Every finding on record at Keyser Healthcare Center

Based on record review and staff interview, the facility failed to ensure a resident was not abused by staff members providing resident care resulting in abuse for one (1) of three (3) residents reviewed for possible abuse throughout the complaint survey. Harm began on 07/30/36 at approximately 1:40 PM when Resident #64 reported that a male aide ( bald, heavy set, tall, and works nights) was touchy with her during care, causing her pain and some discomfort. The alleged perpetrator was immediately removed from the schedule pending the outcome of the facility's investigation.The Administrator was informed of the Harm tag on 08/06/26 at approximately 9:30 AM. The Harm tag was removed and the deficient practice corrected on 08/04/26 at 10:20 AM and was therefore Past Noncompliance.Findings included:a) Resident #64Record review revealed that Resident #64 had capacity and was cognitively intact. Review of the facility reportables revealed Resident #64 had reported, on 07/30/26 at approximately 1:40 PM, that a male aide ( bald, heavy set, tall, and works nights) was touchy with her during care, causing her pain and some discomfort. The alleged perpetrator, Nurse Aide #6, was immediately removed from the schedule pending the outcome of the facility's investigation. The allegation was also immediately reported to the appropriate state agencies. On 07/30/26, Unit Manager #1 and the Interim Director of Nursing (DON) interviewed Resident #64 regarding her allegation. Resident #64 reported that one week he came in and he stuck something up me but was unable to identify what it was but that she was certain it was not a washcloth. The resident also stated, Last night he was here and was touchy feely. Resident #64 stated she did not want the nurse aide back in her room and stated she was [AGE] years old and had never had this happen before. The facility asked if Resident #64 would like to go to the hospital to be examined and the resident agreed to the transfer. On 08/04/26 at 3:20 PM, the State Agency Survey spoke with the Forensic Nurse Examiner at the hospital. The Forensic Nurse Examiner reported that Resident #64 told her that last night, he [Nurse Aide #6] was changing her brief and I felt him rubbing me. The Forensic Nurse Examiner added that the resident clarified that she was referring to her vaginal area and that it was more like caressing the resident's vaginal area. The resident also reported that a couple weeks ago the same male staff member was changing her incontinent brief and he put either his finger or something else in her rectal area, causing pain. Further review of the facility reportable revealed the facility had immediately obtained written statements from nurses and nurse aides. The nurse aide in question (NA #6) was interviewed by law enforcement in the presence of the facility Administrator and did state that his finger may have inadvertently went up inside the resident while cleaning her. The residents complaint was substantiated by the facility and NA #6 was submitted to Human Resources for immediate termination. There was never a time NA #6 was working in the building after the allegation had been made by Resident #64. Additionally as part of their investigation into the incident, the facility identified the need to complete a whole house education regarding the [NAME] Virginia Abuse, Neglect, and Misappropriation policy. The Harm tag was removed and the deficient practice corrected on 08/04/26 at 10:20 AM when the facility submitted their 5-Day Follow-Up report to the appropriate state agencies and was therefore Past Noncompliance.

Based on record review and staff interview, the facility failed to ensure staff used mechanical lifts correctly which resulted in injury for one (1) of three (3) residents reviewed for falls/accidents in the facility. Harm began in the evening hours of 06/08/26 when Nurse Aide #100 used a [NAME]-Lift (sit-to-stand lift) with Resident #114 without a second staff member present and incorrectly. Resident #114 sustained bruising to bilateral upper arms (to the underside of arms), bruising to her waist, and breast.The Administrator was informed of the Harm tag on 08/06/26 at approximately 9:36 AM. The Harm tag was removed and the deficient practice corrected on 06/26/26, and was therefore Past Noncompliance.Findings included:a) Resident #114A record review revealed that Resident #114 had capacity and was cognitively intact. Review of the facility's reportables revealed:-Resident #114 had reported that Nurse Aide #100 had used the sit-to-stand lift alone and incorrectly. -Resident #114 sustained bruising to bilateral upper arms (to the underside of arms), bruising to her waist, and breast.-The alleged perpetrator, Nurse Aide #100, was immediately removed from the schedule pending the outcome of the facility's investigation. -The allegation was also immediately reported to the appropriate state agencies. -The facility obtained statements from the resident, the resident's mother who had been present when the incident occurred, and Nurse Aide #100. -Resident #114 reported to the Interim Director of Nursing (DON) that an aide named [Employee's First Name] came in to take her to the bathroom. When placing the resident in the sit-to-stand lift, Nurse Aide #100 did not connect the clips in the center of the resident's chest. Resident #114 then told the nurse aide, I am not hooked up right but the nurse aide continued to do the transfer. The resident also reported her mother was in the room at the time the incident happened. -Resident #114's mother stated, On Monday evening, the aide came in and hooked [Resident's First Name] up but did not attach the belt around her waist. The resident's mother also acknowledged that the resident's arm hurt.-During a telephone conversation with the Interim DON, Nurse Aide #100 stated [Resident's First Name] rang the bell to use the bathroom and I responded. The nurse aide went on to say that she sat the resident back down and hooked her up. When asked who was with her to assist with the lift, the nurse aide reported, I was alone.During a telephone call on 08/04/26 at approximately 3:35 PM, the hospital's Forensic Nurse Examiner reported that Resident #114 had told her a staff member named [First Name of Nurse Aide]was assisting her back to her bedroom from the bathroom using the sit-to-stand lift. The resident stated, She didn't put the strap around my waist. I told her she didn't do it and she didn't listen to me. Resident #114 went on to report that as the staff member was utilizing the lift to assist her to stand, she started to slide out of it and my arms got caught in it. The resident explained her bilateral upper arms were caught in the lift, causing stretching and snapping. Since the incident occurred, the resident reportedly has had increased pain and swelling to the left upper arm. Resident #114 presented to the hospital her own request, as she was having increased pain and swelling. The Forensic Nurse Examiner reported that the resident's left upper forearm was very swollen and bruised, measuring 44 1/2 cm (44 1/2 cm is equal to approximately 17.52 inches.)Further record review revealed:-A SBAR (Situation, Background, Assessment and Recommendation) Communication Form, dated 06/09/26, which identified a new and worsening pain. The resident's pain was rated an 8 out 10, with 10 being the worst. -A SBAR Communication Form, dated 06/11/26, which identified a worsening pain. The resident's pain was rated a 10 out of 10, with 10 being the worst.-The facility substantiated the fact that Nurse Aide #100 had utilized the sit-to-stand lift alone and incorrectly. The facility identified the need to complete a whole house nursing staff education regarding the use of the sit-to-stand lift. The training covered the following details:-Confirm the appropriate transfer method.-Ensure two (2) staff members are present.-Visually inspect the sling for signs of wear and tear. Do not use a sling that is visibly damaged.-Provide privacy by closing the door to the room or pulling the privacy curtain,-If in bed, assist the resident to sitting position with feet on floor ensuring the resident has proper footwear on with shoes tied.-Open the legs of the stand and position in front of the resident. Lock the bed and wheelchair as well as the wheels of the stand.-Attach the sling to the device and securely around the resident. Secure one loop of the wing to the metal hook at the end of the boom (using the same color loop for all hooks). The harness wings should be positioned 1 to 4 beneath the arms of the resident with the buckle secretly around the waist. -With the lifting arm in the lowest position, attach the adjustment loops to the hooks on the stand. Use the shortest straps possible, making sure to use the same loop position on both sides. -Have the resident place their feet on the foot support plate with their shins against the shin support. -Position the resident's arms on the outside of the harness and place their hands on the padded handles. -Raise the resident to the standing position by pushing the up button on the control. -If necessary, unlock the stand wheels and move the resident to the desired location. -With the back of the resident's knees touching the bed, chair, toilet or commode lower resident by pressing the down button on the control. Instruct and/or assist the resident to let go of lift handles. -Remove lifting sling.-Ensure the resident is in a safe location, has a signaling device as appropriate and desired belongings in reach. The Harm tag was removed and the deficient practice corrected on 06/26/26 when the facility finished the whole house nursing staff education and was therefore Past Noncompliance.

Based on record review and staff interview, the facility failed to ensure that it clearly documented a resident's ability to easily remove bilateral bed wedges. Additionally, the facility failed to have informed consent on file. This was a random opportunity for discovery throughout the complaint survey process. Resident Identifier: #65. Facility census: 111.Findings included: a) Resident #65A record review, completed on 08/05/26 at 3:30 PM, revealed the following details: -A physician order, dated 02/23/26, which stated, Bilateral bed wedges in place while in bed every day and night shift for Fall risk/ safety.-This order was shown to be discontinued on 04/06/26.-An Alert Note, dated 02/26/2026 at 11:21 PM, which read, Resident on alert charting following a fall, no further falls recorded at this time, fall precautions in place, wedges on both sides of the bed, call light within reach, bed maintained at lowest position, resident encouraged to use call light, neuros WNL (within normal limits).-An eMar (electronic Medication administration record) - Medication Administration Note, dated 03/15/2026 at 11:24 PM, which read, Bilateral bed wedges in place while in bed every day and night shift for Fall risk/ safety. Resident states that he doesn't need them.-An Alert Note, dated 03/17/2026 at 9:56 PM, which read, Alerted by activity staff that resident was lying on floor beside bed. Resident reported that he was trying to put his pants on and fell. ROM (range of motion) w/o (without) pain. No noted injuries. Neurochecks initiated. MD (Medical Doctor) notified. Resident has been refusing wedges to bed as ordered for fall intervention. Resident assisted into w/c (wheelchair) by staff and placed at nurses' station for closer supervision. Resident refused VS (vital sign) monitoring at time of fall.-An IDT (Inter-Disciplinary Team) Follow Up note, dated 03/18/2026 9:53 AM, which revealed the resident's fall from bed, on 03/17/26 at 2:15 PM, happened because resident rolled out of bed trying to put his pants on and fell. Tasked to Aides for documentation for compliance with use of bed wedges.The resident's care plan was also reviewed. It read as follows:FOCUS: [Resident's First Name] is at risk for falls due to recent falls Date Initiated: 02/02/2026 GOAL:[Resident's First Name] will not sustain major injury related to falls through review date Date Initiated: 02/02/2026 Revision on: 06/18/2026 INTERVENTION/TASKS:Bilateral positioning wedges while in bed.Date Initiated: 02/23/2026Revision on: 04/08/2026During an interview on 08/05/26 at 4:30 PM, MDS RN #3 stated the facility had not considered the bilateral bed wedges as a physical restraint. When asked if there had been a formal assessment or any form of documentation in the electronic medical record to demonstrate the resident was capable of removing the bilateral wedges in the same manner as they were applied by staff, the MDS RN stated the facility had not. Additionally, MDS RN #3 reported that there had never been an informed consent signed by the resident or the resident's legal representative. An informed consent for a restraint would address the restraint being used as a last resort, a medical necessity (used to treat a specific medical condition), the right to refuse the restraint, and the fact that alternative non-restraint approaches have been tried and proven ineffective. No further information as provided prior to exit from the building.

Based on record review and staff interview, the facility failed to complete neurological checks (neuro checks) per physician orders and/or the standard practice of care. This was true for two (2) of three (3) residents reviewed in the complaint survey process. Resident Identifiers: #65 and #116. Facility census: 111. Findings included: a) Resident #65A record review, completed on 08/05/26 at 11:30 AM, revealed that Resident #65 had experienced a fall on 03/17/26.It was noted that neurological (neuro) checks should be completed every 15 minutes for the first hour following the fall, then every hour for four (4) consecutive hours, then every four (4) hours for the next 16 hours, then daily for four (4) consecutive days. The neurocheck evaluation was noted to include the following details:Date and Time (of the neurocheck).Resident currently out of the facility?Resident refused neurocheck.Level of Consciousness.Pupil reaction Right Eye.Pupil reaction left Eye.Hand Grasp.Extremities.Pain Response.Most recent Temperature.Most recent Pulse.Most recent Respirations.Most recent Blood Pressure. Review of the facility's Neurocheck Evaluation form revealed the #8. 1 Hour - 4th neurocheck evaluation had not been completed and was left blank. b) Resident #116A record review, completed on 08/05/26 at 12:45 PM, revealed that Resident #116 had experienced a fall on 03/02/26It was noted that neurological (neuro) checks should be completed every 15 minutes for the first hour following the fall, then every hour for four (4) consecutive hours, then every four (4) hours for the next 16 hours, then daily for four (4) consecutive days. The neurocheck evaluation was noted to include the following details:Date and Time (of the neurocheck).Resident currently out of the facility?Resident refused neurocheck.Level of Consciousness.Pupil reaction Right Eye.Pupil reaction left Eye.Hand Grasp.Extremities.Pain Response.Most recent Temperature.Most recent Pulse.Most recent Respirations.Most recent Blood Pressure. The following neurochecks were found to be incomplete:-#3 15 Minute - 3rd-#4 15 Minute - 4th-#5 1 Hour - 1st-#6 1 Hour - 2nd-#7 1 Hour - 3rd-#8 1 Hour - 4thc) Interview with Interim Director of Nursing (DON)During an interview on 08/06/26 at 9:25 AM, the Director of Nursing (DON) confirmed the above-mentioned neurochecks had been left blank on the electronic medical record Neurocheck Evaluation Form. The DON went on to state that she may be able to find the paper copies that the nurses would have used. A State Agency Surveyor accompanied the DON to her office where she was unable to locate any paper neurocheck forms. The DON also looked in the electronic medical record to be certain the paper neurocheck forms had not been scanned into the system. There was no evidence this had happened. Lastly, the DON searched in the medical records office for approximately 10-15 minutes before stating, I guess we just don't have them.

