Every finding on record at La Crescent Health Services

Based on observation, interview, and document review, the facility failed to prevent complications of enteral feeding and failed to provide appropriate treatment and services for 1 of 1 resident (R5) reviewed who required tube feedings and medication administration through a gastrostomy tube (g-tube). This failure created the likelihood of serious harm for R5, including worsening symptoms of nausea and vomiting, and additional hospital visits. The immediate jeopardy (IJ) began on 4/8/26 when the facility failed to follow professional standards of medication administration through a g-tube, pharmacy directions for medication administration, identify the symptoms and side effects of incorrectly using the g-tube. Subsequently, R5 experienced nausea and vomiting and was sent to the hospital with a diagnosis of pneumonia. The administrator and director of nursing (DON) were notified of the IJ on 4/9/26 at 6:17 p.m. The IJ was removed on 4/13/26 at 4:07 p.m., however, noncompliance remained at a lower scope and severity of D, indicating no actual harm with potential for more than minimal harm that was not widespread.Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). R5 was admitted to the facility on [DATE] with an admission diagnosis of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), muscle weakness, type 2 diabetes, hypothyroidism (thyroid gland does not produce enough thyroid hormone, symptoms include fatigue, weight gain, cold intolerance, and depression), hyperparathyroidism (parathyroid gland produces too much hormone, symptoms include high blood calcium levels, feeling weak, nausea, vomiting, loss of appetite, constipation, and abdominal pain), and hypercalcemia (blood calcium level greater than 10.5 milligram (mg) per deciliter (dl) causing fatigue, nausea, vomiting, constipation, confusion, cognitive changes, and irregular heart rhythms). A review of R5's medical record identified the following hospitalizations/emergency room visits identified on: 1) 2/12/26: R5 was sent to the hospital after a fall with decrease cognition and returned to the facility on 2/22/26; the primary diagnosis was hypercalcemia. R'5 Power of Attorney (POA) was activated during this hospital visit and thereafter due to ongoing intermittent confusion. Record review of R5's progress notes indicated the following concerns prior to being sent to emergency room:2/6/26 at 11:31 p.m.: stated she was sick to her stomach, the record lacked provider notification2/7/26 at 5:13 p.m.: declined oral medication, she did not wish to take them, the record lacked provider notification2/7/26 at 10:54 p.m., stated she was feeling nauseous and just can't take them, referring to her medications, which she refused. The record lacked provider notification2/9/26 at 3:30 p.m.: R5 took her medications through her g-tube but vomited shortly after administration, record lacked provider notification2/11/26 at 2:07 p.m.: R5 refused all medications stating, her stomach can't handle it.2/12/26 at 10:13 a.m., sent to emergency room 2) 3/6/26: R5 was sent to the hospital as a result of increased nausea and vomiting and returned to the facility on 3/10/26; the primary diagnosis was hypercalcemia. Record review of R5's progress notes indicated the following concerns prior to being sent to emergency room:3/1/26 at 12:33 p.m.: R5's g-tube was flushed and R5 reported feeling nauseous after flush3/2/26 at 10:46 a.m.: R5's g-tube was flushed and R5 reported feeling nauseous after flush3/3/26 at 2:28 p.m., in-person visit with physician assistant (PA)-A, discussed R5's ongoing nausea, no new orders written3/4/26 at 5:28 p.m., notified by hospital team the calcium level is high from recent blood draw, increase cinacalcet to 90 mg, stop vitamin D, push fluids, and repeat calcium level on 3/6/263/6/26 at 12:56 p.m.: R5 vomiting again, instruction to send to emergency room3/10/26 at 4:55 p.m.: POA remains activated 3) 4/6/26: R5 was sent to the emergency room as a result of increased abdominal pain and returned to the facility on 4/6/26; the primary diagnosis was pleural effusion (collection of fluid around your lungs.) Record review of R5's progress notes indicated the following concerns prior to being sent to emergency room:3/17/26 6:06 p.m.: R5 experienced nausea and vomiting, no record of provider or POA notification3/29/26 at 12:07 p.m.: R5 experienced nausea and vomiting after morning medications, no record of provider or POA notification3/30/26 at 12:13 p.m.: R5 experienced nausea and vomiting after morning medications, no record of provider or POA notification3/31/26 at 3:40 p.m.: R5 experienced nausea and vomiting after medications, no record of provider or POA notification4/5/26 at 12:00 p.m.: R5 experienced right-sided abdominal pain that continues until 4/6/26 at 12:00 p.m., ongoing nausea, vomiting, pain; resident sent to emergency room 4) 4/8/26: R5 was sent to the hospital and returned to the facility on 4/9/26; the primary diagnosis was right-sided pneumonia (acute inflammation of the lung caused by an infection, commonly caused by aspiration.). Record review of R5's progress notes indicated the following concerns prior to being sent to emergency room:4/6/26 at 6:00 p.m.: returned from emergency room, R5 was noted to have a heavy stool burden, R5 refused laxatives, no record of provider or POA notification4/7/26 at 5:16 a.m.: R5 refused laxatives, no record of provider or POA notification4/7/26 at 12:22 p.m.: R5 refused laxatives, no record of provider or POA notification4/7/26 at 8:58 p.m.: R5 stated her upper right quadrant pain is worse, no record of provider or POA notification4/8/26 at 12:15 p.m.: R5 received daily medications and 150 ml water flush while positioned less than 30 degrees4/8/26 at 12:42 p.m.: R5 experienced nausea and increased right upper quadrant pain4/8/26 at 2:38 p.m.: R5 experienced nausea and vomiting after receiving 60 ml of the 150 ml water flush, did not proceed with entire amount due to vomiting, R5's care plan indicated the following:-administer tube feeding formula, hydration, and flushes per order-elevate HOB 30-45 degrees (did not provide direction for when and how long to elevate HOB) R5's care plan lacked resident-specific interventions to monitor or prevent recurrence of nausea, vomiting, and abdominal pain; to include the signs and symptoms of hypercalcemia; which include mental status changes, muscle spasms, abdominal pain, and constipation. Additionally, the care plan lacked assessment and interventions for the risk of fluid volume deficits. R5's provider order, dated 1/26/26, included tube feedings (Vital Advanced Formula at 100 milliliter (ml)/hour (hr) for 13 hours) via g-tube. R5 received 150 ml water flush in g-tube every 4 hours, including during tube feeding. R5 received 150 ml of water flush in g-tube after medication administration for the AM medication pass. R5's physician orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids)-prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food)-iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach.-folic acid (vitamin) 1 mg via g-tube daily-apixaban (blood thinner) 2.5 mg via g-tube twice daily-metoprolol tartate (blood pressure) 12.5 mg via g-tube twice daily-senna (laxative) 8.6 mg via g-tube twice daily-cinacalcet (overactive parathyroid) 30 mg via g-tube twice daily-omeprazole-syrspend (antacid) SF Akla oral suspension 10 ml daily-ascorbic acid (vitamin C) 500 mg via g-tube daily During an interview on 4/7/26 at 11:47 a.m., physician assistant (PA)-A stated R5 has a complicated gastrointestinal (GI) tract. R5 has hyperparathyroidism and this is the source of her hypercalcemia. R5 is no longer a surgical candidate to have her parathyroid removed, symptom management has been the primary direction of care. PA-A stated electrolyte imbalances will be an ongoing concern for R5. PA-A stated she is unsure how often the nutrition team is working with R5 or how involved they are with her care. According to the American Society for Parenteral and Enteral Nutrition article, Medication via Enteral Feeding Tubes: A Clinician's Guide, located at https://nutritioncare.org/wp-content/uploads/2026/04/Medications-Via-EN-Tubes.pdf, identified prior to administering medications through a g-tube, medications should be verified for right client, right medication, right dose, right time, right route, and right documentation. When administering medication through a g-tube, medications should be crushed and diluted with 15-20 milliliters (ml) of purified water separately. Additionally, the head of the bed (HOB) should be elevated at least 30-45 degrees during medication administration and for at least 30-60 minutes after medication administration to prevent aspiration and support safe, effective delivery of medication. Further, proper positioning supports breathing, reduces pressure on the