Every finding on record at Island Lake Center

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services to prevent the development and/or worsening of a pressure ulcer. The facility failed to adequately evaluate, monitor, and treat the resident's wound and failed to consistently implement wound care interventions identified in the resident's comprehensive care plan. These failures resulted in the resident developing and/or experiencing worsening of a stage 4 pressure ulcer which resulted in actual harm to the resident for one of two residents reviewed for pressure ulcers, of a total sample of six residents, (#5).Findings: Cross reference F725, F867 Resident #5 was admitted to the facility on [DATE] from an acute care hospital after sustaining a fall at home which resulted in fractures to his right pubic bone and right femur. His diagnoses included Myelodysplastic Syndrome (blood disorder), Alzheimer's dementia, major depression, cognitive communication deficit, and need for assistance with personal care. Review of State Agency Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form 5000-3008 dated 5/30/26, revealed resident #5 had a surgical fracture repair to his right hip. The form indicated he had a right posterior wound to the tibia, and a left leg surgical incision. No other wounds or pressure ulcers were documented on the form. The Minimum Data Set (MDS) admission assessment dated [DATE] noted resident #5 was severely cognitively impaired, dependent on staff for toileting, and required substantial assistance with bed mobility. He was at risk for development of pressure sores but did not present with any on admission. Resident #5 had a care plan initiated on 6/01/26 which noted he was at risk for skin impairment related to weakness and decreased mobility. The goal was for the resident to be free from any new skin impairments through the next review date of 9/11/26. Interventions included minimizing pressure to bony prominences as tolerated, monitoring/observing the skin while performing routine care and reporting concerns to the nurse, preventative skin treatments as ordered, and performing weekly skin checks. The care plan further noted that any signs and symptoms of skin breakdown would be reported to the provider/wound care team. There were no care plans for actual pressure wounds at this time. On 6/15/26 a care plan for resident #5 was initiated for pressure ulcer to the coccyx/sacral area. The goal was for the wound to show signs of healing as evidenced by decrease in size, improved appearance, and be free from infection by review date of 9/11/26. Interventions included weekly skin checks with documentation of the wound status (length, width, depth, and healing progress), monitoring/reporting signs and symptoms of infection, and assisting resident with position changes using pillows to maintain proper body alignment and offloading. Resident #5 was transferred to the hospital on 7/06/26 for abnormal labs. Resident #5's sacral pressure ulcer care plan was not revised until after the resident returned from the hospital on 7/21/26. Review of resident #5's weekly skin checks revealed assessments completed on 6/03/26, 6/04/26, 6/15/26, and 7/01/26. The notes on 6/03/26 and 6/04/26 included existing impairments such as a bump to the back of the head, bilateral heel redness, left lower leg redness, right hip surgical incision with dressing, dry scab to the right elbow, and right ankle redness with small open wound. The next assessment was completed eleven days later on 6/15/26 which noted a new skin impairment to resident #5's coccyx (sacrum) but had no description or measurement of the wound. Sixteen days later the assessment on 7/01/26 noted that prior treatment was in place for a sacral wound but did not specify what those were. There were no skin assessments documented on the weeks of 6/11/26, or 6/22/26. Review of the Order Summary Report dated 7/24/26 revealed on 6/15/26 treatment of the wound had been ordered by the attending provider. Staff were to clean the coccyx (sacrum), pat dry, apply med honey, and cover with border gauze daily on the day shift for open area. A wound consult to evaluate the coccyx (sacrum) was also ordered. Review of resident #5's Medication Administration Report (MAR) and Treatments Report for the months of June 2026 and July 2026 revealed ordered treatments for the sacral wound were not documented as completed on 6/20/26, 6/24/26, 6/25/26, and 7/01/26. Review of wound care consult notes for resident #5 revealed an initial wound evaluation was completed on 6/04/26 by the Wound Care Provider, which noted he had a right ankle abrasion, left lower leg pressure injury, and right elbow skin tear. The initial consult note did not include a sacral or coccyx wound. It was also noted that due to resident #5's medical complexity, any skin breakdown was a clinically expected outcome and potentially unavoidable, however clinical goals included preventing, identifying and treating infections, and to reduce or control modifiable risk factors. The Wound Care Provider completed follow up visits with resident #5 on 6/11/26, 6/18/26, and 7/02/26, however there was no documentation to indicate resident #5's sacral wound was evaluated. Review of the hospital History and Physical from the 7/06/26 admission revealed he had a stage 4 sacral decubitus ulcer (pressure ulcer to the sacral area) present on admission to the hospital. Review of a Computed Tomography of the Abdomen and Pelvis report dated 7/07/26 revealed a 3.5 centimeter by 2.8-centimeter amorphous (necrotic tissue) collection of the left gluteal (buttock) cleft consistent with a forming abscess. The wound was surgically debrided in the hospital on 7/10/26 and a wound vacuum was placed. Further review of hospital records revealed a nephrology consult on 7/17/26 that noted resident #5 had possibly developed severe sepsis from the wound. The wound was described as necrotic (dead tissue), purulent (pus-filled), and foul smelling. Initially, pressure ulcers start as areas of redness and skin irritation (stage 1), where the skin remains intact but shows persistent redness due to reduced perfusion. If untreated, the skin breaks down, forming shallow open wounds (stage 2) as the epidermis and dermis layers are lost. Continued ischemia (loss of blood flow) and pressure cause full-thickness tissue loss (stage 3), exposing fat and deeper tissues. At this stage, the tissue is severely damaged and vulnerable to infection. Without intervention, the ulcer worsens to stage 4, where muscle, tendons, and bone may be exposed, and necrosis (dead tissue) become evident. The progression from a pressure ulcer to necrosis is gradual but relentless without treatment, (retrieved on 8/13/26 from www.helpdementia.com). On 7/23/26 at 6:25 AM, Licensed Practical Nurse (LPN) B stated he was not very familiar with resident #5 because he usually was assigned to a different hallway, but he had cared for the resident once prior to his hospitalization. He stated that weekly skin checks were usually performed by the assigned nurse, but the Wound Care Nurse would sometimes assist. LPN B explained the facility no longer had a Wound Care Nurse because she had resigned previously. LPN B said staff nurses were now responsible for completing all wound care treatments. LPN B was the assigned nurse for resident #5 on 7/05/26, the day before his transfer to the hospital, and he had signed off on wound treatment to the sacrum but there was no documentation to show the status of the wound. In a later phone interview on 8/11/26 at 5:00 PM, LPN B said he could not recall if there were any issues with resident #5's wound but acknowledged any irregularities should be documented in the progress note along with notification to the provider. On 7/23/26 at 7:26 AM, Certified Nursing Assistant (CNA) A, stated she was familiar with resident #5 and was often assigned to him on the night (11 PM to 7 AM) shift. The CNA confirmed the resident required turning and repositioning every two hours as per his care plan. CNA A said she worked the day shift sometimes and it was impossible to complete all assigned tasks due to not having enough staff. On 7/23/26 at 10:30 AM, resident #5 was observed in bed lying on his back with eyes closed. There were no pillows or offloading devices observed to his back. On 7/24/26 at 2:30 PM, the Director of Nursing (DON) stated he was not aware resident #5's sacral wound was a stage 4 and said the resident had been admitted to the facility with it from the hospital on 7/21/26. The DON was not aware that weekly skin assessments had not been completed for three weeks prior to the resident's hospitalization, and he was unable to provide documentation of a wound evaluation. The DON acknowledged the facility had been short staffed in the past few weeks, and they did not have a Wound Care Nurse. Review of progress notes for resident #5 revealed an Interdisciplinary Team (IDT) note dated 6/16/26 which indicated, IDT team reviewed: skin assessment done, MD notified, order received to clean open area, clean with normal saline, pat dry, apply med honey, and cover with clear dry dressing. The note listed the residents' vital signs and noted that a voice message was left for spouse in regard to the new wound. Interventions were listed to assist and encourage residents to reposition frequently and consult with wound physician. Stage 4 pressure ulcers are the most severe form of pressure injury, which extends through skin and fat to expose bone, tendon or muscle. Treatment requires a combination of dead tissue removal, specialized wound dressings, nutritional support, pressure redistribution, and in many cases surgical intervention. These wounds heal slowly often over months and carry serious risks including bone infection and sepsis. Debridement is removing dead tissue from the wound bed and can be either surgical, autolytic (using the body's own enzymes in a moist environment), or enzymatic using chemical agents to dissolve dead skin tissue. Stage 4 pressure ulcers don't appear out of nowhere; they develop when earlier stage injuries go unrecognized or undertreated. Older adults with limited mobility, confined to bed, are most vulnerable. These people need aggressive preventive measures including specialized support surfaces, and scheduled repositioning every two hours, as well as regular skin inspections, (retrieved on 8/20/26 from www.scienceinsights.org). According to the largest group of wound physicians in the United States, federal guidelines stipulate no resident who enters a nursing home should develop a pressure sore unless their clinical condition demonstrates the wound is unavoidable. This group's educational program stresses that unavoidable wounds require frequent and consistent intervention and treatment from nursing staff. The physician group stated, It cannot be understated that even unavoidable wounds still require consistent intervention and treatment to improve patient outcomes. Centers for Medicare and Medicaid Services (CMS) defines an unavoidable pressure wound as a wound that has developed in a patient even though the facility properly evaluated the resident's risk factors, implemented and monitored the appropriate interventions, and adjusted the care plan according to the patient's evolving condition, (retrieved on 8/26/26 from www.vohrawoundcare.com). In a telephone interview on 8/10/26 at 2:00 PM, resident #5's wife said her husband had been admitted to the facility due to a fall at home resulting in a fracture. She said when he was initially admitted to the facility, he had a surgical wound and two other wounds to his legs but no other wounds. Resident #5's wife said prior to his transfer to the hospital he did not have an air mattress and she had to ask them for one, once he returned. She said he was not being turned and repositioned. She said she visited the facility often and always found her husband in the same position with briefs soiled by incontinence. The resident's wife said she felt the facility had a staffing problem because there never seemed to be enough staff around. She recalled being told by the nurse that her husband had a small red spot on his sacrum but was not informed the wound had declined that much until he went to the hospital on 7/06/26. Resident #5's wife said hospital staff told her after the admission assessment on 7/06/26, that he had an infected stage 4 pressure sore which required a surgical debridement to remove the dead tissue. She said she did not understand how the facility did not know his wound was getting worse or that it was potentially infected if they claimed they were providing daily treatments and observing it. In a phone interview on 8/11/26 at 4:23 PM, the former Wound Care Nurse said she worked at the facility from April to the end of June 2026. She explained that most of her time as a Wound Care Nurse was spent working the medication cart due to staffing issues at the facility. She could not recall resident #5 or his sacral wound. Review of the MAR revealed the last time the Wound Care Nurse worked with him was on 6/16/26. The former Wound Care Nurse explained that when the nurse or CNA identified a possible wound on a resident, the process was for her to be notified so she could assess the wound and determine if a wound consultation with the physician was needed. She said it was the responsibility of the assigned nurse to complete weekly skin checks but sometimes she would assist them due to staffing shortages. The former Wound Care Nurse further explained that she rounded with the Wound Care Physician weekly and they would discuss any new wounds that needed to be evaluated. She said she did not recall resident #5 being evaluated for the sacral wound. In a telephone interview on 8/11/26 at 4:42 PM, LPN I confirmed she was assigned to resident #5 on 6/17/26, 6/18/26, 6/21/26, 6/22/26, 6/23/26, 6/29/26, and 6/30/26. She did not recall seeing any changes to the wound. She said the skin around the wound was sagging significantly, which made it difficult to apply the dressing. The nurse said she was aware there was an order for a wound consultation of the sacrum, but she did not know if the resident was ever seen. LPN I acknowledged she did not look to see if there were any wound care notes and did not attempt to speak with the Wound Care Provider. She recalled that on 7/04/26 or 7/05/26, the CNA told the assigned nurse the resident's wound on his back did not smell right, so the Nurse Practitioner (NP) was notified. She said she did not see the resident again until he returned from the hospital. A progress note dated 7/04/26 in resident #5's medical record noted, resident has open area on coccyx and NP [Nurse Practitioner] has been notified. There was no follow up documentation to show the Nurse Practitioner evaluated the resident's sacral wound prior to his transfer to the hospital on 7/06/26. In a telephone interview on 8/11/26 at 1:50 PM, the Wound Care (Physician Assistant) Provider revealed she was not aware of resident #5's sacral wound until after he came back from the hospital. The Wound Care Provider acknowledged she missed the resident's sacral pressure wound evaluation on 6/18/26 because she felt there was no Wound Care Nurse. She explained that typically the Wound Care Nurse would tell her when there were new wounds to evaluate but because there was no Wound Care Nurse currently, the assigned nurses were responsible for informing her if she had to evaluate a wound. She acknowledged she saw the resident on 6/18/26 and 7/02/26 but said the nurse, (LPN I), never told her about the resident's sacral wound so she only looked at his other wounds. The Wound Care Provider said she became aware of the status of the sacral wound after he returned to the facility with a wound vacuum. She explained the resident's his wife informed her the resident developed the wound at the facility which was a stage 4 pressure ulcer that was identified upon arrival at the hospital. The Wound Care Provider confirmed resident #5 was prone to develop wounds due to his co-morbidities and poor nutrition, but acknowledged frequent turning/re-positioning, the proper prevention measures and regular monitoring of the skin were necessary for prevention or worsening. She said she expected staff to monitor the progression of wounds and ensure treatments orders and care plan interventions were being followed. In a telephone interview on 8/11/26 at 9:38 AM, the Medical Director stated he was not aware resident #5 had a stage 4 pressure ulcer that developed in the facility until the previous day. He said they had not held any Ad Hoc Quality Assurance and Performance Improvement (QAPI) meetings regarding resident #5's wound. The Medical Director stated the facility had discussed staffing concerns in previous QAPI meetings and was aware of a Performance Improvement Plan related to skin assessments being completed. He said he expected staff to monitor wounds, complete skin assessments, and follow physician orders/care plans for wound treatment. On 8/11/26 at 11:46 AM, in a joint interview, the Nursing Home Administrator (NHA) and DON who was also the facility's Risk Manager, stated they were not aware of resident #5's stage 4 pressure wound until the resident returned to the facility from the hospital on 7/21/26. The DON said he met with the Wound Care Provider after the resident returned from the hospital and as she had not seen resident #5's sacral wound before the hospitalization she could not say with certainty what condition the wound was in. They acknowledged there was no documentation by the facility prior to the hospitalization that described the condition of the sacral wound. They acknowledged resident #5's sacral wound was never evaluated by the Wound Care Provider prior to the hospitalization on 7/06/26. The DON said the IDT discussed the resident's wound during morning meeting after he was re-admitted to the facility on [DATE]. The DON acknowledged the facility was missing weekly skin assessments, wound evaluation of the sacrum prior to hospitalization, had no documentation of wound progression, and treatments were missed on the MAR. The DON confirmed the facility did not have a Wound Care Nurse during the time the resident's sacral wound was discovered and he acknowledged this was an identified staffing issue. The DON and NHA explained the event was investigated; and their analysis concluded the root cause was staffing. Review of the facility policy for Prevention of Skin Impairments/Pressure Injury revised January 2024, revealed the facility expected staff to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate modifiable risks. The policy indicated staff needed to reposition residents as designated on the care plan, and needed to evaluate, report, and document potential changes in skin.