Based on observation, record review, and staff and resident interviews, the facility failed to ensure safe water temperatures throughout the building and in areas accessible to residents. This failed practice placed an unlimited number of residents currently residing in the facility at risk for possible harm, including scalds, burns, severe injury, and even death. The state agency determined this was an Immediate Jeopardy (IJ) situation, and Immediate action was required to prevent serious injury, scalding, burns, harm, or even death to residents at the facility. In addition, the facility failed to implement appropriate safety precautions for residents at risk of falls. Locations: room [ROOM NUMBER], South Shower Room, Dining Room sink, and Resident #4's room. Facility Census: 109. Findings Includea) room [ROOM NUMBER]On 11/18/25 at approximately 9:04 AM, the water temperature in Room# 116 was noted to be too hot to touch. A request was made to the Maintenance Director for a temperature check, and the following readings were obtained:room [ROOM NUMBER]: The sink water temperature at 9:04 AM was 119.8 degrees Fahrenheit.At 9:11 AM, a follow-up check at the sink in room [ROOM NUMBER] revealed a water temperature of 124.6 degrees Fahrenheit. b) South Shower RoomDuring an inspection of the South shower room, accompanied by Nurse Aide NA #25 at approximately 9:00 AM, on 11/18/25, a whirlpool bath was observed in the South shower room (100 and 200 Hallway). NA #25 stated that she was usually responsible for giving residents baths. NA #25 further stated that she was careful to set the water temperature in the tub. She said that she adjusted the temperature based on the resident's request. It was observed that the knob controlling the water had to be turned counterclockwise to adjust the temperature from hot to cold. When questioned, NA #25 stated that it was the way it had been installed. Further interview revealed that other NA's too bathed residents in the bath. NA #25 further stated that she did not use the temperature gauge on the whirlpool bath to adjust the temperature because the gauge was faulty. She stated that she usually checked the water temperature with her hand while filling the bath. NA #25 stated that she frequently had to instruct the other NA's not to set the temperature too high.NA, observing that temperature checks were being performed in residents' rooms, stated that on 11/17/25, she noticed that the water temperatures in the 200 hallways were very hot.During an interview with the Maintenance Director (MD) on 11/18/25 at approximately 9:41 AM, the MD explained that the facility's hot water was supplied by three (3) hot water heaters. The 100 and 200 hallways were supplied by one water heater; a second water heater supplied the 200 and 300 hallways; and the third water heater provided the kitchen and laundry. The MD stated that the mixing valve connected to the hot water heater servicing the 100 and 200 Hallways had been installed 'backwards', and that it was difficult for him to obtain an accurate reading. He had to climb over the water pipes and get behind the water heater to read the mixing valve setting. The MD stated that the mixing valve had been installed recently. He further stated that it was 'finicky' and he has had difficulty adjusting the water temperatures.Upon inspection, the mixing valve was found to be installed with the back of the valve facing forward. The valve readout faced toward the wall behind the water heater. Visualization of the mixing valve setting showed that the water temperature had been set in the red zone, between 110 and 120 degrees F.During an inspection of the main dining room, at approximately 10:25 AM on 11/18/25, the water temperature at the hand-washing sink was noted to be too hot to touch. Upon requesting a temperature check, the water temperature reading obtained was 127 degrees Fahrenheit. The Administrator was notified, and the hot water supply to the sink was turned off.The MD stated that the water heater that supplied the kitchen and laundry was set at approximately 160 degrees F. He further noted that the water supply to the sink in the dining room, and the staff, and visitors bathroom in the lobby of the facility, were connected to the kitchen hot water supply.Further inspection on 11/18/25 at 10:55 AM revealed that the whirlpool bath in the North shower room was non-operational. Interview with NA #25 revealed that it had not been used for at least the last two months. Staff confirmed that residents were transported to the South shower room for baths. At 11:08 AM the water temperature at the sink in the North shower room was noted to have a temperature of 121 degrees Fahrenheit. The facility turned off the hot water to the sinks in the resident's rooms on the 300 and 400 hallways, and began monitoring temperatures hourly.During an interview with Resident #8, (whose Brief Interview for Mental Status (BIMS) was 15), at 11:00 AM on 11/18/25, resident stated that she has been at the facility for over two years, and she stated that she had observed the maintenance staff frequently adjusting the water temperatures.The facility was notified of the IJ on 11/18/25 at 1:14 PM. The State Office approved the facility's Plan of Correction (POC) at 4:35 PM on 11/18/25. The facility's approved POC consisted of the following:On 11/18/25 at 1:14 PM, the facility implemented the following actions: [Typed as Written] Immediate Action: Facility shut off hot water to the dining room sink and reception area bathroom. The water was adjusted at the mixing valve for the entire facility and rechecked on the 100, 200, and North side bath area. However, instead of this issue, the facility stopped showers/baths until the water temperature was verified. Until water temperatures are stabilized, the facility is not utilizing hot water in resident areas and have provided wipes for hand hygiene. We locked out/tagged out the whirlpool bath on North side at this time due to a water line issue. (Name) plumbing is currently in route to the facility to address all the above-mentioned issues.The facility immediately issued education to the Maintenance Director on the water management plan.The facility immediately issued education to all staff to notify maintenance and the administrator of any noticeable extremes in temperature of water and water line/faucet issues.Auditing: The facility will check every sink every hour for water temperatures until DSO is at the building and they can address the issue. After the issue is resolved with DSO, the facility will continue to monitor and report to the ED water temperature logs every hour for 24 hours. Every 4 hours for 3 days, and then daily for 30 days. The facility will conduct daily routine water temperature checks and provide the results to the administrator 5 times a week for 4 weeks, and monthly, times 2 months. Results will be reported during QAPI meetings.On 11/19/25 at approximately 10:55 AM, the facility requested an amendment to the POC after the plumbing company- (Name of Plumbing Company), notified them that the mixing valve could not be repaired. The amended POC was submitted to the State Office at 12:00 PM on 11/19/25. The State Office approved the amended POC at 12:07 PM on 11/19/25. The amended POC stated the following: [Typed as Written]On 11/18/25, (Name of Plumbing Company) entered the facility to assess a mixing valve issue. This issue is found to only affect the 100 and 200 halls of the building. This could not be resolved at this time as parts need to be ordered. The parts are being located, ordered, and express shipped to the appropriate place. Installation will follow as soon as parts are available.We have continued to monitor per the initial POC every sink, every hour, until we are able to discuss with the survey team. The following is the amended Plan of Correction for F 689.The facility will shut off hot water to halls 100 and 200 at 12:07 PM on 11/19/25. Water temperatures will continue to be monitored every sink, every hour for 2 hours, in 300 and 400 halls, to ensure stabilization of temperatures before returning to patient care. Kitchen and laundry, along with halls 300 and 400, are not affected by the above-mentioned mixing valve issue. Once stabilization of temperatures is made and hot water is resumed on 300 and 400 halls, the facility will then continue to monitor water temps in halls 300 and 400 twice daily in at least two rooms per hall randomly and report to maintenance and administrator until the mixing valve for the other side of the building can be restored. The laundry and kitchen temps will continue as usual.Upon completion of the repair for mixing valve for halls 100 and 200, the water temperature will be checked on halls 100 and 200 in at least 2 rooms per hall randomly every 4 hours for 3 days, then daily for 30 days. Then the facility will carry out routine water temperature checks on 100 and 200 halls daily and provide the administrator 5 times a week for 4 weeks, and monthly for 2 months. Results will be reported during QAPI meetings.Observation and interview on 11/20/25 at 9:40 AM revealed that all hot water to the 100 and 200 wings had been turned off. Residents had been notified of the hot water system issue and were offered bed baths until it was resolved.After observation, staff interview, review of facility documentation, and record review, the State Office was notified of the findings and the implementation of the POC. The survey team was instructed to abate the IJ at 11:57 AM on 11/20/25. On 11/24/25 at approximately 9:30 AM, during a review of the facility's continuing Plan of Correction (POC) on temperatures, the facility provided temperature logs for the 300 and 400 hallways that showed fluctuations between 100- and 132-degrees F. The facility stated that they had immediately turned off the hot water at the sinks for all resident rooms. The administrator noted that the plumbing company had been notified and was in route again. The administrator further stated that the facility had continued to monitor water temperatures in the residents' rooms every hour throughout the night. They had done so by turning on the hot water at each sink, checking the temperature, and then turning it off. The administrator stated that they were requesting approval from the State Aency to immediately turn off the hot water supply. The residents were being notified, and the staff were being educated that residents were to be given bed baths until further notice.The State Aency was notified and confirmed the facility should shut off the hot water to 300 and 400 halls until repairs are completed.The facility provided the following POC [Typed as Written] Currently, residents are being offered/provided bed baths via bath-in-a-bag. The facility may follow the manufacturer's recommendations for heating these wipes in a microwave before use with patients to ensure patient comfort.On 11/25/25 at approximately 9:32 AM, the facility provided a statement [Typed as Written] Currently, the hot water mixing valve for halls 100 and 200 have been fixed. Water temperatures appear stable and have been opened for resident use. The whirlpool bath for the South side will remain locked and tagged out. Some parts are needed for this unit. The whirlpool on the North side will remain locked/tagged out as it needs parts separate from this concern.

Based on observation of food temperatures and resident interview the facility failed to provide residents with palatable food at an appetizing temperature. This is true for Resident's #35 and #107. Facility Census 109. Findings included: a) On 11/18/25 at 3:24 PM during an interview with Resident #35, he report that his food is not good and not hot when served. b) On 11/17/2025 at 2:37 PM during an interview with Resident #107 she reported the food is horrible, often out of anytime menu items when she does not like meals served. She has gone without food due to disliking the taste of everything served c) On 11/19/25 at 12:57 PM the last tray taken out of the cart was tested for food temperatures and the results were as follows: candied sweet potatoes -100 degrees Fahrenheit broccoli florets -114 degrees Fahrenheithoney glazed sliced ham -104 degrees Fahrenheiticed tea - 36 degrees Fahrenheit d) 11/26/25 Review of document titled Food: Quality and Palatability states: Food will be prepared by methods that conserve nutritive value and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature.

Based on observation and interview, the facility failed to ensure that opened medications were discarded within the manufacturer-specified period. In addition, the facility failed to ensure that medications were stored at the manufacturer-specified temperatures. Medication Rooms: 100/200 Hallway, and 200/400 Hallway. Facility Census: 109. Findings Includea) Medication room [ROOM NUMBER]/200 HallwayDuring an inspection of the Medication Room on the 100/200 Hallway, accompanied by Licensed Practical Nurse (LPN) #291 on 11/20/2025 at 12:17 PM, it was noted there were three refrigerators in the medication room, one for medications, another for Insulin, and the third for vaccines. All refrigerators were kept locked. The refrigerator temperature logs were not available for view in the medication room. LPN #291 stated that the logs were in the Narcotic Medication binder on the medication cart. Upon request, on 11/20/25 at 10:01 AM, LPN #291 produced the refrigerator temperature logs for the medication room on the 100 and 200 hallways. The logs revealed the following: The Medication Refrigerator temperature log had not been completed for the day shift on:11/13/2511/17/2511/18/2511/19/25and11/20/25 The insulin storage refrigerator temperature log was not completed for the day shift on:11/12/2511/17/2511/18/2511/19/25and11/20/25 The vaccine storage refrigerator temperature log was not completed for:11/17/2511/18/2511/19/25and 11/20/25 b) Medication room [ROOM NUMBER]/400 HallwayDuring an inspection of the Medication room on the 300 and 400 hallways on 11/20/25 at approximately 10:11 AM, accompanied by LPN #84, three refrigerators. A medication refrigerator, a vaccine refrigerator, and an insulin refrigerator were observed in the medication room. The temperatures in the refrigerators read 41-, 42- and 42-degrees Fahrenheit respectivelyA review of the medication temperature logs for the 300 and 400 hallway medication rooms revealed the following:The temperature logs for the vaccine and insulin refrigerators had been completed.The medication refrigerator temperature log was not documented on:11/17/25and 11/20/25 LPN#84 confirmed that the log was not completed. In addition, during the inspection of the 300-400 medication room, an Ozempic injector for Resident #11 was observed stored in the medication refrigerator. The note on the box stated, Opened on 06/25/25. LPN #84 confirmed that the pen should have been discarded and immediately removed the pen from the refrigerator.Review of Resident #11's medications revealed an Ozempic pen dated 11/03/25 that was currently in use. The manufacturers' recommended guidelines state that an Ozempic pen can be used for up to 56 days after its first use, whether you store it in the refrigerator or at room temperature. After 56 days, the pen must be discarded, even if medication remains in it.

