09:13 AM, Surveyor spoke with FM L (family member) who indicated it was a horrible weekend for R42. FM L indicated R42 reported to her cnas (certified nursing assistants) had come into R42's room Saturday 9/20/25 hot and ready to fight, saying horrible things to R42. FM L indicated the cnas were telling R42 that no one in the facility wants to work with her because she is so picky. The cnas were being nasty to R42 telling R42 they didn't have time to go back and forth between chairs with R42, so if R42 wanted in her recliner they would not come back and put her in her wheelchair to go to lunch because they don't have time. FM L indicated R42 had a bowel movement and the cnas did not clean R42 up in the front only the back side. FM L indicated she felt R42 was being emotionally abused, and FM L had reached out to [Name] from [Name of organization] to report abuse that Saturday morning (9/20/25) and DON B (Director of Nursing) and ANHA C (Assistant Nursing Home Administrator) were sent over to Ingleside. On 10/01/25, at 8:30 PM, Surveyor interviewed ANHA C who indicated that on Saturday 9/20/25 FM L contacted the head of the board of [Name of organization] and alleged abuse with R42, who passed it on to NHA A (Nursing Home Administrator). NHA A passed the information on to ANHA C. ANHA C indicated FM L did not indicate what specific type just a blanket abuse. ANHA C indicated he received the voicemail from NHA A at 11:13 AM on 9/20/25 and arrived at the facility 11:30-11:34AM and went straight to R42's room with a pen and paper. ANHA C indicated R42 made more of a conduct report regarding the cnas rather than abuse. Surveyor asked ANHA C what R42 reported and ANHA C indicated R42 stated the cnas were being rude and not welcoming. Surveyor asked how were the cnas being rude and not welcoming. ANHA C indicated she threw the trigger word out and stated she felt the cnas were being abusive. ANHA C indicated he started an investigation. Surveyor asked ANHA C if a report was filed with the state and ANHA C indicated no because he started investigating and found it unsubstantiated. Surveyor asked ANHA C if an allegation of abuse should be reported to the state. ANHA C indicated yes, and he is still learning. On 10/1/25, at 12:02PM, Surveyor interviewed NHA A. Surveyor asked NHA A what the facility policy says about reporting abuse; NHA A indicated an allegation of abuse needs to be reported within 2 hours to the state. CC D (corporate consultant) entered the office and indicated an allegation of abuse must be reported to the state within 2 hours.

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 4 sampled residents (R2). R2 was admitted to the facility with a wound on her left abdomen. The facility failed to complete ongoing comprehensive wound assessments throughout her stay. While at the facility, R2's wound increased in size and developed a foul odor. No physician notification was made. R2 was readmitted to the hospital with a diagnosis of a wound infection. Evidenced by:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.Per the wound care education institute Best Practices for Wound Assessment and Documentation indicates: Foundational elements of wound assessment. A structured approach to wound assessment is key to capturing the clinical picture and determining the best course of action for care. Here are the essential components to document: .2. Wound classification and etiology. Determine and document the wound's origin. Common types include: Pressure injuries: Classify by stage using the National Pressure Injury Advisory Panel's (NPIAP) guidelines. Arterial or venous ulcers: Note underlying circulatory insufficiencies. Diabetic foot ulcers: These are often neuropathic, so assess the patient's offloading status. The patient should be assigned a [NAME] grade and updated as needed. Surgical incisions or traumatic wounds: Include the mechanism of injury or surgical intent.Documenting wound etiology ensures targeted interventions and appropriate resource use 4. Wound bed characteristics Quantify the percentage and type of tissue present: Granulation: Red, moist, and bumpy - This is a sign of healthy tissue growth. Slough: Yellow/white, stringy, or moist. May be adherent or loosely attached. This is non-viable and may require debridement. Eschar: Thick, dry, black, or brown. Document if stable or if debridement is needed. Hypergranulation: Assess for signs of infection and/or necessary treatment changes, such as stopping a collagen application.Descriptive wound bed assessments help monitor healing phases and guide appropriate debridement strategies.5. Wound edge and margin assessment Evaluate wound edges for signs of healing or chronicity: Defined vs. undefined: Defined edges are more acute, and undefined may suggest chronicity. Epibole (rolled edges): This is common in stalled wounds. Undermining or maceration: This may indicate moisture imbalance or shearing/friction forces.Marginal changes can be early indicators of delayed healing or infection.6. Exudate characteristics Drainage quality provides vital clues about wound status: Amount: None, scant, light, moderate, or heavy. Type: Serous (clear), serosanguineous, sanguineous, seropurulent, or purulent. Color and consistency: Thick yellow/green with odor may indicate infection. Odor: Describe only after cleansing to eliminate confounding factors.Always correlate exudate changes with wound progression and signs of infection.7. Periwound skin statusDocument any abnormal findings in the tissue surrounding the wound: Color: Erythema may signal infection or inflammation. Texture: Watch for induration, bogginess, or dryness. Breakdown: Maceration, excoriation, or denuded skin may indicate excessive moisture or friction.Healthy periwound skin supports optimal wound healing and should be protected as part of the overall care plan.8. Pain and symptom reportingPain is a critical, yet often under-documented, aspect of wound assessment. Capture: Intensity: Use a numeric or verbal pain scale. Descriptors: Burning, aching, stabbing, etc. Timing: Before, during, or after dressing changes. Management: Note what interventions alleviate or exacerbate pain The facility policy entitled, Change in a Resident's Condition or Status, dated 5/2017, states, in part: Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor_ of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an):. d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly. g. need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one are of the resident's health status. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact (Change of Condition Standard Operating Procedure) SBAR (Report Template) Communication Form. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. R2 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (chronic autoimmune disorder causing pain, swelling, and stiffness in the joints and occurs when the immune system mistakenly attacks the joints) with rheumatoid factor of multiple sites (multiple joints are affected) without organ or systems involvement, type 2 diabetes mellitus with diabetic polyneuropathy (type 2 diabetes causing death of nerve fibers leading to symptoms such as pain, numbness, or increased sensitivity), and heart failure. R2's Physician Orders indicate:WOUND CARE: L. (Left) Lateral Abdomen (inferior) - cleanse area with gentle soap and water; pat dry; cut aquacel (anti-microbial wound dressing) to size and dampen with normal saline then place on wound bed; cover with ABD (Abdominal, or large-size gauze pad); Secure with Medipore tape (breathable, cloth tape). Special Instructions: Report signs of infection to NP (Nurse Practitioner)/MD (Medical Doctor). Once A Day; 02:45 PM-10:45 PM. Start Date: 8/21/25.WOUND CARE: L. lateral abdomen (Superior) - cleanse area with wound cleanser; pat dry; apply mepilex (absorbent foam dressing). Once A Day on Mon (Monday), Wed (Wednesday), Fri (Friday); 04:00 PM. Start Date: 8/21/25.WOUND CARE: Left Clavicle/Chest - Cleanse area; pat dry; leave open to air. Special Instructions: Do not tamper with steri strips (narrow, adhesive bandages). Once A Day; 06:00 AM - 02:45 PM. Start Date: 8/21/25. R2's Baseline Care Plan indicates:Problem: [Resident Name] was admitted with open areas ~ left lateral abd (abdomen) area inferior 5.5 cm (centimeters) x 7.5 cm x 0.5 cm, left lateral abd area superior 0.5cm x 0.5 cm x 0.1 cm, and left clavical/chest surgical incision. Problem Start Date: 8/20/25. Last Reviewed/Revised: 08/23/25.Goal: [Resident Name]'s open areas will heal without complications. Short Term Goal Target Date: 10/25/25.Approach:Conduct a systematic skin inspection weekly. Approach Start Date: 8/23/25.Observe and report signs of cellulitis (e.g., localized pain, redness, swelling, tenderness, drainage, fever, chills, malaise, tachycardia, hypotension). Approach Start Date: 8/23/25.Observe and report signs of sepsis (fever, lassitude (wariness or fatigue) or malaise (weakness), change in mental status, tachycardia (fast heart rate), hypotension (low blood pressure), anorexia (not eating), nausea, vomiting, diarrhea, headache, lymph node tenderness/enlargement). Approach Start Date: 8/23/25.Treat as per MD order. Approach Start Date: 8/23/25. R2's Medical Record Indicates:On 8/12/25 at 11:22 AM, a Wound Assessment is recorded by an outside hospital RN. This assessment indicates the wound has a small amount of serosanguineous drainage and measures 4 cm (centimeters) x 4 cm x 0.8 cm. No odor is noted with this assessment. (of note: the 8/12/25 note was from R2's hospital stay prior to facility admission on [DATE].)On 8/20/25 at 8:47 PM, an admission Observation was recorded by LPN (Licensed Practical Nurse) I. This observation includes 3 skin alterations designated as Skin tear. The skin tear located on the abdomen- left lower quadrant, is measured at 1.7 cm x 5.5 cm with no depth recorded. Exudate (fluid that leaks from blood vessels due to inflammation or injury) is present and designated as Serosanguineous (pale red to pink, thin and watery) with a moderate amount present. The observation indicates odor is present. The skin tear located at the umbilicus is measured at 0 cm x 0.2 cm with no depth indicated. Exudate is indicated to not be present for this wound. The skin tear located in the abdomen - left upper quadrant is measured at 0 cm x 0.4 cm with no depth indicated. Exudate is indicated to not be present for this wound. Vital signs taken with this observation indicate R2's blood pressure was 150/73.(Of note: According to N6, Wisconsin Nurse Practice Act LPNs cannot perform assessments, only gather data to report to an RN. No RN signed off on this observation and it was marked completed by LPN I. LPN I indicates R2's wound has odor, there is no indication if an RN was notified and completed an assessment or if a provider was updated regarding this.) On 8/20/25 at 9:00 PM, a Progress Note is written that states, in part: Resident admitted to facility. Resident has a wound on their thigh and abdomen that they wish to leave the bandage on for the night and have it changed in the morning. On 8/21/25, there is no documentation indicating R2's wound odor is being monitored.On 8/24/25 at 6:45 PM, a Progress Note is written that states: Seen on 8-22-25 for initial evaluation of left lateral abd area inferior, left lateral abd area superior, and left clavicle/chest surgical incision. measurements ~ left lateral abd area inferior 5.5 cm x 7.5 cm x 0.5 cm, foul odor, treatment ~ cleanse area with gentle soap and water; pat dry; cut aquacel to size and dampen with normal saline then place on wound bed; cover with ABD (abdominal pad); Secure with Medipore tape, left lateral abd area superior 0.5cm x 0.5 cm x 0.1 cm, treatment ~ Cleanse area; pat dry; leave open to air and do not tamper with steri strips. Tolerated treatments without c/o (complaint of) pain. (of note: this note indicates on 8/22/25, R2 had a foul odor noted, and the wound had increased in size from 8/20/25; there is no evidence this was relayed to R2's provider until 8/24/25)On 8/23/25 at 8:05 PM, a set of vital signs was taken that indicate a pulse of 61 beats per minute, temperature of 97.6 F (Fahrenheit), 110/62 blood pressure, and 94% oxygen saturation (Normal oxygen saturation is between 94-99%).(Of note: This is the last set of vital signs that was recorded for R2, indicating that no vital signs were assessed prior to the resident being transported to the ER on [DATE]). On 8/23, there is no documentation indicating R2's wound odor is being monitored.On 8/24/25 at 6:39 PM, a Wound Management Detail Report is created by DON (Director of Nursing) B. The wound located on R2's abdomen - left lower quadrant under pannus (excess skin and fat that hangs from the abdomen), is measured at 5.5 cm x 7.5 cm with no recorded depth. A comment is written that states first assessment by this nurse. No other data regarding the wound is noted. The wound located on R2's abdomen - left lower quadrant under lateral pannus, is measured at 0.5 cm x 0.5 cm with no recorded depth. A comment is written that states first assessment by this nurse. No other data regarding the wound is noted. The wound located on left clavical pacemaker with type listed as Surgical Incision is measured at 5 cm in length and described as edges well approximated (edges fit neatly together), skin surrounding incision is normal in color and there is no drainage. A comment is written that states first assessment by this nurse ~ steri strips in place.(Of note: there is no indication of wound exudate, or odor being assessed by DON B.)On 8/24/25 at 8:20 PM, a Hucu (a secure instant messaging system) Message is sent that states: Just an FYI (For Your Information). Patient has been requested to be seen in the ED. Her abdominal wound is very foul smelling with green/brown thick drainage. The perimeter of the wound is red around the entire wound and warm. She states she has increased pain. She is worried about an infection as she has just had a pacemaker placed. On 8/24/25 at 8:35 PM, a Progress Note is written that states, in part: Wound care done. Noted to have a very foul odor. Drainage green/brown and thick. Perimeter of the wound is red, warm, and painful. Patient is requesting to be evaluated tonight at the ER (Emergency Room). She is especially concerned about an infection as she just had a pacemaker placed. The pacemaker incision is healing well. No redness and steri-strips are intact. Updated her PCP (Primary Care Provider) [PCP Name] via hucu (secure instant messaging system).(Of note: No RN assessment was recorded prior to sending R2 to the ER). On 8/24/25 at 22:11:24 (10:11:24 PM) an ED Note is written that states, in part: . Abd (Abdominal) wound. 75/54 (blood pressure reported by EMS). On 8/24/25 at 22:18:44 (10:18:24 PM) an ED Note is written that states, in part: Patient presents via [EMS Service Name] from [Facility Name] in [City] with chief complaint of wound infection. Pt (Patient) reports she was discharged to SNF (Skilled Nursing Facility) from hospital 4 days ago post surgery for pacemaker placement. Pt says she has had this wound for a while but the last few days it has developed worsening smell. Pt states she has been lightheaded and dizzy. Blood pressure at nursing facility has been on the lower side and BP (blood pressure) via EMS (Emergency Medical Service) was 75/32. Pt reports hx (history) of sepsis 2x this year. Pt has a cardiac hx of HF (heart failure), Afib (Atrial fibrillation-irregular heart rhythm), and bradycardia (slow heart rate). She is currently paced (Pacemaker is actively sending electrical signals to make the heart beat) at 60 BPM (beats per minute). Alert and oriented x4 (Alert and fully oriented). Pt endorses possibility of fever and chills over the last few days and some n/v (nausea/vomiting). No falls/injuries. Order for 1L LR (Lactated Ringers- IV fluid containing electrolytes) ordered and given. BP (!) 89/47. On 8/25/25, R2's ED Documentation indicates, R2's eCART (AI driven software that utilizes machine learning to continuously assess hospitalized patients' risk of impending death or ICU transfer) score increases to a high of 97 with a Risk Category of High. R2 was administered Vancomycin (Antibiotic) and Zosyn (Antibiotic) medications as well as Norepinephrine (Levophed-Medication that increases blood pressure). On 8/25/25 at 6:25 AM, a Progress Note is written that states, in part: Writer called hospital for update around 2:10 [sic] AM. Writer spoke with [Nurse Name], RN (Registered Nurse) at [ER Name] who reported that resident would be admitted to hospital with the admitting diagnosis of possible sepsis. Wound had been cultured and there were several organisms present. 2 IVs were started, vanco (Vancomycin, antibiotic medication) and Zosyn (antibiotic medication) were being administered. Resident had received 2 bags of fluids and was about to start the third d/t (due to) hypotensive episodes. At the time resident [sic] bp (blood pressure) was 88/52 (normal is around 120/80) and would be admitted to ICU (Intensive Care Unit) for observation if blood pressure did not stabilize. On 8/26/25 at 7:17 AM, a Progress Note - [Facility Name] Critical Care Service Note is written that states, in part: . on immunosuppressive therapy who presented with septic shock. #Septic shock #UTI #Skin/wound infxn (infection) Urine grossly infected appearing, Wound infected appearing CT (computed tomography scan) showing ulceration w/o (without) abscess w/ (with) hypotension (low blood pressure) concerning for septic shock. Initially elevated lactate (blood test measuring the body's oxygen perfusion levels) and persistent hypotension after 3L (liters) resuscitation by ED (Emergency Department) team requiring levo (Levophed-Medication used to increase blood pressure). -Urine culture w/ Citrobacter (bacteria) -Wound culture polymicrobial (multiple bacteria present). On 8/26/25 at 1339 (1:39 PM), an H&P (History & Physical) Note is written that states, in part: . On presentation to [Hospital Name], she was found to be hypotensive and had increased wound drainage with an odor. Zosyn and vancomycin were started and fluids were given, but she remained hypotensive which prompted admission to the TLC (Trauma and life support center) and the initiation of a pressor (vasoconstrictive medication to increase blood pressure). On 8/28/25 at 5:28 PM, a Progress Note is written that states, in part: Son here to pick up items as resident is not returning here at this time. On 8/29/25 at 8:07 AM, R2's Wound Culture resulted and indicated R2's wound contained Proteus mirabilis and Pseudomonas aeruginosa, along with other mixed flora. On 9/3/25 at 12:45 PM, a Discharge Summary Note is written that states, in part: . Primary Discharge Diagnosis: 1. Septic shock from urinary source. Secondary Discharge Diagnoses: 1. Urinary tract infection 2. Wound infection. Dermatology evaluated the wound for concern of pyoderma gangrenosum (rare, painful skin condition characterized by rapidly enlarging ulcers, often associated with underlying systemic diseases) but felt it was more consistent with a chronic, non-healing wound. Wound care orders: 2x daily wound care consisting of: - clean with soap and water - pack wound with Vashe dampened kerlix - apply ABD superficially.On 9/11/25 at 1:36 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E when should an initial assessment get done for someone with a wound. LPN E indicates a skin assessment should be done on admission to establish baseline. Surveyor asked LPN E what the initial assessment for someone with a wound include. LPN E indicates, area of wound, skin temperature, size, color, odor, drainage and amount, location, and skin around wound. On 9/11/25 at 2:25 PM, Surveyor interviewed LPN E. Surveyor asked LPN E if a provider should be notified if a wound has an odor. LPNE E indicates, yes. Surveyor asked LPN E if LPNs can perform assessments. LPN E indicates, no RNs have to conduct assessments. On 9/11/25 at 1:40 PM, Surveyor interviewed RN G (Registered Nurse). Surveyor asked RN G when should an initial assessment get done for someone with a wound. RN G indicates a skin assessment should be done when a wound is discovered and on admission. Surveyor asked RN G what the initial assessment for someone with a wound includes. RN G indicates measurements, odor, what tissue looks like and what skin around the wound looks like. RN G also indicates RNs do the initial assessment and that the NP (Nurse Practitioner) for wounds comes in on Mondays and does wound measurements. On 9/11/25 at 2:35 PM, Surveyor interviewed RN G. Surveyor asked RN G if a provider should be notified if a wound has an odor. RN G indicates, yes. Surveyor asked RN G if LPNs can perform assessments. RN G indicates, no, they can only collect data and report to the RN. On 9/11/25 at 1:45, Surveyor interviewed LPN J. Surveyor asked LPN J when should an initial assessment get done for someone with a wound. LPN J indicates upon admission and an RN does the initial assessment. LPN J also indicates wound NP comes three times a week and would come to the facility to assess if there is a change. Surveyor asked LPN J what the initial assessment for someone with a wound includes. LPN J indicates, size, temperature, drainage, pain, and if there are signs and symptoms of infection. On 9/11/25 at 2:30 PM, Surveyor interviewed LPN J. Surveyor asked LPN J if a provider should be notified if a wound has an odor. LPNE J indicates, yes. Surveyor asked LPN J if LPN can perform assessments. LPN J indicates, no RNs have to conduct assessments. On 9/15/25 at 8:35 AM, Surveyor interviewed LPN K. Surveyor asked LPN K what changes with wounds need to be reported to a physician. LPN K indicates, any drainage change, redness, heat, change in size or depth, and signs of infection. Surveyor asked LPN K if a provider should be notified of wound odor. LPN K indicates, definitely update on any odor because it could indicate more going on with the wound. Surveyor asked LPN K if LPNs can perform assessments. LPN K indicates, no, they can collect data but not assess. On 9/15/25 at 9:00 AM, Surveyor interviewed RN L. Surveyor asked RN L what changes with wounds need to be reported to a physician. RN L indicates, change in drainage amount of appearance of wound itself, redness, swelling, warmth, or increase in pain. Surveyor asked RN L if a provider should be notified of wound odor. RN L indicates, yes. Surveyor asked RN L if LPNs can perform assessments. RN L indicates, they can but they need to report their findings to an RN. On 9/15/25 at 9:20 AM, Surveyor interviewed LPN I. Surveyor asked LPN I what changes with wounds need to be reported to a physician. LPN I indicates, any signs or symptoms of deterioration, stalling, drainage changes, tissue changes, or the wound is getting worse. Surveyor asked LPN I if a provider should be notified of wound odor. LPN I indicates, yes because that would be a sign of deterioration. Surveyor asked LPN I if LPNs can perform assessments. LPN I indicates, no, but they can observe and report to the RN. On 9/15/25 at 10:36 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she could provide some examples of changes in condition that would require physician notification in regards to wounds. DON B indicates, increase in redness, drainage, odor, or pain. Surveyor asked DON B when was the first time she assessed R2's wounds. DON B indicates, 8/22/25. Surveyor asked DON when odor was first noted with R2's wounds. DON B indicates for her, she first notes odor on 8/22/25, which is included in her note. Surveyor asked DON B if a provider should have been notified when odor was identified with the wound. DON B indicates, yes and that the first time she was notified or aware of an odor was the first time she did wound care. Surveyor asked DON B if an LPN is able to perform assessments. DON B indicates, no. Surveyor asked DON B if an RN should review all LPN assessments. DON B indicates, yes. Surveyor notes on 8/24/25, there is a note that indicates resident was seen on 8/22/25 and wounds were assessed to contain a foul odor, Surveyor asked DON B if a physician should have been notified at that time? DON B indicates, yes. Surveyor asked DON B if an increase in wound size requires MD (Medical Doctor) notification. DON B indicates, yes. Surveyor asked DON B if a physician should have been notified when the wound increased in size between 8/20/25 and 8/22/25. DON B indicates, yes.R2 was admitted to the facility on [DATE] with a wound on her left abdomen. The facility failed to complete ongoing comprehensive wound assessments throughout her stay, that included characteristics of the wound such as the type of wound, wound bed description, appearance of the surrounding tissue, if there was drainage or odor. While at the facility, R2's wound increased in size and developed a foul odor. No physician notification was made regarding these changes timely and R2 was readmitted to the hospital with a diagnosis of a wound infection.