Based on observation, interview, and record review, the facility failed to ensure they had sufficient staff to provide care as per physician orders and/or per care plans for 2 of 2 residents reviewed for wound care, (#5, and #2); 1 of 1 resident reviewed for tracheostomy care, (#2); and 1 of 1 resident reviewed for Intravenous (IV) lines, (#6), out of a total sample of 6 residents.Cross Reference F686, F694, F8671. Resident #5 was admitted to the facility on [DATE] after he sustained a fall at home and had surgery at an acute care hospital.Review of State Agency Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form 5000-3008 dated 5/30/26, revealed resident #5 had a surgical fracture repair to his right hip. The form indicated he had a right posterior wound to the tibia, and a left leg surgical incision. No other wounds or pressure sores were documented on the form. The Minimum Data Set (MDS) admission assessment dated [DATE] noted resident #5 was severely cognitively impaired, dependent on staff for toileting, and required substantial assistance with bed mobility. He was at risk for development of pressure sores but did not present with any on admission.Review of documentation from 6/15/26 revealed a weekly skin assessment was completed that identified an open area to his coccyx (sacrum). Treatment of the sacral wound, a wound consult was ordered, and a care plan was created with interventions to turn and reposition resident, complete weekly skin assessments, monitor the wound progression, and document wound measurements. Resident #5 was transferred to the hospital on 7/06/26 due to abnormal labs where they found he had an infected stage 4 pressure ulcer to his sacrum. The hospital records from the 7/06/26 admission revealed the wound was infected with necrotic (dead) tissue, purulent (pus-filled), and required surgical debridement at the hospital on 7/10/26. Review of resident #5's medical record revealed there were weekly skin assessments missing on 6/11/26 and 6/22/26 and wound treatments had not been documented as completed on 6/20/26, 6/24/26, 6/25/,26 and 7/01/26.On 7/23/26 at 7:26 AM, assigned Certified Nursing Assistant (CNA) A, explained she worked the night shift (11 PM to 7 AM), but recently had been asked to cover the 7:00 AM to 3:00 PM shift as well, because the facility was short staffed. She explained she was not always able to turn residents who required turning and repositioning every two hours to prevent pressure sores, because there were not enough staff. She said CNAs were responsible for assisting residents with Activities of Daily Living (ADL)s which included turning/repositioning and observing the resident's skin during bed baths or showers. CNA A said that on days they were short staffed it was difficult to complete tasks such as turning/repositioning or showers because these tasks often required two CNAs to assist. She said when CNAs were unable to complete a task, they had to let the next shift CNA know but sometimes every shift was short so the tasks would not be completed at all. CNA A said they had town hall meetings every month where the short staffing issue was raised with the Nursing Home Administrator (NHA) and Director of Nursing (DON) but felt not much was done. She explained the facility had hired staff but said the new staff often left due to the lack of support from the Administration. The CNA said she knew resident #5's sacral wound had not been treated or monitored as it should because the facility had no wound care nurse and the floor nurses were short staffed as well.On 7/23/26 at 5:45 AM, Licensed Practical Nurse (LPN) C, the attending nurse for resident #5, said she regularly worked the 3:00 PM to 11:00 PM shift. She said lately she had been asked to cover the overnight (11:00 PM to 7:00 AM) shift due to low staffing. LPN C explained usually three nurses were assigned to work on the first floor and two were assigned on the second floor plus the Unit Managers and Wound Care nurse but now instead of at least eight nurses, they had four nurses total for the whole facility. LPN C said when they were short staffed it was difficult to get wound treatments and weekly skin checks completed on the 3:00 PM to 11:00 PM shift. She said sometimes there was no coverage for the oncoming shift, so staff were forced to stay and work until they found someone to come in and cover the shift. LPN C said sometimes they could not find anyone so they would have to stay and keep working.Review of staff scheduled for 7/23/26 revealed the 7:00 AM to 3:00 PM nurse for the first-floor unit had called out and there was no coverage to replace her listed. There were no nurses listed to work on the second floor for this shift.On 7/23/26 at 6:00 AM, LPN D had worked the overnight shift (11 PM to 7 AM) and said she was unsure who would relieve her. She said when there was a call out during the night shift, they were told to reach out to either the NHA, DON, or the Staffing Coordinator but she said they never answered the phone.On 7/23/26 at 6:05 AM, CNA E had worked the overnight (11 PM to 7 AM) shift and said the staff schedule always looked like they had enough staff, but it was not real because most of the staff on the schedule never showed up or did not know they were scheduled to work. CNA E said when they were short staffed, it was difficult for her to complete resident showers or to turn/reposition the residents.On 7/23/26 at 6:25 AM, LPN B worked the 11 PM to 3 AM shift and stated he did not know who would be coming in to take over for him. The nurse said the facility no longer had a Wound Care Nurse or Unit Managers because they had resigned. LPN B said the nurses were responsible for all wound treatments, and it was time consuming depending on the type of wound. LPN B said they had staff meetings monthly and staffing shortages were discussed but the Administration never provided a solution. The nurse said the only solution they had was having the DON, and both MDS nurses cover the medication carts on the day (7 AM to 3 PM) shifts when there were call outs. The LPN said they no longer had a Restorative nursing program for the residents because the Restorative aide had to work on the floor for other CNAs when there were call outs.On 7/23/26 at 6:40 AM, CNA F confirmed she was the Restorative aide and had been working at the facility for over 20 years. She said she was no longer providing restorative care for residents because the facility was short staffed and she was needed to work on the floor in a CNA role. CNA F said since she was not doing the restorative program all staff were responsible for prescribed range of motion exercises and application of contracture devices, but she said it was not always completed due to lack of time.On 7/23/26 at 6:45 AM, the DON acknowledged the facility had some staffing issues but said they were not short staffed all the time. He said the MDS nurses would cover the carts when needed and he assisted rarely, from time to time. On 7/23/26 at 8:30 AM, both MDS nurses and the DON were working on medication carts on the floor to deliver medications to residents. At 11:00 AM the MDS nurses and DON were still passing out morning medications.2. Review of the medical record revealed resident #2 was admitted to the facility on [DATE] with a tracheostomy (surgical hole made in throat to breathe). On 7/23/26 at 8:04 AM, resident #2 was in bed, with his wife at his bedside. Resident #2's wife said her husband was totally dependent on staff for care and was unable to make his needs known himself. She said she was concerned with the care her husband received because the facility was short staffed. She said sometimes her husband did not receive bed baths, wound treatments, or tracheostomy care. She explained that tracheostomy care had to be done daily because there were a lot of secretions that came out of the tube onto his chest and this could cause an infection if not kept clean. Resident #5's wife said she had complained about the tasks not being completed to the staff and they would tell her they were short staffed. She said she had also written some grievances, and the DON told her they were working on staffing. She said she did not trust leaving her husband alone at the facility and was grateful they allowed her and other family members to stay overnight.Review of resident #2's Medication Administration Report (MAR) for the month of July 2026, revealed staff had missed three days of tracheostomy care on 7/04/26, 7/08/26, and 7/10/26. They had also missed three days of wound treatments to the resident's scalp, and left thigh on 7/08/26, 7/10/26, and 7/13/26.On 7/23/26 at 9:55 AM, a phone interview was conducted with the former first floor Unit Manager (UM). She stated she had resigned due to staffing concerns, but her resignation was not effective until 7/31/26. She explained as UM her responsibility was to oversee the nurses and CNAs, perform monthly chart audits to ensure accuracy, provide support for the staff, and ensure residents received needed services. She said she often stepped in to help staff with weekly skin checks, wound treatments, and weekly wound rounds with the provider. The former UM said she was unable to complete UM tasks because she often had to work on the cart delivering medications due to short staffing. She said there was an instance where she was the only nurse on the first floor and did not receive support from the DON or NHA, so she resigned.On 7/23/26 at 2:12 PM, the Staffing Coordinator confirmed the facility had been short staffed for a few weeks due to call outs. She said they were in the process of hiring and staff were aware they could ask the administrative staff for help if they needed it. She said the MDS nurses helped on the carts when needed but not often and she was a CNA so she would assist as well. The Staffing Coordinator said she was responsible for Central Supply and restocked the units twice per week. She said she sometimes was not able to restock supplies due to her working as a CNA on the floor.On 8/11/26 at 4:23 PM, in a telephone interview the former Wound Care Nurse said she had worked at the facility for two months but resigned because she did not feel the facility was a safe place to work due to staffing shortages. The nurse stated she was hired as the Wound Care Nurse and was her job responsibilities included to treat resident wounds, assist with weekly skin assessments, and round with the wound care provider. However, she said due to short staffing she spent more time on the medication carts covering for nurses than completing any wound care treatments. She recalled many times the staff schedule would look like they were fully staffed but was rarely the case because the people on the schedule did not show up to work.3. Review of the medical record revealed resident #6 was admitted to the facility on [DATE] with a peripheral IV line to his right upper arm. On 8/10/26 at 10:32 AM, his IV dressing was dated 7/31/26. Review of resident #6's current physician orders revealed he required an IV dressing change every seven days.On 8/10/26 at 10:49 AM, LPN G, his assigned nurse, revealed she was an agency nurse on her first day at the facility and was not familiar with the resident.On 8/10/26 at 12:30 PM, the DON confirmed the IV dressing had not been changed as ordered and confirmed resident refusal had not been documented. The DON posited the facility had so much turnover by staff the facility were using agency nurses to cover. The DON explained it was difficult for him to monitor what all the nurses were doing and ensure they were documenting appropriately.On 8/11/26 at 9:38 AM, the Medical Director via telephone said the facility discussed staffing concerns during every Quality Assurance and Performance Improvement (QAPI) meeting, but they had not identified any major issues with resident care.On 7/24/26 at 4:00 PM, in a joint interview with the DON and Administrator, they acknowledged they had staffing issues and said they were actively working to hire more staff. The DON said staff had not expressed any concern regarding resident tasks not being completed due to staffing. In a later interview with the DON and NHA on 8/11/26 at 11:46 AM, the NHA stated that during monthly QAPI meetings they discussed the lack of staff, and the quality of the staff they had. The NHA stated the Medical Director was part of those meetings.Review of the facility's Direct Care Staffing Policy dated October 2025 noted the facility would maintain adequate staffing levels at all times to meet resident care needs based on individual care plans and the facility assessment.