Based on record review, resident interview, and staff interview, the facility failed to follow physician's orders regarding wound care for Resident #123, administer medications for Resident #90, #106, #107, and accuchecks for Resident #80, #61, #87, #51 and #102. This was true for nine (8) of 42 residents reviewed during the survey process. Resient Identifiers: #90, #106, #107, #80, #61, #87, #51, and #102.b) Resident #90 -During an interview on 11/17/25 at 3:49 PM with Resident #90, reported his evening medications were sometimes late. -Review of facility policy and form titled Liberalized Med Pass times, it was revealed that the facility utilized liberalized medication pass times listed as follows: Early AM, 4:00 AM- 7:00 AM AM, 6:00 AM - 11:00 AM Afternoon, 12:00 PM - 3:00 PM PM, 4:00 PM - 7:00 PM HS, 8:00 PM- 11:00 PM -On 11/24/25 a 30 day period of Resident #90's medication administration was reviewed and revealed the following medications were administered after the prescribed time: Eliquis Oral Tablet 5MG, give 5 MG by mouth two times a day. Scheduled 10/30/25 at 9:00 PM, given 10/31/25 at 3:45 AM. Tamsulosin HCI Capsule 0.4 MG, give 2 (two) capsules by mouth at bedtime. Scheduled 10/30/25 at 9:00 PM, given 10/30/25 at 3:45 AM. Mirtazapine Tablet 7.5 MG, give 1 (one) tablet by mouth at bedtime. Scheduled 10/30/25 at 9:00 PM, given at 10/30/25 at 3:45 AM. Mirtazapine Tablet 7.5 MG, give one table by mouth at bedtime. Scheduled 11/04/25 at 9:00 PM and given at 11/04/25 11:18 PM. Tamsulosin HCL Capsule 0.4, give 1 (one) capsule by mouth at bedtime. Scheduled 11/04/25 09:00 PM, Given 11:18 PM. Eliquis Oral Tablet 5MG, Give 5 MG by mouth two times a day. Scheduled 11/04/25 at 9:00 PM, given at 11/04/25 at 11:18 PM. Amiodarone HCI Tablet 200 MG, give 1 (one) tablet by mouth one time a day for abnormal heart rhythm. Scheduled for 11/06/25 at 07:00 AM, given 11/06/25 at 11:20 AM. Eliquis Oral Tablet 5 MG (Apixaban) Give 5 MG by mouth two (2) times a day. Scheduled for 11/06/25 at 07:00AM, given 11/06/25 at 11:20 AM. Atorvastatin Calcium Oral Tablet 40 MG, give one (1) tablet by mouth one time a day. Scheduled 11/06/25 at 7:00AM, given 11/06/25 at 11:20 AM. Metoprolol Succinate ER Oral Tablet Extended Release 24-hour 50 mg, give 50mg by mouth one time a day. Scheduled 11/06/25 at 7:00 AM, given 11/06/25 at 11:20 AM. Detrol Oral Tablet 2MG, Give 2 MG by mouth one time a day. Scheduled 11/06/25 at 7:00 AM, given 11/06/25 at 11:20 AM. Detrol Oral Tablet 2MG, give 2 MG by mouth one time a day. Scheduled 11/20/25 at 7:00 AM, given 11/20/25 at 11:28 AM. Metoprolol Succinate ER Oral Tablet Extended Release 24-hour 50 MG, give 50 mg by mouth one time a day. Scheduled 11/20/25 at 7:00 AM, given 11/20/25 at 11:28 AM. Metformin HCI Oral Tablet 850 MG, give 850 MG by mouth one time a day. Scheduled 11/20/25 at 7:00 AM, given 11/20/25 at 11:28 AM. Eliquis Oral Tablet 5MG, Give 5 MG by mouth two times a day. Scheduled 11/20/25 at 7:00 AM, given 11/20/25 at 11:28 AM. Amiodarone HCI Tablet 200 MG, give 1 (one) tablet by mouth one time a day. Scheduled 11/20/25 at 7:00 AM, given 11/20/25 at 11:28 AM. Mirtazapine Tablet 7.5 MG give 1 (one) tablet by mouth at bedtime. Scheduled for 11/23/25 at 9:00 PM, given 11/23/25 at 11:22 PM. Eliquis Oral Tablet 5 MG, give 5 MG by mouth two times a day. Scheduled for 11/23/25 at 9:00 PM, given 11/23/25 at 11:22 PM. Tamsulosin HCI Capsule 0.4MG, give 2 (two) capsules by mouth at bedtime. Scheduled 11/23/25 at 9:00 PM, given 11:22 PM. c) Resident #106 During an interview with Resident #106 on 11/18/25 at 9:52 AM, resident reported he was given late medications on occasion. -On 11/24/25 a 30-day period of Resident #106's medication administration was reviewed and revealed the following medications were administered after the prescribed time: Buspirone HCI oral tablet 10 MG, give 10 mg by mouth three times a day. Scheduled 10/21/25 at 11:00 PM, given 10/21/25 at 5:02 PM. Zyprexa oral tablet 5 MG, give 5 MG by mouth at bedtime. Scheduled 10/30/25 at 9:00 PM, given at 10/31/25 at 3:12 AM. Famotidine oral tablet 20 MG, give 20 MG by mouth at bedtime. Scheduled 10/30/25 at 9:00 PM, given at 10/31/25 at 3:12 AM. Atorvastatin calcium oral tablet 20 MG, give 20 MG by mouth at bedtime. Scheduled 10/30/25 at 9:00 PM, given 10/31/25 at 3:12 AM. Buspirone HCI oral tablet 10 MG, give 10 MG by mouth three time a day. Scheduled 11/18/25 at 1:00 PM, given 11/18/25 at 4:08 PM. d) Resident #107 -During an interview conducted with resident on 11/17/25 at 2:38 PM, Resident #107 reported her medications were not given on time and at times not given to her at all in the past. -On 11/24/25 a 30-day period of Resident #106's medication administration was reviewed and revealed the following medications were administered after the prescribed time: Benzonatate capsule 100 MG, give 1 (one) capsule by mouth three times a day for cough for 14 days. Scheduled 10/21/25 at 1:00 PM, given 10/21/25 at 5:46 PM. Doxycycline Hyclate oral capsule 100 MG, give 1 (one) capsule by mouth two times a day for 10 days. Scheduled 11/02/25 at 7:00 AM, given at 11/02/25 at 12:13 PM. On 11/25/25 at approximately 12:25 PM, the Administrator acknowledged the late medications for Resident's # 90, #106 and #107. Findings Include: a) Resident #123 On 11/25/2025 at 12:07 PM, a record review was completed for Resident #123. The review was completed in reference to a complaint received on 03/20/24. The review found the following treatments were not completed on 03/03/24: --Cleanse right posterior lower leg venous ulcer with normal saline, apply silvadene periwound, xeroform to open areas to base of wound, place abd (abdominal) pads, wrap with kerlix and ace bandage from toes to knees every day shift. (Typed as written.) --Cleanse left lateral lower leg distal venous with normal saline, apply silvadene periwound, xeroform to open areas to base of wound, place abd pads, wrap with kerlix and ace bandage from toes to knee every day shift. (Typed as written.) --Cleanse left lateral lower leg proximal venous ulcer with normal saline, apply silvadene periwound, xeroform to open areas to base of wound, place abd pads, wrap with kerlix and ace bandage from toes to knees every day shift. (Typed as written.) --Cleanse right medial lower leg distal venous ulcer with normal saline, apply silvadene periwound, xeroform to open areas to base of wound, place abd pads, wrap with kerlix and ace bandage from toes to knees every day shift. (Typed as written.) --Cleanse right medial lower leg proximal venous ulcer with normal saline, apply silvadene periwound, xeroform to open areas to base of wound, place abd pads, wrap with kerlix and ace bandage from toes to knees every day shift. (Typed as written.) --Silvadene External Cream 1% apply to bilateral lower extremity topically every day shift for venous ulcer. (Typed as written.) --Cleanse MASD (moisture-associated skin damage) to bilateral buttocks with normal saline and apply chamosyn with manuka honey BID (twice daily) until healed. On 11/25/25 at 12:48 PM, the Administrator confirmed the treatments were not completed on 03/03/24. e) Resident #80 On 11/19/2025 at 3:03 PM, a record review was completed for Resident #80. The review found a physician's order dated 06/27/2025, Accu checks once daily in the morning for Diabetes Mellites (DM). Upon further review the Accu checks were not completed per physicians order. The following dates were not completed, 06/27/25, 07/01/25 and 07/03/25. The Director Of Nursing (DON) was interviewed on 11/19/25 at 3:53 PM, who confirmed the Accu checks were not completed as ordered. f) Resident #61 On 11/24/25 at 12:05 PM, a record review for Resident # 61 revealed a physicians order that stated: Accu check QID (four times a day) with a start date of 06/24/25 and discontinue date of 07/02/25. Upon further review the Accu checks was not completed on 06/29/25. The physicians order was changed on 08/21/24 and the following Accu check were not completed on 02/24/25 at 6:00 AM. The DON confirmed that the physicians orders were not followed. g) Resident #87 On 11/24/25 at 12:15 PM, a record review for Resident # 87 revealed a physicians order that stated: Accu check BID (twice daily) with a start date of 09/23/23. Upon further review the Accu checks were not completed on 07/03/25 at 600 AM and on 02/24/25 at 600 AM. The DON confirmed that the physicians orders were not followed. h) Resident #51 On 11/25/2025 at 10:40 AM, a record review for Resident # 51 revealed a physicians order that stated: Accu check Q am (in the morning) with a start date of 08/12/24. Upon further review the Accu checks on 02/24/25, 04/09/25 and 04/19/25 were not administered. The DON confirmed that the physicians orders were not followed. i) Resident #102 On 11/25/2025 at 11:10 AM, a record review for Resident #102 revealed a physicians order that stated: Accu check one time a day every Mon, Wed, Fri with a start date of 09/13/24. Upon further review the Accu check on 02/24/25 was not administered. The DON confirmed that the physicians order was not followed.

Based on interview, observation, and record review, the facility failed to honor resident choices for baths/showers. This was true for three (3) of four (4) residents. Resident identifiers: #71, #73, and #95. Facility Census: 109. Findings Includea) Resident #71During an interview on 11/19/25 at approximately 11.13 AM, the resident stated that her last tub bath had been on 10/30/25. The resident also said that on 11/02/25, the Nurse Aide had asked her whether she wanted a bed bath or a bath in the tub. Resident #71 stated that she had requested a whirlpool bath. The resident stated that the Nurse Aide (NA) left her room and did not return. Resident #71 stated that she had filed a grievance.Record review revealed a grievance form dated 11/03/25 in which Resident #71 complained about not receiving a bath on 11/02/25. The grievance form noted the following: [Typed as Written] [Resident] was asked on her bath day, 11/02/25, if she wanted a bed bath or a bath in the tub. She told the CNA that she wanted a bath in the whirlpool. CNA didn't come back to bathe her. Task sheet is marked Not applicable.The resolution was noted as: Discussed shower preferences with resident. Shower offered/given 11/04/25During an interview with the Administrator on 11/19/25 at 12:45 PM, the Administrator confirmed that the resident's preferences had not been honored and that the resident had not been given a bath on 11/02/25. The administrator also acknowledged that facility staff failed to thoroughly investigate and implement protocols to ensure that the resident's choices were honored going forward. The Administrator also stated that the facility staff did not accurately document the interventions implemented. b) Resident #73During an interview on 11/19/25 at 11:30 AM, the resident stated that she had not received a shower or bath since 10/21/25.Record review on 11/19/25 at approximately 11:45 AM revealed a grievance form submitted by Resident #73 dated 11/03/25 regarding baths/showers.The grievance form noted the following: [Typed as Written] Has not been offered a bath/shower since 10/21/25.The actions taken by the facility are listed below: Discussed shower preferences with resident. Shower offered/given 11/04/25.During an interview with the Administrator on 11/19/25 at 12:45 PM, the Administrator confirmed that the resident's preferences had not been honored, and that the resident had not been given a bath on 11/02/25. The administrator also acknowledged that facility staff failed to thoroughly investigate and implement protocols to ensure that the resident's choices were honored going forward. The Administrator also stated that the facility staff did not accurately document the interventions implemented. c) Resident #95During an interview with Resident #95 on 11/19/25 at approximately 11:36 AM, the resident stated that she had not received a bath on her scheduled bath day - 11/03/25. Resident #95 had submitted a grievance to the facility.Record review on 11/19/25 at approximately 11:57 AM revealed that Resident #95 had submitted a grievance on 11/03/25. The grievance form stated the following:[Resident] was not offered a bath on her scheduled day of 11/03/25. The task sheet for today was checked Activity not attempted due to medical conditions or safety concerns.The actions taken by the facility are listed as: Discussed shower preferences with resident. Shower offered/given 11/04/25Further record review on 11/19/25 of the physician's notes and nursing notes revealed no notes or documentation of any medical or safety concerns for Resident #95.During an interview with the Administrator on 11/19/25 at 12:45 PM, the Administrator confirmed that the resident's preferences had not been honored, and that the resident had not been given a bath on 11/02/25. The administrator also acknowledged that facility staff failed to thoroughly investigate and implement protocols to ensure that residents' choices were honored going forward. The Administrator also stated that the facility staff did not accurately document the interventions implemented.

Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #55's capacity and Physician's Order for Scope of Treatment (POST) form, Resident #9's transfer form and a progress note listing an incorrect medical diagnosis, a transfer form for Resident #4, and a psychotropic medication evaluation for Resident #5. This was true for four (4) of 42 residents reviewed during the survey process. Resident Identifiers: #55, #9, #4, and #5. Facility Census: 109.Findings Include:a) Resident #55On 11/24/25 at 11:00 AM, a record review was completed for Resident #55. The review found a physician determination of capacity dated 08/04/25 indicating the resident did have capacity to make medical decisions. However, a review of the Minimum Data Set, dated [DATE] section C indicated the resident had a Brief Interview for Mental Status (BIMS) score of -00- (zero) indicating severe cognitive impairment. On 11/24/25 at 2:00 PM, the Administrator was asked, Does the resident have capacity to make medical decisions with a BIMS of -00- ? The Administrator stated, No, the resident does not have capacity to make medical decisions .there is an issue with the capacity forms .it happened when the residents had an emergency evacuation back in August (2025), the other facility did their own paperwork. At this time, the Administrator confirmed the capacity form was incorrect and the facility physician had completed a new form dated 11/19/25, stating the resident demonstrates incapacity to make medical decisions.On 11/24/25 at 11:00 AM, a record review was completed for Resident #55. The review found in the electronic medical record (EMR) the resident was noted as a Do Not Rescusitate (DNR). However, a copy of the POST form was not scanned into the EMR. On 11/24/25 at 11:15 AM, a request was made for a copy of the POST form. The POST form had been completed via verbal consent on 11/19/25 and was not available in the EMR. On 11/24/25 at 11:45 AM, the Administrator stated, The POST form was misplaced when the resident returned from the emergency evacuation from the facility. We just obtained a new one from the Medical Power of Attorney (MPOA). It had not been scanned into the EMR. The Administrator confirmed the POST form was not readily available when the DNR notation was entered into the EMR.b) Resident #9On 11/19/25 at 12:00 PM, a record review was completed for Resident #9. The review found the resident had been sent to an acute care facility on 07/25/25 for abnormal vital signs. However, upon further review the vital signs (temperature, pulse, respirations, blood pressure and oxygen saturation) were left blank. The date on the transfer form was listed as 03/24/25.On 11/19/25 at 1:15 PM, the Administrator confirmed the transfer form was missing the vital signs and the transfer date was listed incorrectly.On 11/24/25 at 3:00 PM, a record review was completed for Resident #9. The review found a progress note dated 08/17/25 which listed the diagnosis of Human immunodeficiency virus (HIV). An additional review of the resident's noted diagnoses was completed; which, did not include HIV. On 11/24/25 at 3:30 PM, a interview was held with the Administrator. The Administrator was asked, Will you verify the diagnosis of HIV for this resident? The Administrator stated, I will get with the Nurse Practitioner and verify if this diagnosis is correct.On 11/25/25 at 8:30 AM, the Administrator provided an addendum dated 11/24/25 at 6:13 PM completed by the faciltiy physician. The addendum states, There was a dictation error on my note of 08/17/25 indicating that the patient has HIV, which is not the case. patient does not have HIV infection. (Typed as written.) At this time, the Administrator verified the diagnosis was incorrect for Resident #9.c) Resident #4On 11/19/25 at 11:00 AM, a record review was completed for Resident #4. The review found the resident was sent to an acute care facility on 11/11/25 for skin discoloration. However, the review found the date on the transfer form was listed as 09/01/25. On 11/19/25 at 11:30 AM, the Administrator confirmed the date on the transfer form was listed incorrectly.d) Resident #5On 11/25/25 at 10:00 AM, a record review was completed for Resident #5. The review found a Psychotropic Medication Evaluation dated 02/24/25. The evaluation did not indicate the targeted psychiatric or behavioral symptoms. Section 3 of the form was left blank, On 11/25/25 at 11:20 AM, the Administrator confirmed the targeted psychiatric or behavioral symptoms under section 3 was left blank.

Based on observation, record review and staff interview, the facility failed to maintain an infection control program while providing housekeeping services in room [ROOM NUMBER] and providing ADL care in room [ROOM NUMBER]. The staff failed to don PPE. Both rooms were under contact precautions. Additioanl issues were found through observation of inappropriate storage of a bath basin and fracture pan in room [ROOM NUMBER], and storage of a nebulizer mask for Resident #75. These were random opportunities for discovery. Room identifiers: #103, and #115. Resident Identifier: #75. Facility Census: 109.Findings Include:a) On 11/17/25 at 2:15 PM, the Administrator was asked for a copy of the door signage for contract precaution rooms. The contact precaution signage was provided by the Centers for Disease Control and Prevention (CDC) and was yellow with black and red lettering. It also, had two (2) red stop signs by the words contact precautions everyone must know. The following was listed on the sign: -Clean their hands, including entering and when leaving the room. -Providers and staff must also: -Put on gloves before room entry. Discard gloves before room exit. -Put on gown before room entry, Discard gown before room exit.-Do not wear the same gown and gloves for care of more than one person.-Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.b) room [ROOM NUMBER]On 11/17/25 at 2:01 PM, Housekeeping #289 was observed in room [ROOM NUMBER], which was under contact precautions, without donning personal protective equipment (PPE). At this time, Housekeeping #289 stated, I thought if they were out of the room, I didn't have to wear it.On 11/17/25 at 2:15 PM, the Administrator was notified and confirmed PPE should be worn in a room under contact precautions.c) room [ROOM NUMBER]On 11/18/25 at 1:00 PM, Nurse Aide (NA) #50 was observed providing activities of daily living (ADLs) to Resident #66. room [ROOM NUMBER] was under contact precautions and NA #50 did not don PPE prior to entering the room. Resident #66's roommate was noted with draining wounds. On 11/18/25 at 1:03 PM, NA #50 stated, I didn't think I had to wear it, if her roommate was out of the room.On 11/17/25 at 1:15 PM, the Administrator was notified and confirmed PPE should be worn in a room under contact precautions.d) room [ROOM NUMBER]On 11/17/25 at 2:06 PM, an interview was being held with Resident #43 and the resident's Medical Power of Attorney (MPOA). An observation was made of a fracture pan and bath basin in the bathroom on a shelf under the sink. The fracture pan and bath basin had no identifying information. of a fracture pan and bath basin, which had no identifying information, was on the shelf without a storage bag in place. At this time, Nurse Aide (NA) #42 was asked, Do you know who these belong to? Do you know if they are used? NA #42 stated, I don't know if they are used or not .I'll get rid of them.On 11/17/25 at 2:25 PM, the Administrator was notified and confirmed the fracture pan and bath basin should be labelled and stored in an appropriate storage bag.e) Resident #75On 11/17/25 at 2:14 PM, an initial interview was held with Resident #75. During the interview, an observation was made of a nebulizer mask laying on the nightstand. On 11/17/25 at 2:15 PM, Nurse Aide (NA) #102 stated, I will get a storage bag.On 11/17/25 at 2:20 PM, the Administrator was notified and confirmed the nebulizer mask should be stored in an appropriate storage bag.