Based on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 4 residents (R6, R4, R12 and R13) reviewed for cleanly environment. R6's room had dried substances and crumbs on the floor and staff identified fecal matter on the outside of the toilet in R6's bathroom. R4 indicates staff come in to clean her room once a week if she is lucky. R12's room was observed to be unclean. R13's room was observed to be unclean. This is evidenced by: The facility policy titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013, states in part… Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 3. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Facility provided Surveyor with copy of Housekeeping/Laundry schedule. The facility has on their schedule one to three housekeeping staff daily. Weekends show one to two housekeeping staff. On 9/11/25 at 8:30 AM, Surveyor interviewed R6. R6 indicated housekeeping had not been in to clean her room this week. R6 indicated housekeeping does not come in often to clean. Surveyor observed the following cleanliness concerns in R6's room; a mound of crumbs at the foot of the bed near the heat registers, multiple dried liquid spills on the floor under the overbed table and between the bed and recliner, crusty circles of brown flaky material in front of the dresser, and clumps of brown dried matter on the outside of the toilet bowl. R6 indicated the brown substance on the toilet bowl was feces and it had been there for over a month. On 9/11/25 at 9:28 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding the cleanliness of R6's room. CNA D indicated the dried spots on the floor looks like food and drinks that may have spilled. CNA D identified the brown matter on the outside of the toilet bowl as “poop”. CNA D indicated the room was not clean. On 9/11/25 at 11:27 AM, Surveyor observed R6's room. R6's room still had the crumbs, dried liquid, and crusty brown flaky circles on the floor and the toilet still had the brown matter on the outside of it. Surveyor also observed two bags of trash outside of R6's bathroom door on her bedroom floor. One trash bag contained linen, the other bag contained dirty personal protective equipment (gloves, gowns and other trash). On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding the cleanliness in R6's room. Surveyor made DON B aware of the above observations. DON B indicated R6's room was not clean and should be. On 9/11/25 at 4:00 PM, Surveyor observed R6's room. The outside of the toilet had been cleaned and R6's floor had been mopped. The two trash bags still remained on the floor outside of R6's bathroom door. Example 2 On 9/11/25 at 9:15 AM, Surveyor interviewed R4. Surveyor asked R4 how often they clean her room. R4 indicates staff come in to clean her room once a week if she is lucky. Example 3 On 9/11/25 at 9:10 AM, Surveyor interviewed R13. Surveyor asked R13 how often housekeeping comes in to clean her room. R13 states, my room is not cleaned daily. I am not sure I can say it is even cleaned weekly. Surveyor noted R13 had debris on floor and floor appeared as it had not been cleaned in some time. On 9/11/25 at 9:30 AM, Surveyor interviewed R12. Surveyor asked R12 how often housekeeping comes in to clean his room. R12 states, my room is not cleaned daily and only has been cleaned once in the last month. Surveyor noted R12 had fly strip hanging on wall next to bed. Room was dusty and floor appears to have debris on it from food and fluids. On 9/15/25 at 8:45 AM, Surveyor interviewed CNA O. Surveyor asked CNA O how often resident rooms are cleaned. CNA O stated that they are not always able to get to all rooms in a day. On 9/15/25 at 11:15 AM, Surveyor interviewed HS N (Housekeeping Supervisor). Surveyor asked HS N if she has any staffing concerns in her department. HS N stated, we don't have enough staff to get it all done. If rooms are not done, will communicate verbally what was not done and it will be completed the next day. Surveyor asked HS N if she meets with residents to see if they have concerns. HS N states that the new Activities Manager does not bring other departments into resident council to listen to resident concerns. If there are concerns the Activities Manager will bring the issue or concern to the department to be addressed. The facility did not ensure each resident had a safe, clean, comfortable, and homelike environment

Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 out of 16 sampled residents (R14, R9, R6, R3, & R17). R14 did not receive scheduled medications for 8:00 AM & 2:00 PM on 8/28/25 due to the facility's internet being down. R9 did not receive scheduled medication for 4:00 PM on 8/28/25 due to the facility's internet being down. R3 did not receive all of her medications as ordered on 8/20/25, 8/21/25, 8/22/25, 8/23/25, 9/8/25. R17 had medications not administered as ordered. R6 did not receive her 9/11/25 medications within the allowed time frame. Evidenced by: The facility policy titled, “Medication Errors”, dated 9/1/10, states, in part: “… 3. Dispensing errors:… 3.1 Data entry error: Entire order or part of an order was incorrectly entered into computer system by data entry. 3.2 Delivery error: Drug product not received by the resident/community at the required/expected time… 4. Administration errors:… 4.7 Omission error: Community fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of a recognized contraindication…” The facility policy entitled, “Administering Medications,” dated 4/2019, states, in part: … “Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: … 4. Medications are administered in accordance with prescriber orders, including any required time frame… 6. Medication errors are documented, reported… 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified…” The facility policy entitled, “Medication Errors,” dated 9/1/2010, states, in part: … “Applicability: This section 10.1 sets forth procedures relating to medication errors. 4. Administration errors: In the event of an administration error, community staff may follow the community's occurrence policy, associated forms and performance improvement processes. Examples of administration errors include, but are not limited to: … 4.7 Omission error: Community fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication…” Example 1: R14 admitted to the facility on [DATE] and has diagnoses that include multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves. Resulting nerve damage disrupts communication between the brain and the body), Unspecified convulsions (rapid, uncontrolled muscle contractions or shaking without a clear, documented cause or a specific type of convulsive event being identified), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), and vitamin D deficiency (too little vitamin D in the body). R14's Medication Administration Record for 8/28/25 indicates R14 is to receive the following medications at 8:00 AM: Baclofen 10 mg (milligrams) 1 tablet gastric tube. Cholecalciferol (vitamin D3) capsule 25 mcg (micrograms) (1000 units) 1 capsule by gastric tube. Ferrous sulfate 325 mg, 1 tablet by gastric tube. Multivitamin with minerals, 1 tablet by gastric tube. Vesicare 75 mg, 1 tablet by gastric tube. Venlafaxine 75 mg by gastric tube. R14's Medication Administration Record for 8/28/25 indicates R14 is to receive the following medication at 2:00 PM: Baclofen 10 mg (milligrams) 1 tablet gastric tube. R14's Medication Administration Record for the above medications on 8/28/25 for 8:00 AM & 2:00 PM were not administered shown by documentation stating, “Not administered…no internet. On 9/11/25 at 4:05 PM, Surveyor interviewed ADON R (Assistant Director of Nursing). Surveyor asked ADON R if it is acceptable to not administer a medication due to internet being down. ADON R indicated if a medication was missed and not administered or omitted that would be considered a medication error. ADON R indicated she would expect the physician and POA (Power of Attorney) and the resident to be notified of the medication error. On 9/11/25 at 4:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked what the process is for medication administration if the internet goes down. DON B indicated the NHA A (Nursing Home Administrator) can make copies of the MAR/TAR (Medication Administration Record/Treatment Administration Record). Surveyor asked DON B if she was aware the internet was down on 8/28/25 and DON B indicated yes, the staff volunteered to use their personal cell phone's hot spot, and the facility offered to reimburse for any charges that may occur. Surveyor asked DON B on 8/28/25 was there another option for staff to use other than their personal cell phone's hot spot. DON B indicated at that time she did not know there was any other option. DON B indicated she just found out a few days ago that the NHA A could make copies of the MARS/TARS. Surveyor asked what would staff do if they did not want to use their personal cell phone or was unable to. DON B indicated staff could have asked management and management could have let the staff use management's cell phone's hot spot. Surveyor asked if this was communicated to all staff and DON B indicated she had mentioned it to a staff member and then it was communicated through word of mouth. Surveyor asked DON B if medications were not given and documented “not administered, internet down,” would that be considered a medication error. DON B indicated yes, and she would expect the physician to be notified. Example 2: R9 admitted to the facility on [DATE] and has diagnoses that include rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) and traumatic ischemia of muscle (occurs when blood flow to a muscle tissue is interrupted due to a physical injury). R9's Medication Administration Record for 8/28/25 indicates R9 is to receive the following medication at 4:00PM: Acetaminophen 325 mg (milligrams) by mouth. R9's Medication Administration Record for the above medication on 8/28/25 for 4:00PM was not administered shown by documentation stating, “Not administered Other Comment: internet down…” On 9/11/25 at 4:05 PM, Surveyor interviewed ADON R (Assistant Director of Nursing). Surveyor asked ADON R if it is acceptable to not administer a medication due to internet being down. ADON R indicated if a medication was missed and not administered or omitted that would be considered a medication error. ADON R indicated she would expect the physician and POA (Power of Attorney) and the resident to be notified of the medication error. On 9/11/25 at 4:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked what the process is for medication administration if the internet goes down. DON B indicated the NHA A (Nursing Home Administrator) can make copies of the MAR/TAR (Medication Administration Record/Treatment Administration Record). Surveyor asked DON B if she was aware the internet was down on 8/28/25 and DON B indicated yes, the staff volunteered to use their personal cell phone's hot spot, and the facility offered to reimburse for any charges that may occur. Surveyor asked DON B on 8/28/25 was there another option for staff to use other than their personal cell phone's hot spot. DON B indicated at that time she did not know there was any other option. DON B indicated she just found out a few days ago that the NHA A could make copies of the MARS/TARS. Surveyor asked what would staff do if they did not want to use their personal cell phone or was unable to. DON B indicated staff could have asked management and management could have let the staff use management's cell phone's hot spot. Surveyor asked if this was communicated to all staff and DON B indicated she had mentioned it to a staff member and then it was communicated through word of mouth. Surveyor asked DON B if medications were not given and documented “not administered, internet down,” would that be considered a medication error. DON B indicated yes, and she would expect the physician to be notified. Example 3: R3 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy (brain dysfunction caused by systemic metabolic disturbances), sepsis (systemic improper response to an infection), acute respiratory failure with hypoxia (low oxygen levels), type 2 diabetes, epilepsy (seizure disorder), hypertension (high blood pressure), kidney transplant status, nontraumatic chronic subdural hemorrhage (chronic brain bleed), and hypothyroidism (thyroid gland does not produce enough thyroid hormone, leading to a slowed metabolism). R3's Medication Administration Record indicates: Calcitriol (Vitamin D) capsule; 0.25 mcg (micrograms) (5,000 unit); amt: 0.25 mcg; oral. Three Times A Day; 8:00 AM, 2:00 PM, 8:00 PM. Start Date: 8/20/25. End Date: Open Ended. 8/21/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” 8/21/25 at 12:00 PM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” 8/22/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” 8/22/25 at 12:00 PM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” 8/23/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” 8/23/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” 8/23/25 at 8:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” Gabapentin (Anticonvulsant) capsule; 100 mg (milligram); amt (amount): 2; oral. Three Times A Day; 8:00 AM, 2:00 PM, 8:00 PM. Start Date: 8/20/25. End Date: 8/22/25. 8/20/25 at 8:00 PM: Space left blank, indicating the medication was not administered. Heparin (blood thinner) (porcine) solution; 5,000 unit/mL (milliliter): amt: 1.5 dose; injection. Three Times A Day; 4:00 AM, 12:00 PM, 8:00 PM. Start Date: 8/20/25. D/C Date: 8/21/25. 8/20/25 at 8:00 PM: Space left blank, indicating the medication was not administered. 8/21/25 at 4:00 AM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable”. 8/21/25 at 12:00 PM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” Rosuvastatin (lowers cholesterol) tablet; 10 mg; amt: 2 tablets; oral. Once A Day; 8:00 PM. Start Date: 8/21/25. D/C Date: 8/22/25. On 8/20/25 at 8:00 PM: Space left blank, indicating the medication was not administered. Rosuvastatin (lowers cholesterol) tablet; 10 mg; amt: 3 tablets; oral. At bedtime; 8:00 PM. Start Date: 8/22/25. End Date: Open Ended. On 8/22/25 at 8:00 PM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” Trulicity (dulaglutide) (improves blood sugar control) pen injector; 3 mg/0.5 mL; amt: 3 mg; subcutaneous. Once A Day on Mon (Monday); 8:00 PM. Start Date: 8/21/25. End Date: Open Ended. On 9/8/25 at 8:00 PM: Reasons/Comments states: “Not Administered: Drug/Item Unavailable” The facility's medication contingency supply list includes: Gabapentin 100 MG Capsule; QOH (Quantity On Hand) 10 each On 9/15/25 at 3:08 PM, Surveyor interviewed DON B. Surveyor noted that R3 did not receive some of her medications from 8/20/25-8/23/25, including her rosuvastatin, gabapentin, and calcitriol. Surveyor asked DON B if she would have expected these medications to be administered as ordered. DON B indicates, yes, and that pharmacy sends two delivers during the day to deliver medications. Surveyor asked DON B if she would consider these medications that were not administered to be medication errors. DON B indicates, yes. Surveyor asked DON B if these medications are in contingency, would she expect staff to pull the medication from contingency to administer to the resident. DON B indicates, yes. Surveyor noted R3 did not receive her Trulicity as ordered on 9/8/25 and asked if DON B would expect that medication to be administered as ordered. DON B indicates, yes. Example 4: The facility's policy titled “Medication and Treatment Orders,” revised in July 2016, states in part: “…11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.” R17 was admitted to the facility on [DATE] with diagnoses that include: end stage renal disease (a condition where kidneys can no longer filter waste products from blood), alcohol abuse with unspecified alcohol-induced disorder, alcohol dependence, epilepsy neurologic disorder characterized by seizures), and dependence on renal dialysis (a treatment that removes waste products from the blood when kidneys are failing). R17's Census indicated that he left the faciity on hospital leave on 8/27/25 and returned on 9/3/25. R17's September 2025 Medication Administration Record (MAR) documents the following medications were not administered after being readmitted to the facility: *Hydrocortisone tablet; 10 mg (milligrams) / Frequency: Once a day-Start date: 7/1/25~9/6/25 8:00 AM: Not Administered: Drug/Item Unavailable ~9/7/25 8:00 AM: Not Administered: Drug/Item Unavailable / Comment: not in cart or c (contingency) box ~9/8/25 8:00 AM: Not Administered: Drug/Item Unavailable ~9/9/25 8:00 AM: Not Administered: Drug/Item Unavailable ~9/13/25 8:00 AM: Not Administered: Drug/Item Unavailable ~9/14/25 8:00 AM: Not Administered: Drug/Item Unavailable *Hydrocortisone tablet; 5 mg / Frequency: Once an evening-Start date: 7/1/25~9/6/25 8:00 PM: Not Administered: Other / Comment: on order ~9/7/25 8:00 PM: Not Administered: Drug/Item Unavailable / Comment: not available in c box or med cart ~9/8/25 8:00 PM: Not Administered: Drug/Item Unavailable ~9/9/25 8:00 PM: Not Administered: Drug/Item Unavailable ~9/10/25 8:00 PM: Not Administered: Drug/Item Unavailable ~9/13/25 8:00 PM: Not Administered: Drug/Item Unavailable *Rosuvastatin tablet; 5 mg / Frequency: At bedtime -Start date: 7/2/25 ~9/4/25 8:00 PM: Not Administered: Drug/Item Unavailable / Comment: on order ~9/5/25 8:00 PM: Not Administered: Other / Comment: on order ~9/6/25 8:00 PM: Not Administered: Other / Comment: on order ~9/7/25 8:00 PM: Not Administered: Drug/Item Unavailable / Comment: not available in cart or c box ~9/8/25 8:00 PM: Not Administered: Drug/Item Unavailable ~9/9/25 8:00 PM: Not Administered: Drug/Item Unavailable ~9/10/25 8:00 PM: Not Administered: Drug/Item Unavailable ~9/13/25 8:00 PM: Not Administered: Drug/Item Unavailable R17's Progress Notes state, in part: 9/7/25 at 12:16 PM – RN (Registered Nurse): “Call placed to pharmacy d/t (due to) lack of meds available in cart. Pharmacy only has two orders on file. Call placed to…DON (Director of Nursing), she will update orders so pharmacy can send new meds.” 9/8/25 at 7:53 AM – DON B (Director of Nursing): “This writer updated orders on 9-7-25. Awaiting delivery of medications.” On 9/15/25 at 12:56 PM, Surveyor interviewed DON B and asked about the process for medication orders when a resident leaves the facility with an expected return date. DON B indicated medication orders must be renewed after a resident is out of the facility for three days. DON B reviewed R17's chart. She indicated his medications were reordered on 9/7 and delivered on 9/13. DON B indicated it shouldn't have taken a whole week for the medications to be delivered. DON B indicated she should have been notified. DON B stated, “I didn't know about him not getting his meds until a couple days after that.” DON indicated this would be considered a medication error. Example 5 On 9/11/25 at 8:30 AM, Surveyor interviewed R6 regarding her medications. R6 states she regularly she gets her medications late. R6 indicated she had not yet received her morning medications that are scheduled at 8:00 AM. R6's 9/11/25 Medication Administration Record (MAR) indicates the following medications are scheduled to be given at 8:00 AM. Celexicob 200 mg (milligram) caplet, Aspirin 81 mg chewable tablet, Diltiazem 30 mg tablet, Lacosamide 100 mg tablet, Levetiracetam 500 mg tablet, Magnesium 250 mg tablet, and Sertraline 25 mg tablet. On 9/11/25 at 9:32 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding her medication administration pass. LPN E stated she had not yet given R6 her morning medications. LPN E stated she was still trying to complete her morning medication administration pass, and it usually takes her until 11:30 AM to complete it. LPN E indicated she is not timely with her 8:00 AM medication administration pass. On 9/11/25 at 10:46 AM, Surveyor interviewed R6. R6 indicated she had not taken her 8:00 AM medications. On 9/11/25 at 5:00 PM, NHA A (Nursing Home Administrator) supplied Surveyor with R6's 9/11/25 8:00 AM MAR including the time stamps of when the nurse signed out she gave the medications. The time stamp on R6's MAR for her 8:00 AM medication administration was time stamped at 12:09 PM. NHA A stated she spoke to LPN E and LPN E told NHA A she did give the medications a little earlier than the time she signed out the medications. On 9/11/25 at 3:56 PM, Surveyor interviewed RN G (Registered Nurse) regarding timely medication administration. RN G indicated if a medication is administered outside of the 2-hour window it is considered a medication error. Of note, the 2-hour window refers to medication administration up to 1 hour prior or 1 hour after the scheduled administration time. For example, if a medication is scheduled for 8:00 AM, administration is considered timely if the medication is administered between 7:00 AM and 9:00 AM. On 9/11/25 at 4:03 PM, Surveyor interviewed LPN F regarding medication administration. LPN F indicated if medication is administered outside of the 2-hour window it is considered a medication error. On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding medication administration. DON B indicated if medication is not administered timely, it is considered a medication error. DON B indicated since R6 had not yet received her 8:00 AM medications at 10:46 AM it is considered a medication error for those medications. DON B indicated medications should be administered timely and R6's was not.

Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 1 of 1 Residents (R6) reviewed for pressure injuries.R6 has a stage 2 pressure injury and pressure injury prevention devices were observed not in place.This is evidenced by:The facility's policy Prevention of Pressure Injuries, dated 4/20, includes: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Use a standardized pressure injury screening tool to determine and document risk factors. Select appropriate support surfaces based [sic] the resident's risk factors, in accordance with current clinical practice.The facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/18, includes: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document report the following: d. Current treatments, including support surfaces. The physician will order pertinent wound treatments, including pressure reduction surfaces. R6 admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of the nerves), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), major depressive disorder (a mood disorder characterized by persistent feelings of sadness and hopelessness), muscle weakness (decreased strength in muscles), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).R6's 8/24/25 Braden Scale for Predicting Pressure Score Risk assessment indicates R6 is at risk for pressure injury.R6's comprehensive person-centered care plan, printed on 9/11/25, includes:Problem: Start date: 8/11/25. Pressure ulcer/injury. R6 presented with a stage 2 pressure injury to her coccyx. Approach: Consider specialty mattress or bed. Elevate heels and use protectors. Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair. Consider specialty chair pad.R6's active physician orders, printed 9/11/25, include:Must be on pulsate mattress. Use pressure offloading cushion (waffle or roho) when up in chair. Must reposition every 30 minutes while up.R6's Resident Profile sheet, used by CNAs (Certified Nursing Assistant), to guide care does not include any pressure relieving interventions.On 9/11/25 at 8:30 AM, Surveyor interviewed R6. R6 was sitting in her recliner, there was no cushion in the recliner. Surveyor observed a cushion in R6's wheelchair. Surveyor observed R6 had a specialty mattress. The settings on the mattress were set to static. R6 indicated she had a pressure injury on her buttocks. Surveyor was in R6's room until 9:28 AM. Surveyor did not observe facility staff encourage or offer R6 to reposition during the 58 minutes surveyor was in the room.On 9/11/25 at 9:28 AM, Surveyor interviewed CNA D about resident care needs for R6. CNA D indicated the CNAs use a sheet that includes pertinent information about the residents. Of note, the sheet being used by the CNAs does not include any pressure injury prevention interventions.On 9/11/25 at 3:59 PM, Surveyor interviewed CNA H regarding resident care needs for R6. CNA H indicated the resident's Resident Profile sheet would state how to care for a resident. Surveyor asked where the CNAs would find pressure injury interventions and CNA H indicated on the Resident Profile sheet.Of note, R6's Resident Profile does not include any pressure injury prevention interventions.On 9/11/25, Surveyor interviewed DON B (Director of Nursing) regarding R6's pressure injury. DON B indicated R6 has a stage 2 pressure injury on her buttocks. DON B indicated R6 should have a pulsating mattress and cushion when up in her chair. DON B indicated staff should ensure the pressure injury prevention devices are in place. Surveyor informed DON B of the observations Surveyor made of R6's cushion not being in the recliner and R6's bed being set to static. DON B indicated R6's bed should be on pulsate and R6 should have a cushion in her recliner. DON B indicated R6's interventions were not being followed for pressure injury prevention and should be.