abdomen, and improves resident comfort. Lastly, complications from g-tube misuse can lead to nausea, vomiting, abdominal pain, tube clogging, aspiration, and toxicities. During an observation on 4/8/26 at 9:39 a.m., registered nurse (RN)-A prepared R5's morning medication administration. RN-A removed and prepped the above-named medications and put each medication in a medication cup. RN-A did not know when the most recent tube feeds had completed. RN-A failed to identify the medication levothyroxine had a pharmacy warning to give on an empty stomach and not within 4 hours of iron supplements (prepped iron-multivitamin suspension) or antacids (prepped omeprazole suspension), which she was preparing to administer at the same time. RN-A failed to identify prednisone should be given with food (tube feeding ended at 5:42 AM.) RN-A failed to identify iron-multivitamin suspension should be given on an empty stomach. Additionally, RN-A prepped the iron-multivitamin suspension with 20ml instead of the ordered 15ml. Prior to medication administration, R5 required enhanced barrier precaution (EBP) due to an indwelling medical device (g-tube). RN-A failed to apply the appropriate personal protective equipment (PPE) prior to providing care. At time of administration, RN-A failed to ensure the head of the bed was 30-45 degrees, with the bed remaining at approximately 10 degrees and R5 slouched down in the bed. RN-A stated R5 received a 30ml water flush before medication administration, 30ml water flush in between each medication, and a 150ml water flush at the end of the medication administration. During medication administration, RN-A diluted each medication with approximately 2ml of water, which failed to dilute the medication enough to allow it to pass through the g-tube. When RN-A put the medication into the barrel of syringe attached to the g-tube, the medication was not diluted enough to flow, RN-A then begun adding additional unmeasured amounts of water and continued to add until the medication would flow; 2 medications required pressure from the syringe plunger to flow through the g-tube. During medication administration process, R5 stated she was having increased nausea and abdominal pain. RN-A failed to recognize R5 was still not at the correct position. During administration RN-A failed to flush the g-tube between medications levothyroxine and metoprolol. RN-A was unsure what effect this could have on R5. After administration was completed, RN-A failed to set the head of the bed up to 30-45 degrees; bed remained at approximately 10 degrees with R5 slouched down in bed. During an interview on 4/8/26 at 10:36 a.m., RN-A stated she was unsure how much additional water she had added to dilute medication enough to flow through R5's g-tube; she guessed it was approximately 5ml. RN-A stated with the complete medication administration and water flushes; R5 had received approximately 450 ml of liquid. RN-A stated she had not had g-tube education for some time. RN-A stated the facility had not had a resident that required tube feedings or had a g-tube for about a year or year and a half. RN-A stated she had been taking care of R5 since her admission in January. During an interview on 4/8/26 at 2:39 p.m., physician assistant (PA)-A stated the resident had been experiencing ongoing nausea and vomiting with intermittent abdominal pain since returning from the hospital on 3/10/26. When R5 returned to the facility on 3/10/26 her calcium level was 9.5. PA-A stated she expected facility staff to know the basic signs and symptoms of hypercalcemia, including mental status changes, nausea, vomiting, and constipation. PA-A stated she expected the nursing team to follow the standard of practice when administering medication via g-tube, including sitting the head of bed at 30-45 degrees during and after tube feeding and medication administration. Additionally, she was unsure of the amount of water needed to dilute the medication; however, she would anticipate this to be approximately 5-10 ml of water, and the nurse should be keeping track of this to adjust the water flushes during administration. PA-A stated she relies on the pharmacist to know what medication can be given at what times in relation to the tube feeding and on the pharmacy team to tell her if there are any specific medication interactions. During observation on 04/08/2026 at 3:09 PM, emergency services arrived at the facility to take R5 to the emergency room; RN-A stated R5 had been experiencing worsening nausea and vomiting and abdominal pain. During an interview on 4/9/26 at 8:53 a.m., PA-B stated she was the hospitalist who cared for R5 during her 3/6/26 to 3/10/26 hospital admission. PA-B stated she had included a statement in her discharge summary that stated, We have asked the staff at your skilled nursing facility (SNF) receive additional education on management of your feeding tube. PA-B stated she included this statement because R5 had told her she felt the staff at the facility did not know how to use her g-tube. PA-B stated she would expect the facility providers to manage the calcium levels after discharge. PA-B expected the head of the bed to be elevated to 30-45 degrees during and after tube feedings and medication administration. PA-B stated medication interactions should be managed by the facility provider and pharmacist. PA-B stated medication administration times should be assessed by the facility provider and pharmacist. PA-B stated medications given with other medications or around tube feedings can have side effects for R5 that include nausea, vomiting, abdominal pain, increased absorption, or decreased absorption. PA-B stated mismanagement of the g-tube with both tube feedings and medication administration could result in complications for R5. These complications could include harm, injury, and in worst case, death. During interview on 4/9/26 at 9:59 a.m., pharmacist (PH)-A stated the hours and times of administration are determined by the facility provider, pharmacist, and manufacturer guidelines. PH-A stated R5 should be in an upright position during tube feedings and medication administration and up to an hour afterwards. Medication interactions should be managed by the facility provider and pharmacist. If medication interactions aren't completed, R5 could experience ineffective medications, medication side effects, and symptom side effects. PH-A stated medications such as prednisone should be taken with food to prevent nausea and vomiting. Medications such as levothyroxine, in this situation, should have been given before the tube feedings were started or several hours after tube feedings have stopped. Additionally, levothyroxine should be spaced at least 4 hours from the iron vitamin solution and the omeprazole solution. PH-A stated the medication errors should have been identified by the facility provider and pharmacist upon medication review at time of admission. During an interview on 4/9/26 at 11:22 a.m., licensed practical nurse (LPN)-B stated R5 had frequent nausea and vomiting. LPN-B stated they only track R5's bowel movements for output. LPN-B stated R5's emesis are not documented in R5's medical record. LPN-B described the process of administering medications via g-tube which did not include elevating head of bed during or after administration of medications or enteral feedings. During an interview on 4/9/26 at 11:42 a.m., registered nurse (RN)-B stated R5 was admitted to her unit at the hospital yesterday evening. Upon arrival at the hospital unit, R5 was nauseous and vomiting. R5 was given medication to resolve these symptoms. RN-B stated she had given R5 her normal medications this morning. RN-B stated the resident has not experienced nausea or vomiting since yesterday. RN-B stated R5 was able to take sips of water or clear liquids without experiencing nausea or vomiting. RN-B stated the resident must be sitting at least 30-45-degree angle during tube feeding and medication administration. RN-B stated if R5 receives tube feeding when not at the correct angle, she is at risk for nausea, vomiting, and abdominal pain. Additionally, she would be at a high risk for aspiration or aspiration pneumonia. During an interview on 04/09/2026 at 11:54 AM, PA-C stated frequently monitoring of calcium should be complete weekly until R5's calcium levels are stable, then monthly, then every six months. R5 has been on cinacalcet to manage her high calcium levels; she is on a consistent dose, but ongoing monitoring should still be weekly to bi-weekly. PA-C stated the most common symptoms of hypercalcemia included altered mental status, muscle cramps, and constipation. Nausea and vomiting aren't necessarily a symptom of hypercalcemia; but they are symptoms of the cinacalcet. PA-C stated if R5 was having nausea and vomiting, there is probably another cause for her symptoms. PA-C stated she would expect the facility staff to know