Based on interview and record review, the facility failed to ensure that residents were provided with assistance for toileting and appropriate care to prevent potential urinary tract infections. This was true for two (2) of three (3) residents sampled. Resident Identifiers: #45 and #73. Facility Census: 109.Findings Include a) Resident #45During an interview on 11/18/25 at approximately 11:22 AM, the resident stated that she was incontinent and must wait for assistance when she needs to go to the bathroom, frequently ending up sitting in wet briefs for long periods of time. Resident #45 added that she had submitted a complaint to the facility on [DATE].A review of the complaint revealed the following note: [Typed as Written] Resident reported that she is tired of using the bathroom in her brief. She puts light on to go to the bathroom and they don't in time to take her!The facility stated that they had updated orders and care plan stating Resident is to be toileted Q 2 hrs.During the interview on 11/18/25 at 1:22 PM, the resident stated that the Nurse Aides (NAs) were checking her more frequently, but it was not every two (2) hours.Record review on 11/18/25 at 12:17 PM revealed that the resident had the capacity to make her own decisions. Resident #45 was diagnosed with:Syndrome of Inappropriate Secretion of Antidiuretic HormoneType 2 Diabetes Mellitus without complicationsHypertensive Heart DiseaseMuscle Weakness Record review of the resident's Care Plan and the physician's orders revealed no orders or updates to the Care Plan that addressed the frequency of toileting, as revealed by the following entries:HYGIENE: PARTIAL/MODERATE ASSIST- Helper does LESS THAN HALF the effortDate Initiated: 11/18/2025 TOILETING HYGIENE: PARTIAL/MODERATE ASSIST- Helper does LESS THAN HALF the effortDate Initiated: 11/18/2025A review of the Bladder Tracker Log on 11/19/25 at 1:20 PM revealed that the resident was not checked every two hours on the following dates and times:10/23/25 at 6:00 AM and then on 10/23/25 at 2:28 PM - 8 hours, 28 minutes.10/23/25 at 6:01 PM and then on 10/23/25 at 9:33 PM - 3.5 hrs10/23/25 at 10:46 PM and then on 10/24/25 at 7:44 AM - approximately 9 hours 10/24/25 at 4:00 PM and then on 10/24/25 at 8:40 PM10/24/25 at 10:35 PM and then on 10/25/25 at 3:24 AM10/25/25 at 6;24 AM and then on 10/25/25 at 1:48 PM10/26/25 at 0:19 AM and then on 10/26/25 at 6:39 AM 11/11/25 at 9:13 AM and then on 11/11/25 at 1:00 PM11/11/25 at 2:27 PM and then on 11/11/25 at 8:05 PM 11/14/25 at 6:06 AM and then on 11/14/25 at 2:30 PM11/14/25 at 3:56 PM and then on 11/14/25 at 10:35 PM 11/16/25 at 2:41 PM and then on 11/16/25 at 7:31 PM 11/18/25 at 9:34 AM and then on 11/18/25 at 2:10 PM11/19/25 at 9:57 AM and then on 11/19/25 at 2:38 PM11/19/25 at 6:10 PM and then on 11/19/25 at 10:38 PM b) Resident #73During an interview with Resident #73 on 11/17/25 at approximately 3:09 PM, the resident stated that the nursing staff did not provide care, and flush her nephrostomy catheters as scheduled, and ordered by her physician. The resident stated that her physician had ordered that her nephrostomy catheters were to be flushed three (3) times a day. She further stated that she frequently had to call the nurse to ask that the nephrostomy catheters be flushed. The resident further stated she had submitted a complaint on 11/03/25 to the facility regarding the failure of nurses to perform the required care. She stated that the Director of Nursing had spoken to her and provided her with log sheets to ensure that nurses flushed her nephrostomy catheters three times a day. The nurses were required to sign the log sheets after they provided care. Resident #73 displayed the log sheets that were on her bedside table. Resident #73 stated that she was frustrated that she had to ensure that the nurses flushed her nephrostomy catheters three times a day. The resident noted that the nurse on duty today had completed nephrostomy care as scheduled. However, she added that some of the other nurses had to be frequently reminded that it was time for nephrostomy care. The resident stated that she had requested that the facility train her to flush her own nephrostomy tubes because of her frustration with having to call and remind nursing staff to provide timely nephrostomy care. Record review revealed the following diagnoses:Chronic Kidney Disease Stage 5Obstructive and reflux uropathyUnspecified HydronephrosisOther artificial openings of urinary tract statusMalignant neoplasm of bladderRetention of urineAnemia in chronic kidney disease Further record review revealed the physician's orders that stated:Enhanced barrier precautions related to the nephrostomy tube when dressing/bathing/showering/transferring/personal hygiene. Changing linens, toileting and peri-care, providing care to resident with history of or colonized multi-resistant drug organism.Nephro-tubes to drain to gravity to prevent clogging.- Every shiftAssess markings on the nephrostomy tube at the exit site to check for dislodgement Q shift. Notify practitioner if dislodgement is suspected - Every shiftFlush Bilateral Nephrostomy Tube with 5mL of sterile saline - Three times a dayCheck nephrostomy tube for kinks or obstructions - Every shiftAssess the tube exit site for redness, swelling, warmth, tenderness, and drainage to detect signs of infection and skin breakdown with each dressing change - Day shift- Every three days A review of the grievance form submitted by Resident #73 on 11/03/25 revealed the following statements: Has not been offered a bath/shower since 10/21.Nephro catheter/tubes not being emptied as ordered. Action taken: Discussed shower preferences with resident.Shower offered/given 11/04/25 Record review revealed that no investigation or action to resolve the resident's complaint regarding the facility staff's failure to follow the physician's orders was documented. During an interview with the Administrator and Regional Director of Clinical Operations (RDCO) #294, on 11/25/25 at 10:05 AM the Administrator and RDCO #294 confirmed that the facility had failed to document actions taken to address the resident's complaint.RDCO #294 further stated that the facility had hired new staff, and there were issues with accurate and timely documentation. She went on to state that the Administrator and DON were in the process of training and educating staff on the importance of timely and accurate documentation.

Based on observation, Resident Council, and staff interview, the facility failed to post a notification of the availability of survey results and provide the survey results in an accessible location for review by residents and visitors. This was a random opportunity for discovery. Facility Census: 109.On 11/18/25 at 2:00 PM, during the Resident Council meeting, of the 14 residents that were attending the meeting, no one was able to verbalize where the survey results binder was located. On 11/18/25 at 3:00 PM, this Surveyor attempted to find the survey results binder without success. On 11/18/25 at 3:10 PM, an interview was held with Social Services designee (SSD) #36. SSD #36 stated, I do not know where it is, let me ask someone. On 11/18/25 at 3:15 PM, the SSD #36 entered the Administrator's office. At this time, the corporate RN entered the front lobby and asked Receptionist #65 the location of the survey results binder. The receptionist obtained the binder from behind the receptionist desk and gave it to the corporate RN. The corporate RN provided the survey binder. The Corporate RN was interviewed about the location of the binder. The Corporate RN stated, I got it from the receptionist. On 11/18/25 at 3:18 PM, Receptionist #65 confirmed the binder was kept behind the receptionist desk due to wandering residents. On 11/20/2025 at 10:53 AM, this Surveyor went to check on the location of the survey results binder. The binder was not visible in the lobby area. It was located at the receptionist's desk and was covered up with COVID supplies. On 11/20/2025 at 11:58 AM, the survey results binder was again covered with COVID supplies. On 11/20/2025 at 12:10 PM, the Administrator was shown the survey results binder was not easily visible and accessible for the residents. The Administrator moved it to a small table which was visible to anyone that entered the lobby. The Administrator stated, I will keep an eye on it.

Based on record review and staff interview, the facility failed to ensure monthly pharmacy reviews were signed, dated or provided with a response to the pharmacisit recommendationby the facility physician. This was true for two (2) of five (5) residents reviewed under the care area of unnnecessary medications. Resident Identifiers: #5 and #12. Facility Census: 109.b) Resident #12 On 11/24/25 at 9:30 AM, a record review was completed for Resident #12. The review revealed the monthly pharmacy review for 05/25/25 was not signed by the physician and no response was recorded. The issue and recommendation read as follows: Resident was prescribed Divalproex and was due for a Valproic Acid level (ordered for every 6 (six) months). Please consider obtaining this level on the next convenient lab day. This note was completed by the consultant pharmacist. On 11/24/25 at 3:13 PM, interview with Regional Director revealed the facility did not have a signed copy of the lab recommendation. Findings Include: a) Resident #5 On 11/24/2025 at 8:54 PM, a record review was completed for Resident #5. The review found the monthly pharmacy review for 07/29/25 was not signed, dated or provided a response to the pharmacist's recommendations by the facility physician. The monthly pharmacy review dated 07/29/25 stated, Dear (Name of facility physician), this resident is currently receiving Clonazepam and Oxycodone, Black Box Warning: Combined use of opiate agonists with benzodiazepines may cause respiratory depression, hypotension, profound sedation, and death. Limit the use of opiate pain medications with benzodiazepines to only patients for whom alternative treatment options are inadequate. If concurrent use is necessary, use the lowest effective doses and minimum treatment durations needed to achieve the desired clinical effect. Please reassess concurrent use of these medications to ensure the benefits outweigh the risks. (Typed as written.) Signed by (Name of Consultant Pharmacist.) On 11/25/25 at 3:10 PM, the Director of Nursing (DON) stated, We don't have the signed copy.

Based on staff interview and documentation review, the facility failed to ensure one (1) residents Pre-admission Screening (PASAR) form contained her current diagnosis at the time of admission. This was true for Resident #5. Facility census: 109. a) Resident #5 On 11/18/25 a review of resident's Pre-admission Screening and Resident Review (PASRR) dated for 09/19/23, question #30 Current Diagnosis Answer (None). On 11/18/25 a review of a Diagnosis Report for Resident #5 revealed a diagnosis of Bipolar Disorder, Unspecified (F41.9) with and onset 8/31/23. On 11/20/25 at 8:45 AM during an interview with Administrator who reported a new PASRR had since been completed and was awaiting the physician's signature so it could be submitted. The facility had started an audit to correct and update all PASRRs.

Based on observation, record review and staff interview, the facility failed to develop a care plan for assistance with showers and implement a fall intervention for Resident #4, and develop a care plan regarding triggers for Post-Traumatic Stress Disorder (PTSD) for Resident #8. This was true for two (2) of 42 residents reviewed during the survey process. Resident identifiers: #4, and #8. Facility Census: 109. b) Resident #8 On 11/18/25 at 12:06 PM, an interview was conducted with Resident #8 who reported she had a diagnosis of Post Traumatic Stress Disorder (PTSD) and had recently had an incident of some concern in this area when the resident were all evacuated from the facility. This diagnosis was confirmed with her electronic chart. On 11/20/25 review of resident's care plan revealed there were no triggers listed as on resident's care plan under the care area of PTSD. On 11/20/25 at 11:15 AM, a second interview with Resident #8 revealed her triggers with interventions for PTSD included specific sounds and smells pertaining to rain, leaves, wet ground, homecoming, specific noises around fall. She reported she had initially seen Dr. (name) r on two occasions but he stopped coming so she lost trust in him. She would have been apt to see him more at the time but he failed to come back, She does not like to leave her room and due to feeling unsafe. When she was at home, she would check the obituaries and the paper for her perpetrator. On 11/20/25 at approximately 2:00 PM during an interview with Director of Nursing and Administrator they acknowledged Resident #8's care plan did not address her PTSD triggers. Findings Include: a1) Resident #4 On 11/19/25 at 7:35 PM, a record review was completed for Resident #4. The review found a care plan intervention indicating the resident was dependent for personal hygiene which indicates the helper does all effort and requires two (2) or more helpers to assist. Upon further review, the resident did not receive a shower or bed bath during the following dates: --09/01/25-09/12/25 11 days --09/19/25-09/26/25 7 days --10/10/25-10/21/25 11 days --10/31/25-11/04/25 5 days On 11/20/25 at 10:00 AM, the Adminstrator confirmed the care plan was not implemented was not implemented regarding the assistance needed for a dependent resident. a) Resident #4 On 11/19/25 at 9:03 AM, a record review was completed regarding a fall with major injury for Resident #4. The review found a fall intervention of fall mat on the right side of the bed. On 11/20/25 at 9:03 AM, an observation was made in Resident #4's room. The observation found the fall mat was not in place at the resident's right side of the bed. On 11/19/25 at approximately 9:05 AM, Nurse Aide (NA) #102 confirmed the fall mat wasnot in place. On 11/19/25 at approximately 10:30 AM, the Administrator was notified and confirmed the fall mat should have been in place.

Based on record review and staff interview, the facility failed to ensure ADLs were provided to dependent resident. This is true for one (1) of two (2) residents reviewed under the care area of activities of daily living. Resident Identtifier: #4. Facility Census: 109.Findings Include:a) Resident #4On 11/19/25 at 7:35 PM, a record review was completed for Resident #4. The review found a dependent resident had not been provided assistance for showers. The resident did not receive a shower or bed bath during the following dates:--09/01/25-09/12/25 11 days--09/19/25-09/26/25 7 days--10/10/25-10/21/25 11 days--10/31/25-11/04/25 5 days On 11/20/25 at 10:00 AM, the Adminstrator confirmed the activities of daily living were not provided to a dependent resident.

Based on record review and staff interview, the facility failed to have an RN at least 8 hours a day, 7 days a week. This deficient practice had the potential to affect all residents in the building. Census: 110. Findings included: a) Registered Nurse Review of staff postings from 12/1/23, to 12/31/23, confirmed no Registered Nurse (RN) designated in the building on 12/23/23. Subsequent review of staff time punches verified RN#35 was on-call but not physically present in the building on 12/23/23. Interview with the Director of Nursing (DON) on 01/09/24 at 12:01PM, confirmed no RN was available on-premises during any shift on December 23, 2023. At 5:00PM on 1/9/24 the DON clarified that RN#35 was scheduled for that shift but ultimately did not cover due to LPN#80 picking up the shift, resulting in an oversight on an alternate staffing matrix.