Based on observation, interviews, and record review, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life for 1 of 1 residents (R6) reviewed for choices.R6 expressed she chooses to eat in the dining room and the facility did not ensure R6's choices were honored.This is evidenced by:The facility's policy titled Resident Rights, version 2/21, includes: Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. self-determination; f. communication with and access to people and services, both inside and outside the facility; h. be supported by the facility in exercising his or her rights;The facility's policy titled Care Plans, Comprehensive Person-Centered, revised 3/22, includes: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: receive the services and/or items included in the plan of care. The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. includes the resident's stated goals upon admission and desired outcomes.R6 admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of the nerves), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), major depressive disorder (a mood disorder characterized by persistent feelings of sadness and hopelessness), muscle weakness (decreased strength in muscles), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).R6's comprehensive person-centered care plan, printed on 9/11/25, includes: Problem: Resident is malnourished/at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands.Goal: .have personal feed and dining preferences metProblem: Cognitive loss/ DementiaGoal: R6 will continue to be given the opportunity to make daily decisions - ex: (example) preferred bed time, meals, activities of preferenceApproach: Provide her opportunities to make decisionsOn 9/11/25 at 8:30 AM, Surveyor interviewed R6. R6 was sitting in her recliner wearing her pajamas and covered up with a blanket. R6 indicated she was supposed to have her shower this morning before breakfast. R6 stated she had not yet had breakfast. R6 stated she prefers to eat in the dining room, but she wants to be clean and dressed prior to going to the dining room. R6 stated she has no place to eat in her room and prefers to go to the dining room for social interaction. R6 indicated she enjoys eating with her tablemates and talking with them. R6 indicated staff do not take her to the dining room for all her meals and will give R6 her meal tray in her room.On 9/11/25 at 9:28 AM, CNA D (Certified Nursing Assistant) entered R6's room and asked R6 if she was ready to take her shower.Of note, R6 did not have breakfast in the dining room on 9/11/25 due to the delay in the timing of her shower.R6's CNA work sheet indicates R6 goes to the dining room for meals.R6's meal tickets, printed 9/11/25, state Main DR (dining room) Table (number).On 9/11/25 at 1:30 PM, Surveyor interviewed DM C (Dietary Manager) regarding R6's meal ticket. DM C stated R6 prefers to eat in the dining room, and it is marked on R6's meal ticket.On 9/11/25 at 3:33 PM, Surveyor interviewed DON B (Director of Nursing) regarding R6's preference to eat in the dining room for her meals. DON B indicated it is the resident's right to eat where they choose. DON B indicated staff should honor R6's choice to eat in the dining room.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R6) reviewed for elopement, 2 of 3 residents (R8 and R10) who smoke, 1 of 1 resident’s (R18) who voiced suicidal ideations, and 1 of 3 residents (R13) at risk for falls. The facility’s failure to supervise a resident who was known to be an elopement risk, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on [DATE] at 4:19 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as evidenced by the following examples: R8 has no smoking assessment or care plan for smoking. R10 has no smoking assessment or care plan for smoking. R18 has no trauma assessment or care plan for suicidal ideations. R13 did not have fall interventions in place nor were fall interventions present on CNA (Certified Nursing Assistant) care cards. This is evidenced by: 1. The facility’s Policy and Procedure titled, “Wandering and Elopements” dated [DATE], documents in part: “…1. If identified as at risk for wandering, elopement, or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety…3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, and c. If the resident is not located, notify the administrator and the director of nursing services, the resident’s legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall; a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident’s legal representative (sponsor); d. notify search teams that the resident has been located; e. complete and file an incident report; and f. document relevant information in the resident’s medical record. 5. When a resident requires a Wanderguard the facility will: a. Ensure a completed elopement risk assessment is in resident chart, b. Request order for Wanderguard from physician and update representative, c. Apply Wanderguard to resident ensuring the band is in a comfortable position, d. Add care plan for wandering to resident chart, e. Assess placement of Wanderguard twice daily…” R6 was admitted to the facility [DATE]. R6 has the following diagnoses: bilateral primary osteoarthritis of knee, dementia severity with other behavioral disturbance, type 2 diabetes mellitus with other diabetic kidney complication, abdominal aortic aneurysm without rupture, anxiety, major depressive disorder, OCD (obsessive compulsive disorder), emphysema, Crohn’s disease, chronic kidney disease stage 3a, and low vision (blind in L (left) eye, ocular obstruction R (right) eye). R6’s elopement assessment dated [DATE] documents the following: R6 is ambulatory, an elopement risk, has diagnosis that could contribute to elopement, history of wandering, and that an elopement care plan should be initiated. R6’s Elopement Care Plan was initiated on [DATE]. Wanderguard device was added to R6’s care plan on [DATE]. R6’s Progress Notes document the following: [DATE] 11:25 PM at approximately 1500 (3:00 PM) R6 was calm and cooperative in his room. By 1700 (5:00 PM) he became very restless, repeatedly asking staff for his car keys stating he needed to go home. He became very agitated and upset because the staff are not telling me the truth. His family tried calling him via face time on his tablet, his tablet was left at the nurses’ station. Upon his return to the nurses’ station, he was told that he missed a call from family. He stated he did not know the password to call the family back on the tablet. Writer and other staff showed R6 where his room was multiple times, but he did not believe it was his room. R6 began walking around the facility. Kitchen staff came to the nurses’ station to report R6 was found in the kitchen. Staff retrieved him and brought him back to his room. Staff offered snacks and beverages and redirected him multiple times. No medications were available to give for agitation. As of this time (2335) (11:35 PM) there are still no medications available since patient was admitted today. At approximately 1930 (7:30 PM) CNA staff took her break. She reported that while driving down the street she saw R6 walking on the side of the street. She picked him up in her car and returned him to the facility. Once CNA told writer of this, writer called … to inquire how to lock front doors to ensure that patient would not elope again. CNA called Administrator and described the above incident. Patient has been on Q (every) 15-minute checks and is now resting in bed as of 2334 (11:34 PM) [sic]. It is important to note that there was no documented set of vital signs or assessment upon R6 returning to the facility. Approximate distance that R6 ambulated was 0.4 miles. He was on the same side of the street as the facility and cemetery. [DATE] 03:07 PM Wanderguard placed to right wrist per resident high risk for elopement. Voicemail left for POA with update. It is important to note that there is no documentation of follow up monitoring after R6 eloped the facility on [DATE]. On [DATE] at 11:41 AM, Surveyor interviewed CNA R (Certified Nursing Assistant). Surveyor asked CNA R to explain what happened on [DATE] when R6 eloped from the facility. CNA R explained that she was going on break somewhere between 8:00 and 9:00 PM, I know the sun was going down. I saw R6 was walking up the street toward Kwik Trip, R6 was walking in the street. CNA R stated R6 had just been admitted to the facility on [DATE]. CNA R stated the Therapist told staff R6 was a huge elopement risk, he kept trying to leave and saying he wanted to leave the facility. CNA R stated R6 was almost by the Kwik Trip near the end of the cemetery, CNA R state she told R6 to get in the car, he just got in my car, and I brought him back in the facility. Surveyor asked CNA R what the weather was like at the time. CNA R said it was nice out, warm but not humid. Surveyor asked CNA R if R6 was dressed for the weather and if he had shoes on; CNA R replied yes, his shoes were on, and he had on appropriate clothes. Surveyor asked CNA R what happened once you returned with R6, CNA R stated they put a Wanderguard on R6, he was placed on 15-minute checks I think, I updated NHA A and reported the event to the nurse and the CNA. On [DATE] at 10:56 AM, Surveyor interviewed LPN Q (Licensed Practical Nurse). Surveyor asked LPN Q if there is an elopement, what do you need to do afterwards; LPN Q stated this is all hands on deck- look for the resident, spread staff outside, notify DON (Director of Nursing) or whomever is on call and the NHA (Nursing Home Administrator). Check Wanderguard placement or place a Wanderguard to the resident’s wrist/leg, check function of the Wanderguard, complete vital signs and assess the resident. Document what the resident was wearing, is there a change in resident baseline, document the entire episode. If the resident is not found quickly, we should call the police, notify the family/POA (Power of Attorney), MD/NP (Medical Doctor/Nurse Practitioner). Surveyor asked LPN Q if the facility does not have a Wanderguard tab what would you do? LPN Q stated report this to the NHA A and assign someone to 1:1 with resident until NOC (night shift), once resident is sleeping, we would complete frequent checks of 15-minute checks during NOC. On [DATE] at 11:54 AM, Surveyor interviewed RN P (Registered Nurse). Surveyor asked RN P if the facility has an elopement, what do you need to do after the elopement occurs. RN P stated to update the DON, take resident’s vital signs, update the family/POA, and document the event in the progress notes. On [DATE] at 12:01 PM, Surveyor interviewed RN O. Surveyor asked RN O if there is an elopement in the facility, what do you need to do after the elopement occurs. RN O said get the resident’s vital signs, a head-to-toe assessment, notify the MD and DON. On [DATE] at 9:20 AM, Surveyor interviewed MT T (Medication Technician). Surveyor asked MT T if she had received any recent training on resident elopements. MT T indicated that she had training on what to do. MT T reported that she would stop what she was doing and look for the resident. 0n [DATE] at 9:50 AM, Surveyor interviewed LPN L (Licensed Practical Nurse) asking if she had received any training regarding elopement. LPN L reported that the facility had a quiz on elopement in the last two months. The quiz covered who gets notified. Surveyor asked LPN L what she would do if she found out a resident had eloped from the building. LPN L replied she would notify management, shut down everything, lock her med cart and start looking for the resident. In halls, bed checks, elevators. If not found after 30 min call 911 or local police. On [DATE] at 11:26 AM, Surveyor interviewed ADON D (Assistant Director of Nursing). Surveyor asked ADON D would you expect every resident that is an elopement risk to have a Wanderguard put on; ADON D stated yes. ADON D stated every resident who is identified as an elopement risk has their picture in an elopement book at nurses’ station and in the employee breakroom. We place orders for function and placement checks of the Wanderguard every shift in the TAR (Treatment Administration Record). We added in the computer system to have everyone check battery life of Wanderguards. Surveyor asked ADON D what would you expect your nurses to do after an elopement. ADON D said a full assessment, update the MD (Medical Doctor), update the POA (Power of Attorney), complete an incident report, and document the event in the progress notes. Surveyor asked ADON D would you expect there to be a set of vital signs, ADON D said yes. Surveyor asked ADON D if she would you expect there to be any type of assessment, ADON D replied yes, a head-to-toe assessment. Surveyor asked ADON D if she would you expect there to be follow up documentation after an elopement, ADON D replied yes. I would expect documentation of the episode, monitoring of residents for a few days after the event, an event report and investigation to follow the elopement. Surveyor asked ADON D what would you expect staff to do if a Wanderguard is needed but there are no Wanderguard tags available, or the tags are expired. ADON D stated the resident should then be 1:1 supervision. On [DATE] at 11:42 AM, Surveyor interviewed ADON D. Surveyor asked ADON D how are the expiration dates of Wanderguards being documented. ADON D said NHA A has list of activated dates and expiration dates. On [DATE] at 2:50 PM, Surveyor interviewed NHA A. Surveyor asked NHA A what the process would be for a late evening or weekend admission in relation to elopement process and care plan. NHA A said they would call on call nurse or manager to come in to put Wanderguard on and do the care plan. On [DATE] at 4:19 PM, Surveyor interviewed NHA A again. Surveyor asked NHA A what would you expect your nurses to do after an elopement. NHA A stated, reach out to MD, POA, myself, the DON, and complete incident report. Surveyor asked NHA A would you expect there to be a set of vital signs, NHA A said yes. Surveyor asked NHA A would you expect there to be any type of assessment, NHA A said yes. Surveyor asked NHA A would you expect there to be follow up documentation after an elopement, NHA A replied yes. Surveyor asked NHA A how the expiration dates of Wanderguards are being documented. NHA A explained that he has them set up on his calendar in his computer by serial number of devices, approximately 1 year after activation they expire so there is a week prior to this date set to remind him. Surveyor asked NHA A what you would expect staff to do if a Wanderguard is needed but there are no tags available or they are expired. NHA A stated they should reach out to me, resident will be placed on 1:1 until Wanderguard is applied. R6 was determined upon admission to be an elopement risk. The facility failed to implement interventions to ensure R6 received adequate supervision to keep R6 safe. R6 eloped from the building without staff being aware R6 left the facility. R6 was found walking down a busy street by a staff member. The facility’s failure to supervise a resident who is a known elopement risk created a reasonable likelihood for serious harm thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement the action plan below and as evidenced by the remaining examples: Noncompliance: On [DATE] R6 was found by CNA walking down a nearby street to facility. Despite resident being assessed by admitting RN as being high risk for wandering/elopement, no measures were put into place to reduce the risk of resident leaving the facility unoccupied or without staff knowledge. Corrective Action: R6 put on 1:1 supervision immediately following incident on [DATE]. [DATE] NHA A reviewed status of Wanderguard system with staff. It was noted that potentially the current Wanderguard bands were expired and not alarming. Upon learning this, NHA A ordered new Wanderguard bands and placed staff 24/7 at exits until new bands were delivered to the facility and activated. [DATE] system was tested…and determined to be functioning. Exits still remained staff until wanderguard bands delivered to facility. [DATE] New Wanderguard bands delivered to facility. The NHA A activated bands and confirmed the function. Current residents with Wanderguards had bands replaced. The Elopement policy was reviewed and updated. Education started with staff on Elopement P/P (policy and procedure). On [DATE] education completed with remainder of staff on Elopement P/P finished up with staff. Corresponding quiz also completed by staff to determine competency of training. Facility TEL’s work order (facility system to place work orders) placed for monthly check to determine battery life of Wanderguard bands. Identification of other residents: [DATE] all residents had Elopement Risk Assessment completed to determine if any other residents at risk for elopement. All residents found to be at risk were care planned to reflect risk. Monitoring Performance: Beginning the week [DATE], NHA A or Designee to audit TELs 1x/week x 8 weeks to determine system testing for proper functioning of Wanderguard system. Beginning the week [DATE]: NHA A or Designee to monitor nursing has completed Q shift checks for Wanderguard battery lift 3x/week x 8 weeks, 2x/week x 4 weeks, 1x/week x 4 weeks. 2. The facility’s “Suicide Threats” Policy and Procedure dated [DATE], documents in part: “…1. Staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. 2. The nurse supervisor/charge nurse shall immediately assess the situation and shall notify the charge nurse/supervisor and/or director of nursing services of such threats. 3. A staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident’s attending physician and responsible party and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident’s behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident’s mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident’s medical record…” R18 is a short-term resident of the facility. R18 has the following diagnoses: psychosis, psychoactive substance abuse, borderline personality disorder, conversion disorder with seizures or convulsions, abnormal involuntary movements, intellectual disabilities, and anxiety disorders. R18’s most recent MDS (Minimum Data Set) dated [DATE] did not document a BIMS (Brief Interview for Mental Status) as it is documented that R18 would not answer the questions. It is documented under “C1000. Cognitive Skills for Daily Decision Making independent”. R18 does not have a care plan for trauma or suicidal ideations. R18’s Progress Notes document the following: On [DATE] 05:30 PM Resident upset with staff member asking her if she threw cigarette butts on the ground, which she denied was her. Resident began shouting profanities down the hall. Resident went down another hall attempting to go confront another resident about the cigarette butts, staff intervened before coming near resident's room. Resident shouted in hall, I just want to die. Writer wheeled resident to room and provided therapeutic communication and active listening. Writer asked resident if she had any thoughts of killing herself, no response. Writer repeated the question, no response. Writer asked resident if she had a plan to harm herself in any way, no response. Writer repeated the question, no response. Writer called for a CNA (Certified Nursing Assistant) to come in room and sit with resident while writer stepped out to call the administrator. On [DATE] 06:15 AM Administrator placed resident on 1 on 1 care with facility RA (Resident Aide) for evening due to behavioral episode. Per NHA A (Nursing Home Administrator) the above note was supposed to be corrected to the time of 6:15 PM not AM. On [DATE] 02:38 PM Resident was upset because they couldn't go to the parade on Sunday. They started making suicide comments. Saying, I just going to cut my throat, I don't want to live anymore, I'm just done with life, and I just want a sharp object. Staff was able to redirect her thoughts to a new topic on fixing cars and going to Walmart. But once the staff was saying they are going and saying bye. Resident mentioned that they are still upset about not going to the parade and wanted to hurt themself. Staff informed CNAs and Nurse about the residents’ [sic] comments and told them to keep a close eye on her and keep her mind distracted. It is important to note that there was no update to the DON (Director of Nursing), no notification to R18’s Provider or family, and no care plan was initiated. On [DATE] at 11:35 AM, Surveyor interviewed AD Z (Activity Director). Surveyor asked AD Z what he did after R18 made the suicidal statements. AD Z said he called NHA A, ADON D (Assistant Director of Nursing), and the DON, they directed me to inform R18’s Nurse and CNAs for monitoring her. Surveyor asked AD Z if he knew what nursing staff he reported this to, AD Z stated he was unsure of what CNA or Nurse was updated. On [DATE] at 11:45 AM, Surveyor interviewed CNA R. Surveyor asked CNA R if R18 had made any suicidal comments to her. CNA R said, I heard her telling her nurse “I want to die.” Surveyor asked CNA R if she knew what happened with R18 after that; CNA R replied they put her on a 24hr watch with a service aide (1:1). On [DATE] at 12:48 PM, Surveyor interviewed RN S (Registered Nurse). Surveyor asked RN S how she became aware that R18 had made suicidal comments. RN S stated, I was aware, I got her to calm down and had her with me. Surveyor asked RN S if she knew who reported the comments to her. RN S initially said she believed it was a CNA but then later she thought it was AD Z that told her. Surveyor asked RN S what she did with the information. RN S said she called ADON D (Assistant Director of Nursing) who instructed her to send R18 to the ER (Emergency Room) for evaluation. Surveyor asked RN S what the process is if a resident makes suicidal ideations. RN S explained that safety comes first so the resident can’t be left alone, update the NHA and DON, call family if applicable, notify Provider, obtain a set of vital signs, full assessment, and care plan should be done. On [DATE] at 4:01 PM, Surveyor interviewed ADON D. Surveyor asked ADON D what are your expectations if a resident makes suicidal ideations; ADON D replied, I may need to check the policy on that, but, don’t leave them, nurse should ask about a plan and details, ensure they are safe, not leave the patient alone, call their Provider, 1:1, and follow the policy. Surveyor asked ADON D would you expect there to be nursing documentation regarding suicidal ideations, ADON D stated yes. Surveyor asked ADON D how was R18 protected on [DATE] with further suicidal ideations. ADON D said she was sent to ER. Surveyor asked ADON D how it is decided when someone comes off 1:1 for suicidal ideations. ADON D replied, there’s a protocol, follow the policy, and discuss with Provider. Surveyor asked ADON D how long R18 was on 1:1 supervision on [DATE]; ADON D stated, I’d have to look. Surveyor asked ADON D would you expect there to be a care plan in place for suicidal ideations, ADON D stated yes. Surveyor asked ADON D would there be referrals for psych services, ADON D said yes, they have a service that comes to the facility. Surveyor asked ADON D what is your expectation of “keep a close eye on her and keep her mind distracted.” ADON D said she would need to verify what that means; role in Activities engage her more . Surveyor asked ADON D if R18 was on any type of monitoring upon return from ER on [DATE], ADON D stated no, she was better then, no further comments made. On [DATE] at 4:23 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if he knew how long R18 was on 1:1 supervision on [DATE]; NHA A stated until the following day. Surveyor asked NHA A how was it determined that R18 could come off 1:1? NHA A replied that R18 hadn’t made any further comments. Surveyor asked NHA A who decided that R18 could come off 1:1; NHA A said it was an IDT (Interdisciplinary Team) discussion. Surveyor asked NHA A if he would expect there to be nursing documentation surrounding a resident making suicidal ideations, NHA A stated yes. Surveyor asked NHA A what is your expectation of “keep a close eye on her and keep her mind distracted?” NHA A said that is up for interpretation. Of note, ADON D was interviewed in place of DON B as during this survey DON B resigned. 3. R10 was admitted to the facility on [DATE]. Diagnoses include Unspecified fracture of L femur, abdominal aortic aneurysm, and repeated falls. R10's most recent Minimum Data Set (MDS) target date of [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R10 was cognitively intact. Surveyors asked for a list of smokers in the facility and R10 was among the residents on the list. R10 did not have a smoking assessment or a care plan related to smoking. On [DATE] at 11:35 AM, Surveyor interviewed ADON D (Assistant Director of Nursing) who indicated she would expect residents who smoke to have a smoking assessment done and have a care plan related to smoking. 