Based on observation, interview, and record review, the facility failed to ensure an intravenous (IV) dressing was changed as ordered for 1 of 1 resident reviewed for IV therapy, out of a total sample of 6 residents, (#6).Findings:Cross Reference F725Resident #6 was admitted to the facility from an acute care hospital on 7/20/26 with diagnoses that included osteomyelitis (bone infection), Parkinson's disease, sepsis, depression, anxiety, and need for assistance with personal care.Review of State Agency Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form 5000-3008 dated 7/20/26 showed resident #6 was being treated with IV antibiotics for sepsis at the hospital which was to continue at the facility.Review of the Minimum Data Set (MDS) admission assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status of 10/15, which indicated moderate cognitive impairment. The assessment revealed he had no refusal of care behaviors. The assessment reflected the resident had bilateral upper extremity impairments, was dependent on staff for most activities of daily living and had IV access.On 8/10/26 at 10:32 AM, resident #6 was in his room, in bed watching television. He had an IV line visible on his right upper arm covered with a clear dressing and tape. The date on the IV dressing was 7/31/26. The resident stated he received his IV antibiotic medications but had not received a dressing change lately. He said he could not remember when it was last completed.Review of physician's orders and the Medication Administration Records for July 2026 and August 2026, revealed resident #6 had an order initiated on 7/21/26 for dressing changes to his IV line on the right arm, which read, change dressing within 24 hours of admission, insertion, or reinsertion and every 7 days and PRN (As needed) thereafter using sterile technique. The last dressing change documented was completed PRN on 7/31/26 and the next one had been due on 8/07/26 but was not documented as completed. The resident's dressing was three days overdue.On 8/10/26 at 10:49 AM, Licensed Practical Nurse (LPN) G, was the agency nurse assigned to resident #6. She looked at the resident's orders and confirmed his IV dressing was ordered to be changed every seven days. Upon observation of the IV dressing, LPN G acknowledged the dressing was dated 7/31/26 and was three days overdue to be changed. She explained it was her first day at the facility and she was not familiar with the residents yet. She received report from the previous nurse who reported the resident had an IV but had said nothing about the IV dressing needing to be changed. LPN G said she was still passing out morning medications but acknowledged the resident's IV dressing needed to be changed. She said it was important to always follow physician's orders.On 8/10/26 at 12:30 PM, the Director of Nursing (DON) acknowledged resident #6's IV dressing had not been changed since 7/31/26. The DON explained staff he was aware since the past Friday 8/07/26 when staff informed him the resident refused to have the dressing changed. He said since it was a Friday he told the nurse they would wait until Monday because they could not force the resident to get the dressing changed. The DON stated resident #6 had behaviors of refusing IV dressing changes and had been care planned for it. He acknowledged there was no documentation to show the resident refused the dressing change or that the physician was notified. The DON was unable to explain whether the resident was re-approached for the dressing change or why no additional attempts to change the IV dressing were documented during the weekend on 8/08/26, or 8/09/26. He said the expectation was for staff to follow physician orders, notify the physician of any changes, and document appropriately.The facility did not have a policy specific to peripheral IV lines.

Based on observation, interview, and record review, the facility failed to implement and sustain its Quality Assurance and Performance Improvement (QAPI) process to identify, monitor, analyze, and correct identified quality deficiencies related to staffing and wound care. This failure resulted in the facility not effectively addressing ongoing low staffing levels and deficiencies in the monitoring and treatment of residents with wounds, (#5).Findings:Cross Reference F686 and F725Resident #5, a total care resident, was admitted to the facility on [DATE] from an acute care hospital with wound care treatments for wounds to his leg, ankle, and a surgical incision on his hip. A Wound Care Consult from 6/04/26 revealed resident #5 was at a high risk for pressure wounds, but he did not present to the facility with any wounds to his sacrum. On 6/15/26 he had a weekly skin assessment that identified an open area to his coccyx (sacrum). Treatment of the sacral wound and wound consult were ordered, and a care plan was created with interventions to turn/reposition resident, complete weekly skin assessments, monitor the wound progression, and document wound measurements. The resident was transferred to the hospital on 7/06/26 due to an abnormal lab but upon admission to the hospital an infected, necrotic stage 4 sacral pressure ulcer was identified which required surgical debridement on 7/10/26. Review of resident #5's medical record revealed there were weekly skin assessments missing on 6/11/26 and 6/22/26 and wound treatments had not been documented as completed on 6/20/26, 6/24/26, 6/25/26 and 7/01/26. On 7/23/26 and 8/11/26 interviews with facility staff revealed statements and description the facility was short staffed for several weeks and did not have a Wound Care Nurse. Review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI), noted the facility would develop, implement, and maintain an ongoing, facility-wide, data driven QAPI program that was focused on indicators of the outcomes of care and quality of life for the residents. The objectives of the program included providing a means to measure current and potential indicators for outcomes of care and quality of life, providing a means to establish and implement performance improvement projects to correct identified negative or problematic indicators, and to establish systems through which to monitor and evaluate corrective actions. On 7/23/26 at 4:00 PM, in a joint interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), they acknowledged the facility was aware of staffing concerns prior to resident #5's transfer to the hospital on 7/06/26 but failed to demonstrate that identified staffing deficiencies were adequately analyzed for their impact on resident care. The NHA said they created a Performance Improvement Plan (PIP) on 7/20/26 which focused on weekly skin checks and wound evaluations. Review of the PIP dated 7/20/26 revealed the goal was to improve timely completion of weekly wound evaluations, ensure weekly skin checks with complete documentation and follow up, eliminate missed assessments, and ensure identified skin or wound changes were addressed promptly. The action steps included completing overdue weekly skin checks and wound evaluations immediately. There was no other documentation, including any audits to show the facility had started implementing this PIP. The PIP failed to show the underlying causes of the breakdown in weekly skin assessments, identification and monitoring of wound progression, and identification of staffing concerns that affected resident care. There was no evidence of a structured root cause analysis, interdisciplinary involvement, measurable improvement goals, or ongoing monitoring for effectiveness. In a later meeting on 8/11/26 at 11:46 AM, the DON stated he had conducted a full investigation of the resident's wound decline and concluded the resident received appropriate wound care prior to his hospitalization. The DON said he felt the wound declined at the hospital. The DON acknowledged the resident was not initially admitted to the facility with an open wound to his sacrum, that weekly skin assessments were not documented, that a wound consult order was not followed, some wound treatments were not documented as performed, and that there was no documentation of the wound's progression or deterioration prior to his hospitalization. The facility's QAPI process did not demonstrate effective tracking of wound-related outcomes or timely identification and correction of wound-care concerns. In a telephone interview on 8/11/26 at 9:38 AM, the Medical Director stated he was not aware resident #5 had a stage 4 pressure ulcer that developed in the facility until the previous day. He said they had not held any Ad Hoc QAPI meetings regarding resident #5's wound. The Medical Director stated the facility had discussed staffing concerns in previous QAPI meetings, and he was aware of a Performance Improvement Plan related to skin assessments being completed. He said QAPI had not identified any major issues with resident care. The cumulative effect of these systemic practices resulted in the facility's failure to effectively implement its QAPI program and address known quality concerns related to staffing and wound care, placing residents at risk for unmet care needs, delayed or inadequate wound treatment, and adverse clinical outcomes.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained which had possibility to affect 113 of 113 residents in the facility.Findings: Review of the undated facility's QAPI Program revealed the objective of the program was to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. The document indicated the components of this process included tracking and measuring performance; identifying and prioritizing quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. During the previous recertification survey conducted 1/27/25 through 1/30/25, the facility had deficiencies cited related to medications left at bedside, and for infection control issues. During the current survey, the facility was found to have noncompliance related to medications observed at bedside and infection control related to personal protective equipment use for a resident on standard precautions. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation. On 3/26/26 at 1:07 PM, the Administrator stated the facility held monthly QAPI meetings. She explained the committee reviewed several areas which included infection control and prior survey results. She stated there had been several staff turnovers in management recently including the Administrator position. The Administrator explained she had only been at the facility for about 3 weeks and their monthly QAPI meeting was scheduled for the following week. The Administrator stated they had not had the chance to review the previous survey results or assess the previous plan of correction and audits related to the concerns. She explained, as a result, she unable to say what happened as she was not aware of what the previous plan was for longevity of results to ensure lasting, systemic change in the facility.

Based on interview, and record review, the facility failed to honor a resident's advanced directive wishes and failed to ensure the medical record accurately reflected advanced directives related to Do Not Hospitalize for 1 of 1 resident reviewed for Advance Directives, of a total sample of 40 residents, (#49).Findings: Resident #49 was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, depression, age-related physical debility, cognitive communication deficit and vascular dementia. Review of the Minimum Data Set significant change assessment with assessment reference date of [DATE] revealed resident #49 had a Brief Interview for Mental Status score of 8/15 which indicated she had moderate cognitive impairment. The assessment revealed she required assistance with activities of daily living and received hospice care services. Review of resident #49's electronic medical record (EMR) revealed a physician order dated [DATE] for Do Not Resuscitate (DNR). This order was also displayed on the resident demographic section in the EMR. An advanced directive care plan initiated [DATE] indicated the resident/resident representative had requested DNR status which meant that cardiopulmonary resuscitation (CPR) measures were not to be performed. Resident #49's EMR contained an Advance Directive Discussion Document dated [DATE] which indicated resident #49 wished for CPR to be withheld. No other advanced directives were indicated. On [DATE] at 1:41 PM, resident #49's daughter stated her mother was admitted to the facility in [DATE]. She confirmed resident #49 currently received hospice care services. She recalled her mother was sent to the hospital a couple of months ago although she had told the staff she did not want her mother to be hospitalized . She stated they sent her anyway. Resident #49's daughter explained she was able to get to the hospital before the hospital treated her and had her mother sent back to the facility. Resident #49's daughter expressed she was upset this occurred and did not understand why her mother was sent to the hospital since her wishes not to be hospitalized were in the chart. Review of the EMR revealed a progress note dated [DATE], written by resident #49's primary physician which read, I discussed advanced care planning with the patient including advanced directives, living will, comfort care/palliative care, end of life care, and resuscitation/intubation status. The POA [Power of Attorney] does not want any heroic life prolonging measures, no tube feeds, no hemodialysis, and no mechanical life support. The patient's HCP/POA [Health Care Proxy/Power of Attorney] consents to DNR/DNI [Do Not Resuscitate/Do Not Intubate], palliative care plan, comfort care measures, and do not hospitalize orders. Review of the medical record revealed resident #49 was noted to have vomited coffee-ground emesis. The physician was contacted and gave an order to send her resident #49 to the hospital for further evaluation. The hospital transfer form documented she transferred to the hospital on [DATE] at 10:00 PM. The change in condition form indicated resident #49's daughter was notified of the transfer on [DATE] at 10:05 PM. On [DATE] at 12:40 PM, the Social Services Director (SSD) stated she discussed Advanced Directives upon admission and completed an Advanced Directive discussion form. The SSD reviewed the physician progress note in the EMR which identified the Advanced Directives for resident #49. She explained she was aware resident #49 was a DNR and acknowledged resident #49's daughter had let everyone know she did not want her mother to be hospitalized . The SSD was unable to explain why there was no order in the chart for do not hospitalize or why the Advanced Directives were not updated to reflect the resident's wishes in the EMR. On [DATE] at 12:53 PM, the Director of Nursing (DON) explained if a resident or resident's representative did not want the resident to be hospitalized , the facility would contact the physician and obtain an order which would be documented on the resident's demographic sheet in the EMR. The DON stated she was aware resident #49 was sent to the hospital. She was unable to explain why an order was not obtained to ensure the resident's Advanced Directives wishes for no hospitalization were honored.

Based on interview, and record review, the facility failed to request a new Preadmission Screening and Resident Review (PASARR) Level I Screening for a resident later diagnosed with a new mental illness diagnosis for 1of 1 residents reviewed for PASARR, of a total sample of 40 residents, (#78).Findings: Resident #78 was admitted to the facility from an acute care hospital on [DATE] with a diagnosis of major depressive disorder. Review of resident #78's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed she had a Brief Interview of Mental Status score of 15 out of 15, cognitively intact. Review of resident #78's PASARR Level I screening completed on 9/23/25 was negative for mental illness or intellectual disability. Review of the order summary for resident #78 dated 3/24/26 revealed she had been prescribed Mirtazapine, an antidepressant, at bedtime for poor appetite related to depression on 3/04/26. On 3/23/26 at 1:30 PM, resident #78 was in her room sitting in her wheelchair. She had her lunch tray in front of her but had not eaten. She stated she was just not really feeling hungry and did not feel like eating. She said she was having trouble adjusting to living in the facility and missed being at home. Resident #78 said she knew her son and daughter-in-law could not take care of her anymore. Review of psychology progress notes for resident #78, revealed she was last seen by the provider on 2/18/26 and reported feeling depressed, having difficulty sleeping, and poor appetite. The treatment plan was for staff to monitor changes in the resident's mood or behavior and continue antidepressants to target depression, appetite, and sleep. On 3/24/26 at 12:20 PM, the director of MDS and Social Service Director (SSD) explained the facility's PASARR process. The SSD said when a resident was admitted either she or the MDS Director were responsible for reviewing the PASARR to ensure it was complete and accurate. She said if the form was incomplete, they would alert the admission Coordinator who would request a new PASARR from the hospital. She stated that PASARRs for new admissions were also reviewed daily during morning clinical meetings, monthly during psychotropic drug meetings with the psychology department, and when there was a significant change in behavior for the resident. Both the MDS Director and SSD confirmed resident #78 had not been screened for a new PASARR Level I. They were unable to explain why a new Level I PASARR was not completed for resident #78, when she had a change in her diagnoses.

Based on interview, and record review, the facility failed to refer a resident with identified mental illness for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 3 residents reviewed for PASARR, of a total sample of 40 residents, (#106).Findings: Resident #106 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, generalized anxiety disorder, major depressive disorder and adjustment disorder. Review of the Minimum Data Set admission assessment with assessment reference date of 1/13/26 revealed resident #106 had a Brief Interview for Mental Status score of 11/15 which indicated she had moderate cognitive impairment. The document indicated her active diagnoses included anxiety disorder and bipolar disorder and received antipsychotic, antianxiety and antidepressant medications. Review of resident #106's electronic medical record revealed a Level I PASARR screening form dated 1/06/26. The form indicated resident #106 had bipolar disorder and depressive disorder. Review of the Level I PASARR screening form revealed resident #106 was identified as having an indication of a serious mental illness which caused her to have serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities which occurred in school or home settings, manifested difficulties in concentration, the inability to complete simple tasks within an established time period, made frequent errors, or required assistance in the completion of these tasks. The form indicated resident #106 required a Level II Evaluation to be conducted prior to admission to the facility. The medical record did not contain a Level II PASRR Evaluation and Determination form. On 3/24/26 at 12:20 PM, the Social Services Director (SSD) stated PASRR screenings for new admissions were reviewed in daily clinical meetings. She explained the screenings were checked for accuracy and a Level II screening was submitted if indicated. The SSD reviewed the Level I PASRR screening for resident #106. She verified the form indicated a Level II screening was required. She acknowledged the required screening had not been completed. The SSD was unable to state why the facility had not submitted for a Level II screening.