Based on observation, record review, and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. Additionally, the facility failed to ensure sufficient staffing to allow residents to dine in the communal areas for breakfast and dinner. This deficient practice had the potential to affect all residents residing in the building. Census: 110. Findings included: a) Charge Nurse Review of staff postings from 12/01/23, to 12/31/23, and further confirmed on 01/02/24, revealed no licensed nurse designated as a charge nurse on any shift in the building. Interview with the Director of Nursing (DON) on 01/03/24, at 12:01 PM confirmed the facility does not formally designate charge nurses. Instead, staff rely on the on-duty RNs for supervision. However, this system lacked a clearly identified individual with leadership and accountability for each tour of duty. b) Sufficient Staffing Observations on 01/03/24, 01/04/24, and 01/09/24, confirmed all residents ate breakfast in their rooms, with no residents using the communal dining areas. Interview with the DON on 01/09/24, at 4:00 PM revealed that communal dining had been suspended since the COVID-19 outbreak in 2020 due to insufficient staffing. Recent staff additions do not yet have training in communal dining procedures. Communal dining for dinnertime is planned to resume on 01/15/24.

Based on observation, resident council meeting and staff interviews the facility failed to make grievances forms accessible to all residents and/or residents family/representatives residing in the facility. This had the potential to affect more than a limited number of residents living in the facility. Facility Census: 110 Findings Included: A review of the facility policy titled Grievance/Concern with an effective date of 01/12/17 read as follows. .Policy: .The facility will make available to all residents posting in a prominent location in the facility information of the right to file grievances orally or in writing; the right to file grievances anonymously. a) Grievance Forms During the Long-Term Care Survey Process from 01/02/24 to 01/10/24 many observations throughout the facility revealed no evidence of grievance forms being made accessible to the residents and/or resident representatives. During the Resident Council Meeting held on 01/09/24 at 10:05 AM, the residents as a group were asked the question, Do you know how to file a grievance? Do you know where to access your grievance forms? The residents as a group stated No, we don't. Did not know we could fill out the form. We usually must tell somebody so they know it is us that is having the issue. During an interview on 01/09/24 11:17 AM, Registered Nurse (RN) #132 stated the grievance forms were kept in the drawer. RN #132 said, We fill them out, and turn them into the appropriate department manager. RN #132 was asked What if a resident and/or representatives wants to file an anonymous complaint? RN #132 said, We tell them to speak to the social worker or administrator. They have to ask for the forms that are not available to the public or the family. During an interview on 01/09/24 at 11:21 AM, the Social Worker(SW) #111 stated, I am the grievance official, the residents come to me or the nurses and tell us the issues they are having. The grievance forms are at the nurses' station and the residents have to ask for the form. This surveyor asked, What if they wanted to file a grievance anonymously? The SW #111 stated, They can write it on a piece of paper and put it under my door. During the interview SW #111 acknowledged the residents should have access to grievance forms to file anonymously. During an interview, on 01/09/24 11:23 AM, the Administrator acknowledged there were grievance forms accessible to the residents and/or the representatives. We will get a box and display them.