4. The facility policy, Smoking Policy - Residents, revision date of [DATE], includes, in part: .7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption; c. desire to quit smoking; d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation) .10. Any smoking relating privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . R8 was admitted to the facility on [DATE] with diagnoses that include in part: acute and chronic respiratory failure with hypoxia (condition in which the body is deprived of adequate oxygen), acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in the bloodstream), obesity, chronic osteomyelitis right ankle and foot (an infection of the bone that causes inflammation and pain), heart disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, depression, non-pressure chronic ulcer of right heel and midfoot, type 2 diabetes mellitus, and nicotine dependence. R8's most recent Minimum Data Set (MDS), target date [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R8's cognition is moderately impaired. On [DATE], Surveyors requested a list of residents who smoke. R8 was one of the residents on the list provided by the facility. On [DATE] at 12:43 PM, Surveyor reviewed R8's Electronic Health Record and was unable to find a smoking assessment and did not see smoking on R8's comprehensive care plan. On [DATE] at 3:40 PM, Surveyor requested to see smoking assessments and smoking care plans for R8 and R10. DO V (Director of Operations) told Surveyor the facility does not have smoking assessments or care plans related to smoking for those residents. On [DATE] at 8:30 AM and 9:50 AM, Surveyor observed R8 outside smoking. Throughout the course of the survey, Surveyor observed R8 smoking outside several more times. On [DATE] at 8:35 AM, Surveyor interviewed CNA W (Certified Nursing Assistant) and asked what the process is if a resident wants to smoke. CNA W indicated she would verify with the nurse that the resident could smoke and escort them to the smoking area. CNA W indicated she would make sure resident didn't have oxygen on. On [DATE] at 8:40 AM, Surveyor interviewed RN E (Registered Nurse) who indicated residents have to be assessed when they first come in to determine they can smoke safely and how much assistance they need. RN E indicated cigarettes are kept in the med cart or medication room and residents are educated to not wear oxygen while smoking. RN E indicated she was unsure if smoking goes on the resident's care plan. On [DATE] at 11:35 AM, Surveyor interviewed ADON D (Assistant Director of Nursing) who indicated she would expect staff to complete a smoking assessment and smoking care plan for a resident who smokes. 5. Facility policy titled, Falls and Fall Risk, Managing, revision date [DATE], states in part: .Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls .Monitoring Subsequent Falls and Fall Risk: .2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. dizziness or weakness) has resolved .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified . R13 was admitted to the facility on [DATE] with diagnoses that include in part: encephalopathy (brain disease that alters brain function or structure), Type 1 diabetes mellitus with diabetic polyneuropathy, schizoaffective disorder, repeated falls, weakness, shock, low back pain, moderate protein calorie malnutrition, alcohol dependence in remission, nicotine dependence, hypertension, congestive heart failure, acute respiratory failure with hypoxia, acute kidney failure, and mood affective disorder. R13's most recent MDS (Minimum Data Set) dated [DATE] states that R3 has a BIMS (Brief Interview for Mental Status) score of 14 out of 15, indicating R13 is cognitively intact. R3's most recent section GG, Functional Abilities and Goals, indicates that R13 is substantial assist for toileting and partial/moderate assistance for dressing and transfers. On [DATE] around 3:00 PM, Surveyor reviewed R13's care plan. R13's Comprehensive Care Plan states, in part: Problem start date: [DATE] Category: Falls - [Resident name] is at risk for falls due to weakness, encephalopathy. Last reviewed/revised: [DATE] Goal: Short Term Goal Target date: [DATE] - Resident will be free of falls. Approach start date: [DATE] - [Resident name] will have fall mats at bedside. *Of note, this approach does not specify when the mats should be at bedside. Approach start date: [DATE] - Implement exercise program that targets strength, gait and balance. Approach start date: [DATE] - Increase staff supervision with intensity based on resident need. Bed in lowest position. Approach start date: [DATE] - Provide individualized toileting interventions based on needs/patterns. *Of note, throughout the survey, Surveyor did not observe a fall mat in R13's room. On [DATE] at 3:30 PM, Surveyor interviewed LPN Q (Licensed Practical Nurse) and asked her what R13's current fall interventions were. LPN Q stated they would be on the Kardex on R13's door. LPN Q indicated R13 had grippy socks and floor mats. At 3:43pm, LPN Q came up to Surveyor and stated the CNA (Certified Nursing Assistant) told her R13 doesn't use the mat anymore, doesn't know when she stopped using it. LPN Q indicated she put the mat down a laundry chute to be cleaned that day. On [DATE] at 3:35 PM, Surveyor interviewed CNA X (Certified Nursing Assistant) and asked about fall interventions for R13. CNA X stated R13 uses grippy socks, making sure call light is in place and within reach, 2 hour toileting schedule, and indicated R13 doesn't use the mat anymore and doesn't remember how long it's been since R13 stopped using the fall mat. On [DATE] at 9:10 AM, CNA X and Surveyor observed the Kardex in R13's room together and noted there were no fall interventions on this Kardex which was dated [DATE]. The only interventions on the Kardex in R13's room were Activities of Daily Living, Functional Status information. CNA X stated the fall interventions should be on there. In a follow up interview on [DATE] at 9:45 AM, CNA X indicated fall interventions are in the care plan and Kardex, she would check the Kardex first, and stated the date last updated should be on both. On [DATE] ar

Based on observation, interview, and record review, the facility failed to ensure a resident who receives assisted nutrition and hydration maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 4 residents (R14) reviewed for nutrition and hydration.R14 has diagnoses including severe protein malnutrition, severe weight loss, and adult failure to thrive (FTT). R14 was admitted to the facility on [DATE]. R14's discharge physician orders included an order indicating NPO (Nothing by Mouth). R14 was to receive enteral feedings. (An enteral feeding, also known as tube feeding, is a method of providing nutrition directly into the gastrointestinal (GI) tract when a person cannot consume enough food or fluids orally.) R14's enteral feeding orders were not transcribed into the MAR (Medication Administration Record) resulting in R14 not receiving his enteral feeding from 6/27/25 until the staff recognized the transcription error on 6/30/25. On 7/1/25, R14 weighed 113 lbs. 7 oz. This is approximately a 12 lb. weight loss from the hospital weight of 125 lbs. 7.1 oz. recorded on 6/25/25. This is approximately a 9.6% severe weight loss in 6 days.The facility's failure to ensure R14 received nutrition and hydration to maintain acceptable parameters of nutritional status, failure to recognize R14's enteral feeding orders were not transcribed into the MAR, and failure to ensure R14 received his enteral feeding and water flushes as ordered created a finding of immediate jeopardy that began on 6/27/25. Surveyor notified NHA A (Nursing Home Administrator) of the of the immediate jeopardy on 7/2/25 at 1:10 PM. The immediate jeopardy was removed on 7/3/25, however, the deficient practice continues at a severity/scope of D (potential for no more than minimal harm/isolated) as the facility continues to implement its action plan.This is evidenced by:The facility's policy titled Reconciliation of Medications on admission revised July 2017, states in part; the purpose of this procedure is to ensure medication safety accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. General Guidelines: Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medication by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages, routes, during the admission/transfer process. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition and not interact in a negative way with other medications/supplements on the list. Medication reconciliation helps to ensure that the medications, routes, and dosages have been accurately communicated to the attending physician and care team. https://www.todaysgeriatricmedicine.com/archive/110310p8.shtml> states in part: FTT (Failure to Thrive) in older adults has been described as a syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels. It may result from issues such as chronic disease and functional decline, physical and emotional deprivation, poor appetite, poor diet, or medical problems. All of these combined can easily lead to inadequate food intake, malnutrition, unintended weight loss, weakness, functional decline, and other complicating factors such as falls, impaired immune response, and poor wound healing. FTT affects 5% to 35% of community-dwelling older adults and 25% to 40% of nursing home residents. Its prevalence appears to increase with age. Studies indicate that it is associated with decreased immunity and increased rates of infection, incidence of hip fractures, pressure ulcers, surgical mortality, mortality rates, and medical costs. FTT is not a normal consequence of aging or chronic disease, and caution should be used in applying the geriatric FTT label. It should not be treated as a diagnosis or a disease or equated with frailty, and it should not signal the withdrawal of efforts to find and treat underlying causes. Instead, it should be viewed as an unexpected and significant change in normal health status, a decline in vigor, weight, and function that can affect even the healthiest of older adults. For older patients exhibiting an unintended reduction of food intake, unintended weight loss, decline in the ability to provide self-care, a decline in cognitive function, and a general decline in interest in daily life, the term failure to thrive should trigger a thorough evaluation to determine possible reversible underlying causes. https://my.clevelandclinic.org/health/diseases/22987-malnutrition> states in part: one of the most common symptoms of FTT (failure to thrive) is unintended weight loss that can result in undernutrition or protein energy malnutrition if left untreated. Depression is common in FTT, and it may be either a cause or a result of the syndrome. Depression can be a major cause of unintended weight loss, and if left untreated, it is associated with increased morbidity and mortality in FTT patients. Malnutrition happens when the nutrients it (your body) gets don't meet these needs. Undernutrition is what most people think of when they think of malnutrition. Macronutrient undernutrition also called protein-energy undernutrition, this is a deficiency of macronutrients: proteins, carbohydrates and fats. Macronutrients are the main building blocks of your diet, the nutrients that your body relies on to produce energy to maintain itself. Without them - or even just one of them - your body soon begins to fall apart, breaking down tissues and shutting down nonessential functions to conserve its low energy.Macronutrient undernutrition (protein-energy undernutrition) deprives your body of energy to sustain itself. To compensate, it begins breaking down its own tissues and shutting down its functions. This begins with its body fat stores and then proceeds to muscle, skin, hair and nails. People with protein-energy undernutrition are often visibly emaciated. Undernutrition is usually caused by not eating enough nutrients. It can also be caused by certain medical conditions that prevent your body from absorbing nutrients.R14 was admitted to the facility on [DATE] with severe protein malnutrition (severe protein-calorie malnutrition (PCM), decreased appetite, and functional decline), autism, psychosis, bipolar disorder, drug induced parkinsonism, aphasia (loss of language), and acute pyelonephritis (kidney infection).R14's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/1/25 indicates R14 has a BIMS (Brief Interview of Mental Status) score of 99 indicating R14 was unable to complete the assessment. Section K of the MDS indicates R14 is on a physician prescribed weight gain regimen and R14 is not on a weight loss regimen. R14's Care Plan dated 6/30/25 Nutritional Status states: Resident requires a feeding tube to meet their nutrition, and hydration needs and to support overall metabolic demands. Resident is malnourished at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands. Goal: Resident to maintain their weight, labs to remain within acceptable ranges, and to remain free of s/s (signs and symptoms) of GI (Gastrointestinal) intolerance of fluid imbalance. Approach: Administer tube feeding as ordered by physician. Provide free water flushes as ordered. Keep head of bed elevated 30 degrees during tube feeding administration. Check proper placement of tube feeding. Check and residuals per physician orders. Hold and resume enteral feeds as ordered. Assess any complications of aspiration, tube dysfunction, or GI intolerance. R14's hospital Discharge summary dated [DATE] states in part; [R14] has bipolar disorder complicated by (c/b) medication-induced Parkinsonism with tardive dyskinesia, who presented for decreased intake now with severe protein malnutrition, bipolar disorder, and acute food refusal by mouth. Ultimately place of a PEG (feeding tube) for nutrition. Issue: Dysphagia (difficulty swallowing) with high aspiration risk. Nutrition via G-tube (Feeding tube). Details of Hospital Stay: Psychosis (Psychosis is a mental state where a person's thoughts, perceptions, and behaviors are significantly altered, and they may lose touch with reality), Psychosis c/b medication-induced Parkinsonism and TD, Autism spectrum disorder, Hx (history of) schizoaffective with bipolar features or bipolar disorder 1, Metabolic encephalopathy, severe protein calorie malnutrition, dysphagia, multiple episodes of aspiration (food/fluid into lungs). Prior to admission noted 43-pound weight loss in 4 months (from September to January). Patient (pt) has been perseverating on food since moving to assisted living facility in February 2025. A Dobhoff (feeding tube through nose) was placed and later a G-tube (feeding tube through stomach) given life-prolonging goals of care. Was evaluated by swallow therapy multiple times and with concerns for ongoing aspiration with the brief assessment able to be completed. Experienced multiple instances of likely aspiration events including one requiring intubation and other resulting in sepsis after attempting further swallow evaluation/therapy. Ultimately determine in discussion with guardian to maintain NPO (nothing by mouth) indefinitely with ongoing nutrition via G-tube given high risk of aspiration and goal of life-prolonging care. Final nutrition plan was tube feeding of 6 cartons of Jevity 1.5 (liquid protein supplement) over 4 bolus feedings per day with free water flushes before and after each feeding for additional hydration. Physical exam at discharge: Weight: 125 lbs. 7.1 oz. (6/25/25 6:00 AM). No apparent distress, fidgeting, mumbling, thin chronically ill appearing. Diet Orders: No solids; no liquids; strict NPO. Being discharged on tube feeding to meet nutrition needs. Tube feed route: Gastrostomy; tube feeding frequency: Bolus; feeding plan: 6 cartons over 4 feeding per day. Give 1.5 cartons (355 ml (milliliters) at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM via a gravity drip over greater than 30 minutes. Flush with 135 ml tap water before and after each bolus feeding (total 8 times per day). Formula: Jevity 1.5 Cal, unflavored. Progress noted dated 6/27/25 7:31 PM: readmitted to the facility from [hospital] this afternoon by ambulance and stretcher. Full code with temporary guardianship. He has a PMH (past medical history) of bipolar I disorder c/b medication-induced Parkinsonism with tardive dyskinesia. He admitted to UW 5/3/25 from his ALF (Assisted Living Facility) due to severe malnutrition and escalating behaviors. After multiple episodes of aspirating resulting in complications, a g-tube was placed for nutrition, and he will remain NPO indefinitely. On 6/20/25 blood cultures were positive for MSSA (Methicillin-Susceptible Staphylococcus aureus) bacteremia. It refers to a bloodstream infection caused by the bacteria Staphylococcus aureus). Single lumen PICC (peripherally inserted central catheter- line inserted in skin to deliver long-term antibiotics) placed in RUE (right upper extremity) for prolonged IV abx (antibiotic) therapy until 7/20/25.R14's June 2024 physician orders state in part:Enteral feeding: Formula: Jevity 1.5 Cal, Unflavored. Start date 6/27/25. (Of note this order is incomplete.)Enteral feeding: Tube site care: Twice a day 8:00 AM and 4:00 PM. Start date 6/27/25.Enteral feeding: Change irrigation set every day. 8:00 AM. Start date 6/27/25.Enteral feeding: Elevate HOB (head of bed) 30 degrees. Continuous. Start date 6/27/25. Discontinued: 6/30/25Enteral feeding: Elevate HOB 45 degrees or greater. Continuous. Start date 6/30/25.Jevity 1.5 Cal (lactose-reduced food with fiber liquid; 0.06 gram-1.5 kcal (kilocalorie/ml); amount to administer: 1.5 cartons (355 ml); oral four times a day. Special instructions: give 1.5 cartons (355ml) at 8:00, 12:00, 1600 (4:00 PM), 2000 (8:00 PM) via gravity drip over greater 30 minutes. Flush with 135 ml tap water before and after each bolus feeding. Start date: 6/30/25.(Of note R14's complete tube feeding order was not entered into the physician orders until 6/30/25.)R14's June MAR (Medication Administration Record) indicates an order for Jevity 1.5 Cal (lactose-reduced food with fiber liquid; 0.06 gram-1.5 kcal (kilocalorie/ml); amount to administer: 1.5 cartons (355 ml); oral four times a day. Special instructions: give 1.5 cartons (355ml) at 8:00, 12:00, 1600 (4:00 PM), 2000 (8:00 PM) via gravity drip over greater 30 minutes. Flush with 135 ml tap water before and after each bolus feeding. Start Date: 6/30/25. The June MAR indicates the first feeding was administered on 6/30/25 at 4:00 PM by RN J.(It should be noted R14's first tube feeding was not signed out until 4:00 PM on 6/30/25.)On 7/1/25 at 3:00 PM, Surveyor interviewed ADON D (Assistant Director of Nursing) regarding entering admission orders. Surveyor asked ADON D how long she has worked at the facility. ADON D stated she started in January 2025; she stated that new admissions orders are entered by her and medical records. ADON D stated she and another nurse will verify the orders that medical records enter. ADON D stated there are always two nurses who verify the orders. ADON D stated if there are treatment orders or more nursing orders she enters these orders into the medical record and has a second nurse verify the orders. Surveyor asked ADON D if she completed the admission orders for R14? ADON D stated she did and stated, that was my error. ADON D explained she thought she must have had R14 and R20's profile up on her computer and she accidentally added R14's tube feeding orders into R20's chart. Surveyor asked ADON D if she had another nurse verify R14's orders and ADON D stated, I asked RN P to verify the orders. Surveyor asked if there is anywhere in the EMR (electronic medical record) to show two nurses verified the orders and ADON D stated there is not. Surveyor asked ADON D when she was notified there was an error. ADON D stated RN J called her on Saturday and she was not on call and stated there were orders for tube feeding in R20's MAR and R20 does not have a tube feeding. Surveyor asked ADON D did RN J state you were the one to enter these orders; ADON D stated I do not recall, she just stated R20 has this order in his MAR, but he does not have a G-tube. Surveyor asked ADON D what she instructed RN J to do. ADON D stated I told her to discontinue them. Surveyor asked at any point when RN J mentioned that R20 had tube feeding orders in his chart, but no tube feeding did it occur to you to check R14 who was a new admission with a tube feeding order? ADON D stated it did not. Surveyor asked ADON D when did the facility realize R14 did not have orders in his MAR to provide tube feedings. ADON D stated on Monday afternoon, 6/30/25, I was reviewing R14's record and realized he did not have tube feeding orders. ADON D stated she immediately entered the orders from admission, called NP G (Nurse Practitioner) and let the nurse working with R14 know to administer the tube feeding. Surveyor asked ADON D is it your understanding R14 did not receive a feeding from admission on Friday until the PM shift on Monday? ADON D stated yes, that is my understanding. Surveyor asked ADON D if new orders were received and ADON D stated NP G ordered an immediate blood glucose check and labs are ordered for 7/3/25. ADON D stated, I did complete an immediate assessment of R14 and R14's blood glucose was within normal limits. R14's tube feeding was immediately started. Surveyor asked ADON D to check R14's progress notes for 6/30/24; Surveyor asked if ADON D documented the assessment findings for R14. ADON D stated she did not write a progress note. Surveyor asked ADON D if she spoke with the nurses who worked with R14 over the weekend to find the root cause of why no one recognized R14 was not receiving his tube feeding. ADON D stated she spoke with LPN L. ADON D stated I am not sure why nurses did not recognize R14 was not receiving his tube feedings, I do not know why no one questioned it. ADON D stated when I realized R14 did not have orders for his tube feedings I asked LPN L if she had provided tube feeding for R14 and she said she did not have orders to administer a tube feeding. ADON D stated it is disheartening that no one checked further into why R14 was not receiving his tube feedings. ADON D stated, I take full responsibility for making the error. Surveyor asked ADON D if anyone contacted R14's guardian; ADON D stated she left a message on Monday for the guardian but has not heard back. Surveyor asked ADON D what the facility's response was regarding the tube feeding error. ADON D stated we complete a medication error report, report to the provider, complete an assessment, vital signs, and in this case completed a blood sugar. Surveyor asked if education had been provided to the nurses. ADON D stated she would be providing education. ADON D stated she will be changing the process for completing admission orders to have two nurses looking at the new admission orders at the same time and verifying the orders together. Surveyor reviewed R20's General Orders which indicate Order Description: Tube Feed via G-tube. Frequency: Bolus. Formula: Jevity 1.5 Cal, Unflavored. Feeding Plan: Give 1.5 cartons (355ml) at 8:00, 12:00, 1600 and 2000 via gravity drip over 30 minutes. Flush with 135 ml tap water before and after each bolus feeding 8x's/day. Start Date: 6/27/25.This order was entered into R20's medical record by ADON D. Of note, R20 does not have a G-tube, and these orders were entered into R20's record in error. The orders entered in R20's chart should have been entered into R14's chart.R14's June MAR indicates an order for daily weights times 3 days. Start Date: 6/28/25. End Date: 6/30/25. The Information Key on the June MAR states in part: Initial parenthesized= Not Administered, see reasons. On 6/28/25 and 6/29/25, R14's MAR has the initials of LPN L with parentheses indicating the weight was not completed; there is no reason documented in R14's medical record. On 6/30/25, the MAR has RN P's initials with parentheses indicating the weight was not completed. There is no reason in R14's record indicating why the weight was not completed.R14's g-tube TAR (Treatment Administration Record) states in part; G-tube: Verify placement of G-tube. Flush with 30 ml of tap water before and after each medication administration. Start Date: 7/2/25. Discontinue Date: 7/2/25. R14's CAA (Care Area Assessment) for Nutritional Status dated 7/1/25 states in part, recent hospitalization for psychosis, acute refusal of food PO (by mouth). Multiple aspiration and hx (history) dysphagia (difficulty swallowing). Noted to have a -43# wt. (weight) loss between [DATE]-[DATE] (significant wt. loss) and presenting w/severe PCM (protein calorie malnutrition). Has dentures but does not wear/no longer fit d/t (due to) wt. loss. Confirmed TF (tube feeding) order w/nsg (nursing) prior to admitting . Ht: (height) 72in. Wt: (weight) 140.0# (6/28). BMI: 19.0 kg/m2 (normal). Wt hx 125# acute 6/27 (At hospital); [DATE] wts. 161-168#. -43#/25.6% significant wt. loss from [DATE]-[DATE]; -28#/16.7% significant wt. loss x10 mons; +15#/12% significant wt. gain x1 week (hospital D/C (discharge) to present; question accuracy d/t differing scales?). It should be noted the 140 lbs. weight recorded in R14's record for 6/28/25 is inaccurate. R14 was