the signs and symptoms of hypercalcemia, medication side effects, and how to properly manage the g-tube during tube feedings and medication administration. PA-C stated if R5's g-tube was mismanaged, R5 could be at risk for harm, increasing symptoms of nausea and vomiting and abdominal pain. Additionally, improper positioning during tube feeding and medication administration could result in serious risk for aspiration or other complications. During an interview on 4/15/26 at 11: 46 a.m., pharmacist (PH)-B stated when a resident has been admitted to the facility, she reviews the discharge summary to verify medications and compare them to the facility medication administration record (MAR). If she notices any discrepancies, she will write a recommendation for the provider to review and determine appropriateness of medication; she would expect response from the provider in one week. PH-B stated she does not evaluate each medication for interactions; the pharmacy providing the medication will go through the interaction checker; the interaction warnings then get placed on the medication and the medication is delivered to the facility. PH-B stated she doesn't check when medications are administered in relation to the tube feedings; she would expect nursing to follow the administration directions from the pharmacy. PH-B stated it is important to follow the administration directions from pharmacy; but could not speak to the importance of accurate medication administration timing. During an interview on 4/7/26 at 3:15 p.m., vice president of success (VPS)-A stated nurses were educated about g-tubes annually and for regular competencies. VPS-A stated nurses can receive g-tube education sporadically; they didn't believe nursing staff were educated about the needs of R5 prior to her arrival. During an interview on 4/7/26 at 3:25 p.m., director of nursing (DON) stated she believed the facility provided education to staff about g-tubes but couldn't find the specific education. DON stated she would expect education to be given for g-tubes, tube feeding administration, medication administration, g-tube complications, and g-tube side effects or symptoms. DON stated the facility had not cared for a resident with a g-tube in about a year. DON stated, generally g-tube education is annually, she did not provide g-tube education to staff about this R5 and her specific needs. DON stated it would have been beneficial to have educated staff specifically about R5 so staff could be prepared for any complications. On 4/14/26 at 10:22 a.m., a call was placed to the facility Medical Director; no return call received. A facility g-tube education titled Enteral Nutrition and Drug Administration dated as provided on 12/22/25, this education failed to identify practice standards for medication administration and tube feeding administration. A facility policy titled Enhanced Barrier Precautions (EBP) dated 8/8/25, high-contact resident care activities include device care or use: feeding tubes. EBP should be followed when performing high-contact resident care activities. A facility policy titled Medication Administration dated January 2026, medications are administered in accordance with written orders of the prescriber. Timing of medication administration must align with manufacturer specifications. A facility policy titled Medical Director Responsibilities dated 4/22/25, the medical director's responsibilities include implementation of resident care policies, such as ensuring physicians and other practitioners adhere to facility policies on diagnosing and prescribing medications and intervening with a health care practitioner regarding medical care that is inconsistent with current professional standards of care. A Facility assessment dated [DATE], training and skills unique to resident population: our nurses are trained in enteral feedings; our facility not only conducts a skill assessment during floor orientation of nurses and nursing assistants but also conducts monthly competencies of various skills to ensure that annual training occurs to keep skills honed. The IJ that began on 4/9/26 was removed on 4/10/26 when it was verified the facility implemented the following:-The facility immediately addressed R5's medical needs (nausea, vomiting, medications, and g-tube management)-The facility developed strategies to prevent g-tube complications during and after tube feedings and medication administration (staff education, g-tube education, and medication administration via g-tubes)-The facility reviewed and updated if needed g-tube policies including medication administration through a g-tube, condition monitoring, and fluid management-R5's medications were reviewed by a pharmacist and medication director to ensure appropriate timing is optimal to prevent nausea and vomiting-The facility developed processes to evaluate and monitor the side effects and effectiveness of medications-The facility educated staff on the policy and procedures to ensure consistency in the care of residents with g-tubes-The facility educated staff on the potential medication side effects and monitoring as well as the disease process for hypothyroidism, hyperparathyroidism (hypercalcemia). -The facility educated staff about tube feedings and the procedures and standards of practice of medication administration via a g-tube-Audit will be conducted by the DON or designee starting 4/10/26 on tube feeding administration, medication administration via g-tubes and positioning of residents with enteral nutrition or medications. Audits will be completed daily on varying shifts x7 days. Audits will continue no less than 3 times per week for 4 weeks or until substantial compliance is maintained. DON or designee will review facility charting daily to identify resident change in condition, to ensure proper documentation of assessments/evaluation and timely provider notification. These audits will be completed daily x7 days then with morning clinical 5 days per week for 8 more weeks or until substantial compliance is maintained. -Results of audits will be brought to Quality Assurance and Performance Improvement (QAPI) for review and recommendation-QAPI meeting on 4/10/26 to discuss with interdisciplinary team (IDT) and medical director to review findings and ongoing plan

Based on interview and document review, the facility failed to ensure 1 of 1 medical director had appropriate oversight of policies and procedures and ensured appropriate medical care was being provided for 1 of 1 (R5) resident who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube).Refer to 684 Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current, undated care plan indicated the following:-urinary incontinence: report changes in skin integrity found during daily care-potential for pressure ulcer development:administer treatments as ordered, and monitor effectivenessfollow facility policies/protocols for the prevention/treatment of skin breakdownmonitor nutritional statusmonitor/document/report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length x width x depth)-The need for a feeding tube/potential complications from that tube. R5 was to have no complications from the feeding tube. Staff were to administer formula and hydration and flushes per order. R5's care plan lacked identification of skin breakdown on R5's coccyx; further lacking goals and interventions for monitoring, treating, and documenting R5's actual skin breakdown. Additionally, R5's care plan lacked identification of R5's refusal of cares and treatments; further lacking goals and interventions to apply when R5 refused cares and treatments. R5's care plan lacked identification of R5's risk for fluid-volume imbalances; further lacking goals and interventions for monitoring, treating and documentation. R5's care plan lacked specific time requirements to elevate the head of the bed (HOB) to 30-45 degrees during and after tube feeding. Lastly, R5's care plan lacked specific symptoms, side effects, and monitoring of hypercalcemia, hypothyroidism, and hyperparathyroidism. R5's provider order, dated 1/26/26, included tube feedings (Vital Advanced Formula at 100 milliliter (ml)/hour (hr) for 13 hours) via g-tube. R5 received 150ml water flush in g-tube every 4 hours, including during tube feeding. R5 received 150ml of water flush in g-tube after medication administration for the AM medication pass. R5's physician's orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids)-prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food)-iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach.-folic acid (vitamin) 1 mg via g-tube daily-apixaban (blood thinner) 2.5 mg via g-tube twice daily-metoprolol tartate (blood pressure) 12.5 mg via g-tube twice daily-senna (laxative) 8.6 mg via g-tube twice daily-cinacalcet (overactive parathyroid) 30 mg via g-tube twice daily-omeprazole-syrspend (antacid) SF Akla oral suspension 10 ml daily-ascorbic acid (vitamin C) 500 mg via g-tube daily R5's physician's orders lacked monitoring of electrolytes, monitoring accurate intake and output, managing fluid balance in relation to tube feedings and free water, medication interaction and interventions to prevent adverse effects, a process to monitor ongoing symptoms of nausea, vomiting, abdominal pain, and when staff should alert the provider when R5 refuses medications or treatments. During an interview on 4/7/26 at 11:47 a.m., physician assistant (PA)-A stated R5 has a complicated gastrointestinal (GI) tract. R5 has hyperparathyroidism and this is the source of her hypercalcemia. R5 is no longer a surgical candidate to have her parathyroid removed, symptom management has been the primary direction of care. PA-A stated electrolyte imbalances will be an ongoing concern for R5. PA-A stated she didn't have plans to order follow up bloodwork to monitor electrolytes because she thought the consulting services (Nephrology, Endocrinology) would be monitoring them. PA-A stated she was not sure what the electrolyte monitoring schedule would be. PA-A stated she is unsure how often the nutrition team is working with R5 or how involved they are with her care. She is unsure if the nutrition team was monitoring specifically intake and output. During an interview on 4/7/26 at 12:02 p.m., director of nursing (DON) stated the medical director could be available during survey; he was seeing patients at his outpatient clinic. Further, he had been the medical director at the facility for a short time and this position at the facility was new to him; his first medical director position in long-term care. During a follow up interview on 4/8/26 at 2:39 p.m., PA-A stated she relied on the pharmacist to know what medication can be given at what times in relation to the tube feeding and on the pharmacy team to tell her if there are any specific medication interactions. PA-A had not directly communicated to the facility consultant pharmacist about R5's medication needs in relation to her tube feedings. During an interview on 4/9/26 at 8:53 a.m., PA-B stated she was the hospitalist who cared for R5 during her 3/6/26 to 3/10/26 hospital admission. PA-B stated she expected the facility providers to manage the calcium levels after discharge as she was a member of the hospital consulting service and infrequently sees R5. PA-B stated medication interactions should be managed by the facility provider and pharmacist; additionally, medication administration times should be assessed by the facility provider and pharmacist. During an interview on 04/09/2026 at 11:54 AM, PA-C stated frequently monitoring of calcium should be complete weekly until R5's calcium levels are stable, then monthly, then every six months. R5 has been on cinacalcet to manage her high calcium levels; she is on a consistent dose, but ongoing monitoring should still be weekly to bi-weekly. PA-C stated the facility providers are responsible for monitoring electrolytes, she would not be requesting electrolyte levels unless she saw R5 again as outpatient or in the hospital. During an observation on 4/10/26 at 3:18 p.m., the DON and vice president of success (VPS)-A stated they were waiting for the medical director to sign off on the immediate jeopardy (IJ) plan of correction; stating, having a difficult time reaching him, he is seeing outpatients. The VPS stated she wasn't sure if he understood what an IJ was and the importance of lifting the IJ. On 4/14/26 at 10:22 a.m., a call was placed to the facility Medical Director; no return call received. A facility policy titled Medical Director Responsibilities dated 4/22/25, the medical director responsibilities included addressing issues related to coordination of medical care and implementation of resident care policies, ensuring the appropriateness and quality of medical care and medically related care, discussing and intervening (as appropriate) with a health care practitioner regarding medical care that is inconsistent with current standards of care.

Based on observation, interview and document review, the facility failed to ensure food was served in a timely manner to preserve desired temperatures of food for 4 of 4 residents (R1, R10, R15, R30) reviewed who expressed concerns for food temperatures and palatability. This had the potential to affect all residents who consumed food from the facility kitchen. Findings include: On 4/8/26 at 1:34 p.m., an informal resident council meeting was held with R10, R15 and R30. The residents were asked, as part of the meeting, about bedtime snacks which prompted a conversation regarding food. R30 stated that she eats in the dining room for her meals and her food was frequently served cold. R30 stated this had been an issue for a long time and had talked to staff about this. R10 stated today my food was ice cold even with the cover on it. R10 stated the facility started putting covers on the food and it isn't helpful. R10 stated he eats his meals in the dining room, and his meals are almost always cold when they should be hot. R10 stated he had talked to staff about this. R15 stated she eats in the dining room, and it had been an ongoing issue with getting served cold food when it should be hot. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment, demonstrated no hallucinations or delusional thinking during the review period, and was independent with eating. During an interview on 4/6/26 at 2:56 p.m., R1 stated the food is cold and he must send it back a lot, it doesn't matter if he eats in the dining hall or his room; the food is always cold. The facility had the hardest time keeping eggs, mashed potatoes, and beans warm. He stated he has told them so many times and, no one ever does anything about it. During an observation on 4/7/26 at 8:13 a.m., R1 was observed in the dining hall tasting his food (French toast), he motioned for dietary staff to come to his table. R1 asked them to heat up his food. R10's comprehensive Minimum Data Set (MDS) dated [DATE], identified R10 had no cognitive impairment, demonstrated no hallucinations or delusional thinking during the review period, and was independent with eating. During an observation on 4/7/26 at 8:18 a.m., R10 was observed in the dining hall tasting his food (French toast, eggs), he motioned for dietary staff to come to his table. R1 asked them to heat up his food. R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had no cognitive impairment, demonstrated no hallucinations or delusional thinking during the review period, and was required setup/clean up assistance with eating. During an interview on 4/7/26 at 8:40 a.m., R15 stated the food is cold sometimes, and doesn't know why they have such a hard time keeping the food warm, especially when residents are in the dining hall. She has stopped telling staff about the cold food, they don't do anything to change how they keep things hot. R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had no cognitive impairment, demonstrated no hallucinations or delusional thinking during the review period, and was required setup/clean up assistance with eating. During an interview and tray tasting on 4/7/26 at 12:37 p.m., dietary manager (DM)-A stated the plate covers in the dining hall, seen this morning, were just started today as a response to complaints of cold food. DM manager tasted food and noted the temperature of the food seemed appropriate to her. She does not attend resident council; she might at some point but right now she hasn't gone to any of the meetings. It is important to know how residents feel about the food so she can adjust based on their concerns. During an interview on 4/7/26 at 1:15 p.m., ombudsman (OM)-A stated residents at the facility started reaching out to her in October 2025 about the ongoing concerns with food temperatures and food being served cold. She also informed management about food menu options as well. During an interview on 4/13/26 at 10:04 a.m., DM-A stated residents frequently ask for foods to be reheated during meal services. Again, stated the lids on meal plates were started as a response to complaints about food temperatures; was unsure if they are helping with temperature or not. During an interview on 4/14/26 at 9:27 a.m., administrator stated she would expect residents to tell any facility staff about cold food. She stated she had not heard any concerns about cold food recently. Additionally, the plate lids weren't necessarily new, they just resumed the practice as an infection prevention method. Due to recent dietary staff changes and recommendations from the regional dietary staff, they had ceased this practice; but now had opted to bring it back. It is important to keep foods warm, so residents enjoy their food. A facility policy titled Food Temperatures dated 8/16/22, food must be cooked to appropriate temperatures, held appropriate temperatures.