Based on observation, interview, and record review, the facility failed to provide an individualized on-going activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 of 1 residents reviewed for activities, of a total sample of 40 residents, (#52).Findings: Resident #52 was admitted to the facility 8/30/25. admission diagnoses included arthritis of the hip, type two diabetes, total retinal detachment of the right eye, and blindness in left eye. The [NAME] Data Set assessment dated [DATE] revealed resident #52 had a Brief Interview for Mental Status score of 10/15 which indicated he had moderately impacted cognitive impairment. The assessment indicated the resident required full assistance with meals, toileting, hygiene, and transfers. His preferences included television movies, sports, classic rock and country music, audible books, sports and bingo. The setting preferences for activities reflected to take place both outside and inside the room. Review of resident # 52's medical record revealed no active care plan for activities. On 3/22/26 at 10:30 AM, resident #52 was observed lying flat in his bed with the head of bed slightly elevated. His eyes were open. The resident stated he had to wait for someone to help him with his breakfast because he was blind. At 1:30 PM, he was observed in the same position. He stated that he was never sure what time of the day it was and gauged time based on his meals. He stated he couldn't see the remote for the television and liked to listen to sports. The next day on 3/23/26 at 10:15 AM, resident #52 was observed in same position and there was no television audible. The resident revealed he was not aware that there was a dining room or that there were activities for residents. He stated no one had ever offered for him to eat in the dining room, attend activities, or bring activities to him. He stated no one asked if he wanted to sit in a chair except when physical therapy came, right before dinner. The resident stated his brother was the only person who had visited him. Later in the day at 1:45 PM, resident #52 was in same position in his room. On 3/24/26 at 9:15 AM, resident #52 was observed in same position and no audible television. He stated he had been waiting for someone to help him with his breakfast and a couple times they had forgotten him. At 1:15 PM, resident #52's brother was visiting. The television was on with sports audible. The brother stated he always brought food, turned sports on the television, and downloaded audible books when he visited. He revealed his brother was always in bed and wasn't aware of his brother participating in any activities at the facility. Resident #52 stated he would like to go to the dining room for meals and participate in some activities. On 3/25/26 at 9:10 AM, resident #52 was observed in same position and no audible television. Resident #52 stated he was going to ask to go to the dining room for dinner. He stated he never knew what his meals were going to be because no one read the menu to him. At 4:10 PM, resident #52 was observed in a wheelchair in the hallway working with physical therapy. On 3/26/26 at 1:00 PM, the Activity Director revealed resident #52's admission 'Lifestyle and Activity Preferences Evaluation' was completed on paper dated 9/02/25 but it was not scanned into the resident's medical record until that day, 3/26/26. She acknowledged there was no activity care plan for resident #52. The Activity Director stated her department was responsible for reading the daily menu and offering daily activities to resident #52 but did not explain why it had not been done. On 3/26/26 at 3:00 PM, the DON stated the facility had no activity policy.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to acknowledging and following the consultant dermatologist's recommendations for 1 of 2 residents reviewed for non-pressure skin concerns, of a total sample 40 residents, (#30). Findings: Resident #30 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and atopic dermatitis (dry, itchy skin). On 3/22/26 at 10:00 AM, resident #30 was in her room scratching her wrists. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #30 had a Brief Interview for Mental Status score of 3/15, indicating severe cognitive impairment, and she exhibited rejection of care behaviors 1 to 3 days in the lookback period. Resident #30 was dependent on toileting, personal hygiene, dressing, and mobility. Active diagnoses included atopic dermatitis and dementia. On 3/22/26 at 10:00 AM, resident #30 was in her room and was observed scratching her wrists. On 3/23/26 at 10:37 AM, resident #30 was in her room, rubbing the skin on her abdomen and thighs up and down. On 3/25/26 at 10:23 AM, resident #30 was observed scratching her right hand. She had reddened, dry cracked skin on her right hand and a scratched area on her right wrist as she turned her hands over two times to show the skin. Resident #30 said her hands itched and rubbed both of her hands together to demonstrate. Review of resident #30's progress notes revealed a dermatology consult note dated 3/02/26 at 11:58 AM. The dermatology note showed resident #30 was seen for a rash which was not a new rash. The dermatologist documented resident #30's four extremities had dry patches, dark spots and rough bumps. The consult revealed a diagnosis of dermatitis (inflammation) of the chest, back and abdomen with persistent itching. The dermatologist's note indicated an order for Permethrin 5% cream to be applied overnight and washed off in the morning. Review of resident #30's current physician orders revealed no order for the treatment recommended by the dermatologist on 3/02/26. Review of resident #30's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2026 contained no treatment of Permethrin 5% as recommended by the dermatologist on 3/02/26, nor any refusal of the medication. Review of progress notes did not show resident #30's primary physician, or representative were called for an approval of the dermatologist's recommendation on 3/02/26. Review of the progress notes contained no documentation of resident #30's representative refusal of the treatment to be applied to resident #30's skin. The progress notes did not include documentation of attempt(s) made to apply the treatment to resident #30's skin, or refusal by the resident. On 3/23/26 at 10:37 AM, Certified Nursing Assistant (CNA) E said resident #30 liked to stay in her room but at times she came out to ask staff for water or snacks. CNA E said she was not aware of any skin problems for resident #30. On 3/25/26 at 10:25 AM, Licensed Practical Nurse (LPN) F said the last time she worked with resident #30 she had something on her skin but was not sure what resident #30 had on her body. LPN F verified resident #30 had a treatment order for Hydrocortisone every eight hours, as needed for itchiness which was written on 2/08/26. LPN F said resident #30 was itching the last time she worked but could not recall the day or date. The nurse said resident #30 let staff know when she needed anything. She felt resident #30 would have told the staff if she had itching. On 3/25/26 at 10:32 AM, the 200 Hall Unit Manager (UM) said resident #30 had no concerns that morning when she saw her and was not itching. The UM and LPN F said when there was a new recommendation from a consulting physician, such as a dermatologist, the resident's physician would be called by the nurse who spoke to the consulting specialist and the order would be placed in the medical record. They explained, the same nurse would call the responsible family member and inform him/her of the new order. On 3/25/26 at 10:35 AM, the 200 hall UM and LPN F entered resident #30's room and confirmed she was observed rubbing her hands together. The UM and LPN F said resident #30's hands were red, and dry and confirmed resident #30 had a scratch on her right wrist. The 200 hall UM asked resident #30 if she was itchy and resident #30 rubbed both her right and left hands in a circular motion from her hands to her wrists, to indicate where she itched. On 3/25/26 at 10:40 AM, the 200 hall UM and LPN F reviewed resident #30's physician orders in the computer. LPN F removed a tube of medication from the treatment cart, went to resident #30's room and applied the cream to both of her hands and wrists. Resident #30 did not refuse the treatment. On 3/25/26 at 2:58 PM, in a joint interview with the Regional Nurse Consultant (RNC) and the Director of Nursing (DON), the DON said the process when a specialty physician such as a dermatologist recommended a new order, that specialty physician will verbally communicate the recommendation to a nurse. The DON continued that the nurse was responsible for documenting the new order or recommendation in a physician's order after they had spoken to the primary physician for approval of the new order or treatment. She explained the new order would be placed in the MAR and/or TAR, then the nurse would call the resident's family to let them know of the new order then complete documentation in a progress note. The DON reviewed the dermatology note dated 3/02/25 and read the physician's recommendation aloud: Start Permethrin 5% cream applied from neck down overnight and wash off in the morning; repeat in seven days for total of two treatments. The DON and the Regional Nurse Consultant (RNC) reviewed resident #30's physician orders for the dermatology recommendation for Permethrin. The DON and the RNC confirmed there were no corresponding physician orders in electronic medical record (EMR). The DON said resident #30 refused her medications many times and her family was aware. The DON said, in the past, the resident #30's son agrees with only certain medications or treatments prescribed by the physician. The DON acknowledged a progress note should be in the medical record if the son refused the treatment recommended by the dermatologist. The medical record was reviewed by the DON and the RNC and confirmed the EMR revealed was no progress note to indicate the recommendation from the dermatologist was communicated to resident #30's physician and/or family. They confirmed there was no progress note or other documentation in resident #30's medical record to indicate her family refused the treatment recommended by the dermatologist. Review of the policy revised on January 2026 titled, 'Standards and Guidelines: Physician Orders,' revealed, that verbal orders should be recorded in the resident's chart by the authorized person who received the order and should include the prescriber's name, credentials, the date and time of the order. The policy noted the resident would be informed of medication changes as they occurred, and if the resident was incapable of making health care decisions, the resident's responsible party would be informed of medication changes as they occurred.