not weighed at the facility until 7/1/25 when Surveyor requested a weight for R14. On 7/1/25, R14's weight was recorded at 113 lbs. 7 oz. Progress notes dated 6/30/25 2:36 PM state in part; Patient seen today for initial evaluation of a stage II pressure injury to his coccyx. Pressure injury was present at time of admission on [DATE].Patient is on a strict NPO diet and has G-Tube in place. Receives Jevity 1.5- 1.5 cartons (355 mL) four times daily with 135 mL water flush after each feeding. Has PICC line to right AC (antecubital/bend in arm at elbow) which is currently infusing ABX, Cefazolin 2g/100 mL. All medications are administered via G-Tube. Progress notes dated 7/1/25 12:16 AM: NP G (Nurse Practitioner) contacted by phone for missed tube feeds over the weekend. N/O (new order) Check blood glucose 1x on 6/30/25, cmp & cbc (complete metabolic panel and complete blood count) lab order placed for 7/3/25.On 7/2/25 at 3:30 PM, Surveyor interviewed NP G regarding R14. NP G stated she was contacted on 6/30/25 at 3:02 PM by ADON D who stated she had not entered R14's tube feeding order into correct chart and R14 had not received his tube feeding. NP G stated ADON D explained day shift nurses thought the resident was receiving his tube feeding on NOC (night) shift and NOC shift thought he was receiving on day shift, and no one realized R14 was not receiving his feeding. NP G stated she ordered labs and had the staff check an immediate blood sugar which was normal.On 7/1/25 at 4:00 PM Surveyor interviewed LPN L (Licensed Practical Nurse) regarding R14. Surveyor asked LPN L if she was familiar with and had worked with R14. LPN L indicated she was not at the facility on the day of R14's admission but has worked with him since. Surveyor asked LPN L about R14's tube feeding. LPN L stated when she worked with R14 what showed up on the MAR was to do tube site care. LPN L stated, I was aware he has a tube feeding, I saw the pole for the tube feeding, and tube feeding supplies in his room; I knew R14 was to receive nutrition by a g-tube. LPN L stated R14 did not have scheduled tube feedings on her shift, so she assumed they were not scheduled on her shift. LPN L stated on Monday 6/30/25, at the end of her shift, ADON D told her she (ADON D) messed up, she said she entered R14's tube feeding orders into the medical record of another resident who resides on the north wing (R20). LPN L indicated she doesn't work the north wing, so she doesn't know the resident but heard the orders were placed on R20's MAR. LPN L indicated she was told this at 3:00 PM yesterday (6/30/25). LPN L stated R14 did not receive any of his tube feedings from the date of admission which was Friday 6/27/25 until Monday 6/30/25 on the PM shift. LPN L stated she sent a text message to NHA A (Nursing Home Administrator) regarding the incident. LPN L stated she called NP G and reported R14 had not received tube feeding since admission. LPN L stated NP G called back around 5:00 pm on 6/30/25. LPN L stated we put the tube feeding orders in yesterday 6/30/25 for 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. LPN L indicated she told the oncoming nurse the next tube feeding was due at 4:00 PM and it's 3:00 PM, you should give it to him now. LPN L stated R14 received his first tube feeding since admission at 3:00 PM on 6/30/25. Surveyor asked LPN L the process for entering new orders into the medical record. LPN L stated she does not do admissions as she is an LPN. LPN L stated new orders are placed in Matrix (the facility's electronic health record) under orders and staff can select nursing role, treatment, medication etc. This information is placed in order entry and based off the information a resident is being admitted with from hospital or home. Staff should collaborate with whomever they receive report from and verify orders are entered into the system correctly. Surveyor asked LPN L about flushing R14's feeding tube. LPN L stated she did not have orders to flush R14's tube on her shift, which isn't uncommon as not every resident has flush orders for each shift. LPN L stated she assumed R14 was receiving flushes on other shifts. Surveyor asked LPN L if she checked R14's tube feeding site. LPN L stated yes, it's on his left upper abdomen and the tube site has always been healthy pink tissue. LPN L stated R14 was cooperative with care and able to state random things that made sense. LPN L stated he would state he wanted to stand up and he was always cooperative with g-tube site care. Surveyor asked LPN L about R14's weight. Surveyor stated it looks as if you recorded R14's weight as 140 lbs., was that accurate? LPN L stated there is a note that is taped on the computer at the nursing station that states NOC shift must complete weight sheet for day shift to fill out, then the CNA (Certified Nursing Assistant) fills it out and hands it to the nurse when completed. LPN L stated staff would mark the weight down. Surveyor asked was R14's weight obtained? LPN L stated if a weight is not obtained staff can mark as last previous weight known, refused, or unable to obtain. LPN L stated R14's weight was recorded as the last previous weight known. LPN L stated if a weight appeared incorrect staff would try to reweigh the resident the next day. Surveyor asked LPN L how often a new resident is weighed. LPN L stated daily for the first 3 days. On 7/2/25 at 8:37 AM, Surveyor interviewed RN J (Registered Nurse) and asked if she worked with R14. RN J stated either Saturday or Sunday she was asked by the LPN to come over and hang R14's IV antibiotics. RN J stated, I was not on R14's hall but did assist to hang his antibiotic one day. Surveyor asked RN J if she worked with R20 over the weekend. RN J stated yes. Surveyor asked if anything unusual occurred with R20. RN J asked are you referring to the tube feeding orders? RN J stated she noticed on Saturday that R20 had an order for Jevity to be administered via feeding tube. RN J stated R20 does not have a feeding tube. RN J stated she called ADON D and told her, ADON D entered an order for R20 to have a tube feeding but R20 does not have a g-tube, and she was calling to clarify. RN J stated ADON D stated she was at a concert and not on call. RN J stated she then texted ADON D and stated an order was put in R20's chart for a tube feeding, did you put in the wrong chart but did not hear back from ADON D until Sunday. On Sunday, ADON D told RN J she meant to put the order in another resident's chart and to go ahead and discontinue the order for R20. Surveyor asked did ADON D state who the tube feeding order belonged to and RN J stated she did not, only that it was meant to go into another resident's chart. Surveyor asked RN J if she could clarify the admission order process and how orders get into the electronic health record. RN J stated up until a few weeks ago the facility had an admissions nurse, now ADON D or medical records enters the orders. RN J stated the orders are entered from the hospital discharge summary and then the nurse can verify the orders. RN J stated, I can enter a new order, but I do not enter admission orders. Surveyor asked RN J how you verify the orders. She said if we have questions, we can look at the discharge summary and compare to the orders entered into the resident record. Surveyor asked, are you asked to verify orders? RN J stated I have not been asked to do that. On 7/1/25 at 4:14 PM, Surveyor interviewed CNA K (Certified Nursing Assistant) regarding R14. CNA K stated she worked day shift on Friday 6/27/25 and R14 was admitted to the facility at the end of her shift. CNA K stated she worked a double shift on Saturday and noticed R14 had a feeding tube, R14 was not receiving a feeding on her shift. CNA K stated it was reported to her R14 had not voided (excreted urine) on the night shift. CNA K stated R14 did not void on day shift on Saturday either. CNA K stated she noted R14 was very agitated and R14 was mumbling about food. CNA K stated she told R14 he could not have food by mouth, but the nurses would give him his feeding. CNA K stated on Saturday PM she had rearranged R14's room so staff could see him better from the hall when he was in bed or up in the recliner. CNA K stated, I moved his feeding pole close to the doorway so I could move his bed and recliner. CNA K stated on Monday when she returned to work, she noticed the tube feeding pole to be in the same spot she put it on Saturday. CNA K stated later that day when the tube feeding pole still had not moved, I asked the floor nurse, LPN L, when R14 receives his tube feeding and LPN L shared there had been a mistake and R14 had not received his tube feeding all weekend. CNA K stated, I could not believe R14 had not received any feedings from admission until Monday afternoon. Surveyor asked CNA K if she had weighed R14; CNA K stated she had not weighed R14. CNA K stated usually there is a list for the residents that need a weight, and she did not see R14 on the list.R14's Vital Report indicates R14 did not void on the NOC (night) shift of 6/28/25.On 7/1/25 at 12:50 PM, Surveyor interviewed RN E (Registered Nurse) regarding R14. Surveyor asked RN E if she could share any information regarding R14 and his tube feeding. RN E stated she understood R14's orders were not entered in R14's record upon admission and R14 did not receive his feeding from time of admission on Friday afternoon until late in the afternoon on Monday. RN E stated there were orders to flush R14's tube and to provide site care; I cannot understand how a nurse would not question or research why the resident was not receiving a tube feeding on their shift, this should have never happened. R14 is really deteriorating, he is very thin and frail. Surveyor asked RN E if resident had been weighed. RN E looked in the medical record and stated it does not appear there is a weight - I can weigh him today for you. On 7/1/25 at 2:05 PM, Surveyor interviewed R14's Guardian, Guardian F. Surveyor asked Guardian F if she was notified R14 had not received tube feedings. Guardian F stated she was not notified R14 had not received tube feedings. Guardian F stated how did this happen, my goodness he just had the tube feeding permanently placed due to him not eating. I'm just sick this has happened to him. Guardian F stated she has been newly appointed as R14's guardian; however, she is aware of his very poor nutritional status and need for feedings via a g-tube. R14 stated she would be contacting the facility to find out how this occurred.On 7/1/25 at 2:30 PM, RN E called Surveyor and reported R14's weight today was 113 lbs. 7 oz. Of note, this is approximately a 12 lb. weight loss from the hospital weight of 125 lbs. 7.1 oz. recorded on 6/25/25. This is approximately a 9.6% severe weight loss in 6 days.On 7/2/25 at 8:25 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H if she worked over the weekend with R14. LPN H stated she did work with R14. Surveyor asked LPN H if she gave R14 a tube feeding during her night shift/s. LPN H stated she did not as R14 did not have an order to receive a tube feeding, only an order to give medications and provide water flushes before and after medications.On 7/2/25 at 8:57 AM, Surveyor interviewed RN I. Surveyor asked RN I if she had worked with R14 over the weekend. RN I stated she worked Saturday night shift. Surveyor asked RN I if she had provided R14 with a tube feeding. RN I stated she had not as RN I did not have an order for tube feeding on her shift. On 7/1/25 at 12:30 PM, Surveyor observed R14 sitting up in his recliner in his room. R14 was very cachectic appearing (a condition characterized by severe weight loss and muscle wasting), very thin, frail, and restless. R14 was mumbling words but speech was unintelligible and R14 was unable to converse with Surveyor. R14's feeding was hanging and administering via gravity. R14 had a box of Jevity complete balance nutrition with fiber 1.5 cal. 355 calories/8oz. at bedside. R14 was admitted with orders to receive nothing by mouth and all enteral nutrition and water flushes to be administered via G-tube. R14's enteral feeding orders were en[TRUNCATED

Based on interview and record review, the facility did not ensure that a resident received treatment and care to prevent hospitalization in accordance with professional standards of practice for 1 of 6 residents (R18) that were reviewed for hospitalization s out of a total sample of 16. R18 had a change in condition and the facility did not complete full assessments and monitor symptoms. R18's condition continued to decline and R18 was hospitalized with atrial flutter (an abnormal heart rhythm in the heart's upper chambers (atria) when the atria beats too fast. This may cause dizziness and fatigue,) acute decompensated heart failure with preserved ejection fraction (Decompensated heart failure is a phase in the progression of chronic heart failure where symptoms worsen and become more severe. The heart cannot pump enough blood to meet the body's needs under this condition. Patients may experience acute shortness of breath, significant swelling in the legs or abdomen due to fluid accumulation, and fatigue, among other symptoms,) and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart.) Evidenced by: AMDA (American Medical Directors Association) guidelines, 2003, state, in part: In the long term care setting, a primary goal of identifying ACOCs (Acute Change of Conditions) is to enable staff to evaluate and manage a patient at the facility and avoid transfer to the hospital or emergency room .Examples of Staff Roles and Responsibilities in Monitoring Patients With ACOCs .Staff nurse *Recognize condition change early, *Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms, *Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame, *Report patient status to practitioner as appropriate . The facility's policy titled Acute Condition Changes - Clinical protocol dated 3/18/24, states in part, .2. In addition, the nurse shall assess and document/ report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain .d. Level of consciousness; e. Cognitive and emotional status; .j. All active diagnoses .8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less) .Treatment/ Management: 1. The physician will help identify and authorize appropriate treatments .3. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting . R18 was initially admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, type 2 diabetes mellitus, lymphedema (swelling caused by excess lymph fluid within the body,) chronic kidney disease stage 3, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs,) and congestive heart failure (impairment in the heart's ability to fill and pump blood.) R18's most recent MDS (Minimum Data Set) dated 5/29/24 states that R18 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that R18 is cognitively intact. R18's care plan dated 1/22/21 states in part, .Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential: Impaired physical mobility R/T (related to) my size and de-conditioning d/t (due to) recent illness .Approach start date: 10/7/2023 Transfers: one assist SPT (Stand-Pivot Transfer) R18 was readmitted from the hospital on 10/6/23 with diagnoses that include decompensated heart failure. R18's weights are as follows: 10/6/23: 345 10/7/23: 357.8 10/8/23: 352 (Of note: R18 is up 12 pounds on 10/7 and indicated as being up 7 pounds on 10/8/23, there is no documentation the provider was updated or that an assessment was completed for R18 regarding her weight gain with a history of CHF.) Nurse's notes state the following: On 10/8/23 at 9:38 PM: Resident used hoyer lift (full body lift) to transfer from wheelchair to bed due to fatigue. Noted increased fatigue in afternoons/evenings. Had 2 short episodes of retching this shift. Appears tired with facial expressions. Vital signs within baseline. Continues to oxygen at 2 L/M (liters per minute) via nasal cannula . It is important to note that there are no documented vital signs or assessments to accompany R18's change of condition. R18 was transferred via a Hoyer lift due to fatigue when she was a stand pivot upon returning from the hospital per her care plan on 10/7/23. There is no documentation of R18's provider being notified. On 10/8/23 at 11:59 PM Vital signs are documented as follows: O2 saturation 96% on 3 liters, blood pressure 142/94, respirations 28/per minute, pulse 126/per minute. On 10/9/23 at 12:33 AM: wretching [sic] frequently productive small amount of sputum, tums received. VS (Vital Signs) recorded Pulse 128, R (Respirations) 28-32, O2 (oxygen) 3 L/min NC (Nasal Cannula). 2400 (12:00 AM) requested to sit at side of bed. When CNAs (Certified Nursing Assistant) arrived she was sitting at bedside .Continued to wretch [sic], without emesis, tired appearance. Explained condition as it relates to VS. On 10/9/23 at 12:38 AM: Cardiopulmonary assessment: Breath sounds clear R (right), crackles L (left) base post (posterior). Note, feet black when dependent. She asked for her daughter, states she is coming Tuesday. It is important to note that the facility did not contact the physician when R18 had an elevated heart rate, increased respirations, increased oxygen need, or when R18's feet were noted to be black when dependent. There were no further vital signs or assessments documented. On 10/9/23 at 2:54 PM: Per report from noc (night) nurse: resident was tachycardic in the 130s, RR (respiratory rate) near 40, O2 sat (saturation) stable. On-call MD (Medical Doctor) notified and resident sent to (hospital name) ER (emergency room ), leaving around 0430 (4:30 AM). R18 was in the hospital from 10/9/23- 10/18/23. The hospital's Inpatient Discharge Summary dated 10/18/23 states in part, .Primary Discharge Diagnosis: Atrial Flutter, AKI (Acute Kidney Injury) II on CKD (Chronic Kidney Disease) III, Acute decompensated heart failure with preserved ejection fraction (HFpEF), and Pulmonary hypertension .Details of Hospital Stay: .recent hospitalization (10/2-10/6 for decompensated HF (Heart Failure) admitted with acute on chronic HFrEF (heart failure with a reduced ejection fraction). And atrial flutter. Hospital Course: Control of atrial flutter attempted with adjustment of beta blockade (medications used to treat irregular heartbeat, high blood pressure, and are given after a heart attack). Cardiology was consulted for cardioversion (medical treatment that uses quick, low-energy shocks to restore a regular heart rhythm) which she underwent on 10/11 with successful conversion to sinus rhythm .Regarding [R18] decompensated heart failure she was aggressively diuresed with IV (Intravenous) bumetanide (a diuretic used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease.) .With regards to her respiratory failure she was treated similar to COPD (Chronic Obstructive Pulmonary Disease) exacerbation given fairly significant wheezing on exam even after aggressive diuresis. She was given a prednisone burst (steroid) with improvement in respiratory symptoms . The facility's admission note dated 10/18/23 states in part, .New pulmonary edema noted during this hospital stay. UA (Urinalysis) positive, treated with antibiotics. [R18] was given IV metoprolol 2.5 mg (milligrams) x2 ., Bumex 4mg IV, K (potassium) and Mg (Magnesium) repletion, a 1L bolus of LR (Lactated Ringers (fluids)), Duonebs (nebulizer), and started on cefepime (antibiotic) while still in the ED (Emergency Department). On 7/11/24 at 9:37 AM, Surveyor interviewed NP R (Nurse Practitioner). Surveyor asked NP R when the on-call MD was notified of R18's condition. NP R stated that the facility called around 4:00 AM. Surveyor asked NP R if she would expect the facility to call with R18's change of condition. NP R stated that if R18 was having crackles in her lung sounds, they should have called, especially with her CHF and COPD. Surveyor asked NP R if she was updated on R18's 12 lb. (pound) weight gain, NP R stated no. NP R reported that the facility does not obtain a weight on the day of admission, but instead uses the hospital weight. On 7/11/24 at 10:34 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E if R18's provider was notified of R18's 12 lb. weight gain from 10/6/23 to 10/7/23. RN E stated that the facility obtained a reweight on 10/8/23. Surveyor asked if the facility notified the provider of R18's weight on 10/8/23 which was a 7 lb. weight gain since admission, RN E stated no. On 7/11/24 at 3:23 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the facility's process is for weighing new admissions. DON B stated that the facility should be weighing them when they arrive. Surveyor asked DON B if staff should have notified the provider with R18's weight gain, DON B stated yes. Surveyor asked DON B if she would have expected the nurse to recheck R18's vital signs with the change in condition. DON B stated that she would expect the nurse to complete an assessment. Surveyor asked DON B if she would expect the nurse to notify the MD with R18's change of condition, DON B stated yes. Surveyor asked DON B if she would expect the nurse to complete the documentation on R18 and not leave it for the next shift, DON B stated yes. It is important to note that the facility provided education to staff regarding change in condition and physician notification on 3/18/24, 4/29/24, and 6/24/24 but the nurse caring for R18 on the night of 10/18/23 did not attend or sign in on any of the education provided. The facility failed to identify an acute change in condition and update the MD appropriately, resulting in R18 being hospitalized due to CHF and required IV diuretics.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed for falls (R3 and R1). R3 is being cited as actual harm/isolated. R3 experienced multiple falls with fractures and the facility did not assess or find the root cause to prevent additional falls from occurring. R3's comprehensive care plan does not include interventions as written in fall reports. R1 had smoking materials in his room despite the facility being aware of his noncompliance with smoking. Findings include: Example 1 The Board of Nursing's N6 states: N 6.04 Standards of practice for licensed practical nurses states in part; (1) (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an L.P.N. knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. The facility's fall policy states the following: *When a resident has fallen, do not move resident until nurse has assessed the person. Keep the resident lying on the floor. Do not give resident pillow until after nurse determines there is no head, neck, or back injury. Call for help and give comfort measures. Then the nurse shall evaluate the resident at the site of the fall. Assess head, neck, spine and extremities for possible injuries, fractures, or bleeding. *Documentation of fall: 1.) completed fall report. 2.) Document initiation of additional interventions in Nurse's Notes. 