Based on observation, interview, and document review, the facility failed to ensure a medication administration error rate of less than 5 percent (%) resulting in an 8.57 % medication error rate, identified during 3 of 25 medication administration observations. Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). R5's physician's orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids) -prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food) -iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach. -folic acid (vitamin) 1 mg via g-tube daily -apixaban (blood thinner) 2.5 mg via g-tube twice daily -metoprolol tartate (blood pressure) 12.5 mg via g-tube twice daily -senna (laxative) 8.6 mg via g-tube twice daily -cinacalcet (overactive parathyroid) 30 mg via g-tube twice daily -omeprazole-syrspend (antacid) SF Akla oral suspension 10 ml daily (prepped 15ml) -ascorbic acid (vitamin C) 500 mg via g-tube daily During an observation on 4/8/26 at 9:39 a.m., registered nurse (RN)-A prepared R5's morning medication administration. RN-A removed and prepped the above-named medications and put each medication in a medication cup. RN-A did not know when the most recent tube feeds had completed. RN-A failed to identify the medication levothyroxine had a pharmacy warning to give on an empty stomach and not within 4 hours of iron supplements (prepped iron-multivitamin suspension) or antacids (prepped omeprazole suspension), which she was preparing to administer at the same time. RN-A failed to identify prednisone should be given with food (tube feeding ended at 5:42 AM.) RN-A failed to identify iron-multivitamin suspension should be given on an empty stomach. Additionally, RN-A prepped the iron-multivitamin suspension with 15 ml instead of the ordered 10 ml. During an interview on 4/8/26 at 10:36 a.m., RN-A stated she had not had g-tube education for some time. RN-A stated the facility had not had a resident that required tube feedings with medication administration or had a g-tube for about a year or year and a half. RN-A stated she had been taking care of R5 since her admission in January. RN-A stated she should have read the pharmacy alerts on the medications. She acknowledged she should have verified the liquid dose a 2nd time to make sure she had the right amount of the liquid. During an interview on 4/9/26 at 11:22 a.m., assistant director of nursing (ADON) stated the process to administer medication includes verifying the right resident, right dose, right route, right drug, and right time. She stated if the individual medications have a pharmacy alert such as take with food, don't give with certain medications; it is an expectation you follow those drug administration guidelines. She stated if you don't follow those recommendations, medications could be less effective, more effective, cause side effects, or not be effective at all. During an interview on 4/15/26 at 11: 46 a.m., pharmacist (PH)-B stated she doesn't check when medications are administered in relation to the tube feedings; she would expect nursing to follow the administration directions from the pharmacy. PH-B stated it is important to follow the administration directions from pharmacy; but could not speak to the importance of accurate medication administration timing. During an interview on 4/14/26 at 9:35 a.m., the administrator stated the medication regulation is facilities should have less than a 5% error rate. The facility's medication error rate of 8.57% is above the acceptable regulation standard. Staff should be confirming the five medication rights (right resident, right dose, right route, right drug, and right time) and it is an expectation staff should follow the pharmacy directions on each medication package. If staff can't follow the direction of medication from pharmacy, they are expected to reach out to pharmacy or the resident's provider to get order administration clarification. She stated the importance of performing medication administration accurately is to maintain patient safety. A facility policy titled Medication Administration dated January 2026, medications are administered in accordance with written orders of the prescriber. Timing of medication administration must align with manufacturer specifications.

Based on observation, interview, and record review the facility failed to ensure professional standards of practice were followed during medication administration for 1 of 1 resident (R5) reviewed for gastrostomy tube (g-tube) medication administration.Findings include:According to the American Society for Parenteral and Enteral Nutrition article, Medication via Enteral Feeding Tubes: A Clinician's Guide, located at https://nutritioncare.org/wp-content/uploads/2026/04/Medications-Via-EN-Tubes.pdf, identified prior to administering medications through a g-tube, medications should be verified for right client, right medication, right dose, right time, right route, and right documentation. When administering medication through a g-tube, medications should be crushed and diluted with 15-20 milliliters (ml) of purified water (sterile or distilled) separately. Additionally, the head of the bed (HOB) should be elevated at least 30-45 degrees during medication administration and for at least 30-60 minutes after medication administration to prevent aspiration and support safe, effective delivery of medication. Lastly, proper positioning supports breathing, reduces pressure on the abdomen, and improves resident comfort. R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's care plan indicated the following:-administer tube feeding formula, hydration, and flushes per order-elevate HOB 30-45 degrees (did not provide direction for when and how long to elevate HOB) R5's provider orders included tube feedings (Vital Advanced Formula at 100ml/hr for 13 hours) via g-tube. R5 was to receive 150ml free-water flush in g-tube every 4 hours, including during tube feeding. R5 was to receive 150ml of water flush in her g-tube after medication administration for the AM medication pass. R5's medication orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids) -prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food) -iron-vitamins oral liquid 15ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach. -folic acid (vitamin) 1mg via g-tube daily -apixaban (blood thinner) 2.5mg via g-tube twice daily -metoprolol tartate (blood pressure) 12.5mg via g-tube twice daily -senna (laxative) 8.6mg via g-tube twice daily -cinacalcet (overactive parathyroid) 30mg via g-tube twice daily -omeprazole-syrspend (antacid) SF Akla oral suspension 10ml daily -ascorbic acid (vitamin C) 500mg via g-tube daily Review of the April 2026, Medication administration Record (MAR) identified R5's last tube feeding ended at 5:42 AM. During observation and interview on 4/8/26 at 09:39 a.m., registered nurse (RN)-A prepped R5's morning medication administration. RN-A removed and prepped the above-named medications and put each medication in a medication cup. RN-A did not know when R5 had their last tube feeding completed. Prior to medication administration, R5 required enhanced barrier precaution (EBP) due to an indwelling medical device (g-tube). RN-A failed to apply the appropriate personal protective equipment (PPE) prior to providing care. RN-A failed to ensure the head of the bed was at 30-45 degrees, with the bed remaining at approximately 10 degrees while R5 was observed to be slouched down