Based on observation, interview, and record review, the facility failed to follow physician's orders consistent with professional standards of practice for 1 out of 4 residents reviewed for respiratory care, of a total sample of 40 residents, (#92). Findings: Resident #92 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, Alzheimer's disease, Type two Diabetes Mellitus and dementia. A review of the Annual Minimum Data Set with assessment date 1/29/26 revealed resident #92 was cognitively impaired with a Brief Interview for Mental Status of 0 out of 15. Review of the medical record revealed documentation that resident #92 had a change in condition on 3/06/26. The documented assessment revealed the resident had shortness of breath and her oxygen saturation was at 88%. Subsequent orders from the physician on 3/06/26 included delivery of continuous oxygen at 2 liters per minute (LPM) via nasal cannula, provide portable oxygen tank for 2 LPM nasal cannula, monitor oxygen saturation twice a day and to consult pulmonology. Resident #92's current plan of care indicated she was at risk for altered respiratory status or difficulty breathing related to shortness of breath. Interventions included administer oxygen as ordered and monitor oxygen saturations as ordered. The care plan most recent revision was on 3/10/26 and did not mention non-compliance with oxygen therapy and had no interventions regarding non-compliance. Review of the medical record showed oxygen saturation levels were documented on 3/13/26 but contained no documentation of the actual levels from 3/06/26 on. The nurses' progress notes contained no documentation of the resident's refusal to wear oxygen as ordered and no documentation of a pulmonary consultation on 2/17/26 and 3/06/26. Review of the medication administration record (MAR) revealed nurses checked off the task of monitoring oxygen saturation twice daily but did not record the measurement of the percentage of oxygen saturation. On 3/22/26 at 10:46 AM, resident #92 was observed sitting in the common area. She was not wearing the nasal cannula connected to oxygen, as ordered by the physician. On 3/24/26 at 4:38 PM, resident #92 was observed not wearing the oxygen as ordered. Registered Nurse (RN) A was present and said she was not aware the resident used oxygen and was ordered to be on 2 LPM of continuous oxygen. Both RN A and Certified Nursing Assistant (CNA) C, who joined the interview, verified there was neither an oxygen concentrator nor a portable oxygen tank at the resident's bedside. CNA C said she remembered the resident had a portable oxygen tank but she never used it. RN A then verified the physician's order for oxygen in the computer and said she would call the doctor to change it from continuous to as needed. RN A continued to explain that the resident would let them know if she was short of breath, that she did not complain of any shortness of breath lately and that her oxygen was fine. She said she checked the resident's oxygen saturation earlier and it was fine. On 3/25/26 at 9:45 AM, the Director of Nursing (DON) reviewed resident #92's MAR and explained the resident's oxygen was monitored by the indication of the check marks on the MAR. The DON was unable to say how anyone including the physician would know what the oxygen saturation was if the actual measurement was not documented, and no refusals were noted by the nurses. On 3/25/26 at 1:31 PM, in a telephone interview, resident #92's attending physician said if there was an order to monitor oxygen saturation, she expected the actual oxygen saturation measurement to be recorded in the medical record so it could be reviewed. She said together with her Nurse Practitioner, the facility's staff would often say that the resident was fine, but when her and the Advanced Practice Registered Nurse (APRN) did their own test, they found resident #92's oxygen saturation was low, so they placed orders for the resident to be monitored twice a day. The physician explained this situation happened again and they placed the orders in addition to a second pulmonary consult when they could not find any documentation in the record of whether the resident had the pulmonology consult or not. She said she had not been informed the resident had not been wearing her oxygen but would reach out to the APRN for more information. On 3/25/26 at 3:52 PM, in a telephone interview, the APRN for resident #92 said she requested the oxygen delivery to be continuous and for the oxygen saturation to be monitored once during the day and once at night. The APRN explained the resident had low oxygen saturation in the past and her order for oxygen was as needed at that time, but that situation had resolved. She continued that when she saw the resident in March, her oxygen saturation was low and placed new orders for oxygen and pulse oximetry measurements. The APRN explained staff reported the resident's oxygen saturations were not low but whenever she checked the oxygen saturation it was. She said facility staff indicated the resident was not going to be compliant with the orders when she had seen the resident not wearing oxygen. She said she explained to staff they needed to remind resident #92 to wear her oxygen. The APRN conveyed her experience was the resident understood she needed the oxygen, agreed to wear it and was given an oxygen tank. She continued that staff reported the resident would not be compliant with wearing the oxygen because she walks with a rolling walker and it's not like she had a third arm. The APRN said this was the reason we asked for the pulmonary consultation and ordered oxygen saturation checks twice daily. She said she figured the resident could have had a small portable tank she could carry around. The APRN confirmed there were two orders placed for a pulmonary consultation and the Unit Manager reported the resident was seen by a pulmonologist, but they had no documentation or paperwork from the consult. The APRN said a facility nurse called yesterday stating the resident's oxygen saturation was fine and they requested to discontinue the oxygen. The APRN explained she did not discontinue the oxygen order but changed it to as needed instead of continuous in case the resident needed it. The APRN elaborated that the order for monitoring, meant she expected the nurses to use a pulse oximeter and record the percentage of oxygen for everyone involved in her care to see in the medical record. She said, I find that they don't always do that. On 3/25/26 at 4:36 PM, the Transportation Coordinator confirmed she managed transportation and scheduling of consults at the facility. She said the pulmonary physician used by the facility was in-house. The coordinator verified she did not schedule an outside appointment with the pulmonologist and said the nurses or the Unit Managers usually took care of those consults or referrals. On 3/25/26 at 5:06 PM, Licensed Practical Nurse (LPN) D explained if a resident was ordered a consult, she would put the physician order into the computer, she would print it out and the Unit Manager would be expected to follow up and follow through. LPN D continued that for any physician's orders she followed what was ordered and if a resident refused something, she would notify the physician, write a note in the record, and wait for any new orders. On 3/25/26 at 3:56 PM, the DON confirmed that nurses monitoring oxygen saturation should include the actual numbers as measured. She explained the expectation for nurses was to monitor the oxygen saturation and document the percentage of oxygen in the medical record as ordered by the physician. The DON said for consultations, once the recommendation, referral or order was placed, the Unit Manager should communicate to the Transportation Coordinator. She continued, once an appointment was made the Unit Manager should be made aware, would discuss the appointment in morning meeting and would get back to the physician if the resident was unable to make the appointment. The DON conveyed the Unit Manager would document in the medical record all new orders obtained from the consult or the physician and if there were no new orders in the residents' chart, they would discuss that in their morning meetings. The DON was unable to provide documentation regarding resident #92's pulmonary consult. The facility's policy on physician orders issued October 2020, and revised January 2026 indicated physician orders should be followed as prescribed and if not followed it should be recorded in the resident's medical record during that shift. The policy detailed that the physician and the party responsible should be notified, if indicated. Review of the Guidelines for Oxygen Administration issued October 2019, and revised January 2026 revealed staff should notify the supervisor if the resident refused the procedure and should report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure safe and accurate administration of medication to meet the needs of residents, for three of six residents reviewed for medication administration, of a total sample of 40 residents, (#41, #37, and #77).Findings: 1. Resident #41 was admitted on [DATE] from an acute care hospital with diagnoses that included Alzheimer's disease, dementia with psychotic disturbance, gastro-esophageal reflux disease (GERD) and dysphagia-oral phase. The American Speech-Language-Hearing Association says a disorder in swallowing is called dysphagia. Dysphagia oral phase is a problem with sucking, chewing and moving food and/or liquid into the throat which could lead to it going into the airway (aspiration), and pneumonia or other lung infections, (retrieved on 4/08/26 from www.[NAME].org). Review of resident #41's current physician orders revealed medications including Sucralfate one Gram tablet, by mouth, four times a day for GERD. The instructions directed the nurse to dissolve one tablet in 10 milliliters of water before meals and at bedtime for administration. Resident #41 had additional orders including the medication Pantoprazole Sodium Oral tablet Delayed Release 40 milligrams with instructions to give one tablet by mouth twice a day for GERD. The instructions for the nurse included do not crush, chew or split with a start date of 4/09/25. There were no physician orders for self-administration of medication. Resident #41 had a care plan for dated 7/20/24 for impaired cognitive function/impaired thought processes related to Alzheimer's and diagnosis of dementia with psychotic disturbance. A care plan dated 7/20/24 for risk for alteration of nutrition related to GERD included an intervention to Administer medications as ordered. Resident #41 had an additional care plan dated 8/14/24 for a risk for aspiration related to mechanically altered diet. Interventions included encourage resident to eat in an upright position, keep head of bed elevated, monitor for excessive excretions, and any signs of dysphagia including pocketing, choking, coughing, drooling, and holding food in mouth. There was no care plan for self-administration of medication. On 3/22/26 at 10:20 AM, resident #41 was in his bed by the window with his eyes closed. On the floor there was a blanket dirty with dried food stuck to it and on the floor. There was dried food on his sheets, and the room-divider curtain. On the resident's nightstand was a small plastic cup containing two white tablets. (photo evidence obtained). A few minutes later outside the room Licensed Practical Nurse (LPN) K was standing at her medication cart and confirmed she was the assigned nurse for resident #41. LPN K described resident #41's mentation as confused. She confirmed resident #41 was not able to self-administer his medications due to his confusion. The LPN said she had not left the cup of medications in the room and had not seen the cup on the nightstand when she gave him his morning medications earlier that morning. LPN K went to resident #41's bedside and retrieved the cup of medications. She said they were resident #41's Pantoprazole and Sucralfate probably left with the resident by the night shift nurse. LPN K looked in her Medication Administration Record (MAR) and said the night shift nurse erroneously signed off in the MAR they were administered at 6:03 AM that morning. LPN K explained the large white tablet was Sucralfate, which was supposed to be dissolved in water before administration to the resident. The nurse confirmed resident #41 could not self-administer his medications and acknowledged if the medicine was left at the bedside, the nurse would not know if the resident actually took the medications or they could be taken by someone else. On 3/25/26 at 3:18 PM, in a joint interview with the Director of Nursing (DON) and the Regional Nurse Consultant, the DON explained the facility policy was that no medication should be left at the bedside unless the resident was assessed by the nurse for self-administration of medications and there was an order for self-administration from the physician. The DON confirmed resident #41 did not have an assessment or a physician order to self-administer his medications. She stated a resident with a low cognitive assessment test score like resident #41 would not be safe to take medications on their own. Review of the Standards and Clinical Guidelines: Medication Administration, with most recent revision January 2026, revealed medications should be administered in accordance with prescriber orders, and residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team has determined the resident had the decision-making capacity to safely do so. 2. Resident #37 was admitted to the facility from an acute care hospital on 3/05/26 with diagnoses that included osteoarthritis of the right hip, prostate cancer, muscle weakness, and chronic pain. On 3/25/26 at 1:21 PM, Registered Nurse (RN) L was observed during medication administration for resident #37. She looked at the resident's order on the computer and pulled two of his medication peel packs containing tablets and a bottle of Acetaminophen 500 milligrams (mg). From each peel pack and the Acetaminophen bottle she took one tablet and dropped them each into a medication cup for a total of three tablets. The nurse proceeded into resident #37's room with the medication and a cup of water. She told the resident what each tablet was and administered the medication. Review of resident #37's order summary dated 3/26/26 revealed an order for Acetaminophen 500 mg two tablets by mouth, three times per day for pain, which was a total of 1000 mg per administration. On 3/25/26 at 1:47 PM, RN L was notified she had administered only one tablet of the Acetaminophen instead of two as was ordered by the physician. She stated she only saw the 500 mg dosage but did not realize she was supposed to give two tablets for a total of 1000 mg. The nurse acknowledged she made a mistake and should have verified the amount of medication to be given, not just the strength of the medication to ensure the resident was not being under or over medicated. She confirmed she did not follow the physician order. 3. Resident # 77 was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included systemic lupus erythematous, immunodeficiency, chronic kidney disease stage 3, cognitive communication deficit, and colostomy status. On 3/24/26 at 8:56 AM, LPN M was observed during medication administration for resident #77. She pulled up a total of eight medications including a metered dose inhaler and Cranberry 450 mg tablets. LPN M proceeded to administer the inhaler first followed by the other medications, which were all tablets. The LPN did not have the resident rinse their mouth after receiving the inhaler, which is recommended after administration of metered dose inhaled medications. A metered dose inhaler (MDI) is a small handheld device that disperses medication into the airways via an aerosol spray or mist through the activation of a propellant. A measured dose of the drug is delivered with each push of a canister, and dosing is usually achieved with one or two puffs. After administration of the inhaler patient should rinse mouth and gargle with warm water two minutes after treatment. Rinsing removes residual medication from mouth and throat and helps prevent oral candidiasis, (retrieved on 4/09/26 from drugs.com). Review of resident #77's order summary dated 3/26/26 revealed an order for Cranberry oral tablet 300 mg, one tablet once per day for urinary tract infection ordered on 1/26/26. On 3/24/26 at 9:07 AM, LPN M acknowledged she did not administer the correct dose of the Cranberry and had grabbed the house stock bottle without realizing the dosage was different than what was ordered. She also acknowledged she did not have the resident rinse her mouth following the administration of the inhaler. On 3/26/26 at 1:28 PM, the Director of Nursing (DON) acknowledged the two medication errors. She stated the expectation was for nurses to ensure they verified the resident's orders prior to administering medications to ensure they were giving the correct medication and dosage.

Based on observation, interview, and record review, the facility failed to ensure staff followed transmission-based precautions to prevent spread of infection and ensure residents were provided a safe, sanitary and comfortable environment by preventing the development and transmission of communicable diseases and infections for 1 out of 1 resident reviewed for transmission based precautions, of a total sample of 40 residents, (#56).Findings: On 3/22/26 at 10:15 AM, room [ROOM NUMBER]'s door was open with a Contact Precaution sign posted but nothing on the sign to identify which bed was on precautions. A nursing student completed hand hygiene and donned gloves then walked into room [ROOM NUMBER] to see resident #56 in the B bed by the window. Registered Nurse (RN) H was outside the room at her medication cart. RN H completed hand hygiene and proceeded into room [ROOM NUMBER] bed B to see resident #56 and administered oral medications. RN H did not don gloves or gown. RN H and the nursing student exited the room, and a few minutes later at approximately 10:25 AM, RN H stated resident #9 (#118A) had scabies and was on contact precautions. At 10:30 AM, RN H completed hand hygiene and donned gown and gloves, then entered room [ROOM NUMBER]. She administered inhaled medications to resident #56, in the B bed and walked into the bathroom. RN H doffed the gown and gloves, completed hand hygiene and explained she wore the gown and gloves this time when administering medications to resident #56 because resident #9 used the same bathroom and was on contact precautions for the scabies. On 3/22/26 at 10:40 AM, resident #9 was in bed watching TV and said as she pointed to her roommate, resident #56, she has scabies, not me. Review of resident #56's (room [ROOM NUMBER]B) medical record revealed a physician order for contact precautions for possible scabies to continue 14 days on 3/19/26. On 3/26/26 at 10:30 AM, the Infection Preventionist Nurse confirmed resident #56 had physician orders for contact precautions for scabies. She revealed she was aware RN H had mistakenly believed resident #9 had contact precautions instead of resident #56 and did not wear the proper protective equipment when providing care.

Based on observation, and interview, and record review, the facility failed to provide a homelike environment for resident dining in the upstairs Vista View unit dayroom for 9 of 40 residents sampled. Findings: On 1/27/25 at 11:55 AM, in the Vista View dayroom nine residents were sitting around tables waiting for lunch. There were no tablecloths or centerpieces on the tables and staticky music was playing from a radio in the background. The Social Services Assistant (SSA) changed the channel several times in an attempt to find appropriate dining music but the static persisted. A short time later at 12:07 PM, lunch trays were delivered to the residents in the dayroom. The plates, cups, bowls and eating utensils were left on the trays and not set on the table for dining. On 1/30/25 at 12:00 PM, approximately eight residents were engaged in an activity in the Vista View dayroom. The meal cart with residents' lunches sat in the hall unattended. A few minutes later, the meal trays were passed to residents in their rooms and residents were guided back to their rooms to eat. No one ate lunch in the dayroom. On 1/30/25 at 12:15 PM, the Activities Director (AD) explained the upstairs Vista View unit's dayroom also functioned as a dining room. The AD stated the residents did not always eat meals in the dayroom but often ate in their rooms. On 1/30/25 at 12:34 PM, the Vista View Unit Manager (UM) stated sometimes the staff had residents eat in the dayroom, but there were often activities going on when the lunches came, so the residents ate in their rooms. She added it was different downstairs who received their meal trays on carts organized for the residents who ate in the dayroom. The Vista View UM explained they didn't use tablecloths for the dining room because some residents pulled on them. She explained staff didn't take the dishes off the meal trays because the tray provided a limitation of space for residents to know what items were theirs and to prevent them from going after other resident's food. She added for the assisted diners, the facility liked them to eat in their room because they felt there were less distractions. The Vista View UM acknowledged it was good practice to have residents dine in the dining room to promote socializing and created a more homelike environment. She explained the main dining room downstairs was larger and the residents there had better cognition. The Vista View UM acknowledged staff could prevent residents from pulling tablecloths off the tables and said the facility did not always encourage residents to eat in the dining room because it sometimes conflicted with activities. She confirmed dishes and silverware left on the trays for dining was not home-like. On 1/30/25 at 12:53 PM, the Director of Nursing (DON) stated there was no reason for dishes to be left on the trays during meals in the dining room and explained the facility encouraged residents to eat in the dining room for the social experience. The DON acknowledged residents being allowed to eat in the dining room in a home-like setting was a dignity issue. A short time later at 1:20 PM, the Vista View UM and the AD joined the DON and the AD explained that earlier, residents ate in their rooms because an activity was taking place in the dayroom and the meal trays arrived on two separate carts. The AD continued, residents whose meals came on the first cart had to eat in their room while residents whose trays were on the second cart continued with the activity until the second cart arrived. The DON, UM and AD agreed dining in their rooms or without tablecloths or trays removed was not a homelike dining experience for the residents. The facility's policy entitled Standards and Guidelines for Dining Services dates July 2023 indicated the facility should provide a pleasurable dining experience in a courteous and dignified manner. The document included that an appropriate number of nursing personnel should be stationed in the dining room to assist with eating.