3.) Document any new safety interventions on patient care flow sheet and permanent care plan. 4.) Monitor for delayed complication for a minimum of 48 hours and document findings in nurse's notes (vital signs, pain, swelling, bruising, decreased mobility, cognitive changes, neuro checks). *Post fall evaluation: Unit nurse will complete a comprehensive fall/safety assessment through completion of the fall report. This includes 1.) Summary of fall events, 2.) Actual and potential complications related to fall, 3.) Nature, cause, and frequency of falls 4.) Presence of reversible and irreversible risk factors, and 5.) Current interventions in place and modifications initiated. *Unit nurse or designee will update permanent care plan for managing falls and fall risks. *Director of nursing or designee will review each comprehensive fall/safety assessment with the Interdisciplinary Team (IDT) at the morning meeting. R3 was admitted to the facility on [DATE] and has diagnoses that include dementia and altered mental status. Her most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 4, indicating R3 is severely cognitively impaired. R3 requires the use of a wheelchair for locomotion, was admitted to hospice in May of 2022, and has an activated Power of Attorney (POA). The facility conducted fall assessments for R3 on 7/18/23 (score: 22), 7/24/23 (score: 24), and 10/11/23 (Score: 21). The facility's assessments indicate a score of 13 or higher is deemed a high risk for falls. R3's care plan states, At risk for falls due to: altered mental status, history of falls, dementia, restless leg syndrome .Goal: R3 will not sustain a serious injury from a fall .Approach: Obtain air mattress with bolsters from hospice (10/5/23), keep resident by nurse's station for observation when not involved in an activity and for stimulation (3/7/23), frequent rounding (1/22/23). These interventions are only on the comprehensive care plan initiated in 2023. Additionally, R3's in-room Certified Nursing Assistant (CNA) Care Plan states, Falls: Keep resident by nurse's station for observation when not involved in an activity and for stimulation (3/7/23) .low bed and floor mat (3/7/23). No other fall precautions or interventions are on R3's in-room care plan. Since March 2023, R3 has experienced 9 falls: *4/28/23 at 7:30 AM: Unwitnessed fall, R3 was found sitting on the hallway floor next to the nurse's station. No bruising or apparent injury noted. The intervention on the fall report was gripper socks. Of note, there is no root cause for the fall and this intervention is not on R3's care plan. *5/13/23 at 9:53 PM: Unwitnessed fall, R3 was found on the floor at nurse's station. Intervention; hospice to evaluate pommel cushion on Monday (in 2 days, 5/15/23.) Of note, there is no root cause for the fall. The pommel cushion is not on R3's care plan. *5/28/23 at 2:07 AM: Unwitnessed fall, R3, Found on the floor by the bird cage face down, fell from wheelchair, unable to recall what happened and where she was going. Bruise on left hand side between thumb and index finger .continue to monitor. No fall report or additional details were documented. Of note, there is no root cause for the fall. *7/16/23 at 2:30 PM: Unwitnessed fall, R3 found lying supine on the floor in the entry way of her room bathroom. No injury. Intervention on fall report: keep resident in common areas and toilet every two hours as needed. Of note, there is no root cause for the fall. Keep resident at Nurses' station was added on 3/7/23 there were no other changes to the care plan related to common areas. *7/18/23 at 10:44 PM: Unwitnessed fall, R3 was found in the doorway of another resident's room. No interventions noted on fall report or progress notes. Of note, there is no root cause for the fall. *7/23/23 at 9:53 PM: Unwitnessed fall, R3 found leaning on the wall of the nurse's station. No injury. No interventions detailed in the fall report or progress notes. Of note, there is no root cause for the fall. On 7/24/23, R3 experienced 2 falls, one witnessed at 6:00 PM at the nurse's station, and one unwitnessed at 6:42 PM in the hallway. No fall report was completed for the witnessed fall and the fall report for the unwitnessed fall states the intervention is to keep in common area. The facility's progress note at 9:18 PM states, Resident had 2 falls tonight. The first one was witnessed and there were no injuries. This happened around 1758 (5:58 PM) at the nurse's station. Resident did not hit her head. The second one was in the hallway. This was unwitnessed, resident complaining of right knee pain. Neuro checks were restarted, hospice notified at 1842 (6:42 PM). The hospice nurse came out to evaluate her and stated she seemed comfortable. R3's Medication Administration Record (MAR) indicates R3 had 8/10 pain in her right knee on the night of 7/24/23. Of note, there is no root cause for the fall. There is a care plan intervention since 3/7/23 to keep at nurses' station but no additions to keep in common areas. On 7/25/23 at 1:41 PM, facility progress notes indicate R3 was having increased pain to her right knee and thigh area and there was noted swelling. At 3:56 PM, NP D (Nurse Practitioner), who works with R3's physician, placed a STAT (immediate) order for an X-ray of R3's right knee and hip. The mobile imaging company was unable to come on 7/25 as indicated by a progress note at 10:18 PM, and R3's X-ray was completed on 7/26/23, with a note by the facility at 3:12 PM on 7/26 stating the results as a right femoral fracture (between knee and hip). According to the Mosby Dictionary, The term 'stat,' which comes from the Latin 'statim,' meaning immediately, is designed to give priority to orders that are needed most quickly. It should be noted R3 had a STAT order on 7/25/23 at 3:56 pm. R3 did not receive the X-ray until 7/26/23 with results coming in at 3:12 PM noting a fracture almost 24 hours after the STAT order was written. Additionally, there is no evidence the facility contacted the NP or MD regarding the delay in X-ray. On 11/6/23 at 2:01 PM, Surveyor interviewed NP D who stated that ideally a STAT order for imaging gets completed within 8 hours. Additionally, NP D stated that she was unaware that the mobile imaging company was not able to make it to the facility on [DATE] when she placed the STAT order and, had she been notified, she would have had R3 sent to the ED (Emergency Department) for imaging. On 11/2/23 at 2:46 PM, Surveyors interviewed DON B (Director of Nursing) who stated that STAT when placing an order means 24 hours. R3 was admitted to the hospital on 7/26/23 and returned to the facility on [DATE]. R3's family declined any surgical intervention. A facility progress note, dated 7/26/23 at 9:41 AM states, IDT Team (Interdisciplinary Team) at the morning meeting talked about resident falls. Activities to provide one on one sitters for residents between the hours of 2 to 6pm. Nursing staff to lay resident down after lunch. On 8/2/23 at 2:52 PM, a facility progress note documents a facility discussion with hospice as to whether a Broda chair would be appropriate for R3. Hospice decided against the Broda chair as it would inhibit the resident to self-propel. On 10/4/23, R3 experienced another fall at approximately 3:36 PM. The facility's progress note for this event, created by LPN C (License Practical Nurse) states, Resident was found sitting with legs out extended in front of her on the floor mat next to bed. Bed was in lowest position. No external leg rotation bilaterally, no injury. Resident did not know how she got out of bed. She stated that her right leg was hurting. Resident is post femur/knee fracture months ago, with no transferring limitations .phone call placed to hospice who reported that they would be emailing resident's care team as well as contact the POA regarding the fall. The facility's fall report states, Interventions: bumper air mattress, anticipate needs, frequent checks. A 10/4/23 hospice note detailing a phone conversation with LPN C states, At 1515 (3:15 PM), patient slid out of bed, it was in low position with fall mat, resident was sitting on the floor/fall mat in front of the bed, looked like she just slid out of bed. She was checked 10 minutes prior to fall, but was getting antsy, so they went back in to check on her .LPN gave her morphine because patient knee/leg was hurting, post femur fracture in July. They got her up with Hoyer lift, back into bed, then the chair . On 11/1/23 at 12:28 PM, Surveyor interviewed LPN C. LPN C stated that although she documented that R3 was having pain in her right side, R3 states that frequently, so she did not think this was out of her baseline. Additionally, LPN C stated that she believed she had the training to determine if there was an injury to R3 or not. LPN C stated she did not see any deformities and pain is a judgement call. LPN C stated she did not contact the doctor, but did contact hospice, who typically will contact the physician or NP. Of note, despite R3 complaining of knee pain post fall there was no RN assessment of R3's lower extremity. Additionally there were no further assessments of R3 after her fall on 10/4/23 until 10/6/23 when R3 was tearful and complaining of pain. On 11/6/23 at 2:01 PM, Surveyor interviewed NP D who stated that given R3's recent fall with fracture on 7/24/23, she would have expected an RN to assess R3 and had she (NP D) been notified, may have ordered additional imaging at that time. On 11/2/23 at 2:46 PM, Surveyors interviewed DON B (Director of Nursing) who stated that there is no record and she was unable to find any documentation that an RN assessed R3 after her fall on 10/4/23 but there should have been one there. Additionally, DON B stated that frequent checks refers to every 2 hours and as needed, but the facility does not document these nor have they instructed floor staff what frequent checks means. The following CNA interviews were conducted on 11/2/23 regarding frequent checks for R3: *At 2:34 PM, CNA F stated frequent checks means every 2 hours and as needed. *At 2:35 PM, CNA G stated that frequent checks means every 2 hours but probably more for R3 as she moves around a lot and she (CNA G) has seen R3 moving her legs off the bed and very fidgety. *At 2:40 PM, CNA H stated frequent checks means checking on a resident every hour, if not more. CNAs F, G, and H all stated that they refer to the in-room care plan to find safety and fall interventions for residents. Additionally, all stated that they do not document frequent checks, nor have they been told what frequent checks means. The facility provided Surveyors additional information, stating that they did the following after each of R3's falls: *5/28/23-continue to monitor *7/16/23-PT notified for screening (no documentation was provided that this occurred), visual supervision *7/18/23-Monitor *7/23/23-monitor for 48 hours *7/24/23-Asked for a sitter from hospice between 2-6 PM *7/31/23-evaluation for transfer status R3 was known to be a fall risk, continued to fall, and the facility did not document each fall (in the case of 1 fall on 7/24/23 and 5/28/23) including what the root cause of the falls was and how the facility was going to keep R3 safe. As mentioned in R3's care plan, her 7/16/23 and 1 of her 7/24/23 falls, the facility wanted to keep R3 at the nurse's station or in common areas even though most of R3's falls occurred at the nurse's station or common areas. R3's care plan did not give floor staff direction on how and when to monitor R3, how to keep R3 safe, or how to help prevent her from falling other than taking her to the nurse's station. Additionally, the facility did not have a plan for how to monitor and keep R3 safe outside of the hours of 2-6 PM as most of her falls occurred outside of this time frame. R3 experienced back to back falls with fractures, one requiring surgical intervention. Example 2 The facility's smoking policy states the following: *The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker the evaluation will include: Ability to smoke safely with or without supervision. *Residents who have independent smoking privileges are permitted to keep cigarettes, E cigarettes, pipes, tobacco, and other smoking articles in their possession. R1 was admitted on [DATE] from the hospital and has multiple diagnoses that include cognitive communication deficit. R1's smoking risk assessment, dated 10/6/23, indicates that he is a safe smoker. Within the assessment, a question asks, Smokes in unauthorized area, which was marked Moderate Problem. A facility progress note, dated 10/6/23 at 6:55 PM states, Per hospital report resident was caught smoking in the room. On 11/1/23 at 10:18 AM, Surveyor interviewed R1 in his room. R1 stated that he keeps his smoking materials in the room with him and pointed towards his jacket sitting in his wheelchair. Surveyor could see a pack of cigarettes in his pocket. Surveyor then observed what appeared to be an e-cigarette lying next to R1 in his bed. Surveyor asked if R1 used e-cigarettes and he said No. When Surveyor pointed to e-cigarette lying next to him, R1 said, Oh that. Yeah. R1 stated that he did not use the e-cigarette in his room, only outside. On 11/2/23 at 4:21 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that R1 could have his smoking materials in his room because he was deemed safe to smoke independently. When asked why the smoking assessment was marked Moderate Problem and if she was aware that R1 was smoking in his room at the hospital prior to admission, NHA A stated she was aware, but that the facility was monitoring him. When asked if she was aware that he had an e-cigarette in his room in his bed, NHA A stated, No, but I will look into it. The facility was aware R1 was smoking in his room prior to his recent admission to the facility but allowed him to have smoking materials in his room and were not aware that he had an e-cigarette in his bed.

Based on interview and record review, the facility did not ensure a resident's environment remained free of accident hazards and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (R) reviewed for falls (R1). R1 was left in her room without her bed being moved to low position and without fall mat in place next to bed, contrary to the resident's fall care plan. R1 fell out of bed and sustained a fracture of her right humerus. This is evidenced by: The facility policy, Falls and Fall Risk, Managing, revised March 2018, states, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy lists several fall risk factors, including, 2. Resident conditions that may contribute to the risk of falls include: a. fever; b. infection; c. [CONDITION(S)] and other cognitive impairment; d. pain; e. lower extremity weakness; f. poor grip strength; g. medication side effects; h. orthostatic hypotension; i. functional impairments; j. visual deficits; and k. incontinence. According to the policy, Resident-Centered Approaches to Managing Falls and Fall Risks, interventions include, but are not limited to, . 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [CONDITION(S)], as applicable) to try to minimize serious consequences of falling. The facility procedure document titled, Assessing Falls and Their Causes, states, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. According to this document, Steps in the Procedure include, but are not limited to, . Defining Details of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred . Identifying Causes of a Fall or Fall Risk: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident specific evidence including medical history, known functional impairments, etc. 2. Evaluate chains of events or circumstances preceding to a recent fall, including: a. Time of day of the fall; b. Time of the last meal; c. What the resident was doing; d. Weather the resident was standing, walking, reaching, or transferring from one position to another; e. Weather the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved; and/or h. Whether there is a pattern of falls for this resident. 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found . R1 admitted to the facility on [DATE] with diagnoses including, but not limited to: [CONDITION(S)], Type 2 diabetes mellitus with diabetic polyneuropathy, [CONDITION(S)], major depressive disorder, mixed incontinence, anxiety disorder, and psychotic disorder with delusions. R1's Falls Care Plan with problem start date of 5/6/2020 states, I am at risk for falling R/T [related to] seizures and dementia. An approach dated 7/22/2020 reads, Low bed and floor mat. On 1/21/22, at 6:16 PM, R1's Nurse's Notes read, Resident had unwitnessed fall and was found by writer while doing vital rounds. Resident bed above standard height, no floor mat in place, call light not on. Resident was faintly calling for help. Resident on ground laying on right shoulder, head on ground, and on stomach. Resident has slight skin tears to both knees and to left anterior hand. Resident having complaints of right shoulder pain. Faint bruising apparent to right forearm. Unknown amount of time on the ground. Resident sent out by ambulance to [hospital name]. POA [Power of Attorney] and PCP [Primary Care Provider] have been updated. The facility self-reported a Misconduct Incident Report related to the above occurrence, which indicates the date and time the incident occurred was known indicating 1/21/2022, at 5:15 PM. The incident report states, Resident had a fall, was sent to the hospital and hospital notified facility that she had a fractured right humerus. Investigation started immediately. POA notified. On 3/1/22, the facility provided Surveyor with an Investigation Summary, indicating the self-report was opened on 1/22/22. The investigation summary reads: On January 22, 2022, [Facility Name] received a call from [Hospital Name] stating that [R1] had a right humerus fracture secondary to a fall on January 21,2022. An investigation was initiated immediately, due to the bed being at standard height, the care plan states it should be low with floor mats; POA was updated. On January 25, 2022, skin assessments were conducted by RN C (Registered Nurse) on the affected unit, resident's (sic) were at baseline. On January 26, 2022, from 8:30am - noon, all residents (50) were interviewed and asked the following questions with the following answers: 1. Do staff follow your care plan? a. Yes, or unable to answer 2. Is there anything you want in your care plan that isn't? a. No, or unable to answer 3. What can we add to your care plan to reduce the risk of you falling? a. No, nothing, no-I don't fall, nope, nothing-they help me a lot, they help me all the time so nothing, (many variations of these answers all resulting in no) 4. Do you feel safe here? a. Yes, or unable to answer On January 25 - 28th, 2022, RN C and RN D completed 51 fall audits to ensure that all fall interventions were in place, there was no deficient practice identified. Albeit the facility failed to provide education to staff to assure fall interventions remain in place to prevent falls with major injury. On January 27, 2022, HR E (Human Resources) interviewed staff that cared for [R1]. CNA F (Certified Nursing Assistant), CNA G, LPN H (Licensed Practical Nurse), and NA I (Nursing Aide). These staff members did not have evidence suggesting why the bed was not at standard height. On January 27, 2022, [R1] readmitted to [Facility Name] following her hospital stay. [R1] readmitted with [Hospice Provider] services (was previously on service). The goal continues to be comfort care and pain management. On January 28, 2022, at 8:24pm, [Nursing Home Administrator] called [R1's] POA to discuss the investigation. After reviewing the above data with [POA], she stated that she had more information she wanted to share. [POA] stated that her friend, [name of friend] had come in to visit [R1] shortly before supper and had asked for the bed to be raised so she could sit with her. [POA] stated her friend [name of friend] then left for the evening and did not tell anyone that she had left, thus leaving the bed at standard height. The friend [friend's name] shared this information with the POA once she heard that [R1] had fallen and sustained an injury shortly after her visit. [POA] stated she had no concerns and knows this was an accident. The facility concluded in the Investigation Summary, After thorough investigation that included review of the fall event, skin assessments of other residents, interviews with staff and with the POA, [facility name] cannot substantiate neglect. The care plan was followed. Shortly before dinner on January 21, 2022, a visitor asked for [R1's] bed to be raised and floor mat to be removed so she could visit directly at bedside. When the visitor right before dinner [sic], she failed to lower the bed or tell staff she was leaving, [R1] was then found on the floor minutes before 5pm. [R1's] care plan has been reviewed and updated. Through the investigative process, it was found that when the nurse found [R1] on the floor the bathroom door was partially open, blocking the line of site to the bed. A sign was placed on both sides of the bathroom door to state: keep open (so staff can identify if visitors leave the bed at standard height). In good faith effort, [facility name] will continue to periodically audit fall interventions and report audits to QAPI (Quality Assurance and Performance Improvement). [R1's] pain will continue to be assessed and treated. *Of note, R1's Care Plan was not followed, as R1's bed was left in high position without supervision and fall mat was not in place next to bed when the fall occurred. Surveyor reviewed the Staff interview question forms. The questions included: 1. Did you help (R1) with cares on 1/21/22? 2. What time did you help (R1) with cares on 1/21/22? 3. Did you see anyone in (R1's) room between 2pm - 5pm? If so, who and what were they doing? 4. Did you make any other observations in (R1's) room on 1/21/22? The facility provided Surveyor with staff interview answer sheets with answers as follows: - CNA G answered no to questions 1, 3, and 4 and N/A (not applicable) to question 2. - CNA F answered, doesn't remember, doesn't think so to question 1, N/A to question 2, and no to questions 3 and 4. - LPN H answered no, was her nurse to question 1, meds - last time was noon to question 2, no to question 3, and no, nothing abnormal to question 4. - There was no Staff Interview Question form provided for NA I, although the facility investigation summary indicates she was interviewed. On 3/1/22, at 11:35 AM, Surveyor spoke with NHA A (Nursing Home Administrator) regarding R1's fall investigation and asked who put the bed up. NHA A stated, We don't know who raised it. We talked to all staff who worked on the hall on the shift. None of them said they raised the bed. No one fessed up. On 3/1/22, at 11:55 AM, Surveyor spoke with R1's POA who was in the facility to visit R1. POA stated she was out of state at the time R1's fall occurred but was called. POA indicated R1's visitor on the day of the fall was a family friend who would visit often when POA was not able to. POA stated from what she understood, on the day of the fall, the family friend came to visit, and a meal tray was brought in so the visitor asked if R1's bed could be raised to eat. POA said the visitor thought just the head of the bed would be raised, but they raised the whole bed. POA said when the visitor left, she didn't tell anyone and didn't think to because, she's not a medical person. On 3/1/22, at 12:14 PM, Surveyor spoke to R1's visitor/family friend from the day of 1/21/22 on the phone. R1's visitor/family friend indicated on 1/21/22 she visited after lunchtime. Surveyor asked R1's visitor/family friend for a summary of what took place when she arrived to when she left, and R1's visitor/family friend indicated when she arrived, R1's meal tray was sitting off on a side table away from the bed and R1's bed was in low position. The lid was still on her food, so she asked if staff could raise the bed so R1 could eat and they did, but she could not remember whom she asked or who did raise the bed. R1's visitor/family friend stated R1 woke up and ate well, and she wondered if she would have eaten if R1's visitor/family friend had not come in that day. R1's visitor/family friend said shortly after she arrived, a staff member from R1's Hospice provider arrived to bathe R1. R1's visitor/family friend said she continued to visit while R1 finished her meal and then left so Hospice could work with R1. R1's visitor/family friend indicated the Hospice staff member was in R1's room when she left. Surveyor requested a copy of R1's visitor sign in sheet, which revealed R1 had only one visitor on 1/21/22 with a sign in time of 12:12 (PM) and a sign out time of 1:10 (PM). On 3/1/22, at 12:00 PM, Surveyor spoke with LPN H, who indicated she was the nurse who found R1 on the evening of 1/21/22 after her fall. LPN H stated she thought the incident might have happened around 4:00 and it was before supper. Surveyor asked who delivers meal trays, and LPN H stated it is typically done by CNAs. On 3/1/22, at 1:50 PM, Surveyor spoke with NHA A and asked when staff were interviewed to find the root cause of R1's fall. NHA A stated, I spoke to the three staff here that day around 4:45 and indicated HR E did the document interviews a few days later (1/27/22). Surveyor asked NHA A if she was aware Hospice had been in to work with R1 on 1/21/22 prior to her fall, and she said, Yes [staff name - Social Worker] reminded me of that today. Surveyor asked if Hospice had been contacted or interviewed regarding their interactions with R1 on the day of her fall and she indicated SW J (Social Worker) called hospice. Surveyor asked NHA A what the expectations were from an outside provider working with a resident in the building and she stated, Follow the care plan. [POA's name] thought hospice was here first, then the visitor. Surveyor asked NHA A if the facility interviewed R1's visitor/family friend. NHA A stated, I did not. [POA's name] said she felt bad, and I didn't want to re-traumatize her because it wouldn't have changed what we did for (R1). On 3/1/22, at 2:14 PM, Surveyor spoke with SW J and asked if she spoke with hospice or interviewed anyone from hospice regarding R1's fall. SW J stated, I didn't. SW J indicated she spoke with R1's visitor/family friend while R1 was still in the hospital. It is important to note that R1's visitor left the facility at 1:10 PM and R1 was found on the floor in her room at 5:15 PM according to the facility self-report. The facility did not complete a thorough investigation into the fall and did not realize hospice staff was in the room after R1's visitor left. Facility staff did not identify R1's fall interventions were not in place prior to her fall with fracture. The facility does not have documentation related to hospice care provided to R1 on 1/21/22 and did not request information or attempt follow up with hospice prior to the day of survey. The facility did not conduct interviews with all staff in the facility on the day of R1's fall or interview R1's visitor, both of which could have provided more information for the investigation. Staff were not educated to assure fall interventions remain in place. R1's fall interventions were not in place R1 fell and sustained a fracture.

Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 sampled residents (R1). R1 had an acute change of condition evidenced by an elevated heart rate, appeared tired and had decreased oral intake. The facility failed to recognize the change of condition, complete a full system assessment, or complete further monitoring of R1 or update R1's physician. R1 deteriorated further the following day and was sent to the emergency room where R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The Facility's Policy and Procedure entitled Acute Condition Changes- Clinical Protocol with a revision date of March 2018, documents, in part: Assessment and Recognition .someone with unstable vital signs .the nurse shall assess and document/report the following baseline information: a. Vital signs .The nursing staff will contact the physician based on the urgency of the situation .The nurse and physician will discuss and evaluate the situation .The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician with adjust treatment accordingly . R1 is a long term resident of the facility. R1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's vital signs record documents her range of heart rates prior to 11/13/21 to be between 63-84. R1's progress notes document the following: 11/13/21 at 2:45 PM- Several staff report to RN D (Registered Nurse) that R1 is not herself, appearing tired and very anxious at times, only took a couple bites and sips of food and fluids for breakfast and lunch, staff note she has a new roommate, R1's sister hadn't been visiting regularly due to her mother being ill, heart rate of 115, non-verbal signs (flinching/jumping, facial expressions) of pain with repositioning, no [CONDITION(S)] to extremities, sister/POA (Power of Attorney) updated, in agreement that symptoms more likely mental and situational than medical, ADON (Assistant Director of Nursing) and will update NP (Nurse Practitioner). Of note- normal resting heart rate for an adult is 60-100 beats per minute; generally a lower heart rate at rest implies more efficient heart function and better cardiovascular fitness per Mayo Clinic. It is important to note that R1's medical record does not show that the facility consulted with R1's Physician/NP regarding her elevated heart rate or pain. It is also important to note that there is no further documentation in R1's medical record that shows the facility was monitoring and assessing R1's elevated heart rate or pain. 11/14/21 at 9:23 AM- R1 appears worse today, very lethargic and pale, not able to receive oral intake or medications, heart rate of 138, respiration rate of 22, POA and Physician contacted with order to send R1 to ER (emergency room ). Of note- normal resting respiration rate for an adult is 12-16 breaths per minute per John's Hopkins. 11/14/21 at 1:40 PM- R1 will be admitted at least related to not eating/drinking, she's dehydrated, high WBC (white blood cell count). R1's record does not include any other heart rates on 11/13/21 after the reading of 115 or on 11/14/21 until the heart rate of 138 is documented, after which R1 is being sent to the ER. R1's hospital documentation had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was given 2 liters of LR ([MEDICATION(S)] Ringer's- is used to replace water and electrolyte loss in patients with low blood volume or low blood pressure) IV (intravenous- directly into a person's vein). On 1/12/22 at 5:05 PM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D to explain the events as she recalls from 11/13/21, the day prior to R1 going to the ER; RN D explained that R1 didn't want to eat or drink that day at all but that she would do that from time to time, she had an elevated heart rate, that she called the POA 1st to get directive as to what she wanted to do. Surveyor asked RN D what did R1's POA say at that time, RN D said she'd prefer R1 not to go to the hospital as she felt like this could be from all the changes in her routine. Surveyor asked RN D if she notified R1's Physician, RN D said she updated an on call Physician that told her to keep R1 at the facility and monitor. Surveyor asked RN D how often should R1's heart rate have been re-checked, RN D said it should have been checked at least every shift. Surveyor asked RN D if there should be documentation of Physician notification, RN D replied yes. On 1/12/22 at 3:34 PM, Surveyor interviewed ADON C (Assistant Director of Nursing). Surveyor asked ADON C if she had a resident with an elevated heart rate, what she would do; ADON C stated I would re-check the heart rate to ensure it was accurate, notification of Physician and Family/POA, repeat vital signs and add that resident to the clinical report sheet for change of condition. Surveyor asked ADON C how often would vital signs be repeated, ADON C said at least every shift or as directed by Physician. On 1/12/22 at 4:12 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when a Physician should be consulted in relation to vital signs, DON B said if they are abnormal for the resident elevated or lower than normal; it should be re-checked to verify that it is accurate and then the Physician to be updated. Surveyor asked DON B if a resident has an elevated heart rate, what would she expect her staff to do; DON B stated first re-check the heart rate, if it is consistent then update the Physician, follow orders given by the Physician and update the DON and POA on situation. Surveyor asked DON B if the resident is to remain in the facility and the heart rate is to be monitored, how often would she expect that to occur; DON B said at least every shift. Surveyor asked DON B if there should be documentation of Physician/NP notification, DON B said yes, in the progress notes. Surveyor asked DON B if there was anywhere else that it could be documented, DON B said possibly on their clinical report sheets. NHA A (Nursing Home Administrator), who was also present, stated if the on call Physician was updated they would have this documented as well. On 1/12/22 at 5:10 PM, Surveyor interviewed RN E. Surveyor asked RN E if he could explain what he recalled from 11/13/21, the day prior to R1 going to the ER; RN E said he was in the facility working the floor that day, it was a Saturday, he had attempted to assist R1 with her meals and he could only get her to take sips and very little food; no symptoms of pain and flat affect, which wasn't like R1, she wasn't herself. Surveyor asked RN E if he knew if a Physician was notified about the changes noted in R1; RN E said he believed RN D had taken R1's vital signs, called the on call Physician. Surveyor asked RN E if he knew what the on call Physician said, RN E replied to monitor her and possibly draw labs on 11/14/21 but then on 11/14/21 after RN D talked with the POA R1 went to the ER. It is important to note that the Facility was unable to provide evidence the on-call physician was notified. There was no further documentation to show the facility continued assessments related to R1's change of condition until her condition significantly deteriorated and R1 was transferred to the ER.

Based on interview and record review, the facility did not ensure each resident was provided adequate pain management consistent with professional standards of practice the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 supplemental residents (R13). On 9/9/19, R13 began having new complaints of right hip pain. The facility failed to assess R13's new complaints of pain from 9/9/19 to 9/17/19. On 9/28/19, an x-ray was ordered and R13 was found to have a sub capital [MEDICAL CONDITION] hip. This is evidenced by: The facility policy, Pain Management, undated, states, in part: . Policy: A comprehensive pain assessment will be completed if pain is present at admission and with the onset of any new pain. Purpose: To provide comfort at a level acceptable to each resident through adequate recognition, assessment, treatment and monitoring of acute and chronic pain. Procedure: I. Recognition of pain will occur through regularly and systematical assessment for pain. B. At each quarterly review and at any time that a change in condition prompts completion of the MDS. D. With the onset of new acute or uncontrolled chronic pain per weekly pain summary and TCP (Temporary Care Plan) protocol. 1. Initiate a Pain TCP for all uncontrolled pain (moderate, severe, or very severe or use of more than 5 as needed (PRN) meds in one week for same condition). II. 3. Observe the resident for nonspecific or behavioral signs and symptoms that suggest pain. B. 3. Assess how pain is affecting the resident's mood, ADL's (Activities of Daily Living), sleep, and selected quality of life measures. Determine whether the current level of pain relief is consistent with the resident's care goals. 6. Note dosage and frequency of administration of all pain medications. C. 1. All pain assessments and ratings will use the (Facility Name) Pain Rating Scale to assure inclusion of verbal and non-verbal signs of pain. 2. PRN [MEDICATION NAME] will have the level of pain (0-10 scale) recorded in the reason and result column of the PRN MAR (Medication Administration Record). 3. Nurses will record the pain rating, location of pain, treatment, sedation level, and other observations on the Pain Flow Sheet twice per shift and with PRN medications given, when active Pain TCP is in place. 4. All physicians' orders for [MEDICATION NAME] will include the level of pain that the [MEDICATION NAME] is to be used for. 5. Residents with acute pain will be reassessed at least daily until the pain is substantially controlled. C. 1. Pain characteristics (e.g. frequency, intensity). In the cognitively impaired resident, review and assess behavioral signs and symptoms that suggest pain. 2. The impact of pain on the resident's mood, activities of daily living, sleep, and selected quality of life measures. 3. The treatment plan and effectiveness of current medications and complementary treatments. The facility policy, Behavioral Assessment, Intervention and Monitoring, dated (MONTH) 2019, states, in part: . General Guidelines. 1. Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. b. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. Cause Identification. 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address and modifiable factors that may have contributed to the resident's change in condition, including: [NAME] Physical or medical changes (for example): 3. Pain or discomfort. Management. 1. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident or staff, or behavior that signals underlying distress. The facility policy, Acute Condition Changes - Clinical Protocol, last revised (MONTH) (YEAR), states, in part: . Assessment and Recognition. 2. In addition, the nurse shall assess and document/report the following baseline information. c. Current level of pain, and any recent changes in pain level. e. Cognitive and emotional status. g. Onset, duration, severity. 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident. (For example, a decrease in food intake, increased agitation) and how to communicate these changes to the Nurse.) 4. Nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. 9. a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. Monitoring and Follow-up. 3. a. The physician will make interim visits as needed to assess the situation (especially if the individual is not stable or is not improving as anticipated). R13 was admitted to the facility on [DATE]. R13's [DIAGNOSES REDACTED].[MEDICAL CONDITION] and [MEDICAL CONDITION] following cerebral infarction, dysphagia, [MEDICAL CONDITION] disorder, Vitamin D deficiency, dementia with behavioral disturbance, and major [MEDICAL CONDITION] single episode. R13 has a history of long term use of anticoagulants and is currently taking Eliquis. R13's MDS (Minimum Data Set), dated 7/10/19, indicates a BIMS (Brief Interview of Mental Status) score of 8, indicating moderate cognitive impairment. Section D, Mood indicates resident has symptoms of feeling down, depressed, or hopeless several days and is feeling tired or having little energy nearly every day. Section E, Behaviors indicates R13 had no behaviors during the look back period. Section J, Health Conditions indicates R13 is on a scheduled pain regimen, does not use PRN (as needed) pain medications and has not used any non-medication interventions for pain. Pain interview was able to be completed with R13. R13 voiced rarely has pain. Pain does not interrupt sleep and does not limit day-to-day activities. Total pain severity score for R13 is a 3 on a scale of 0/10 (zero out of ten with zero meaning pain free and 10 meaning unimaginable pain). Surveyor reviewed Physician and NP J's (Nurse Practitioner) Notes which indicate, in part: . NP J last saw R13 on 8/5/19 . R13 has no acute medical concerns. Mood/behaviors: Increase in depression recently related to husband's death. No issues with anxiety. Pain: Denies pain or discomfort. Behavior monitoring for R13 indicates the following: August Behaviors: Agitated or yelling at staff: Did not happen any more than 4 times each day shift, no more than 6 times on evening shift, and no more than 2 times on night shift. Sign and symptoms of depression (i.e. - negative statements, tearfulness, sad mood, I want to go home): Did not happen any more than 6 times on day shift, 10+ times on evening shift, and no more than 4 times on night shift. September Behaviors: Agitated or yelling at staff: 10+ times on day shift, 10+ times on evening shift, and no more than 4 times on night shift. Sign and symptoms of depression (i.e. - negative statements, tearfulness, sad mood, I want to go home): 10+ times on day shift, 10+ times on every evening shift from 9/2/19 to 9/30/19, and no more than 5 times on night shift. (Note: Behaviors did increase from (MONTH) to September.) Surveyor requested R13's care plan prior to revisions that were made on 10/1/19. Facility was unable to provide that documentation. Nurse's Notes, from 9/9/19 thru 9/28/19, state in part; 9/9/19 at 11:08 AM, Resident tearful with bed mobility c/o (complained of) R (Right) hip pain. 9/9/19 at 10:42 PM, Assisted primary CNA (Certified Nursing Assistant) in getting her up for dinner; res (resident) very teary with each 'roll;' Yelled 'it hurts' when asked where she replied, 'right hip' (she has been laying on right hip). When grippy sox put on 'it hurts' when place in sling 'it hurts' and was crying openly because of her pain. Primary states, 'she's always been teary, but the intensity and frequency has increased over the past month.' Writer did request low-dose MS04 ([MEDICATION NAME]) for comfort and to ease distress. 9/10/19 at 11:12 AM, Writer discussed pain/behaviors with NP [NAME] NP J would like staff to monitor for a week and update. 9/10/19 at 11:57 PM, Writer interviewed resident after greeting inquired how are you doing. She replied 'terrible' and immediately began crying. Waited a bit and asked 'why, how can we help.' She just cried. Asked if she had pain, she cried. Was there anything we could do? Declined to respond. Primary CNA informs Writer her crying spells have increased in frequency and intensity lately. 9/11/19 at 8:53 AM, Resident crying and difficult to console this shift. When asked why crying responded, Who the hell wouldn't be crying? 9/12/19 at 9:47 PM, Resident very tearful after supper and stated, get me out of here, Give me my car back, Please just help me get out, Send me out in an ambulance. 9/13/19 at 1:19 PM, Resident tearful after breakfast and observed as uncomfortable. PRN Tylenol had been given and muscle rub applied. PRN Tylenol given at 13:00 (1:00PM), NP J notified of resident c/o hip pain. (Note: Muscle rub not signed out on MAR (Medication Administration Record), discontinued on 9/13/19.) 9/13/19 at 3:08 PM, Writer returned call to NP J d/t (due to) increased anxiety and pain. Writer left message stating that PRN Tylenol, muscle rub, or the pain patch it (sic) not helping control the pain. NP J gave verbal order given to increase APAP (Tylenol) to 1000 mg (milligram) TID (three times a day) and to dc (discontinue) the PRN APAP dosage. NP J also gave verbal order to start [MEDICATION NAME] 1% gel 4x (times) a day. 9/14/19 at 6:24 AM, CNA informed Writer that pt (patient) was crying around 03:00 (3:00AM), Writer went in to see pt and awake crying in bed. Writer asked what the matter was, she said, I want to get out of this place or I'll call the police. Writer asked if there was anything else she'd like, she said, Get me out of here I want to go home or I'll call the police. Writer said she could not take her out of the nursing home but would come check on her later. She went back to crying. 9/14/19 at 9:24 AM, Reported some pain to R hip. Reported APAP and [MEDICATION NAME] somewhat effective. 9/15/19 at 9:38 AM, Resident continues to cry in bed and report pain to hips and legs, especially with bed mobility and cares. [MEDICATION NAME] applied with little improvement. 9/15/19 at 10:47 PM, Behaviors, crying and negative statements monitored this shift. When resident was awake she was miserable AEB (sic) crying, negative statements, Get me outta here; I'm gonna call 911; I'm gonna walk outta here, et al. Staff got her dressed and into DR (dining room) for dinner and she was crying while waiting for dinner. Resident does state, Everything hurts. 9/16/19 at 12:59 PM, Resident had 1 episode of crying and frustration. 9/16/19 at 9:31 PM, Resident tearful throughout shift. Resident stated, Just kill me. I want to get out of here. I wish I would just die. 9/17/19 at 1:25 PM, Tearful episodes noted intermittently throughout shift. Resident states, I need to get out of here, I need to get home. I will call the police if you don't help me. 1:1 (one-on-one), redirection, music and memory, food/fluids and repositioning ineffective. 9/17/19 at 9:24 PM, Resident tearful tonight. C/o of right hip pain with movement. No apparent injury noted e/b (evidenced by) no inward/outward rotation of feet, able to bend knee without difficulty. Resident crying out for help during cares. Resident currently sleeping. (Note: This was the first time an RN (Registered Nurse) had completed any form of assessment on R13.) 9/19/19 at 2:43 PM, Resident reported pain to CNA during cares, requested PRN APAP. No PRN APAP available, PRN muscle rub applied to hips and lower back. 9/20/19 at 11:26 AM, Continues to have intermittent tearful episodes. 1:1, music and memory, distraction, food/fluids, repositioning, scheduled medications and muscle rub minimally effective. States, I need to get out of here. 9/20/19 at 10:54 PM, Resident tearful at supper. Resident frequently calling out Is anyone out there. Help me! 9/21/19 at 12:28 PM, Staff reported resident was in tears with morning cares and stated she had R leg pain. [MEDICATION NAME] applied and pain patch applied to back. 9/21/19 at 1:15 PM, Staff reported resident was c/o R hip pain. Resident told Writer her pain was all over. Resident currently receives scheduled Tylenol 1000 mg TID (three times a day). Writer palpated hip area anterior and posterior, no moaning, or facial grimacing noted. Writer offered position change, declined. NP is aware and has orders in place to monitor and document mood, behavior and pain. (Note: 9/21/19 at 1:15 PM, note was completed by an LPN (Licensed Practical Nurse) . This LPN did not pass on complaint or request an RN assessment of R13.) 9/21/19 at 8:56PM, Resident tearful before supper, facial grimaced and made negative statements just let me die. Resident tearful after supper and yelled out Can I get some help in here? Somebody come help me. Help me or else I will just leave. Resident refused music and memory. Resident unconsolable (sic) with 1:1 and kept crying. Resident grimaced with using the medi lift stating 'my leg.' Resident grimaced and tearful with repositioning stating it's the whole leg that hurts. 9/22/19 at 9:19 PM, Resident crying in room after supper. Resident frequently calling out Can I get some help in here, Is anyone there, Please help me. Writer asked resident if she was in pain and resident stated, It's my legs. If you do not help me I will call an ambulance. Scheduled APAP and [MEDICATION NAME] applied. Resident did not want to listen to music but chose to watch TV. Writer re-assessed in one hour and resident continued to be tearful and make negative statements. 9/22/19 at 9:26 PM, Resident expressed facial grimacing and started to cry when staff changed the resident's incontinent brief. Scheduled [MEDICATION NAME] applied post care. 9/23/19 at 10:53 PM, Behavior: Near 11 PM, Writer just walked down hall to get snack for 2 residents; heard resident crying out loud, states 'my legs hurt' and wants to 'get outta here.' 'Will call the police.' Very unhappy and has pain in BLE (bilateral lower extremities). 9/24/19 at 10:14 AM, Crying with AM (morning) cares but once up in w/c (wheelchair) stopped. CNA just told Writer crying again so Writer repositioned R leg in bed (stated her R leg hurt all over) and gave scheduled [MEDICATION NAME] gel. 9/24/19 at 11:49 PM, Writer assisted with PM (evening) cares and observed resident quiet at first, but when legs moved she yelled it hurts and began to cry. PM scheduled meds administered. 9/25/19 at 5:31 AM, Resident had tearful episode around 00:30 (12:30AM), baseline behavior noted. I want to get out of this place, I want to go home. PRN [MEDICATION NAME] applied to BLE for comfort. 9/25/19 at 9:28 PM, Resident crying in dining room stating, What's going on? Get me out of here. Resident crying in her room stating Can I get some help in here? I'm never going to come back here. I'm going to call an ambulance. Resident grimaced and cried with turning side-to-side in bed and using the medi lift. Resident stated, Please just let me die. States her legs hurt when moving them. 9/25/19 at 9:35 PM, Left message for NP J asking if she recommends the resident get an x-ray of her legs to see if she has a pathological fracture. (Note: There is no documentation that NP J ever responded to the nurse's request for x-ray.) 9/26/19 at 10:34 PM, Resident continues to have intermittent tearful episodes. 1:1, food/fluids, diversion, music and memory, repositioning and scheduled APAP minimally effective for tearfulness. Writer followed up with ADON (Assistant Director of Nursing) regarding plan moving forward - NP J would like nursing to continue to observe/monitor behaviors and pain at this time. 9/27/19 at 2:41 PM, Writer spoke with HCPOA (Healthcare Power of Attorney) regarding resident's pain and behaviors. Writer discussed progress notes with HCPOA and ineffectiveness of APAP, [MEDICATION NAME] and [MEDICATION NAME] gel orders. Writer discussed alternative options with HCPO[NAME] HCPOA stated, I want my mom to be comfortable and would like her started on [MEDICATION NAME] to help with pain and behaviors. 9/27/19 at 4:32 PM, Resident began crying out before supper stating, Can I get some help in here? Is anyone out there? Writer spoke with resident and asked Are you in pain? Resident stated, All over! If I don't get some help in here I am going to the emergency ward. 9/27/19 at 9:43 PM, Crying and calling out after supper. Can I get some help in here? Where is everyone? Please just let me die! 9/28/19 at 4:19 AM, Patient yelling and crying, I want to go to the hospital, c/o pain in R leg. Repositioning did not help. There are no PRN pain meds Writer can give. Call placed to Pt's POA (Power of Attorney) to inquire if she would like pt sent to ER (emergency room ) for evaluation of uncontrolled pain in RLE (right lower extremity) That despite her scheduled APAP and [MEDICATION NAME] gel, she continues to cry every shift for most of the shift and she has nothing ordered on N[NAME] shift Writer can give her. POA states, What about the [MEDICATION NAME]? Writer said that RN O noted a conversation with her about getting [MEDICATION NAME] for R13, but there was no order for it. Writer said the on-call doctor for the weekend could be called and Writer would ask for [MEDICATION NAME] as she requested, and call her back with answer. POA Agreed. (Note: [MEDICATION NAME] was requested by HCPOA on 9/27/19 at 2:41PM, but there is no documentation indicating it was requested.) 