in the bed. RN-A stated R5 received a 30 ml water flush before medication administration, 30 ml water flush in between each medication, and a 150 ml water flush at the end of the medication administration. During medication administration, RN-A diluted each medication with approximately 2 ml of tap water, which failed to dilute the medication enough to allow it to pass through the g-tube. When RN-A put the medication into the barrel of syringe attached to the g-tube, the medication was not diluted enough to flow. RN-A then began adding additional unmeasured amounts of tap water into the g-tube and continued to add water until the medication would flow; 2 medications she added additional tap water had to use the syringe plunger to apply pressure to advance the medication. During medication administration process, R5 stated she was having increased nausea and abdominal pain. RN-A failed to recognize R5 was still not at the correct positioning and was now experiencing side effects of incorrect positioning. During administration RN-A failed to flush the g-tube between medications levothyroxine and metoprolol. RN-A was unsure what effect this could have on R5. After administration was completed, RN-A failed to once again, to ensure R5's HOB was set to 30-45 degrees. During the above observation, it was identified RN-A failed to:Identify the medication, levothyroxine, had a pharmacy warning to give on an empty stomach and not within 4 hours of iron supplements (prepped iron-multivitamin suspension) or antacids (prepped omeprazole suspension). Identify prednisone should be given with food or that R5's iron-multivitamin suspension should be given on an empty stomach. prep the iron-multivitamin suspension with 15 ml and instead prepped with 20 ml of water. Prior to medication administration, R5 required enhanced barrier precaution (EBP) due to an indwelling medical device (g-tube). RN-A failed to apply the appropriate personal protective equipment (PPE) (gloves and gown?) prior to providing care. During an interview on 4/8/26 at 10:36 a.m., RN-A stated she was unsure how much additional water she had added to dilute medication enough to flow through tube; she guessed it was approximately 5 ml. RN-A stated with the complete medication administration and water flushes; R5 had received approximately 450 ml of liquid. RN-A stated she had not had g-tube education for some time. RN-A stated she should probably have sat R5 upright in bed, but she looked ok, so she administered the medication. RN-A stated the facility had not had a resident that required tube feedings or had a g-tube for about a year or year and a half. RN-A stated she thought it was fine to have used tap water for the medication dilution and water flushes and could not state what other types of water could be used for medication administration using a g-tube. RN-A stated she had been taking care of R5 since her admission in January. During an interview on 4/8/26 at 2:39 p.m., physician assistant (PA)-A stated the resident had been experiencing ongoing nausea and vomiting with intermittent abdominal pain since returning from the hospital on 3/10/26. PA-A stated she expected the nursing team to follow the standard of practice when administering medication via g-tube, including elevating the HOB at 30-45 degrees during and after tube feeding and medication administration and using sterile water to dilute medications and water flushes. Additionally, she was unsure of the amount of water needed to dilute the medication; however, she would anticipate this to be approximately 5-10ml of water and the nurse should be keeping track of this to adjust the water flushes during administration. PA-A stated abdominal pain and increased nausea, and vomiting could be side effects of having the HOB less than 30 degrees. During an observation on 4/8/26 at 3:09 p.m., R5 was seen being taken via ambulance to the local emergency room; RN-A stated R5 was sent to the emergency room due to vomiting since receiving medications this morning. During an interview on 4/9/26 at 8:53 a.m., physician assistant (PA)-B stated R5 should be seated at a 30-45-degree angle, at minimum, for tube feeding and medication administration and remain upright for 30-60 minutes after completion. PA-B stated medications should be given as ordered, especially right dose. PA-B stated after crushing medications, nurses should follow national standards for administering medication, to include medication dilution and free water flushes. During an interview on 4/14/26 at 10:29 a.m., director of nursing (DON) stated she expected R5 to have received the correct ordered dose of medication. The correct medication dilution should have been with 15 ml of sterile water, not tap water; to ensure the medication didn't get clogged in the tube. The HOB should be elevated to about 30-45-degrees for tube feedings and medication administration; to prevent aspiration, pain, and discomfort during feedings or medication administration. The DON stated she expected nurses to know what side effects R5 had related to receiving medications via g-tube, abdominal discomfort, nausea, vomiting, and constipation. Facility g-tube education titled Enteral Nutrition and Drug Administration dated as provided on 12/22/25, failed to identify practice standards for medication administration and tube feeding administration. A facility policy titled Medication Administration dated 1/26, medication dose should be verified three times before administration; when pulling medication, when dose is prepared, and before dose is administered. If a resident is tube-fed, staff were to ensure medications were crushed finely to prevent clogging. Medications were to be administered in accordance with written orders. Timing must align with manufacturer's specifications. Review of the 8/10/22, Verifying Placement of Tube Feeding policy identified before beginning a feeding, flushing the tube, or administering a medication via a feeding tube, proper placement and functioning of the tube was to be verified. A resident's HOB was to be kept elevated, at a minimum, of 30 degrees at all times to prevent aspiration and pneumonia. To verify tube placement, staff were to check that the enteral retention device was properly attached to the abdominal wall by gently tugging on the tube and noting the marking on the tube. Staff were to notify the supervisor and/or physician of abnormal findings. Next, they were to measure the length of the tube from insertion site to the tip and record the length prior to feedings etc per facility policy. If staff were unable to confirm placement, they were to notify the supervisor and/or physician. Staff were to also measure the pH (acidity) of gastric secretions by drawing back on the syringe slowly to obtain 5-10 ml of stomach aspirate, place into a cup, and dip a pH strip into the aspirate. Gastric fluid should usually have a pH of 5 or less. Staff were to then flush the tube with 30 ml of water or per physician's order. Staff were to monitor residents for complications such as respiratory distress which may indicate aspiration or tube dislodgement. A facility job description titled Registered Nurse dated 2/14/2018, the registered nurse (RN) adheres to the standards of care for the area, manages environment to maintain resident safety, and supervises the resident care activity. RNs prepares and administers medications and performs treatments as ordered by the physician.