Based on observation, interview, and record review, the facility failed to ensure a resident was evaluated for safe self-administration of medication and failed to obtain a physician order for self-administration of medication for 1 of 10 residents reviewed for medication, of a total sample of 40 residents, (#65). Findings: Resident #65 was admitted to the facility on [DATE] with diagnoses that included mild Neurocognitive disorder, chronic kidney disease and lack of coordination. Review of resident #65's annual Minimum Data Set assessment dated [DATE] indicated resident #65 had mild cognitive impairment. On 1/27/25 at 1:20 PM, a bottle of Vicks VapoRub was seen on the floor in resident #65's room. She explained she applied the Vicks VapoRub under her nose nightly from the jar which she had dropped on the floor. Review of resident #65's physician's order summary for January 2025 revealed no order for Vicks VapoRub or for self-administration of medication. Review of the medical record revealed no documentation of a self-administration of medication assessment. On 1/27/25 at 1:30 PM, Licensed Practical Nurse (LPN) L stated she was unaware resident #65 had the medication Vicks VapoRub in her room and applied it to herself. LPN L went to resident #65's room and saw the medication in resident #65's possession. A short time later when LPN L returned from resident #65's room, she said she had given the bottle of Vicks VapoRub to the Unit Manager (UM). On 1/27/25 at 3:00 PM, the Caribbean Cove UM acknowledged resident #65 had a bottle of Vicks VapoRub in her room that she self-administered. She verified there was no physician's order for the Vicks VapoRub, nor had there been an Interdisciplinary team assessment to determine resident #65 was safe to self-administer medication which was required before self-administration of medication.

Based on interview, and record review, the facility failed to ensure a resident was involved in developing and making decisions regarding her care plan for 1 of 1 resident reviewed for care planning, of a total sample of 40 residents, (#24). Findings: Resident #24, a [AGE] year-old female was admitted to the facility on [DATE], with a most recent readmission on 2/12/24. Her diagnoses included muscle wasting and atrophy, traumatic subdural hemorrhage without loss of consciousness, diabetes type II, repeated falls, dementia, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 11 of 15. On 1/27/25 at 2:41 PM, resident #24 stated she was not invited to her care plan meetings, and did not know if her son was invited to the care plan meetings either. Review of the Interdisciplinary Plan of Care Plan Meeting (IPOC) documents in the resident's electronic clinical record, revealed on 3/26/24, and 7/02/24, the IPOC indicated the resident's son attended the care plan meeting via telephone. There was no documentation to indicate the resident was ever invited/attended/declined or participated in her care plan meeting. On 10/01/24 documentation on the IPOC did not indicate if the resident or the resident's representative was in attendance or had participated. Documentation read, IDT attempted to call son with no answer. Left voice mail to return call. On 1/29/25 at 11:52 AM, the Vista View Unit Manager (UM) stated the facility's protocol pertaining to care plan meetings was that the MDS Coordinator provided a list of residents with scheduled care plan meetings to the Receptionist, who would then send emails to family/resident representatives regarding the scheduled care plan meetings. She stated if the resident was awake, alert, and oriented, the Receptionist or the MDS Coordinator would provide the resident with the schedule of the care plan meeting, and on the day of the care plan meeting, the UM would remind the resident of the meeting. The LPN/UM said if the resident attended the care plan meeting, it would be documented on the IPOC, and the resident's signature would be obtained. On 1/29/25 at 12:07 PM, MDS Coordinator N explained that upon completion of an MDS assessment, the next schedule would be opened and added to the care plan calendar. She stated the Receptionist received a copy of the schedule and sent an email notification of the care plan meeting schedule to the resident's family. If the resident was awake, and alert, a notification of the meeting would be provided to the resident. She verbalized if the resident's cognition was impaired, they would still be invited to the care plan meeting, and on the morning of the scheduled meeting, staff would go around to let the Certified Nursing Assistants know which residents needed to be up and ready for their care plan meeting. MDS Coordinator N said if the resident attended the care plan meeting, the resident would sign the IPOC document to indicate they attended. She stated that typically MDS would call the resident's son, and on the day of the care plan meeting they would ask the resident if they wanted to attend. She said resident #24 usually did not attend, and documentation on the IPOC document should have indicated that the resident declined. The resident's IPOC dated 3/26/24, 7/02/24, and 10/01/24 were reviewed with the MDS Coordinator. She acknowledged there was no documentation to indicate the resident was invited /attended/ or participated in her care plan meetings. MDS Coordinator N stated she would review the resident's clinical records as sometimes a progress note regarding the care plan meeting would be documented by the UM. A review of the clinical records showed no additional documentation regarding the resident's invitation/attendance or participation in her care plan meetings. This was acknowledged by MDS Coordinator N. On 1/29/25 at 2:09 PM, MDS Coordinator N stated the facility did not have a policy regarding residents' participation in the care plan meeting process, but they followed the MDS 3.0 Resident Assessment Instrument Manual . On 1/30/25 at 11:26 AM, the Director of Nursing (DON) stated residents were always invited to their care plan meetings and encouraged to participate. The resident's clinical records were reviewed with the DON. She acknowledged that there was no documentation to indicate the resident was invited/attended/declined or participated in her care plan meetings on the dates identified. The Center For Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual Version 1.19.1 dated October 2024 described care planning as Establishing a course of action with input from the resident (resident's family and/or guardian or other legally authorized representative) . that moves a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise; crafting the how of resident care. Chapter 4 of the Manual titled Care Area Assessment Process and Care Planning directs that care plans should be developed by Involving resident, resident's family and other resident representatives as appropriate.

Based on observation, interview, and record review, the facility failed to maintain a sanitary environment by not ensuring reusable oxygen humidifier bottles were cleaned per manufacturer's guidelines for 1 of 3 residents reviewed for humidified oxygen use, of a total sample of 40 residents, (#52). Findings: Resident #52 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart failure, sick sinus syndrome, and COVID-19, onset date of 1/18/25. On 1/28/25 at 10:05 AM, resident #52 was observed with the Director of Nursing (DON) in his room. He had his nasal cannula connected to an oxygen concentrator with a reusable humidifier bottle. Clear liquid bubbled inside the reusable humidifier bottle. The DON verified the humidifier bottle was dated 10/31/24 as written on the reusable humidifier bottle. Review of the undated oxygen concentrator user's manual, in the section regarding cleaning of the humidifier bottle, the next step after cleaning the bottle was to disinfect the humidifier parts by immersing them in a disinfection solution, then rinse under running water, and dry. On 01/29/25 at 10:35 AM, Licensed Practical Nurse (LPN) F said he was the Weekend Supervisor. He explained that on 1/25/25 he did an audit of residents who received supplemental oxygen including cleaning resident #52's reusable humidifier bottle with soap and water. LPN F said he dried the bottle with paper towels, added sterile water to the bottle, and reconnected it to the concentrator for use. LPN F said the reusable humidifier bottles should be cleaned weekly and replaced with a new bottle once a month. He stated he did not recall seeing the date 10/31/24 written on resident #52's reusable humidifier bottle, and acknowledged he did not date the bottle himself. LPN F verified he did not document that he cleaned resident #52's reusable humidifier bottle in the resident's medical record. He confirmed he did not know the bottle should be disinfected after washing as recommended by the manufacturer. On 1/29/25 at 2:50 PM, the Assistant Director of Nursing (ADON) reviewed clinical in-service education regarding infection control for oxygen use dated 12/07/24, 12/08/24, and 12/09/24. The in-service information entitled, Standards and Guidelines: Oxygen with revision date December 2024, noted in the general guidelines that when utilizing humidified oxygen staff should follow manufacturer recommendations for guidance. The ADON could not elaborate if such guidance was discussed or what it comprised. On 1/30/25 at 10:19 AM, the DON confirmed the oxygen concentrator user's manual noted that disinfection should occur after washing. She thought the Facility Management Director and his staff completed the disinfection. The Facility Management Director confirmed he and his staff had not been completing the disinfection but preferred to replace the reusable humidifier bottle instead. The DON verified there was no documentation regarding resident #52's reusable humidifier bottle having been cleaned nor disinfected in the medical record .

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice for 1 of 1 resident reviewed for IV care, out of 32 total sampled residents, (#215). Findings: Resident #215 was admitted to the facility from an acute care hospital on 5/4/23 with diagnoses including fractured sacrum, diabetes, chronic kidney disease, and muscle weakness. Review of resident #215's medical record revealed a physician order dated 5/5/23 for 1 liter NS (normal saline) solution 0.9% at 75 ml. (milliliters) per hour x 1 only for BUN 111 (blood urea nitrogen) for 3 days. Blood urea nitrogen is a medical test that measures the amount of urea nitrogen found in blood . Normal human adult blood should contain 6 to 20 . (www.wikipedia.com). On 5/7/23 at 10:20 AM, resident #215 was observed lying in bed in her room. She had a midline IV inserted in her left upper arm with undated gauze dressing over the IV site. She was alert and oriented and stated she was getting IV fluids for dehydration. The 1000 ml. bag of 0.9% NS was hanging on the IV pole and was attached to the resident's midline IV left upper arm but was not infusing. The NS bag had 400 ml. of fluid remaining and was dated 5/5/23 with the time of 11:55 PM. A midline catheter is put into a vein by the bend in your elbow or your upper arm . The midline tube ends in a vein below your armpit .midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments .(www.drugs.com). Review of the medical record revealed a contracted company's Registered Nurse (RN) had placed a midline IV catheter on 5/5/23 at 5:48 PM in resident #215's left basilic vein. On 5/7/23 at 10:35 AM, Licensed Practical Nurse (LPN) F said she was resident #215's assigned nurse yesterday and today on the day shift and was not aware the resident had an IV or fluids as she did not receive this information in report. LPN F validated the resident had NS bag of fluids still connected to the IV line dated 5/5/23 and timed 11:55 PM and it was not infusing. The nurse then opened the clamp on the IV tubing and the fluid did not drip. The LPN looked at the dressing and acknowledged it was gauze over the left upper arm IV site with no date. The LPN stated, IV tubing and fluids should be changed at least every 24 hours. On 5/7/23 10:45 AM, the Director of Nursing (DON) acknowledged resident #215's bag of IV fluids NS dated 5/5/23 with 400 ml. of fluid remaining and the IV site left arm with gauze over insertion site that was not dated. After reviewing the medical record, the DON verified that resident #215 had a 1-time order for IV fluids for hydration. The DON explained the nurse on 5/5/23 did not enter the batch orders into the electronic medical record and a task would not be generated for nurses to monitor the IV site each shift or make sure the fluids were infusing. She reported that 3 nurses worked on Saturday 5/6/23 and did not document monitoring the IV site or the bag of fluids hanging on the IV pole adjacent to the resident. The DON said nurses should have questioned the bag of normal saline IV hanging with no orders for monitoring. The DON added any of the nurses could have entered the needed batch orders for IV care/services for resident #215 whose fluids should have been completed by Saturday 5/6/23 at 1 PM. On 5/7/23 at 1:26 PM, after further review of the medical record, the DON said that although LPN D documented she hung the IV fluids on 5/5/23 at 11:54 PM, it was done by RN C. The DON added since RN C hung the IV fluids, he should have signed the medication administration record instead of LPN D. The DON verified there was no evidence in the medical record that once the IV was inserted and fluids were started on 5/5/23 that any further care/services were provided until the concerns were identified by the surveyor on 5/7/23 at 10:35 AM. The DON noted that because the orders were not entered correctly of Friday 5/5/23, the weekend supervisor RN was not aware the resident had an IV or IV fluids. The DON verbalized the IV batch orders included monitoring IV site, dressing changes and flushes. On 5/9/23 at 3:48 PM, during a telephone interview, LPN B verified she worked the 3 PM to 11 PM shift on Saturday 5/6/23 and was assigned to resident #215. She explained she did not receive report from the off going nurse that resident #215 had IV or was getting IV fluids. The nurse verbalized, she did see the bag of IV fluids hanging on the IV pole for resident #215 during her shift but did not look at the IV site left arm, nor did she notice if the fluids were infusing. LPN B stated she should have checked for the IV orders and if there were no orders, she should have informed the weekend supervisor or the DON. By the end of the survey, on 5/10/22, the DON did not provide an interview from LPN A who was agency nurse assigned to the resident on 5/6/23 to 5/7/23 on the 11 PM to 7 AM shift as the nurse would not return her calls. The facility's policy and procedure, Intravenous Administration of Fluids and Electrolytes, revised 3/28/2018, read, Staff will be knowledgeable regarding the safe and aseptic administration of intravenous fluids and electrolytes for hydration .Assessment: Inspect intravenous catheter and insertion site for signs and symptoms of complications at scheduled intervals [per facility policy], during routine site care and changing administration sets .Inspect solution for leaks, cracks, precipitate, and expiration dated .When infusion is complete: For intermittent therapy: Clamp tubing and disconnect from catheter. If tubing will be reused, replace sterile cap. Flush catheter per protocol .Documentation: The following information should be recorded in the resident's medical record .The condition of the IV site before and after administration .Quote from resident stating how they tolerated the procedure .Notify provider, supervisor, and oncoming shift of complications .Report other information in accordance with facility policy and professional standards of practice. The facility's policy and procedure, Midline Dressing Changes and Care, revised April 2016, read, The purpose of this procedure is to prevent catheter related infections associate with contaminated, loosened, or soiled catheter site dressing and care of the site .Care of Midline Site: Observed site for signs and symptoms of infections, redness, presence of edema or purulent drainage every shift. Observe for signs and symptoms of pain or discomfort at IV site and intervene appropriately .