9/28/19 at 5:04 AM, Doctor ordered a 2 view x-ray of R hip for tomorrow in addition to PRN [MEDICATION NAME] 5-325 mg, 1-2 tab for 3 days only, to give once on N[NAME] (Night) shift PRN. Also to hold HS (bedtime) APAP for those 3 days. 9/28/19 at 12:35 PM, Mobilex arrived and completed x-ray. Resident tearful in bed/Broda for most of shift, though sometimes denies pain to R hip but then will state, Well yeah I have pain there. What do you think? Also stating, Just get me out of here or I will call the police, etc. Administered [MEDICATION NAME] with no reported good results. Did wince and cry out with transfers. On 9/28/19 at 2:14PM, Facility received results of x-ray ordered by on-call physician. Radiology report conclusion is a subcapital [MEDICAL CONDITION] hip. There is severe [MEDICAL CONDITION]. R13's pain medication was administered and changed as follows: [MEDICATION NAME] 4% on in the AM and off at HS starting 4/17/18 Tylenol 1000 mg 8 AM and 8 PM from 4/3/19 - 9/13/19 Tylenol 650 mg every 4 hours PRN from 4/3/19 - 9/13/19. R13 received PRN Tylenol 1 time on 9/9/19, on 9/10/19 and 9/13/19. Tylenol 1000 mg TID from 9/13/19 - 9/28/19 [MEDICATION NAME] 1% gel four times a day starting 9/13/19 - open ended Tylenol 1000 mg at 6 AM and 12 PM from 9/28/19 - 10/1/19 [MEDICATION NAME] 5-325 mg, 1-2 tabs every 4 hours PRN, starting on 9/28/19 - open ended. R13 received PRN [MEDICATION NAME] 1 time on 9/28/19, on 9/29/19 and 9/30/19. On 10/1/19 at 8:17 AM, Surveyor interviewed CNA G. Surveyor asked CNA G what she could tell Surveyor about R13. CNA G stated R13 is always weepy; recently I noticed that transfers were okay, but when rolling for cares, R13 was a little more teary, when rolled onto the left hip. Surveyor asked CNA G if crying was new for R13. CNA G stated, The increase in crying, is different than R13's normal. Surveyor asked CNA G what she would do when R13 would begin crying. CNA G stated, I would try to get resident as comfortable as possible, then tell the Nurse working on unit, and that could be either an RN or LPN. Surveyor asked if CNA G ever reported R13's complaints to ADON C or DON B (Director of Nursing). CNA stated, I never reported the increase in behaviors or crying to the ADON C or DON B, just the Nurse on the unit. Everyone thought it was just behaviors, but R13 was saying she wanted to go to the hospital and that was new. Surveyor asked when and what other things did you notice R13 doing or saying that was new. CNA G stated, Last month has been saying 'ouch' a lot and cried more with rolling than normal. On 10/1/19 at 8:29 AM, Surveyor interviewed LPN H. Surveyor asked LPN H what she could tell Surveyor about R13. LPN H stated, I was not really familiar with her until she was moved from the North Hall to the South Hall. I was told that R13 had always been tearful. Then two weeks ago, I noticed she was still more tearful than normal, so I approached ADON C and asked what the plan was for R13. ADON C stated, that per t NP J, they were going to continue to monitor resident and that R13's calling out did not appear to be more than baseline. Surveyor asked LPN H if she ever looked back at R13's previous behaviors or notes to see if this was new. LPN H states she reviewed previous notes and spoke with RN I about behaviors and crying, as she was familiar with R13 from the North Hall. R13's husband has recently passed away and she has changed rooms. I thought the behavior was normal, did not suspect an injury. Surveyor asked LPN H if she ever asked an RN to assess R13. LPN H stated, I don't know that I did, but everyone was aware of the situation, the tearfulness, and discomfort R13 was having, everyone knew about. On 10/1/19 at 8:39 AM, Surveyor interviewed CNA K. Surveyor asked CNA K what she was able to tell Surveyor about R13. CNA K stated, Since R13 has been here, she has always had crying behaviors, but last month she has been crying harder and more often, so similar but more intense. Surveyor asked when CNA K noticed more crying with R13. CNA K stated, Rolling in bed, there was an increase in crying. Sometimes she would say that her leg hurts, but others it was whole body or just wants to get out of here. Surveyor asked CNA K what was done by staff when R13 would show an increase in crying behaviors. CNA K stated, A Lot of the time we will do repositioning to make R13 more comfortable, put to bed, and report to the Nurse. We did a lot of distraction and that has not been working. We would move off side that hurts and that works for only a short time. Surveyor asked CNA K if she ever reported R13's complaints to anyone. CNA K stated, I reported to the Nurse every time I noticed R13 to be more upset or agitated. Surveyor asked CNA K if she ever reported new symptoms to ADON C or DON B. CNA K stated, I never reported it to the ADON C or DON B. On 10/1/19 at 9:08 AM, Surveyor observed CNA G and CNA L complete transfer and cares on R13. CNA G hooked R13 up to full body lift. CNA L explained to R13 that they were going to lift her up and put her into bed. When CNA L began to lift R13 up from Broda chair, R13 began to moan. CNA L moved R13 towards the bed and began lowering R13 into bed. R13 continued to be tearful and crying. CNA L explained to R13 that they were going to roll her to remove sling from under her. R13 continues to moan and cry as CNA G and CNA L rolled R13 back and forth to remove full body sling from under her. CNA G asked R13 how that feels, R13 states, Terrible. On 10/1/19 at 9:11 AM, Surveyor spoke with R13 and asked how she was feeling. R13 stated, Terrible. Surveyor asked what hurt, R13 states, Everything. It took days to figure out what was wrong with me. The pain is terrible. R13 continues to cry and moan. R13 then states to Surveyor, I am going to sue this place. R13 asked if Surveyor was the building Administrator; Surveyor explained to R13 who I was and asked if she wanted Surveyor to have the Administrator come speak with her. R13 stated, I want some help, I don't think I should have to suffer. Surveyor left R13's room and approached CNA G. Surveyor asked CNA G if resident was able to have any pain medication, as she was complaining of pain. CNA G stated R13 was not able to have any pain medication at this time. Surveyor asked CNA G, who also is the Medication Aide, when and what R13 last received for pain. CNA G states, Tylenol 1000 mg was given at 6:30 AM, but nothing since. We try to give pain medication around the time we are going to be doing cares. Surveyor asked CNA G if staff stop doing something that is causing pain to R13 and come back later. CNA G stated, I will usually stop. Talk with her and distract or redirect. Don't normally stop and reapproach; just get transfer or cares completed and get R13 more comfortable. On 10/1/19 at 9:18 AM, Surveyor interviewed CNA M. Surveyor asked CNA M what she could tell me about R13. CNA M stated, About a month ago I noticed increased crying and words being used, like get me an ambulance, take me to the hospital. R13 was also stating her hip hurt and those things were all new. Surveyor asked CNA M when she noticed increased complaints of pain. CNA M states, When rolling onto the left hip, noticed R13 crying out more and when in the sitting position in full body lift. I kept telling everyone and finally I said, 'NO, something is wrong.' Whenever there was a Nurse around, I would talk to them about R13. DON B was the Nurse on floor one day and she did an evaluation. I literally talked to all the Nurses. A lot of them would just tell me it was a behavior. I kept telling them it was something different. CNA M also stated, I had another CNA with me one day and when we rolled her over onto the left hip, exposing the right hip, the right hip did not look right, it looked like 'Jell-O'. I went right away and told the Nurse on the floor, who was LPN N, and she went in to look at R13. LPN N pushed on the hip, but R13 didn't yell out, so we rolled R13 to show LPN N the discomfort she was having. I also heard the family was being difficult with pain medications. On 10/1/19 at 10:45 AM, Surveyor interviewed ADON C. Surveyor asked ADON C what she could tell Surveyor about R13. We notified NP and MD (Medical Doctor) multiple times about increased crying and pain. Surveyor asked ADON C when the change in R13 was noticed. ADON C stated, It's hard to tell, R13 does have a crying behavior. R13 was recently moved from North Hall to South Hall, the South Hall is not as loud. ADON C goes on to state, NP J wanted to let R13 acclimate to new room. ADON C states, Staff kept raising concerns about behavior and pain. At one point I told NP J that R13 used to be on [MEDICATION NAME]. NP J was not aware of her being on [MEDICATION NAME] in the past and requested we continue to monitor for behaviors. Surveyor asked ADON C if CNA's or Nurses reported R13's complaints of hip pain to her. ADON C states, Not specifically. Surveyor asked ADON C if she ever reviews Nurse or CNA charting. ADON C stated, Sometimes. Surveyor asked ADON C what she would expect staff to do when a resident shows a change in behaviors or complains of pain. ADON C stated, Staff should report concerns to me or another Nurse. I expect new complaints to be reported so that we can look into them. I know NP J was updated on new sources of pain for R13. Surveyor asked ADON C about requests made for [MEDICATION NAME]. ADON C stated, I just heard this yesterday. The APOAHC (Activated Power of Attorney for Healthcare) is out of state. My concern is that we aren't treating pain. Surveyor asked ADON C, if you don't get an answer from NP J or the MD, what would you expect staff to do. ADON C states, Staff should be reporting to me, DON B, or consult with the Medical Director. Surveyor asked ADON C, Can an LPN assess? ADON C stated, No, they should not be assessing. They should have an RN do any assessments or observe an RN assessment. Surveyor asked ADON C if she had completed any observations of transfers with R13. ADON C stated, No, I have not observed a transfer, but staff report crying and discomfort. Surveyor asked ADON C, if R13 is crying and shows discomfort during cares or transfers, what is your expectation of staff? ADON C stated, I expect staff to report discomfort, to stop and reapproach. Surveyor asked ADON C if R13's crying was a targeted behavior for her that staff monitored. ADON C stated, I don't know. On 10/1/19 at 10:00 AM, Surveyor completed a phone interview with LPN N. Surveyor asked LPN N if staff had reported to her R13's pain complaints. LPN N stated, Yes, staff had been reporting pain periodically for the last couple of weeks. NP J is aware and we were aware of R13's complaints. We were charting to try to establish a pattern and determine where the issue lies. Surveyor asked LPN N what else she could tell Surveyor about R13. LPN N stated, I don't know her well, she is on South Hall now, was on the North Hall prior to this. There were behavior concerns when R13 was on North Hall, according to those staff members. Surveyor asked LPN N what concerns staff of the North Hall had with R13. LPN stated, R13 would yell 'Help!' 'I'm going to call the police,' 'Call an ambulance,' 'I want to go home.' I believe this was her baseline on the other hall. Surveyor asked LPN N if she ever did any observations of R13. LPN N stated, I did assess pain. The CNA working thought it was knee, I lightly palpated, looked for any abnormality, and there was no warmth, no grimacing and no yelling. R13 just laid there. I checked both hips front and back, no reaction was given from R13. LPN N also stated, There were times the CNA would tell me that R13 was crying and had pain and I would go in there and she would be smiling, no pain. Yesterday, she was calling out and I got her something for pain. R13 looked at me and stated, 'I'm okay,' but she had to have been having pain. I then contacted x-ray, but they couldn't tell me how old R13's injury was, but said she had [MEDICAL CONDITION]. Surveyor asked if R13 was able to tell LPN N about pain. LPN N stated, I think she has lucid moments and behaviors. She does answer appropriately sometimes and can tell you what is wrong. Surveyor asked LPN N when she first was informed of R13 complaining of right hip pain. LPN N stated, Early last week I was told by the CNA's that R13 was complaining of leg pain. I gave her scheduled Tylenol and that seemed to work well. Surveyor asked LPN N if she ever observed a transfer with R13 when she was told of complaints of pain with transfers and cares. LPN N stated, Not that I recall. CNA's would report discomfort with cares or transfers, but not every transfer. On 10/1/19 at 10:55 AM, Surveyor interviewed DON B. Surveyor asked DON B what she could tell the Surveyor about R13 and R13's recently diagnosed [MEDICAL CONDITION]. DON B stated, I worked the floor Tuesday, (MONTH) 17th, CNA's noticed pain while turning in bed. She does cry, so it is hard to assess. R13 was stating, 'I want to go home.' She was crying and complaining of pain to right hip. CNA voiced to me she thought R13 should have an x-ray. Surveyor asked DON B if she ever completed an assessment of R13's right leg and hip. DON B stated, I assessed and there was no inward or outward rotation of the leg, no shortening of the leg, and no indication of fracture. The CNA said R13s' right knee got bent up and R13 wasn't crying. CNA said that when she rolled over she cried out, complaining of right hip pain, and she felt that R13 should have an x-ray. DON B also stated, R13 was moved from North Hall to South Hall. Staff on South Hall didn't know her behaviors. She cried out on North Hall, too and did complain of pain, but not a lot, not like this on the South. Surveyor asked DON B, when you did your assessment, did you complete ROM (range of motion) for R13's right hip. DON B stated, I did. Surveyor asked DON B where documentation of that could be found. DON B stated, I palpated hip and knee was bent. I should have

Based on interview and record review, the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment significantly for 1 of 15 residents reviewed for significant changes (Resident 15). Resident 15 was found to be unable to grasp or flex her wrist and was unable to follow with her eyes side to side or up and down. This was a significant change from Resident 15's baseline. Resident 15's physician was not updated immediately with Resident 15's significant changes. Evidenced by: The American Medical Director's Association (AMDA), Protocols for Physician Notification, includes the following: Suggested Guidelines for Physician Notification of Clinical Problems in Facility Residents, Weakness, arm or leg: Abrupt onset of noticeable change in strength or use: Notify Physician Immediately. Vision, partial or complete loss: Abrupt onset with pain, redness or other symptoms: Notify Physician Immediately. Resident 15's [DIAGNOSES REDACTED]. Resident 15's Minimum Data Set (MDS), with an ARD (Assessment Reference Date) of 3/21/14, indicated Resident 15 had moderate cognitive impairment, had adequate vision and had no upper or lower extremity impairment. Resident 15's medical record included the following Nurse's Notes entries: 5/7/14, 0440 (4:40 AM), Asked by CNA (Certified Nursing Assistant) to check resident while she was on the toilet. Had been transferred per EZ Stand. Resident unable to grasp hand rail, looked at hand as if it didn't belong to her body. After returning her to bed BP (blood pressure) 132/73, HR (heart rate) 63, R (respirations) 14, O2 Sat (oxygen saturation) 91% RA (room air). Able to raise her arm up off the bed without difficulty but wasn't able to flex wrist or grasp writers hand. Also not able to follow writers finger from side to side or (up or down) (with) her eyes, just looked forward. Answers questions appropriately. Will continue to observe and pass on info to AM nurse. It is important to know this was written by a Licensed Practical Nurse (LPN). 5/7/14, 0830 (8:30 AM), Resident L (left) arm completely flaccid (with) facial drooping. Able to move L leg. Able to lift her arm over w/c (wheelchair) arm. Res (Resident) (not) able to grip. c/o (complains of) arm aching. Call into (Resident 15's physician). Called therapy to assess as well. It is important to know this was written by an LPN. 5/7/14, 0900 (9:00 AM), Send to ER (emergency room )/(Resident 15's Physician's Nurse). Called daughter. Called 911. Called St. Mary's ER. Resident A & O (alert and oriented). Will continue to monitor. 5/7/14, 1224 (12:24 PM), admitted for possible stroke. Nurse at St. Mary's states "She is going to have an MRI (Magnetic Resonance Imaging, a medical test)." Resident 15's Hospitalist Discharge Summary, dated 5/9/14, included the following: Discharge Diagnosis: [REDACTED]. On 8/12/14 at 2:15 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility follows the AMDA Guidelines for Physician Notification. DON B stated she would have expected the nurse to have contacted Resident 15's physician immediately with the changes as they were documented.

Based on observation, interview, and record review, the facility did not provide comprehensive assessments to ensure that residents who are incontinent of bladder receive appropriate treatment and services to maintain or restore bladder function for 1 (Resident 7) of 16 sampled Residents. Resident 7 had declines in bladder function. The facility did not comprehensively assess the cause of the declines in bladder function, did not monitor the residents' usual voiding patterns, did not identify the types of incontinence, and did not explore reversible causes of incontinence in order to assist Resident 7 with restoring or maintaining as much bladder function as possible. This is evidence by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. The Long-Term Care Nursing Desk Reference states, " ... Incontinence is not a normal consequence of aging and can frequently be cured or improved. Many treatable problems contribute to incontinence. Some residents have several coexisting problems, and to successfully manage the incontinence, all must be identified and treated... Remember that the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. Their problem is often one of communication. They are unable to communicate the need to use the bathroom...Most believe that toileting residents every two hours is the best means of keeping them dry, when in fact this is a dated and ineffective method..." The facility policy titled "Bladder Assessment", dated 9/96, indicates: Purpose: to minimize episodes of incontinence. Policy; Incontinent residents will receive appropriate treatment to restore continence. Procedure: 1. Assess bowel and bladder continence at time of admission, quarterly, and when changes in incontinence are noted. 2. Complete Minimum Data Set (MDS) and, if triggered, RAP (Resident area problem) Urinary Incontinence... 3. Initiate Incontinence TCP (Temporary Care Plan) as indicated to collect data. 4. After 1 week, initiate TCP for bladder incontinence, prompted voiding, scheduled toileting, check and change as indicated on bladder log. 5. After 2nd week, decide approaches from TCP to be added to permanent care plan... The facility template TCP titled "Incontinence Bladder" approaches indicates... 3. initiate... bladder log to establish pattern of bladder emptying for 5 days... 6. Evaluate for reversible causes. Document in the nurse's notes. 7. Evaluate for other causes... 9. Reassess in 5 days (date) with Supervisor to determine treatment option. 10. Initiate TCP for appropriate treatment options. a. Habit training. b. Prompted voiding. c. Scheduled Toileting. Resident 7's current [DIAGNOSES REDACTED]. The facility completed a Significant change in status assessment MDS (Minimum Data Set) for Resident 7 on 1/6/12 and noted the following: Resident 7 has the complete ability to be understood, and usually understands others (May miss part or intent of the message). Resident 7's cognitive score is 3 (Severe cognitive impairment) Resident 7 requires extensive assistance with toilet use; Resident 7 is always continent of urine. The facility completed a Significant change in status assessment MDS (Minimum Data Set) for Resident 7 on 3/20/12 and noted the following: Resident has the complete ability to be understood, and usually understands others (May miss part or intent of the message.). Resident 7's cognitive score is 4 (cognitive impairment) Resident 7 requires extensive assistance with toilet use; Resident 7 is frequently incontinent (7 or more episodes of urinary incontinence) of urine. Resident 7's MDS indicates Resident 7's cognitive status has improved and Resident 7's urinary status has declined from the MDS completed on 1/6/12. Resident 7's Care Area triggered for Urinary incontinence. The MDS indicates a decline in bladder function. There was no bladder log completed to identify a pattern of incontinence for Resident 7. There was no bladder assessment completed to determine the cause of the decline in attempts to restore continence. Review of the urinary incontinence CAAs (Care Area Assessment) completed on 3/21/12, indicates; Environmental factors: Restricted mobility. Type of incontinence; Functional (can't get to toilet in time due to physical disability, external obstacles, or problems thinking or communicating)... Description of problem: Alteration in elimination related to dementia... Care Plan; Will develop care Plan continue current plan. Resident 7's CAAs does not indicate Resident 7 had a decline in urinary status since the last assessment of 1/6/12. Resident 7's care plan titled "Potential for Alteration in elimination", dated 6/25/10, Goal: Resident 7 will remain "continent of urine". Approaches, dated 6/25/10, 1. Certified Nursing Assistants (CNA) 1. Follow scheduled toileting plan: Assist to use bathroom with cares, before and after meals, at HS (bedtime), with rounds at night, as requested. 2. Bath room supervision for toileting... An entry on 5/30/12; Pull ups on at all time. Resident 7's urinary incontinence care plan has not been updated with a goal or approaches to improve or maintain current incontinence since Resident 7's urinary decline on 3/20/12. On 5/30/12, at 9:35 AM Surveyor observed Certified Nursing Assistant (CNA) E ask Resident 7 if she had to use the bathroom. Resident 7 stated yes. (Indicating Resident 7 was aware of the need to use the bathroom.) CNA E removed Resident 7 from the dining room to assist Resident 7 to use the bathroom. CNA E applied a gait belt to Resident 7 and with 1 assist transferred Resident 7 to the toilet. Resident 7's adult brief was dry and Resident 7 voided on the toilet. On 5/31/12, at 2:00 PM, Surveyor spoke with Nurse Manager (NM) C regarding Resident 7's bladder log and assessment related to her decline in urinary incontinence status for the MDS of 3/12. NM C stated the facility does not do a bladder incontinence assessment quarterly. NM C also stated the facility only does a bladder incontinence log and assessment when there is a decline in urinary continence function. In addition, NM C stated she did not do a bladder log or assessment for Resident 7's decline in bladder function during the 3/20/12 MDS assessment time. On 5/31/12, at 2:00 PM, Surveyor spoke with NM C regarding Resident 7's MDS of 3/20/12 the comparison of the prior MDS. NM C stated Resident 7 did have a decline in bladder function on the 3/20/12 MDS. NM C stated Resident 7 also had a decline related to her Dementia during the 3/20/12 assessment period. In addition NM C stated she did not do a new bladder log or a new bladder assessment with Resident 7's decline in urinary incontinence. On 6/1/12, at 8:10 AM Surveyor spoke with Director of Nursing (DON) B regarding Resident 7's decline in urinary status during the assessment period of 3/20/12. DON B stated a Temporary Bladder Incontinence care plan (TCP) should have been put in place when there is a decline in urinary status. DON B also stated The Nursing staff is to follow the TCP and do a bladder log and with the results of the bladder log an assessment should have been completed. In addition, DON B stated No Resident 7 did not have a TCP for Bladder incontinence, a bladder log or a bladder assessment completed after the decline in urinary incontinence on the MDS of 3/20/12. On 6/1/12, at 8:20 AM, Surveyor was provided and written nursing note indicating the following: On 6/1/12, at 6:00 AM, Resident 7 assessed for quarterly review for incontinence and toileting schedule. Resident 7 has shown to have 5 incontinent episodes at this time... last quarterly assessment Resident 7 was showed to have 8 incontinent episodes. Resident 7 has a history of refusing toileting during the night hours. This has improved and is now compliant with toileting schedule. Resident 7's physician feels functional ability decline is related to progression of Dementia... Despite Resident 7 having the ability to voice the need to use the bathroom, there is no evidence the facility completed an assessment which could have identified interventions to assist Resident 7 in remaining continent of bladder (i.e. - complete 3 day bladder diary, timed / prompt voiding, identifying non verbal indicators of need to void ...).