Based on observation, interview, and document review the facility failed to monitor and implement individualized interventions to prevent/mitigate the risk of pressure ulcers and/or deterioration for 1 of 1 resident (R5) reviewed for pressure ulcers.Findings Include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5's current face sheet identified diagnoses of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), muscle weakness, type 2 diabetes, hypothyroidism (thyroid gland does not produce enough thyroid hormone, symptoms include fatigue, weight gain, cold intolerance, and depression), hyperparathyroidism (parathyroid gland produces too much hormone, symptoms include high blood calcium levels, feeling weak, nausea, vomiting, loss of appetite, constipation, and abdominal pain), and hypercalcemia (blood calcium level greater than 10.5 milligram (mg) per deciliter (dl) causing fatigue, nausea, vomiting, constipation, confusion, cognitive changes, and irregular heart rhythms). R5's hospital Discharge summary dated [DATE] noted the following:-Pressure injury to coccyx: red, blanchable: treatment offloading, barrier cream (Zinc, Petroleum) and open to air-Skin problem to left heel: clean, dry, intact: treatment offloading and open to air-Skin problem to right heel: clean, dry, intact: treatment open to air R5's care plan indicated the following:-urinary incontinence: report changes in skin integrity found during daily care-potential for pressure ulcer development: -administer treatments as ordered, and monitor effectiveness-follow facility policies/protocols for the prevention/treatment of skin breakdown-monitor nutritional status-monitor/document/report any changes in skin status: appearance, color, woundhealing, signs and symptoms of infection, wound size (length x width x depth) R5's care plan lacked resident-specific interventions to prevent or mitigate pressure ulcers that included reposition changes, specialty pressure redistribution boots for heels, toileting program to prevent wet skin, specialty padding for chairs, and barrier protection creams. R5's February, March, and April 2026 treatment administration record (TAR) noted to Monitor Mepilex dressing to buttock daily and change every 3 days and as needed when soiled beginning on 2/25/26. February, March, and April TAR lacked additional interventions to prevent or mitigate the worsening of skin issues such as position change schedule, heel protectors, barrier creams, toileting program, and pressure offloading interventions. R5's weekly skin assessments were completed 1/23/26, 1/30/26, 2/7/26, 3/3/26, 3/27/26, and 4/3/26, stating no skin issues. The weekly skin assessments failed to identify R5's coccyx stage I pressure injury, ongoing monitoring, and ongoing assessments. During an interview on 4/7/26 at 11:31 a.m., R5 stated she does have breakdown on her buttocks. R5 stated the staff at the facility put a covering over it every few days; sometimes it gets wet when she is incontinent, so they must replace it then too. R5 is unsure if the skin breakdown is better or worse because she can't see it. Sometimes her buttocks and her heels get sore; but she doesn't get up much so that won't change much. R5 doesn't remember if facility staff have asked her to reposition herself or offered to assist her to reposition. R5 prefers to sit up because she gets nauseous a lot. During an observation and interview on 4/7/26 at 11:47 a.m., physician assistant (PA)-A stated she was not aware R5 had any skin breakdown on her coccyx and awas unaware of fragile skin on her heels. PA-A and the director of nursing (DON) evaluated R5's coccyx, PA-A stated this was a stage I pressure ulcer. Additionally, the mepilex dressing on the coccyx was not placed correctly to prevent further skin breakdown. PA-A stated she would expect to see a pressure ulcer care plan with interventions to prevent further breakdown. During an interview on 4/7/26 at 12:02 p.m., DON stated R5 came back from the hospital in February with a stage I pressure ulcer. DON stated the facility ordered the mepilex for her coccyx, but she acknowledged the facility did not update the care plan or TAR to include interventions to prevent or mitigate skin breakdown. DON was unaware about the fragile skin on her heels; acknowledged R5 should have had interventions in place to prevent pressure injuries of her heels. During a follow up interview on 4/7/26 at 3:25 p.m., DON stated R5's care plan was appropriate when she first arrived in January; but should have been updated upon her return in February to include interventions to prevent or mitigate skin breakdown. DON confirmed R5 had a current stage I pressure ulcer. Additionally, the DON confirmed the facility had not been assessing the coccyx weekly since 3/4/26. The DON stated it is important to implement a complete resident-specific care plan to prevent additional skin breakdown and alterations. A facility policy titled Pressure Injuries and Non-Pressure Injuries dated 7/20/22, the facility will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity.

Based on interview and document review, the facility failed to implement their facility assessment to identify 1 of 1 resident (R5) who required specialty care and services and the facility failed to train and perform skill competencies as outlined in the facility assessment.Refer to F684 Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). R5 was admitted to the facility on [DATE] with an admission diagnosis of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), muscle weakness, type 2 diabetes, hypothyroidism (thyroid gland does not produce enough thyroid hormone, symptoms include fatigue, weight gain, cold intolerance, and depression), hyperparathyroidism (parathyroid gland produces too much hormone, symptoms include high blood calcium levels, feeling weak, nausea, vomiting, loss of appetite, constipation, and abdominal pain), and hypercalcemia (blood calcium level greater than 10.5 milligram (mg) per deciliter (dl) causing fatigue, nausea, vomiting, constipation, confusion, cognitive changes, and irregular heart rhythms). A review of R5's medical record identified the following hospitalizations/emergency room visits identified on:2/12/26: R5 was sent to the hospital after a fall with decrease cognition and returned to the facility on 2/22/26; the primary diagnosis was hypercalcemia. R'5 Power of Attorney (POA) was activated during this hospital visit and thereafter due to ongoing intermittent confusion.3/6/26: R5 was sent to the hospital as a result of increased nausea and vomiting and returned to the facility on 3/10/26; the primary diagnosis was hypercalcemia. 4/6/26: R5 was sent to the emergency room as a result of increased abdominal pain and returned to the facility on 4/6/26; the primary diagnosis was pleural effusion (collection of fluid around your lungs.) 4/8/26: R5 was sent to the hospital and returned to the facility on 4/9/26; the primary diagnosis was right-sided pneumonia (acute inflammation of the lung caused by an infection, commonly caused by aspiration.). R5's care plan indicated the following:-administer tube feeding formula, hydration, and flushes per order-elevate HOB 30-45 degrees (did not provide direction for when and how long to elevate HOB) R5's care plan lacked resident-specific interventions to monitor or prevent recurrence of nausea, vomiting, and abdominal pain; to include the signs and symptoms of hypercalcemia; which include mental status changes, muscle spasms, abdominal pain, and constipation. Additionally, the care plan lacked assessment and interventions for the risk of fluid volume deficits. R5's provider order, dated 1/26/26, included tube feedings (Vital Advanced Formula at 100 milliliter (ml)/hour (hr) for 13 hours) via g-tube. R5 received 150 ml water flush in g-tube every 4 hours, including during tube feeding. R5 received 150 ml of water flush in g-tube after medication administration for the AM medication pass. R5's physician orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids) -prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food) -iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach. -folic acid (vitamin) 1 mg via g-tube daily -apixaban (blood thinner) 2.5 mg via g-tube twice daily -metoprolol tartate (blood pressure) 12.5 mg via g-tube twice daily -senna (laxative) 8.6 mg via g-tube twice daily -cinacalcet (overactive parathyroid) 30 mg via g-tube twice daily -omeprazole-syrspend (antacid) SF Akla oral suspension 10 ml daily -ascorbic acid (vitamin C) 500 mg via g-tube daily According to the American Society for Parenteral and Enteral Nutrition article, Medication via Enteral Feeding Tubes: A Clinician's Guide, located at https://nutritioncare.org/wp-content/uploads/2026/04/Medications-Via-EN-Tubes.pdf, identified prior to administering medications through a g-tube, medications should be verified for right client, right medication, right dose, right time, right route, and right documentation. When administering medication through a g-tube, medications should be crushed and diluted with 15-20 milliliters (ml) of purified water