Based on interview, and record review, the facility failed to act on physician order as per pharmacy recommendations for 1 of 5 residents reviewed for Medication Regimen Review (MRR) from a total sample of 32 residents, (#3). Findings: A review of the medical record revealed resident #3 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 5/08/2022 with diagnoses including dementia, psychosis, delusional disorder, depression, anxiety, malnutrition, hemiplegia, diabetes, and hyperlipidemia. The Order Summary Report showed the resident had active medication orders including Risperidone 1 milligram (MG) at bedtime, and 0.5 MG once daily for psychosis, Lexapro 5 MG once daily for depression, Melatonin 3 MG at bedtime for sleep, Tramadol 50 MG as needed for pain, and Pravastatin 40 MG at bedtime for high cholesterol. The MRR dated 1/27/2023 noted a lipid profile blood test was recommended to monitor effects of Risperidone and Pravastatin. On 2/02/2023, the physician signed orders to follow the pharmacist's recommendations. Review of the February 2023 Treatment Administration Record documented nurses signed laboratory blood testing was completed on 2/02/2023 and 2/07/2023 for a lipid profile. Review of the resident's laboratory results showed there was not a lipid profile test completed on 2/02/2023 or 2/07/2023. On 5/10/2023 at 4:10 PM, the Director of Nursing said she was not able to locate records to show the physician's order for lipid profile on 2/02/2023 was completed. She explained the order should have been completed on 2/02/2023 or 2/07/2023 when nurses signed it as completed. She stated, I can't believe it didn't get done. The facility's policy titled, Medication Regimen Reviews dated May 2019, read, 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication., 5. to prevent, identify, report, and resolve medication related problems. f. potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences.

Based on observation, interview, and record review, the facility failed to provide proper storage and sanitation practices for the clean storage of nested pans and cooking sheets, failed to provide appropriate and scheduled cleaning of kitchen equipment, and failed to provide proper training for the washing and storage of pots and pans to prevent potential food contamination. Findings: On 07/12/21 at 9:57 AM, during the initial kitchen observation, the cook and dietary aides prepared food that would be placed onto the steam table for the lunch meal and prepped the steam table with metal warming pan inserts. An open rack of washed and nested metal pots and pans was observed on the wall by the walk-in freezer. There were five steam table pan inserts that were 6 inches deep noted to be wet and nested on top of each other. Drops of water were observed on the pans when removed from on top of each other. There were 2 metal baking sheets that were also wet on the same rack nested on top of each other. At this time, the Dietary Manager (DM) acknowledged the warming inserts and baking sheets were not dry. She stated that for food safety purposes, washed pots and pans needed to be air dried before being stored. She explained the evening shift dietary Cook/Aide B was new to the facility and had stacked the pots and pans after washing them the night before. On 07/12/21 at 10:00 AM, a portable fan in the dish washing room was observed mounted in the corner of two adjoining walls. The fan was observed to have stringy gray lint residue on the outer metal wire cover. There was dark residue located in the inner grooves of the fan paddles. The fan was on high speed, blowing air onto clean drinking cups and plate covers that were drying on racks. The inside of the cups and plate covers were exposed to the blowing air. The DM said, the room gets really steamy and hot. The fan helps to cool it off. She revealed the fan had not been cleaned in three weeks, since the first day she started in her role as DM. Review of the equipment cleaning log with the DM showed the dish washing room fan was not included in the cleaning schedule. She acknowledged the fan was not included in the cleaning schedule. On 7/14/21 at 11:20 AM, the evening Cook/Dietary Aide B said he started work at the facility October 2020. He acknowledged he had stacked the wet pans onto the rack. He said he did not realize they were wet when he stacked them. Review of his orientation paperwork did not reveal any specific education about the importance of air drying pots and pans to prevent potential food contamination. Review of the facility's Policies and Procedures for Washing Pots and Pans and for Sanitation/Infection Control included the sanitary practices of air drying pots and pans after being washed to reduce the possibility of food contamination. It included the Dietary Manager and Consultant Dietician were responsible to develop a cleaning schedule and responsible for supervising and training all personnel in proper sanitation procedures for storing, preparing, and servicing foods.