Based on interview, observation and record review, the facility failed to establish and maintain an infection control program to prevent the spread of infection to the extent possible. The facility failed to implement isolation precautions and communicate the the resident precaution status to visitors, residents and staff. Due to the potential for the exposure to other residents, staff, and visitors, an immediate jeopardy to the health and well-being of others was determined. Residents placed at immediate risk of infection, hospitalization resulting in serious harm and death as a result of the spread of Respiratory Syncytial Virus (RSV) is highly contagious infection. RSV is especially serious for those who are elderly and other with compromised health conditions causing serious harm, impariment and even death. Resident #53 on the 100 hall and Resident #70 on the 200 hall were on droplet isolation since RSV culture was positive on [DATE] and [DATE], respectively. Resident #13 and #46 remain in the center having had a positive RSV results on [DATE] and [DATE] respectively. The following details the timeline of the IJ situation. --The IJ started on [DATE]. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 6:02 PM on [DATE]. --The facility submitted their first abatement Plan of Correction (POC) at 7:40 PM on [DATE]. --The SA requested changes to the abatement POC, and the facility submitted their second abatement POC at 8:00 PM, on [DATE]. -- The SA requested changes to the second abatement POC, and at 8:25 PM, the third abatement POC was submitted by the facility on [DATE]. --This POC was accepted by the SA at 8:25 PM on [DATE]. The surveyors began assessing the implementation of the POC abatement plan at 6:02 PM. 1. At 4:00 PM, the facility closed the 100 and 200 hallway for containment from other residents at risk. Signage was posted at the front door and all doors leading to the 100 and and 200 halls. The facility Medical Director was notified. At 7:30 PM, the 300 and the 400 hallways were closed as additional precautions. 2. All staff including housekeeping currently in the building at the time of closure were educated. Education will continue throughout the oncoming shifts until all staff have received education to include signs and symptoms of RSV, mode of transmission, handwashing, cleaning and disinfectant of surfaces. Staff assignments are being contained to the affected unit until no further signs and symptoms are exhibited. The Director of Nursing (DoN) #139 and the Infection Preventionist (IP) #59 will monitor daily across all shifts until symptoms are resolved. A newly initiated line list, starting today, of residents with respiratory like symptoms and potentially affected staff will be maintained throughout until full resolution. 3. Upon post resolution the DoN and the infection Preventionist will monitor five (5) days a week in the clinical meeting for potential further issues which would result in re-instituting line list and containment measure be taken. The Infection Preventionist will report to Quality Assurance (QA) monthly or more frequently as needed. Further guidance will be provided by Quality Assurance Performance Improvement (QAPI) committee. Monitoring is indefinite at this point. 4. The facility placed a sign informing anyone entering the front entry of the isolation precautions due to RSV. The door entering the hallways of 100, 200, 300, and 400 of the hallways has been closed to visitation due to isolation of respiratory illness from others. All visitation is strongly discouraged. Absolutely no children permitted. Education was given related to RSV/droplet precautions to the facility's staff. The education the staff received was related to signs and symptoms of RSV, mode of transmission, handwashing, cleaning and disinfectant of surfaces. A list of the staff schedule to contain to a affected unit until no further signs and symptoms are exhibited. The DoN and the IP are monitoring daily until no further signs and symptoms are resolved. A newly initiated respiratory line list started today of residents with respiratory like symptoms and potentially affected staff throughout until full resolution. 5. The facility stated they will report to the QA monthly or more frequently as needed. Further guidance will be provided by the QAPI committee. Monitoring is indefinite at this point. --The immediate jeopardy was abated at 8:55 PM on [DATE]. Resident identifiers: #13, #46, #53, and 70. Facility census: 119. Findings included: a) Facility's Policy A review of the facility's policy-infection prevention and control manual outbreak management finds control measures may include resident or unit isolation or quarantine measures for the entire facility. The identification of a single unusual or highly contagious infection (CDC) If there is one laboratory-confirmed influenza positive case with other cases of respiratory infection in a unit of a long-term care facility, an outbreak might be occurring. To establish an outbreak investigation: provide timely, appropriate monitoring of all ill residents, prevent transmission of infection to residents, staff, visitors, and family members. To provide facility employees, medical and administrative staff, and state/local agencies with accurate, organized, and objective information. To prevent future outbreaks of similar illness. The facility must prepare by educating the staff, monitor, by performing a surveillance and trending infections. Identify whether an outbreak is occurring. The facility must contain, control and prevent more cases. Notify the staff, residents, and visitor about an existences of an outbreak and their responsibilities and potential risk for them and methods of prevent transmission. The facility must enforce proper precautions, notify the state and local health officials, continue to monitor, adjust when control measures remain ineffective, re-evaluate, and modify as need, including possible closure of a unit or a the facility to new admissions or transfers out, except in medical emergency. Restrict movement of staff between units limit visitors, vendors, and non-essential staff. Resolve once outbreak has stopped. The facility must routine educated the staff with description of what an outbreak is and their role in an outbreak and methods of preventing such as Hand hygiene, remaining at home if they are ill. Reporting infectious diseases, diarrhea illness, or respiratory illness to infection control/employee health nurse. Control measures that my be implanted during an outbreak such as isolation or quarantine. The need to maintain a list of symptomatic residents, staff restriction if they are ill. Routine surveillance and trending of infection types and sites to provide a benchmark that can be used to measure possibly significant increased in new cases of a given infection. Identifiey whether a outbreak is occurring. Identify possible strategies that could be implemented to prevent future outbreaks or improve the process. Report these findings to the Quality Assurance Committee and determine actions to take that my assist prevent or control future outbreaks. 2. The facility's policy on employee work restriction-infection diseases It is the responsibility of the employee to report the presence of any communicable or infectious disease of importance in health care settings to his or her supervisor. Employee who are restricted from work shall remain away from work until no longer contagious or cleared by a medical provider. During a [CONDITION(S)] respiratory infections, acute febrile consider excluding from the care of high risk patients or contact with their environment during a community outbreak of Respiratory Syncytial virus (RSV) and Influenza. Until acute symptoms solve. 3. Long-Term Care (TLC) Respiratory Surveillance Line List from the CDC A review of the Long-Term Care (LTC) Respiratory Surveillance Line List from the CDC provides a template for data collection and active of both residents and staff during a suspected respiratory illness cluster or outbreak at a nursing home or other LTC facility. Each row represents an individual resident or staff member who may have been affected by the outbreak illness (i.e., cases). The information in the columns of the worksheet capture data on the case demographics, location in the facility, clinical signs/symptoms, diagnostic testing results and outcomes. During an outbreak, once a single laboratory-confirmed case of influenza/RSV has been identified in a resident, it is likely there are other cases among exposed persons. Conduct daily active surveillance until at least one (1) week after the last laboratory-confirmed influenza case was identified. Test for influenza/RSV with a molecular assay in the following: Ill persons who are in the affected unit(s) as well as previously unaffected units in the facility. Persons who develop acute respiratory illness symptoms after beginning antiviral chemoprophylaxis. The template was developed to help with data collection for common respiratory illness outbreaks. Information on the worksheet should be used to build a case definition, determine the duration of outbreak illness, support monitoring for and rapid identification of new cases, and assist with implementation of infection control measures by identifying units where cases are occurring. The form identifies outbreak start, which is the date of symptoms onset of first case, total number of cases- whether residents or staff, and the outbreak end, which identifies resolution date of the last case. The facility's outbreak control measures are: educate on hand hygiene practices, implemented transmission-based precautions, dedicate staff to care for only affected residents, suspend activities on affected unit, notify family/visitor about outbreak, monitor appropriate hand hygiene, and person protective equipment use by staff. Cohort ill resident within unit/building, place ill staff on [NAME], educate family/visitors about outbreak. The facility must track the number of new cases per date of residents, staff. The facility must identify each person recovered from the outbreak illness and was symptom free for 24 hours. Whether or not hospitalization was required for a resident or staff member during the outbreak period. The outbreak period is the time from the date of symptom onset for the first case to the date of symptom resolution of the last case. Were any ill staff delivering resident care, and did the staff seek medical attention for an acute respiratory infection at any time during the outbreak must be identified. Did any staff receive care at the emergency department, or hospitalized . b) Residents findings for RSV. Resident #13, who resides on on the 400 hallway, had positive swab sent from (hospital's name) to the facility on [DATE] at 12:00 AM. The facility staff notified the physician on [DATE] at 4:41 AM. Resident #46, who resides on the 300 hallway, was sent to the hospital and she was admitted on [DATE]. The hospital's (physician name), wrote on a progress notes on [DATE], Resident #46 has a positive swab for RSV. Returned to the facility on [DATE]. The facility stated that Resident #46 had a positive result for RSV on [DATE]. No evidence found in the progress notes that Resident #46 had positive swab for RSV on [DATE]. There is a note written after the Resident #46 was readmitted back to the facility by RN #141 on [DATE] at 3:15 AM, per hospital discharge resident was RSV positive on the 4th. Resident placed on droplet isolation. At the close of exit the facility did not provide evidence of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #53, who resides on the 100 hallway, was sent to the hospital and admitted on [DATE]. Resident #53 had a positive swab for RSV. Resident returned to the facility on [DATE]. Droplet isolation precautions for RSV on [DATE]. Discontinuation of the Isolation precautions on [DATE] and a new order for isolation on [DATE]. Resident #70, who resides on the 200 hallway, had Respiratory illness symptoms on [DATE] at 10:30 PM, of a non-productive harsh cough, his lungs are slightly diminished in the bases, with insiratory and expiratory wheezes noted. On [DATE] at 6:33 AM, a note stated the resident continues with congested cough, lungs wheezing bilaterally. Physician made aware, gave new order for flu swab. LPN wrote a note on [DATE] at 7:13 AM, she had received an order to swab Resident #70 for a RSV and isolated him unit the results come back. The (hospital) faxed the results to the facility on [DATE] at 8:12 AM. Resident #70 was positive with RSV. c) Observations Observation on entering the facility on [DATE] at 11:00 AM, found no signage on the front door alerting visitors, vendor, or family member that all visitation is strongly discouraged due to isolation of respiratory illness from others. There were no posting upon entering the 100 and 200 hallway, nor on the 300 and 400 hallways. Observations on [DATE] at at 7:15 AM, found no signage on the front door alerting visitors, vendor, or family member that all visitation is strongly discouraged due to isolation of respiratory illness from others. There were no posting upon entering the 100 and 200 hallway, nor on the 300 and 400 hallways. d) Record Review A review of the facility's Respiratory Line Listing for February 2020, on [DATE] at 9:00 AM, found for Resident #13, #46, and #53 the facility's list did not identify the case load, they did not identify types of specimens: nasopharyngeal swab, Oropharyngeal swab, urine, sputum or specify other, date the specimen collected, type of test ordered, pathogen detected, symptom resolution date, hospitalized , died , case or to a case. The Infection Preventionist (IP) was not monitoring resident with common respiratory illness outbreaks on the LTC Respiratory Surveillance outbreak summary for the month of February 2020. The IP did not have any resident's identified on the Respiratory Line Listing, nor Respiratory surveillance outbreak summary started for March. On [DATE] at 10:53 AM, Resident #70, had symptoms of harsh cough, lungs wheezing bilaterally, also diminished in the bases. New order for Flu swab, Nebulizers every six (6) hours for five (5) days, [MEDICATION(S)] Pearls 100 milligram (MG) three (3) times a day and Z pack ( Z pack is a type of antibiotic that works for bacterial infections, not [CONDITION(S)] infections. On [DATE] at 7:12 AM, swab for RSV ordered. Resident was not placed on isolation until [DATE] at 7:13 AM. The (hospital) faxed the results to the facility on [DATE] at 8:12 AM. Resident #70 was positive with RSV. A review of the facility's Respiratory Line Listing found the facility was using a Respiratory Line Listing that did not identify all the information needed in order to track and monitor the resident's infection. The facility did not track in chronological order ( accordance with the time sequence in which they occurred), They were not using the guideness the CDC recommended. For the resident's below the facility did not identify where the staff's primary floor assignment was, type of specimen ordered, date of collection, type of tested ordered, pathogen detected, symptoms resolution date, hospitalized , died , case or not a case. The facility did not complete a LTC Respiratory Surveillance outbreaks summary for the below residents in February 2020. --Resident residing on the 100 hallway: #15, #43, #9, #7, #99 and #118. --Resident residing on the 200 hallway: #16, #88, #45, #76, and #24. --Resident residing on the 300 hallway: #12, #38, #73, #48, #5, #2, #115, and #41. --Resident residing on the 400 hallway: 84, #51, #13, #64, 36. A review of the facility's monthly line listing found the below resident on the line listing for common respiratory Respiratory illness. The below resident were not being monitored and tracked on the Respiratory Line Listing for common respiratory like illness. --Resident #105, had cough on [DATE]. --Resident #219 had cough on [DATE]. --Resident #220 had cough on [DATE] --Resident #147 had cough/congestion on [DATE]. In an interview on [DATE] at 9:00 AM, with the IP, she was asked, why she had not identified and monitored items on the residents/and staffs respiratory surveillance line list and on the respiratory surveillance outbreak summary. The IP was completing the form from the CDC at this time for February 2020. The IP stated, that she no longer had an outbreak since [DATE]. The IP stated that she had notified the Health Department Nurse (HDN), but could not remember when she notified the HDN. The IP was informed the facility did have an outbreak with resident who had respiratory like illness. Surveyor informed the IP the form she was using for February did not have all the appropriate steps included on her LTC Respiratory Surveillance Line list and the LTC Respiratory surveillance outbreak summary should have been monitored and tracked each day for common respiratory illness on each Resident/staff to determine whether the facility had an outbreak. The form should not to be completed the following month. A review of the facility's employees list of absences for February 2020, revealed on the following dates, employee had called in sick, but the facility staff had not monitored or tracked the reason for the employees call in's, whether the staff had common respiratory illness. There was no information collected on a LTC Respiratory Surveillance Outbreak Summary form. The below staff had called in during February 2020 with no monitoring or tracking to determine if any of their staff had common respiratory illness outbreaks. [DATE] -- Employee #22 Housekeeper -- Employee #133 Nurse Aide (NA) -- Employee #140 Licensed Practical Nurse (LPN) -- Employee #56 Activity Aide (AA) [DATE] -- Employee #133 NA -- Employee #140 LPN -- Employee #56 AA [DATE] -- Employee #59 Registered Nurse (RN)- (IP) [DATE] -- Employee #150 Dietary Aide (DA) -- Employee #12 LPN -- Employee #21 NA -- Employee #140 LPN [DATE] -- Employee #41 Food Service Director (FSD) -- Employee #21 NA -- Employee #27 NA -- Employee #143 RN [DATE] -- Employee #41 FSD -- Employee #25 Environmental services -- Employee #21 NA -- Employee #68 DA 02 /,d+[DATE] -- Employee #41 FSD -- Employee #15 LPN -- Employee #21 LPN -- Employee #68 DA -- Employee #193 [DATE] -- Employee #13 NA -- Employee #27 NA -- Employee #193 [DATE] -- Employee #27 NA -- Employee #193 -- Employee #109 LPN [DATE] -- Employee #27 NA -- Employee #193 -- Employee #41 FSD -- Employee #43 Restorative NA -- Employee #79 Housekeeper [DATE] -- Employee #7 LPN -- Employee #173 NA --Employee #41 FSD -- Employee #148 Housekeeper [DATE] -- Employee #42 NA -- Employee #78 Restorative Aide (RA) -- Employee #68 DA -- Employee #84 Cook -- Employee #157 Medical Record Clerk -- Employee #104 NA -- Employee #79 Housekeeper [DATE] -- Employee #24 NA -- Employee #193 -- Employee #106 NA -- Employee #157 Medical Record Clerk [DATE] -- Employee #77 LPN -- Employee #193 -- Employee # 179 RN [DATE] -- Employee #24 NA -- Employee #77 LPN -- Employee #110 NA -- Employee #106 NA [DATE] -- Employee #24 NA [DATE] -- Employee #149 Medical Records -- Employee #27 NA -- Employee #140 RN -- Employee #42 NA -- Employee #188 NA [DATE] -- Employee #174 Restorative Aide -- Employee #188 NA [DATE] -- Employee #170 DA -- Employee #169 RN [DATE] -- Employee #171 Housekeeper -- Employee #24 NA [DATE] -- Employee #67 DA -- Employee #170 DA -- Employee #169 RN [DATE] -- Employee #37 NA -- Employee #169 RN [DATE] -- Employee #124 NA -- Employee #176 Activity Director -- Employee #169 RN [DATE] -- Employee #54 Social services [DATE] -- Employee #102 DA [DATE] -- Employee #85 NA -- Employee #24 NA -- Employee #30 NA -- Employee #47 NA [DATE] -- Employee #22 Housekeeper -- Employee #13 NA -- Employee #69 NA [DATE] -- Employee #62 NA -- Employee #122 RN- Minimum Data Set Coordinator (MDSC) -- Employee #24 NA -- Employee #33 NA -- Employee #161 LPN -- Employee #106 NA [DATE] -- Employee # 62 NA -- Employee #24 NA -- Employee #33 NA -- Employee #140 LPN [DATE] -- Employee #18 NA [DATE] -- Employee #178 RN e) Interview with staff In an interview on [DATE] at 9:00 AM, with the IP, she was asked, why had she had not identified and monitored the above items on the residents/and staffs Respiratory Surveillance line list and on the Respiratory surveillance outbreak summary. The IP was completing the form from the CDC at this time for February 2020. The IP stated, that she no longer had an outbreak since [DATE]. The IP was informed the facility did have resident with respiratory outbreaks. Informed the IP the form she was using for February did not have all the appropriate step included on her LTC Respiratory Surveillance Line list and the LTC Respiratory Surveillance outbreak summary should have been already completed in order to monitoring and tracked Respiratory illness outbreaks on each Resident/staff, not to be completed on [DATE]. The IP was interviewed at 9:45 AM, on [DATE], stated that once she had identified the facility had an outbreak, she did a verbal education to the staff, and talked to the housekeeping on cleaning the rooms, but she had no evidence to support this occurred. The IP gave me a list of employees who went to the outbreak control isolation precautions, hand hygiene, on [DATE] and [DATE], but only 34 employees had attended this in-service. The facility's employee list reveal the facility had 193 employees. The IP on [DATE] at 1:00 PM, confirmed they had three (3) employee who had the flu. When asked for the LTC Respiratory Surveillance Outbreak Summary, she said she did not complete one. She stated that, she just tracked whether staff had positive Influenza test. She was unaware of the need to track and monitor staff for respiratory illness for outbreaks. The IP handed over a list of employee call off line listing. There were three (3) employees names on call off line listing for February 2020. Employee #157 Medical Record Clerk, employee # 77 LPN, Employee #147 NA. Two (2) were positive for Influenza A and one (1) was positive for Influenza B. The form only had employee name, date and illness. No further information was on the form indicating monitoring or tracking was performed as recommended from the CDC on the LTC Respiratory Surveillance Outbreak summary form. The IP already confirmed that she had not filled out any item on the LTC Respiratory Surveillance Outbreak Summary for the staff nor the residents who reside in the facility. When the IP was asked if she was tracking and monitoring all employee call in's. The IP confirmed that does not get any information about employee call in's, so there is not way for her to monitor or track employee with respiratory like illness for an outbreak. The IP stated the front office receive this information. In an interview on [DATE] at 1:10 PM, with the Director of Nursing (DoN), she was asked whether she had asked the staff who called in, what their reason was for calling in. The DoN stated that, the staff write that down, but then then when the information is passed on they have been shredding this information and their tracking only says the staff called in, and whether they are paid for that day off or not. The DoN confirmed they had no been monitoring or tracking in to determine whether the staff had a respiratory illness in order to prevent an outbreak. In an interview on [DATE] 12:56 PM, Health Department Nurse (HDN), she stated someone from the facility had called her about having some respiratory problems, but not an outbreak. The HDN was asked whether anyone had called and informed her they had resident with positive swab for RSV. The HDN stated that, she was unaware of any resident residing in the facility had RSV. f) Resident #2 Observation on [DATE] at 8:06 AM, Resident #2's Nebulizers (Respiratory equipment) was lying on the resident's chair beside her bed underneath her bedroom slippers, heel protector boots, lotion, body spray, and afghan. The Assistance Director of Nursing (ADoN) #49 was present in the room at this time, and observed the Nebulizers lying in Resident #2's chair as stated above. The ADoN confirmed the staff should be putting her Nebulizers in a closed baggies. The Nurse who worked last night must of left it out. A review of the facility's policy revised on [DATE], finds finds the Nebulizers circuit should be disassembled after each treatment, rinsed with water and left open to air. The facility's policy reveals to place the Nebulizers circuit in the equipment bag for infection control purposes.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for nutritional services, in a total sample of twenty-nine (29) Stage 2 residents, was provided services to maintain acceptable parameters of nutritional status, resulting in actual harm to the resident. The facility did not identify, assess, or address the resident's severe weight losses. In a forty-two (42) day period, the resident experienced three (3) weight losses of over 5% each. The weight losses were not recognized, assessed, or addressed by the facility until the resident had already experienced an overall weight loss of 15.64% in forty-two (42) days. Resident identifier: #147. Facility census: 105. Findings include: a) Resident #147 Review of Resident #147's medical record, on 04/10/14 at 9:00 a.m., revealed the resident was admitted on [DATE]. The admission weight was recorded as 104.8 pounds (lbs). The resident's five (5) recorded weights from 11/06/13 to 12/18/14 were as follows: 1. 11/06/13 = 104.8 2. 11/20/13 = 97.6 (loss of 6.87%) - The facility rounded this up to 98 for the minimum data set (MDS) 3. 11/27/13 = 92.2 (additional loss of 5.3%) 4. 12/04/13 = 94.2 (increase of 2.12%) 5. 12/18/13 = 88.4 (loss of 6.15%) The resident's minimum data set (MDS), with an assessment reference date (ARD) of 11/20/13, was reviewed on 04/10/14 at 9:17 a.m. Item K0300, indicating a weight loss of five (5) percent or more in the last month was coded "Yes." It also noted the resident was not on a physician-prescribed weight-loss regimen. Review of the resident's care plan, on 04/10/14 at 9:22 a.m., revealed Resident #147 had no care plan related to weight loss until 02/13/14. The resident experienced a significant weight loss between 11/06/13 and 11/20/13, and again between 12/04/13 and 12/18/13. An interview was conducted with Resident #147 on 04/10/14 at 9:49 a.m. She said when she first came to the facility, she could not eat the food because it was "too sweet." She said she had pancakes that morning and could not eat them because the syrup was too sweet. When asked if she had discussed this with the dietary department, she stated they had been told the food was too sweet for her liking. The registered dietitian's (RD), Employee #178, progress notes were reviewed on 04/14/14 at 11:00 am. The first RD note was dated 11/07/13. There were no other nutritional notes in the medical record, until the next RD notes dated 12/18/13. There was no documentation in the resident's medical record by Employee #180, the food service director/general manager. The RD's note on 11/07/13 stated the resident was within her ideal body weight, and had no [MEDICAL CONDITION]. The RD wrote, "Wt (weight) fluctuation possible with res (resident) recently [MEDICATION NAME] and on [MEDICATION NAME]." The RD noted the resident was to be weighed weekly for four (4) weeks. No nutritional interventions were necessary and/or recommended at that time. Review of the RD's documentation dated 12/18/13, revealed the first evidence the RD had identified and addressed the resident's weight loss. The RD noted a conversation with the resident's son, who reported his mother was not eating and disliked the food. The RD made recommendations for vanilla nutrition shakes twice a day and vanilla ice cream for weight loss. This was the first nutritional intervention recommended for the resident's weight loss. By 12/18/13, the resident had experienced two (2) significant weight losses (5% or more) and had an overall loss of 16.4 lbs (15.64%) between 11/06/13 and 12/18 13, representing a severe weight loss. An interview was conducted on 04/15/14 at 9:07 a.m. with the RD. She stated the resident was [MEDICATION NAME] while in the hospital, prior to coming to the facility. Upon inquiry, the RD stated she had not recommended a supplement/intervention because the resident was placed on [MEDICATION NAME], a medication for anxiety, that would help with improving her appetite. When asked if anyone from the facility notified her Resident #147 was losing weight, she said they had not. She confirmed she was not aware of the weight loss until 12/18/13. Review of the medical record, on 04/15/14 at 9:20 a.m., revealed on 11/19/13, Resident #147 was ordered [MEDICATION NAME] 0.5 mg as needed (PRN) every six (6) hours for anxiety. She was given the PRN [MEDICATION NAME] only once in November 2013, on 11/19/13. She was not given the [MEDICATION NAME] during the month of December 2013. An interview was conducted with Employee #180, the food service director/general manager on 04/15/14 at 9:10 a.m. She stated she reviewed Resident #147's weight loss during their department head morning meeting, where they document everything that was discussed in the meeting. Employee #180 said she would review the notes and provide a copy of the note where she had discussed Resident #147's weight loss. Later, Employee #180 returned and stated she could not find any evidence Resident #147's weight loss was discussed during the department head morning meetings. When asked if she had identified Resident #147 was having weight loss, and what nutritional interventions were put in place for the severe weight loss, Employee #180 made no comment. During an interview and review of the weights for Resident #147, with the director of nursing (DON) on 04/15/14 at 11:15 a.m., she said the scales may have been inaccurate, but that she was not aware of a problem so she did not have the scales checked for inaccurate weighing. She confirmed Resident #147 was not re-weighed after weight losses were indicated on the weights and vital summary sheet. The DON said facility procedure was for the nursing assistant to weigh the resident and report the weight to the nurse. The nurse was responsible for documenting the weight in the computer. The DON said the nurse on duty the day the weights were obtained was responsible for reviewing the weights. If a weight loss had occurred, the nurse was responsible for informing the physician and the food service director/general manager. She stated if a resident had a weight loss, the nurses were also to put the resident on a critical alert form. The DON stated she reviewed the critical alert forms, and there was no evidence staff placed Resident #147 on the critical alert form for weight loss. She also confirmed she had no evidence the weight loss was reported to the physician and food service director/general manager as required. On 04/15/14 at 11:50 a.m., an interview was conducted with Employee #142, the MDS coordinator. She was asked about the completion of the 11/20/13 MDS and section K0300 for Resident #147, related to a weight loss of five (5) percent in the last month or a loss of ten (10) percent or more in last six (6) months. Employee #142 said she looked at the weights seven (7) days back to determine the weight for the MDS. She stated she rounded the weights up or down. For instance, Resident #147's weight was 97.6 lbs, so she rounded it up to 98. When asked if she notified other staff members about weight losses she found while doing MDSs, she stated she discussed them during the stand-up meetings. Employee #142 said she had tried to find the information to prove she had brought this to the department head meeting, but she could not find evidence she had discussed the resident's weight losses with anyone. An interview was conducted on 04/15/14 at 12:20 p.m., with Employees #62 (administrator), #178 (dietitian), #179 (dietitian),#101 (director of care delivery), and #72 (director of nursing.) When asked if they identified Resident #147 had a severe weight loss, the DON stated they believed the weights were not accurate; however, she had no evidence to provide to indicate the weights were inaccurate. During this interview, Employee #101 stated the resident had anxiety, was medicated with [MEDICATION NAME], and this medication had helped to improve her appetite. The DON stated they reviewed information about Resident #147 having weight loss in the department head meeting, but she confirmed she could not find any evidence in the meeting minutes about Resident #147 and her weight loss. When the above staff members were asked what interventions they implemented to prevent further weight loss, no one commented. An additional review of the medical record, on 04/15/14 at 12:30 p.m., after the interview on 04/15/14 at 12:20 p.m., revealed no evidence any employee had identified, assessed, and/or addressed the resident's weight loss until 12/18/13. The resident's weight records indicated a 6.87% (severe) loss between 11/06/13 and 11/20/13. Between 11/20/13 and 11/27/13, the resident's weight records indicated another severe weight loss of 5.3%. By 12/18/13, when the RD became aware the resident's records indicated a weight loss, all evidence suggested the resident had lost 15.64% of her total body weight between 11/06/13 and 12/18/13. Even if the weights were inaccurate, as suggested by the DON, the resident's weight records indicated weight losses which the facility failed to identify and assess to determine accuracy and/or to determine if interventions were necessary. In addition, although the resident had an order for [REDACTED].#101. As well, the DON stated they had reviewed information about Resident #147 having weight loss in department head meetings. When asked to see that evidence, staff confirmed they could not find evidence of discussions of this resident's weight losses in the department head meeting minutes. An interview on 04/15/14 at 1:00 p.m., with Employee #179 (dietitian), and Employee #72 (DON) confirmed the facility had no evidence they identified, reported, assessed, or provided nutritional interventions related to Resident #147's weight loss. .