Based on observation, interview and record review, the facility failed to provide a secure environment and adequate supervision for 1 of 12 residents at risk for elopement (#2). These failures contributed to the elopement of resident #2 and placed her at risk for serious injury/impairment/death. While resident #2 was out of the facility unsupervised, there was a high likelihood she could have been hit by a car, become lost or drowned. On 8/11/19 at approximately 1:35 PM, resident #2 exited the facility unsupervised, through the front lobby door. She walked through the facility's parking lot and continued along a moderately-trafficked driveway over areas of uneven pavement, until she was stopped near a pond. Resident #2's whereabouts were unknown to the facility until an employee arriving at work at approximately 1:45 PM observed her on the driveway. The facility's failure to provide a secure environment and adequate supervision resulted in substandard quality of care at the Immediate Jeopardy level, starting on 8/11/19. The Immediate Jeopardy was removed on 8/28/19. Findings: Resident #2 was admitted to the facility on [DATE]. She was readmitted on [DATE] with staples to a [CONDITION(S)] that she suffered from a fall. Her diagnoses included dementia, generalized muscle weakness, abnormalities of gait and mobility, repeated falls and cognitive communication deficit. Review of resident #2's medical record revealed a Nursing Admission Evaluation dated 4/13/19. The document indicated the resident was forgetful, confused and disoriented on re-admission to the facility. In the Safety/Falls section, the evaluation revealed resident #2 had fallen in the previous 30 days, had medical conditions that predisposed her to falling and took medication that could contribute to falling. The document indicated resident #2 was . able to maneuver independently throughout center and had a history of wandering. The evaluation triggered a wandering care plan and directed, Also apply wandering device. Review of the comprehensive care plan for wandering, initiated on 4/19/19, revealed resident #2 was noted to have wandering behaviors and required an adult monitoring device. The interventions on that date included, apply wandering device to left ankle, check device function on night shift and placement on every shift, attempt to ascertain causes for wandering and exit-seeking behaviors, notify the physician and representative of escalating behaviors, alert staff to resident's tendency to wander, and re-direct resident when device sounds during attempts to leave the facility. The care plan's focus was revised on 6/11/19 to specify . when attending meals in [dining room] need re-direction when leaving to be escorted upstairs, resistive at times. However, the care plan interventions were not updated to include appropriate and individualized interventions to address the newly added concerns. On 8/12/19, the wandering care plan was revised to read, Observed in parking lot in front of [building] . and an intervention was added for 1 on 1 supervision until a psychology or psychiatry evaluation was conducted. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 6/17/19, revealed resident #2 had a Brief Interview for Mental Status score of 4 on a 0 to 15 scale, which indicated severe cognitive impairment. The assessment indicated she displayed disorganized thinking and inattention. Resident #2 had wandering behaviors on 1 to 3 days in the 7 day look back period. She required supervision (oversight, encouragement or cueing) with set up help only for bed mobility, transfers, walking and locomotion. Resident #2 used a walker for mobility, had steady balance and no functional limitation in range of motion. The MDS assessment revealed resident #2 used a wander/elopement alarm daily. On 9/15/19 at 12:17 PM, the weekend nursing supervisor (WNS) confirmed resident #2 exited the building unsupervised on 8/11/19. She stated resident #2's room was on the 2nd floor and she used the elevator to go freely from one floor to another. The WNS explained a staff member should accompany residents who had monitoring devices from the 2nd floor to the dining room and escort them back at the end of the meal. The WNS stated on the day she eloped, resident #2 had lunch at the first seating in the dining room, from 11:30 AM to 12:30 PM. She stated to her knowledge, resident #2 was escorted back upstairs. The WNS said, She went back downstairs by herself. She is ambulatory. The WNS explained a housekeeping staff member, a floor technician, was coming to work that afternoon and recognized resident #2 as she walked along the driveway, away from the facility. The WNS stated the floor technician alerted the Manager on Duty (MOD), then ran down the driveway to find resident #2. She confirmed resident #2 was returned to the building by the floor technician and the MOD. On 9/15/19 at 1:15 PM, licensed practical nurse (LPN) A stated she was assigned to resident #2 on 8/11/19. LPN A said, She was a little more antsy than usual. I don't know what happened, the door should have alarmed. LPN A explained resident #2 ambulated with a 4 wheeled walker, had a steady gait and wore a monitoring device because of exit-seeking behavior. She described resident #2 as confused, wandering, curious about the outdoors and sometimes wanted to go to church. LPN A stated on the day resident #2 eloped, staff escorted her back upstairs after lunch, but she went back downstairs without being seen. Observation of a monitor screen on the wall opposite the nurses' station showed live camera footage from areas in the facility including elevator doors and exit doors. There was a large blue area on the screen. When asked about camera footage from the facility's front lobby door, LPN A pointed to the blue area on the screen and said, That camera was out on that day. We have not been able to see the front door camera on the monitor for at least a month. In interviews conducted on 9/15/19 at 2:19 PM and 3:45 PM, the floor technician stated on 8/11/19 at approximately 1:45 PM, he was driving to work and observed resident #2 on the driveway past the facility's parking lot. He recalled she had her walker and was headed away from the facility. The floor technician stated he continued driving to the facility, parked his car in the parking lot then ran to the lobby to tell the MOD that a resident was on the driveway by herself. He explained he ran towards the area where he observed resident #2, but she was no longer there. The floor technician stated when he rounded the corner, he saw her much further along the driveway. The floor technician showed the exact location where he reached resident #2, near a pond and by a speed bump. He stated he asked her, Where are you going? You lost your direction? The floor technician explained he was easily able to re-direct resident #2 back to the facility. He acknowledged although resident #2 did not appear very sweaty, it was a hot day. The weather on 8/11/19 at 12:57 PM was 92 degrees and partly sunny, and at 1:55 PM the temperature was 90 degrees. (www.timeanddate.com) On 9/15/19 at 2:45 PM and 9/16/19 at 12:49 PM, resident #2's elopement route was retraced. She exited through the front door, turned right and walked approximately 100 feet from the facility's front door to the parking lot. Resident #2 continued walking for approximately 100 feet through the parking lot on uneven pavement, passing by a parking area with a gravel surface. The small stones were scattered along the driveway along resident #2's path, and she had to navigate her 4 wheeled walker either over or around a speed bump designed to slow traffic entering the facility's parking lot. Resident #2 continued around a blind corner, an approximate 90-degree curve in the driveway, and was then out of sight of the facility and off the property. She walked along the moderately-trafficked driveway, past a private road, for approximately 350 feet until she reached another speed bump. The floor technician caught up with resident #2 as she prepared to navigate her 4-wheeled walker over the speed bump. Resident #2 was found 0.1 miles or 528 feet away from the facility. At the location, a sloping concrete channel for water runoff from the driveway led into a pond surrounded by a fence. There was an unlocked and unlatched gate to the fence that when touched lightly, swung open inwards, directly over the pond. Additional observations of the surrounding area revealed another private driveway a few feet beyond the location where resident #2 was found. If resident #2 had turned right at the next intersection, approximately 200 feet away and walked another 200 feet, she would have arrived at an extremely heavily-trafficked 6 lane highway. Resident #2 was approximately 0.08 miles or 425 feet away from the busy highway when she was found by the floor technician, closer to the highway than to the facility. On 9/16/19 at 12:56 PM, the Director of Engineering (DOE) for the assisted living facility (ALF) on the property adjacent to the facility stated the pond and fence were maintained by the ALF. He explained the gate to the fence provided access for the aquatic services company that cleaned the pond. The DOE stated the workers launched a small boat from the sloping concrete area, through the gate, into the pond. He stated at the deepest point, the water in the pond was at his waist level, using his hands to indicate a height of between 3 and 4 feet. The DOE validated the gate to the pond was never locked and said, It is possible for a wandering person to get in there. On 9/15/19 at 6:58 PM, a telephone interview was conducted with the MOD. She explained her responsibilities included covering the front lobby desk when the receptionist was on her lunch break. The MOD stated she was seated at the front desk on the afternoon of 8/11/19 and noticed resident #2 lingering around the front desk. The MOD described resident #2 as having . impaired cognition. She is one of the customers who roam the building, but I'm not aware she actually made attempts to go out the front door. The MOD stated LPN B was nearby and she asked LPN B to take resident #2 around the corner and away from the lobby. The MOD stated she became distracted by visitors at the front desk and did not see resident #2 when she walked past the front desk, through the lobby and out the front door. She explained resident #2 wore a monitoring device that should have set off the alarm at the door, but it did not. The MOD stated the floor technician came into the lobby and told her a resident was outside. She said, I told him to hurry. I ran to the first parking space to the right and he ran around the corner. She stated she stopped and returned to the lobby since the floor technician was going after the resident. The MOD stated she went back outside a few minutes later and saw the floor technician at the far end of the parking lot with resident #2. The MOD recalled resident #2 said, It's hot outside today and mentioned she was tired. The MOD stated resident #2 explained she was going to her house and then stated she was going to her daughter's house. The MOD stated after resident #2 was taken to the 2nd floor, the maintenance technician tested the function of the monitoring system at the front door. The door would not lock sometimes and described the locking function as sporadic. The MOD stated the maintenance technician requested a service call for the malfunctioning door. The service technician found . condensation that had built up into the motherboard and was causing faulty action of the door. In interviews conducted on 9/15/19 at 1:45 PM and 6:06 PM, LPN B stated she was in the front lobby on 8/11/19 and saw resident #2 standing at the receptionist's desk. LPN B recalled the MOD saying, Can you take her up for me? LPN B stated the MOD mentioned resident #2 said she wanted to go back to [NAME] where she was born. LPN B explained she escorted resident #2 back to the 2nd floor and left her on the landing in front of the elevator at about 1:30 PM. She said, I re-directed her towards her room then I went back down [to the 1st floor]. LPN B acknowledged she did not take resident #2 to her room, nor report to the assigned nurse or certified nursing assistant (CNA) that resident #2, a resident at risk for elopement, was in the lobby near the front door. On 9/15/19 at 4:09 PM, CNA D stated she was assigned to resident #2 on 8/11/19, the day she eloped. She confirmed resident #2 had a monitoring device . because she walks all over. CNA D explained she saw resident #2 at about 11:30 AM when she was on her way down to the dining room on the 1st floor. CNA D stated dining room staff usually brought residents back to the 2nd floor after meals, but she did not see resident #2 immediately after lunch that day. CNA D stated the nurse later told her resident #2 was found outside the facility. On 9/15/19 at 6:21 PM, CNA C stated he was assigned to assist in the dining room on 8/11/19 during the second seating for lunch, from approximately 12:30 PM to 1:30 PM. He stated he observed resident #2 in front of the elevator on the 1st floor, opposite the dining room. CNA C explained he tried to encourage resident #2 to return to the 2nd floor but she wanted to walk around the 1st floor. He said, I left her in front of the elevator and that was the last time I saw her. On 9/15/19 at 3:17 PM, the maintenance technician explained if a resident with a monitoring device came within range of the sensor, it should set off an alarm. He explained if the door was closed, it would lock and alarm and if the door was already open, the alarm would sound. The maintenance technician stated the front lobby door would remain locked and/or the alarm would continue sounding until a code entered on the keypad beside the door temporarily disarmed the monitoring system. He explained only staff members should have the code but said, Some family members had the code. I don't know how they got it. The maintenance technician stated he tested the function of the monitoring system for the front lobby door on 8/11/19, prior to resident #2's elopement, and again before he left at approximately 3:30 PM. He said, It was locking then. Not sure how she got out without the door alarming. The alarm buzzer didn't sound right. It wasn't as loud as it used to be. He stated he was informed the system had water damage from heat and condensation. On 9/15/19 at 4:32 PM, an interview was conducted with the administrator and the Director of Nursing (DON). The administrator stated on 8/11/19 at 2:00 PM, the MOD notified her that resident #2 left the building unsupervised and was found in the parking area by a staff member. The administrator confirmed resident #2 was a known elopement risk prior to the incident. She explained interviews with direct care staff revealed on the day she eloped, resident #2 was very restless, and kept removing clothing from her closet. The administrator stated she was not sure if the behavior was reported to the assigned nurse. She acknowledged the monitoring system at the front lobby door did not work as resident #2 exited the building. She explained a service technician inspected the system and validated there was a malfunction caused by condensation in the panel. The DON stated staff members were accountable for the safety of their assigned residents. She stated her expectation was all nurses and CNAs would do walking rounds with shift change report to obtain pertinent information on resident status. The DON explained CNAs should do regular rounds at least every 2 hours, and residents who were high risk for elopement, like resident #2, should be monitored more often. In an interview on 9/16/19 at 5:05 PM, the DON said, Staff supervision is important. In this case, staff communication did not occur as it should have. It was a breakdown in communication. The nurse should have evaluated the reason for her anxiety. The DON stated nurses could have called her or spoken to the supervisor if resident #2 required 1:1 supervision for a while. The DON stated although the facility provided education on elopement procedures since the incident, they did not develop in-services on behavior monitoring and interventions to prevent and de-escalate exit-seeking behaviors. On 9/16/19 at 11:07 AM, the Business Office Manager (BOM) stated her responsibilities included training and supervising the receptionists. She explained that monitoring the front door in the lobby was a very important part of their job. She stated although receptionists had many responsibilities, the most important part of their training was to be attentive to the residents. The BOM stated the front door was to be supervised by the receptionists when it was unlocked. She said, We expect the same degree of supervision from the relief person, usually a manager. The BOM stated nurses identified residents with wandering tendencies and applied a monitoring device if necessary, and receptionists were familiar with those residents. When asked how it was possible for resident #2 to exit the facility unsupervised if the MOD was at the receptionist's desk, the BOM said, It's one of those mysteries that she got out the door. It makes your heart stop and lets you realize how important it is to keep your guard up. Review of the medical record revealed nursing progress notes for March and April 2019 related to resident #2's behaviors including forgetfulness, anxiety, severe confusion and combativeness. The nurses' documentation indicated resident #2 used a walker for mobility and repeatedly went into other residents' rooms, lay on their beds and removed assorted items. The progress notes revealed resident #2 required increased observation, frequent redirection and had escalating behaviors leading up to her elopement from the facility. A Health Status note dated 5/24/19 revealed resident #2 walked towards the front door after lunch . and the monitoring alarm went on to alert the facility that customer was existing (sic-exit) seeking . Staff will pay more attention to customer, ensuring customer is assisted back to the unit after lunch in the dining room. A progress note dated 6/7/19 indicated resident #2 was confused, belligerent and exit seeking. The note revealed she was ambulating without her walker and tried to exit through a window in the therapy gym while claiming it was a door. Review of Multidisciplinary Note progress notes revealed on 6/11/19, Customer tends to wonder [sic] in the halls and exit seek, staff are redirecting customer to room. On 6/30/19, resident #2 was seen by a psychiatrist and found to have poor concentration, insight and judgement. On 7/01/19, resident #2's daughter attended a care plan meeting that included discussion on her mother's exit-seeking behavior. The note indicated resident #2's daughter wanted her mother to have lunch and dinner in the dining room. It read, Explained that she has to be escorted back to Vista View [2nd floor] after meals. Nursing notes for July 2019 revealed resident #2 remained confused, forgetful and required frequent re-direction. An Exception Note dated 8/11/19 revealed at 1:45 PM, an exit seeking incident was discovered by the floor technician. The note read, Customer observed by an employee in front of the facility, in the immediate parking lot. He notified front desk employee and they were able to redirect her back into the building. Resident #2's daughter and the attending physician were notified, and LPN A received an order to . have psych see her again and place her on 1:1 until evaluated by psych. Review of the psychology Initial Diagnostic Interview date 6/24/19 revealed resident #2 was referred for reduction of disorganized and confused thinking. Her symptoms included depressed mood, excessive worry and anxiety, short and long-term memory problems and poor insight, judgement and impulse control. Resident #2 was found to be cognitively impaired. On 6/26/19, resident #2 had an Initial Psychiatric Evaluation for stabilization of depressed mood. The evaluation indicated resident #2 appeared to have a down mood and was cognitively impaired. The psychiatrist's examination revealed she was confused, had disorganized thought processes and poor fund of knowledge, concentration, insight and judgement. New diagnoses made after the examination were major neurocognitive disorder with behavioral disturbance due to Alzheimer's disease, and moderate major depressive disorder. The psychiatrist's recommendations included [MEDICATION(S)] 5 milligrams (mg) once daily for depression. A Subsequent Psychiatric Evaluation on 8/07/19 revealed no new psychiatric recommendations and Continue monitoring for response/potential adverse reactions. Review of the Order Summary Report revealed [MEDICATION(S)] 5 mg was not initiated for resident #2 as recommended by the psychiatrist on 6/26/19. The progress notes showed no interdisciplinary discussion regarding the medication proposed to treat resident #2's mood and behaviors. However, resident #2 had an active order dated 8/21/19 for the anti-depressant [MEDICATION(S)] 10 mg once daily, initiated 10 days after she eloped from the facility. On 9/16/19 at 6:23 PM, the administrator explained the Quality Assessment & Assurance (QAA) committee met 4 days after the elopement incident on 8/15/19 at 11:45 AM. The meeting agenda read, Event reviewed, customer care plan and behaviors reviewed. Interventions discussed in conjunction with possible root cause. The administrator explained the incident was reviewed with the Medical Director by phone prior to the QAA meeting. She stated the QAA committee determined the root cause of resident #2's elopement to be the mechanical malfunction of the monitoring system at the front. When asked about other contributory causes, the administrator acknowledged the QAA committee did not focus on or identify concerns with assessments, lack of individualization of care plan interventions, psychiatry recommendations, compliance with elopement drill schedules and supervision of resident #2 by staff. The administrator confirmed resident #2's care plan for wandering did not include the known effectiveness of distraction by a preferred recreation aide. In addition, she stated the facility discovered resident #2 was an elopement risk at her home after the incident. She validated the root cause of the incident was determined before the QAA committee had an accurate account of the incident, including the fact resident #2 was off the facility's property, was found in a particularly hazardous location, and was approximately 5 minutes away from a busy 6-lane highway. On 9/16/19 at 7:18 PM, a telephone interview was conducted with the facility's medical director. He confirmed the administrator informed him of resident #2's elopement by telephone and they discussed the corrective measure implemented by the facility related to repair of the monitoring system's keypad. The Medical Director stated monitoring devices and removable stop sign banners across doorways were appropriate interventions for residents at risk for elopement. When asked about additional measures to decrease elopement risk, the Medical Director said, We can have the staff be more astute in monitoring residents. He acknowledged evaluation and supervision by staff was as important or more important than physical or mechanical barriers. He added it was essential for staff to report and implement interventions for restlessness and exit-seeking behaviors, and conduct chart reviews that included physician's orders, nurses' notes and consultants' notes for prevention of elopements. The Medical Director stated he was told resident #2 was found in the facility's parking lot. He confirmed he was not made aware of resident #2's escalating behaviors on the day of her elopement nor that she was off the facility's property and approximately 400 feet from a busy, 6-lane highway. The Medical Director said, It is always a concern if someone is out, and every second is precious. The time is important. He explained resident #2's distance away from the facility when found was a factor, but the greater issue was the length of time she was unsupervised. Review of the Facility Assessment approved 9/27/18, revealed the facility would provide basic care interventions and services for all residents, to include assessment, care planning, careful execution of care plans, monitoring of care plan interventions for effectiveness, changing of ineffective care plan interventions, following physician orders for medication . and implementation of systems to maximize customer safety . The document indicated the facility was able to meet the needs of residents with dementia and Alzheimer's disease, and would use individualized interventions to appropriately address behaviors. The Facility Assessment read, The center provides a secure environment for customers with dementia and who may become an elopement risk. The facility utilizes electronic monitoring devices throughout building to address potential for elopement at-risk customers. The facility conducts, at a minimum, quarterly elopement drills. However, review of Logbook Documentation provided by the administrator revealed elopement drills were done prior to resident #2's elopement on 12/28/18 and 5/03/19. The forms did not show the time or shift the drills were conducted. There was no documentation of an elopement drill in the first quarter of 2019, nor evidence of compliance with the procedure to Document the drill on missing resident drill form, secure required signatures and maintain original copy of drill in the life safety binder. Review of the receptionist's job description (3/31/18) revealed responsibilities of greeting visitors, giving directions to residents and Performs other duties as requested. The job description indicated the receptionist had general safety related duties including reporting safety issues. However, the receptionist's job description did not list specific responsibilities related to the front lobby door, the monitoring device system and recognition of residents at risk for elopement. The DON's job description (3/31/18) revealed the responsibility to ensure care plan interventions were implemented, reviewed and modified as necessary. The DON was accountable for ensuring all incidents were fully documented and promoting the safety of all residents. Review of the policy and procedure (P&P) Wandering Customer revised on 6/29/17, revealed a purpose To maintain customer security while facilitating reasonable physical freedom. The process included evaluation of residents for exit-seeking behavior through medical record review and determination of a prior history of wandering. Residents who were deemed to require a monitoring device would have their photographs placed in a binder at the front desk to ensure prompt recognition if exit-seeking attempts were made. The document indicated those residents would have an individualized care plan for wandering. The P&P revealed the maintenance department was responsible for ensuring the monitoring device system's door alarm was kept in instant alarm mode. Review of the P&P for Elopement of Customer revised on 10/20/16, revealed residents should not leave the facility or its immediate surroundings without permission and knowledge of staff. The purpose of the P&P read, To maintain the safety and security of Customers while facilitating both reasonable physical freedom and preventing elopement. The document revealed the facility's maintenance director would conduct elopement drills . three times per year, one drill on each shift. Review of corrective measures implemented by the facility revealed the following: Resident #2's monitoring device was checked for placement and function on return to the facility. She was observed with the device on her left ankle and had an assigned sitter present. Her care plan was reviewed and updated to include 1:1 supervision and re-evaluation by the psychiatrist and psychologist. The facility implemented a Fire Watch on 8/11/19 at 2:30 PM, and had employees assigned continuously to monitor the front door until the service technician repaired the monitoring system and declared it fully operational. Staff education was provided on responding to door alarms and monitoring residents at risk for elopement. Review of in-service attendance sheets revealed in-services were attended by 92% of staff, and was on-going with a goal of 100%. All full-time staff received in-services as of 8/28/19, and education on elopement was included in new-hire orientation and annual education. Interviews conducted indicated staff were knowledgeable about elopement procedures, supervision of residents at risk for elopement and response to door alarms. Documentation of elopement drills was reviewed, and drills were on-going to incorporate staff on all shifts. The QAA committee implemented random audits for verification of placement and function of wandering devices. The sample was expanded to include all residents who wore monitoring devices due to the risk for elopement. Observations and record reviews conducted revealed no concerns related to residents #5, 8, 9, 11, 13 & 14. Residents #4, 6, 7, 10 & 12 were appropriately assessed, but their monitoring devices were not applied according to manufacturer's recommendations.