Based on record review and staff interview, the facility failed to formulate a care plan to address the active weight loss and/or to include a measurable goal for one (1) of three (3) residents reviewed for nutritional services. The active care plan did not include a measurable goal to address the focus of weight loss; and failed to include interventions that were currently in place. Resident identifier: #147. Facility census: 114. Findings include: a) Resident #147 Review of Resident #147's medical record, on 06/24/14 at 10:00 a.m., revealed the resident lost seven (7) pounds in nineteen (19) days. On 06/04/14, she weighed eighty-four (84) pounds; on 06/18/14, she weighed seventy-eight (78) pounds, and her most recent weight was seventy-seven (77) pounds on 06/23/14. The resident's active problem of prior weight loss was identified on the minimum data set (MDS), with an assessment reference date (ARD) of 05/15/14, prior to this survey date. The registered dietitian's (RD), Employee #170, progress note dated 06/04/14 identified a three (3) pound weight loss in one (1)month, a meal consumption of "25 - 100% with mostly 50% of meals with one (1) refusal in seven (7) days;" and nutrition shakes twice a day with two (2) refusals in seven (7) days. A follow up note written later on 06/04/14 stated the resident's intake was inadequate. Nutritional shakes were increased to three (3) times a day. The RD's progress note written on 06/19/14, noted the resident had again lost 5.4 pounds, and her weight was down to seventy-eight (78) pounds. Nutritional shakes were increased to four (4) times a day. An interview was conducted with nursing assistant (NA) #74, on 06/24/14 at 10:30 a.m. She demonstrated how the nutritional supplements were documented in the Kiosk system. After the supplements were passed out, the NA documented whether the resident accepted or declined the supplement. There was no documentation to reflect the amount of supplement the resident consumed. The current care plan, with a revision date of 05/23/14, identified the focus of actual weight loss related to poor intake. The goal stated, "Res(ident) will tolerate diet and texture/consistency within the next review" (typed as written). There was no goal addressing the resident's poor oral intake. The care plan interventions did not include the enhanced foods the resident was receiving, staff actions to encourage intake, or monitoring of the intake of the six (6) prescribed nutritional supplements the resident received daily. The care plan was reviewed on 06/24/14 at 2:30 p.m., during an interview with the director of nursing (DON), Employee #66, the certified dietary manager (CDM), Employee #168, and the registered dietitian (RD), Employee #170. The DON and CDM agreed the current care plan goal did not address the resident's poor intake and there were no specific interventions to provide direct care staff guidance in an attempt to prevent further weight loss for the resident. The DON reported they did not document specific interventions in the care plan to address the resident's individual needs such as enhanced food. .

Based on medical record review, resident interview, and staff interview, the facility failed to ensure the development of a care plan for one (1) of three (3) residents reviewed for nutritional services, in a total sample of twenty-nine (29) Stage 2 residents. This resulted in actual harm for the resident, who experienced three (3) severe weight losses, each over 5%, in a forty-two (42) day period. Weight loss was indicated on the minimum data set (MDS) assessment; however, the facility failed to care plan for the weight loss until the resident had already experienced an overall weight loss of 15.64% in that forty-two (42) day period. Resident identifier: #147. Facility census: 1 05. Findings include: a) Resident #147 Review of Resident #147's medical record, on 04/10/14 at 9:00 a.m., revealed the resident was admitted on [DATE]. The resident's admission weight was recorded as 104.8 pounds (lbs). The resident's five (5) recorded weights from 11/06/13 to 12/18/14 were as follows: 1. 11/06/13 = 104.8 2. 11/20/13 = 97.6 (loss of 6.87%) The facility rounded this weight up to 98 pounds for the minimum data set (MDS) 3. 11/27/13 = 92.2 (additional loss of 5.3%) 4. 12/04/13 = 94.2 (increase of 2.12%) 5. 12/18/13 = 88.4 (loss of 6.15%) The resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/20/13, was reviewed on 04/10/14 at 9:17 a.m. Item K0300, indicating a weight loss of five (5) percent or more in the last month was coded "Yes." It also noted the resident was not on a physician-prescribed weight-loss regimen. On 04/15/14 at 11:50 a.m., an interview was conduced with Employee #142, the MDS coordinator. She was asked about the completion of the 11/20/13 MDS and Item K0300 for Resident #147, related to a weight loss of five (5) percent in the last month or a loss of ten (10) percent or more in last six (6) months. Employee #142 said she looked at the weights seven (7) days back from the ARD to determine the weight for the MDS. When asked if she notified other staff members about weight losses she found while doing MDSs, she stated she discussed them during the stand-up meetings. When asked if she put a care plan in place related to weight loss for Resident #147, she stated she did not. Review of the resident's care plan, on 04/10/14 at 9:22 a.m., revealed Resident #147 had no care plan related to weight loss until 02/13/14. The resident experienced a significant weight loss between 11/06/13 and 11/20/13, and again between 12/04/13 and 12/18/13. There was a care plan, initiated on 02/25/14 and revised on 04/03/14, related to the resident's weight loss; however, there was no care plan or interventions related to the three (3) severe weight losses the resident experienced between 11/06/14 and 12/18/13.An interview was conducted with Resident #147 on 04/10/14 at 9:49 a.m. She said when she first came to the facility, she could not eat the food because it was "too sweet." She said she had pancakes that morning and could not eat them because the syrup was too sweet. When asked if she had discussed this with the dietary department, she stated they had been told the food was too sweet for her liking. An interview was conducted on 04/14/14 at 11:00 a.m., with Employee #178 (dietitian) and Employee #180 (food service director/general manager). When asked if Resident #147 had a care plan related to weight loss, Employee #178 stated she placed the resident on a supplement on December 18, 2013. She stated she did a care plan, but she thought she had changed the date to a later date somehow, so the initial date was removed. When asked, Employee #180 made no comment about whether she developed a care plan related to weight loss for Resident #147. These employees were unable to provide any additional information when they were informed there was no care plan related to the resident's severe weight losses which occurred between 11/06/13 and 12/18/13. On 04/15/14 at 12:20 p.m., a discussion of Resident #147's weight loss was conducted with Employees #62 (administrator), #178 (dietitian), #179 (dietitian),#101 (director of care delivery), and #72 (director of nursing). When asked what interventions they implemented to prevent further weight loss, no one commented. After the discussion at 12:20 p.m., at 12:30 p.m., an additional review was conducted of the resident's medical record. This review confirmed there was no evidence the facility developed a care plan related to the resident's weight losses which occurred between 11/06/13 and 12/18/13. Between those dates, the resident lost 15.64% of her total body weight. .

Based on medical record review and staff interview, the facility failed to ensure that medication was administered according to manufacturer's specifications and / or according to accepted professional standards for one (1) of fifteen (15) sampled residents. Resident identifier: #25. Facility census: 120. Findings include: a) Resident #25 Review of the medical record for Resident #25 revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. He had a physician's orders [REDACTED]. Apply one (one) patch topically every 72 hours (rotate sites)". [MEDICATION NAME] is a narcotic pain medication. This medication is in a form to slowly release the stated dose evenly over a 72 hour period. Based on the physician's orders [REDACTED]. of the medication over the prescribed time of 72 hours. During an observation, on 01/24/12 at 8:55 a.m., Resident #25 was found to have two (2) [MEDICATION NAME] 25 mcg. patches in place, one (1) on each upper arm. Nurse #71 removed the [MEDICATION NAME] 25 mcg. patch from his left arm, which was dated 01/16/12. The remaining [MEDICATION NAME] 25 mcg patch on the right arm had been dated 01/22/12. The patch dated 01/16/12 would have been in place on 01/19/12, when another patch should have been applied. During an interview with the director of nursing, on 01/24/12 at 4:15 p.m., she said their standard of practice is to remove the old [MEDICATION NAME] when applying a new one. A review of the medical record, including nurse's notes, vital signs, and hospice visit notes, revealed no negative symptoms related to the medication error, but the potential for overdose was present as the patches continue to release medication even after 72 hours. .

Based on medical record review, family interview, facility policy review, and staff interview the facility failed to ensure that one (1) of nine (9) sampled residents received sufficient fluid intake to prevent dehydration resulting in the resident being hospitalized for [REDACTED]. Facility census 117. Findings include: a) Resident #61 A review of the medical record for Resident #61 revealed that he was an [AGE] year old male who had been determined to lack capacity to make health care decisions. His daughter was his medical power of attorney (MPOA). He required total care for all activities of daily living (ADLs), including feeding assistance, and was unable to make his needs known. He was admitted initially on 12/12/06 and recently readmitted on [DATE], after hospitalization . His admitting [DIAGNOSES REDACTED]. A review of the nurse's notes revealed, at 11:59 p.m. on 10/16/11, the resident had a "period of unresponsiveness" and the physician was notified. Labs and x-rays were ordered for 10/17/11. The laboratory results had several abnormal findings which were reported to the physician, and the resident was transported to the hospital, at 10:00 a.m. on 10/17/11. The abnormal results were: BUN 67 (normals) 7 - 18 mh/dL (09/06/11) 32 CREATININE 3.37 0.6 - 1.3 mg/dL 1.67 SODIUM 150.9 136 - 146 mmol/dL 139.3 CHLORIDE 112.3 98.0 - 107.0 mmol/L 104.5 The hospital Admission summary, which was done by the resident's attending physician, who treats him at the nursing home also, stated: "(Resident #61) is an eighty-four year old admitted to __ ___ Hospital with acute [MEDICAL CONDITION], dehydration, confusion, [MEDICAL CONDITIONS] symptoms and impaction." The physician stated the resident was treated with IV fluids and on discharge back to the nursing home (10/20/11) the resident was more awake, alert, his oral intake was back to his usual, and he was comfortable. The physician recorded being told by the resident's daughter that the resident had not been eating and drinking well for the last two weeks. He wrote a readmission order stating: "Please help with feeding - Total feed. Please document time spent with feeding TID (three times daily)." Review of the medical record revealed the resident had been on antibiotic therapy for a urinary tract infection from 09/22/11 - 10/04/11 with daily documentation of antibiotic tolerance. There was no evidence of any change in physical or mental status being assessed after that date, until 10/16/11 when the "period of unresponsiveness" occurred. There were NO nurse's notes in the medical record from 10/12/11 - 10/16/1. The resident's care plan identified the resident was at risk for alteration in hydration. The nursing goal stated: "Resident will be well hydrated as evidenced by but not limited to moist mucous membranes, good skin turgor, etc within next review" Among the planned interventions initiated on 03/10/09 were: 1. "Monitor for and report changes r/t (related/to) signs of dehydration (tenting skin, dry mouth, etc)" 2. "Encourage and feed resident to consume all fluids offered at and between meals." 3. "Notify physician and significant other of any significant changes." 4. "Monitor for and report any [MEDICAL CONDITION] or changes in [MEDICAL CONDITION] level There was no evidence, in the medical record, of any changes during the two (2) weeks prior to the resident's transfer to the hospital. Additionally, there was no evidence the above planned monitoring was done or that fluids were encouraged and/or consumed. Review of the Plan of Care Legend Report, compiled by the aides, revealed it did not include a method for documentation of fluid intake, except on night shift. Twenty-four (24) of thirty-one (31) entries were marked "R, NR" (refused,not required). The documentation of amount of meal taken revealed that in fourteen (14) of forty-eight (48)) meals from 10/1/11 - 10/16/11, the resident's intake was less than 50%. There was no comment found in any nurse's note related to food or fluid intake. During an interview with the MPOA, on 11/03/11, she stated that several times in the two (2) weeks prior to the resident's transfer to the hospital on [DATE], she had told the nurses she noticed a change in the resident's condition and was worried that he wasn't eating or drinking. She stated when she told the nurses this, they "shrugged her off". She stated that she had spoken to the Charge Nurse (Nurse #18) on 10/19/11 (after he had been hospitalized ), and told her that she did not think the staff had been offering him fluids when she wasn't there. The MPOA told Employee #18 she thought this was the reason he had to go to the hospital. She stated that she told the nurse she was reporting this to the state. Document review on 11/21/11, revealed no complaints made by the MPOA. There had been no comments during the meeting with Nurse's #163 and #18 at 8:40 a.m. on 11/22/11. The director of nurses (Employee #163) stated the facility had recognized they had a problem with the monitoring of fluid intake, unless the resident was on ordered "intake and output," and they were trying to solve it. They had no answer about the lack of documentation of a condition that does not happen overnight (dehydration) in a resident that was familiar to all the staff, including the complete absence of nurse's notes for four (4) day.. Shortly after the meeting, Nurse #18 presented surveyors with a "Resident Concern Form," dated 10/19/11, which had been documented by her and described the concern presented by the resident's daughter as: "Resident's daughter states she has reported to nurses that resident has changed, not eating/drinking." .

Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide, for one (1) of twelve (12) sampled residents, sufficient fluid intake to maintain proper hydration and health. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance, which was not prohibited by the resident's advance directives. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ... " According to a Transfer Summary Report hemodynamically stable". Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. Upon admission, the physician ordered a "no added salt", pureed diet with "level II fluids" (honey-thick liquids). According to the resident's weights and vitals summary, her weight on admission (07/14/10) was 130.0# and her height was 63 inches. The diet order was changed to mechanical soft with pureed meats and nectar-thick liquids on 07/20/10. - 3. A nutrition risk assessment, completed by a registered dietitian (RD) on 07/21/10, identified Resident #115 as being at HIGH RISK (score of 8 or higher), with a total score of 16. The RD calculated the resident's total fluid needs as 1737 cc/day. The resident's risk factors included an average intake of 33% at meals during a 7-day observation period, dementia, an [MEDICATION NAME] level of 2.7 (residents with [MEDICATION NAME] of less than 3.0 are at high risk), and one (1) Stage III pressure sore on the coccyx (with Stage I pressure sores also noted on the right hip and left heel). The RD recommended the addition of "Med Pass Supplement 2.0 60 ml 4 x day" on 07/21/10 to provide additional calories and protein for wound healing. On 07/27/10, the physician ordered: "Dietary consult - res(ident) not eating. ..." On 07/28/10, the RD noted, "Consult for res refusing to eat and wt (arrow pointing down) (sic) Res current wt 9-25-10 90.6 (pounds) /s (without) boots verified by re-wt. Boots weighed = 1# each. Res wt 7-23-10 98.2# wt 7-22-10 99.4# wt 7-18-10 127.4#. 130# 7-14-10. (Arrow pointing down) 39.4# / 30% / since adm (admission). Wt quest (questioned) on admit. Res has been refusing to eat per Nsg (nursing). Res current diet NAS mech soft, pureed meats & nectar liquids. Res avg (meal intake) 13% x 7 days (arrow pointing down) from 33% last review 7/21/10. Res currently receiving Med Pass 2.0 60ml 4 x day to supplement diet. Staff stated res consumed ice cream well 7-27-10 Rec (recommend) to add magic cup 1 x day at afternoon snack to provide 300cal/9g protein. Will contact POA to updated likes & dislikes. Will continue to encourage meal intakes." On 07/29/10, the RD noted, "Update (sic) res has started to consume meals better per Nsg (nursing). Nsg stated res will consume bite if presented /c (with) ice cream in between bites. ... D/T (due to) res intakes at meals are improving recommend to add Benical to lunch tray to help meet res needs. No further recommendations at this time. ..." While the RD was addressing the resident's weight loss and nutritional needs on a periodic basis, there was no mention of whether the resident was meeting her daily fluid needs. - 4. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the need to monitor the resident's hydration status, in view of the fact that her final [DIAGNOSES REDACTED]. - 5. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the "Indicators of Fluid Status" (Items "a" through "d" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark "Dehydrated; output exceeds input" or "Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 6. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration. A review of all problems, goals, and interventions identified on the 14-page care plan found no problem, goal, or intervention addressing the need to encourage adequate fluid intake or routinely assess / monitor the resident's hydration status / fluid balance. - 7. Nursing notes indicated, beginning on day of admission, that resident would refuse to eat by refusing to open her mouth. The resident would eat for the MPOA on visit to the facility. A nursing note, dated 07/25/10 at 10:30 a.m., revealed, "... Staff able to get 2 bites of brfast (breakfast) & 60 ml of fluid into resident this am (morning)." On 07/27/10 at 10:00 a.m., a nursing note revealed, "... Res conts (continues) to ref (refuse) to eat / drink ... Res conts to allow food / liq (liquid) to run out of mouth." - 8. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 9. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..." The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 10. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." She further stated, "I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection." - 11. There was no evidence to reflect the facility had routinely assessed / monitor Resident #115's hydration status / fluid balance for signs / symptoms of dehydration with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. - 12. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 13. In an interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., she stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." .

Based on record review, review of hospital records, family interview, staff interview, and interview with the hospital social worker, the facility failed to provide care and services necessary to attain or maintain the highest practical level of physical well-being for one (1) of twelve (12) sampled residents. Resident #115 was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, severe dehydration, and an infected pressure sore. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in her hydration status, quantity and quality of her urinary output, and/or presence of signs / symptoms of UTI. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Her admitting orders [MEDICATION NAME] mg twice daily for five (5) days. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. Review of the resident's initial acute care plan (developed prior to completion of the comprehensive admission assessment), dated 07/15/10, found no mention of the resident receiving five (5) days [MEDICATION NAME] daily or of the need to monitor the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI, in view of the fact that her final [DIAGNOSES REDACTED]. - 4. The resident's comprehensive admission assessment, with an assessment reference date of 07/21/10, revealed in Section B, the resident's cognitive skills for daily decision-making were severely impaired and she had problems with both short and long term memory. In Section G, she was totally dependent upon staff for bed mobility, transfers, dressing, eating, toilet use, and bathing. In Section I2, the assessor noted the resident had a UTI in the preceding thirty (30) days. None of the "Indicators of Fluid Status" (Items "a" through "d" in Section J1) was marked, indicating the resident did not have any problems with dehydration in the preceding seven (7) days; for example, the assessor did not mark "Dehydrated; output exceeds input" or "Insufficient fluid; did NOT consume all / almost all liquids provided during last 3 days". In Section V, the person completing the care planning decision indicated the interdisciplinary care team would proceed with addressing dehydration / fluid maintenance on the resident's comprehensive care plan. - 5. Review of the resident's comprehensive care plan, with an initiated date of 07/26/10, found no problem statements specifically addressing the resident's recent history of or risk for dehydration, oliguria, or UTI. The care plan did contain a problem statement addressing incontinence as follows: "Urinary incontinence and bowel incontinence related to impaired Mobility, Cognitive Deficit, Physical Limitations." The goals associated with this problem statement were: "Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction" and "No acute infection". The interventions intended to assist the resident in achieving these goals were: "Monitor for and report any changes in amount, frequency, color or odor of urine and stool and continency (sic). record (sic) bms (sic) (bowel movements) qs (every shift). Check for incontinence frequently and provide incontinent (sic) care." - 6. Review of nursing notes, since admission on 07/14/10 through 08/07/10, found no evidence of periodic assessment or monitoring of the resident's hydration status, quality or quantity of urinary output, or for the presence of signs / symptoms of a UTI. The nursing notes did, however, note the resident was refusing to open her mouth and was not eating and/or drinking. - 7. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 8. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. Patient was also given IV antibiotic, [MEDICATION NAME] 1 gram daily and [MEDICATION NAME] 250 mg IV daily. ..." The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute on [MEDICAL CONDITION]. ..." - 9. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." She further stated, "I did not feel that the resident needed to go to the hospital, and she was not exhibiting any signs and symptoms of a urinary tract infection." - 10. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not want a feeding tube inserted, she did want the resident to receive antibiotics and IV fluids if necessary. - 11. There was no evidence to reflect the facility conducted periodic assessment or monitoring of the resident's hydration status, of the quality or quantity of the resident's urinary output, or for the presence of signs / symptoms of a UTI with the knowledge that the resident was not eating, that her fluid intake was at a minimum, and that, prior to her admission to this facility, she had been treated for [REDACTED]. .

Based on record review, review of hospital records, staff interview, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to ensure a resident who entered the facility with pressure sores received necessary treatment and services to promote healing and prevent infection. Resident #115 entered the facility on 07/14/10 with a Stage III pressure sore on her coccyx and Stage I pressure sores on her right hip and left heel. From 07/28/10 to 08/04/10, the wound on the resident's coccyx significantly increased in size and developed necrotic tissue and slough which prevented staging of the wound; the staff did not notify either the resident's responsible party or attending physician of the worsening of this wound. Upon the resident arrival at the hospital (after being transferred at the insistence of the resident's responsible party on 08/07/10), the wound was "large and foul-smelling" and the odor was "overpowering"; prior to her transfer, the facility's documentation of this wound made no mention of any odor or signs / symptoms of infection. The resident was subsequently treated with intravenous antibiotics and the wound received surgical debridement. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10 following a hospital stay. Prior to this hospitalization , she had been living at the home of her caregiver and medical power of attorney representative (MPOA). According to the hospital history and physical examination was brought to the ER (emergency room ) following (sic) history of generalized weakness, lethargy, not eating or drinking, oliguric (low urine output) with dark foul-smelling urine. In theER on workup, patient was noticed to be dehydrated. Patient was also noticed to have urinary tract infection. Patient was advised (sic) hospitalization for further workup and management of urosepsis and dehydration. ..." According to a Transfer Summary Report hemodynamically stable" and received [MEDICATION NAME] mg every twelve (12) hours to treat the UTI, and her discharge medications [MEDICATION NAME] twice daily for five (5) more days. Her list of final [DIAGNOSES REDACTED]. - 2. Review of Resident #115's admission orders [REDACTED]. Also present on her chart was a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated; the resident's MPOA did not select "comfort measures". In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. The nursing admission evaluation, dated 07/14/10, identified the resident was admitted with a Stage II pressure sore on the coccyx area measuring 5 cm x 4 cm x 0.2 cm, a Stage I pressure sore on the right hip measuring 2 cm x 2 cm, and a Stage I pressure sore on the left heel measuring 5 cm x 6 cm. On 07/14/10, the physician ordered the following treatment to the Stage III pressure sore on the coccyx: "Stage III coccyx: Cleanse q3d (every three days) /c (with NSS (normal sterile saline). Apply [MEDICATION NAME] Aq. Cover /c [MEDICATION NAME] dsg (dressing)." On 07/15/10, the order was changed to: "Cleanse area /c NSS. Apply [MEDICATION NAME] (white). Cover /c [MEDICATION NAME]. Change dressing Q3D (every three days) & PRN (as needed)." A review of the resident's comprehensive care plan, with an initiated date of 07/15/10, revealed the following problem statement: "Stage I on right hip, left heel and stage (sic) III on coccyx related to recent hospitalization secondary to refusing to eat, drink, diabetes, mobility, contractures, impaired mobility (sic), incontinence." The goal associated with this problem statement was: "Skin will heal within the limits of the disease process." Interventions intended to assist the resident in achieving this goal included: " ... Evaluate and record wound status per facility guidelines until healed. ... Monitor for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify family / responsible party of skin condition. ..." - 4. A late entry in the skin progress notes, dated 07/15/10 (for 07/14/10), stated, "Res (resident) admitted on [DATE] /c (with) diagnosis (sic) of UTI, [MEDICAL CONDITION], dementia,[MEDICAL CONDITIONS], TIA ([MEDICAL CONDITION]), contractures of upper & lower extremities. She had a Braden (scale) of 9 on admit (sic) very high risk for skin breakdown. Also not eating / drinking at hospital. She was admitted /c a Stage I on Right hip 2 x 2 red area, not open, PUSH = 6. Stage III on coccyx - 5 x 4 x 0.2 20% slough /c 80% granulation, no odor, no drainage, no swelling, no c/o (complaints of) pain /c tx (treatment). PUSH score = 12, also has a Stage I on left heel 5 x 6 , PUSH score = 10. Tx order. ... Enc (encourage) to eat & drink. ..." A skin progress note, dated 07/21/10, stated, "Wound rounds completed. DCD (director of care delivery) & wound nurse on rounds. (R) (right) hip 1 x 0.2 PUSH = 3 Stage I - coccyx 0.8 x 3.0 x 0.2 D (depth) PUSH = 8 Stage III - (LE) (left) heel 4 x 6 PUSH = 9 Stage I. Coccyx - 75% slough / 25% granulation, 0 (no) odor, 0 drainage, 0 swelling, 0 s/s (signs / symptoms) infection - tolerated tx well. ..." A skin progress note, dated 07/29/10, stated, "Wound rounds completed. Late entry (for 07/28/10). DCD ' s, DON (director of nursing), wound nurse, dietary, therapy present. (R) hip - 0.8 x 0.5 Stage I PUSH = 2, (L) heel - 3.0 x 5.0 Stage I PUSH = 9, coccyx - 2.8 x 0.7 x 0.3 Stage II PUSH = 7, 10% slough 90% granulation, 0 odor, 0 drainage, 0 s/s inf (infection) 0 s/s pain. ... Cont /c ordered tx." A skin progress note, dated 08/04/10, stated, "Wound rounds completed. DON, DCD ' s, wound nurse & therapy present. (R) hip 1.4 x 1.0 Stage = I PUSH = 5. (L) HEEL 2.0 x 3.0 Stage = I PUSH = 7. Coccyx 7.0 x 7.0 x 0.8 unstageable PUSH = 14 50% necrotic tissue, 25% slough, 25% granulation. 0 odor, 0 drainage, 0 s/s inf. 0 s/s pain. ... Cont /c ordered tx." From 07/28/10 to 08/04/10, the pressure sore on Resident #115's coccyx increased in size and was no longer able to be visualized for staging due to the presence of necrotic tissue, although the wound care nurse documented there was no odor, drainage, or signs / symptoms of infection. The Stage I pressure sores or the resident's right hip and left heel did not open or change during this time. - 5. A review of the nursing notes, from 07/15/10 until 08/07/10, did not contain any assessment of the resident's pressure sores or documentation to reflect identification of any odor or other signs / symptoms of infection in the pressure sore on the resident's coccyx. - 6. On 08/07/10, the facility transferred Resident #115 to the hospital at the request of the resident's MPOA due to a change in the resident's mental status. - 7. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ..." Under "Clinical Assessment" was noted: "1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ..." Under "Plan" was noted: "Is to admit the patient, we will give her IV antibiotics and IV fluids. ..." A review of the hospital's discharge summary, dated 08/19/10, found: "(Resident #115) is an eighty-five year old Caucasian female, a nursing home resident who was hosptalized on [DATE] following history of unresponsiveness associated with generalized weakness, lethargy. On admission, patient was in septic shock. Patient was severely dehydrated ... Patient was hypotensive. Patient was started on IV fluids and was hospitalized for [REDACTED]. ... Clinical Assessment: 1. Infected decubitus ulcer. 2. Urinary tract infection - resolved. 3. [MEDICAL CONDITION]. ... Hospital Course: Patient was given normal saline, IV fluid challenge, followed by 150 cc per hour of IV fluids. ..." A hospital follow-up note, dated 08/26/10, stated: " This patient had a large decubit that was debrided and getting wound VAC (vacuum-assisted closure) treatment. The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ..." - 8. An interview with a registered nurse (RN) supervisor (Employee #70), on 09/03/10 at 10:00 a.m., revealed the MPOA wanted Resident #115 to be sent to the hospital on [DATE]. Employee #70 stated, "I offered to call the physician and obtain blood work to determine what was wrong with the resident, and the MPOA stated she wanted the resident sent to the hospital immediately. I called the physician and sent the resident to the hospital." - 9. An interview with the wound care nurse, a registered nurse (RN - Employee #61), on 09/02/10 at 1:35 p.m., revealed, when the pressure sore on Resident #115's coccyx was assessed to have increased in size on 08/04/10 and was not able to be visualized for staging due to the presence of necrotic tissue, she did not call the physician. She further stated she was new to the position and relied on some of the other nursing staff to tell her what she needed to do concerning the pressure sores. She also stated that, now, if a resident's pressure sore changed as Resident #115's did, she would call the physician immediately and schedule the resident with the wound clinic. She stated she works during the week and, after she leaves the facility each day, the floor nurses are responsible for the treatments. The floor nurses are also responsible for the treatments on the weekends. - 10. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m., revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker went into the emergency room . She stated, "The odor from the pressure sore was overpowering. I could not stand the smell. The emergency room nurses took pictures of the pressure sore on the resident's coccyx. It was large and foul smelling." She further stated, "I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids." - 11. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 12. The resident was admitted to the nursing home on 07/14/10, with a Stage III pressure sore on the coccyx. On 08/04/10, the pressure sore became larger in size and was no longer able to be visualized for staging due to the presence of necrotic tissue; neither the resident's MPOA nor the attending physician was notified of the deterioration in the status of this pressure sore. (See citation at F157.) On 08/07/10, the resident's MPOA asked that the resident be sent to the hospital. Upon arriving at the hospital, the pressure sore was found to be overwhelmingly malodorous and severely infected; however, the nursing notes in the resident's medical record at the nursing facility failed to identify the presence of any odor or signs / symptoms of infection prior to her transfer to the hospital. During the resident's second hospital stay, she required treatment with intravenous antibiotics related to the infected wound, and the wound subsequently received surgical debridement. .