separately. Additionally, the head of the bed (HOB) should be elevated at least 30-45 degrees during medication administration and for at least 30-60 minutes after medication administration to prevent aspiration and support safe, effective delivery of medication. Further, proper positioning supports breathing, reduces pressure on the abdomen, and improves resident comfort. Lastly, complications from g-tube misuse can lead to nausea, vomiting, abdominal pain, tube clogging, aspiration, and toxicities. During an observation on 4/8/26 at 9:39 a.m., registered nurse (RN)-A prepared R5's morning medication administration. RN-A removed and prepped the above-named medications and put each medication in a medication cup. RN-A did not know when the most recent tube feeds had completed. RN-A failed to identify the medication levothyroxine had a pharmacy warning to give on an empty stomach and not within 4 hours of iron supplements (prepped iron-multivitamin suspension) or antacids (prepped omeprazole suspension), which she was preparing to administer at the same time. RN-A failed to identify prednisone should be given with food (tube feeding ended at 5:42 AM.) RN-A failed to identify iron-multivitamin suspension should be given on an empty stomach. Additionally, RN-A prepped the iron-multivitamin suspension with 20ml instead of the ordered 15ml. Prior to medication administration, R5 required enhanced barrier precaution (EBP) due to an indwelling medical device (g-tube). RN-A failed to apply the appropriate personal protective equipment (PPE) prior to providing care. At time of administration, RN-A failed to ensure the head of the bed was 30-45 degrees, with the bed remaining at approximately 10 degrees and R5 slouched down in the bed. RN-A stated R5 received a 30ml water flush before medication administration, 30ml water flush in between each medication, and a 150ml water flush at the end of the medication administration. During medication administration, RN-A diluted each medication with approximately 2ml of water, which failed to dilute the medication enough to allow it to pass through the g-tube. When RN-A put the medication into the barrel of syringe attached to the g-tube, the medication was not diluted enough to flow, RN-A then begun adding additional unmeasured amounts of water and continued to add until the medication would flow; 2 medications required pressure from the syringe plunger to flow through the g-tube. During medication administration process, R5 stated she was having increased nausea and abdominal pain. RN-A failed to recognize R5 was still not at the correct position. During administration RN-A failed to flush the g-tube between medications levothyroxine and metoprolol. RN-A was unsure what effect this could have on R5. After administration was completed, RN-A failed to set the head of the bed up to 30-45 degrees; bed remained at approximately 10 degrees with R5 slouched down in bed. During an interview on 4/8/26 at 10:36 a.m., RN-A stated she had not had g-tube education for some time. RN-A stated the facility had not had a resident that required tube feedings or had a g-tube for about a year or year and a half. RN-A stated she had been taking care of R5 since her admission in January. During an interview on 4/9/26 at 11:22 a.m., licensed practical nurse (LPN)-B stated R5 had frequent nausea and vomiting. LPN-B stated they only track R5's bowel movements for output. LPN-B stated R5's emesis are not documented in R5's medical record. LPN-B described the process of administering medications via g-tube which did not include elevating head of bed during or after administration of medications or enteral feedings. During an interview on 4/7/26 at 3:15 p.m., vice president of success (VPS)-A stated nurses wereeducated about g-tubes annually and for regular competencies. VPS-A stated nurses can receive g-tube education sporadically; they didn't believe nursing staff were educated about the needs of R5 prior to her arrival. During an interview on 4/7/26 at 3:25 p.m., director of nursing (DON) stated she believed the facility provided education to staff about g-tubes but couldn't find the specific education. DON stated she would expect education to be given for g-tubes, tube feeding administration, medication administration, g-tube complications, and g-tube side effects or symptoms. DON stated the facility had not cared for a resident with a g-tube in about a year. DON stated, generally g-tube education is annually, she did not provide g-tube education to staff about this R5 and her specific needs. DON stated it would have been beneficial to have educated staff specifically about R5 so staff could be prepared for any complications. A Facility assessment dated [DATE], the facility leadership uses the facility assessment for decision-making purposes including when to consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population. Further, training and skills unique to resident population: our nurses are trained in enteral feedings; our facility not only conducts a skill assessment during floor orientation of nurses and nursing assistants but also conducts monthly competencies of various skills to ensure that annual training occurs to keep skills honed. Relias training and skill competencies are scheduled monthly. Facility staff are specifically trained with skills unique to resident population, such as tube feedings.

Based on interview and document review, the facility failed to ensure 1 of 1 primary care physician assistant (PA-A) had appropriately managed the care for 1 of 1 resident (R5) who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube). Refer to F684Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current, undated care plan indicated the following:-urinary incontinence: report changes in skin integrity found during daily care-potential for pressure ulcer development:administer treatments as ordered, and monitor effectivenessfollow facility policies/protocols for the prevention/treatment of skin breakdownmonitor nutritional statusmonitor/document/report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length x width x depth)The need for a feeding tube/potential complications from that tube. R5 was to have no complications from the feeding tube. Staff were to administer formula and hydration and flushes per order.R5's care plan lacked identification of skin breakdown on R5's coccyx; further lacking goals and interventions for monitoring, treating, and documenting R5's actual skin breakdown. Additionally, R5's care plan lacked identification of R5's refusal of cares and treatments; further lacking goals and interventions to apply when R5 refused cares and treatments. R5's care plan lacked identification of R5's risk for fluid-volume imbalances; further lacking goals and interventions for monitoring, treating and documentation. R5's care plan lacked specific time requirements to elevate the head of the bed (HOB) to 30-45 degrees during and after tube feeding. Lastly, R5's care plan lacked specific symptoms, side effects, and monitoring of hypercalcemia, hypothyroidism, and hyperparathyroidism. R5's provider order, dated 1/26/26, included tube feedings (Vital Advanced Formula at 100 milliliter (ml)/hour (hr) for 13 hours) via g-tube. R5 received 150 milliliters (ml) water flush in g-tube every 4 hours, including during tube feeding. R5 received 150 ml of water flush in g-tube after medication administration for the AM medication pass. R5's physician's orders, dated 1/26/26, included:-levothyroxine 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids)-prednisone 4 mg via g-tube daily (instruction to take with food) -iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach.) -folic acid 1 milligrams (mg) via g-tube daily -apixaban 2.5 mg via g-tube twice daily -metoprolol tartrate 12.5 mg via g-tube twice daily -senna 8.6 mg via g-tube twice daily -cinacalcet 30 mg via g-tube twice daily -omeprazole- oral suspension 10ml daily -ascorbic acid 500 mg via g-tube daily R5's physician's orders lacked monitoring of electrolytes, monitoring accurate intake and output, managing fluid balance in relation to tube feedings and free water, medication interaction and interventions to prevent adverse effects, a process to monitor ongoing symptoms of nausea, vomiting, abdominal pain, and when staff should alert the provider when R5 refuses medications or treatments. During an interview on 4/7/26 at 11:47 a.m., physician assistant (PA)-A stated R5 has a complicated gastrointestinal (GI) tract. R5 has hyperparathyroidism and this is the source of her hypercalcemia. R5 is no longer a surgical candidate to have her parathyroid removed, symptom management has been the primary direction of care. PA-A stated electrolyte imbalances will be an ongoing concern for R5. PA-A stated she didn't have plans to order follow up bloodwork to monitor electrolytes because she thought the consulting services (Nephrology, Endocrinology) would be monitoring them. PA-A stated she was not sure what the electrolyte monitoring schedule would be. PA-A stated she is unsure how often the nutrition team is working with R5 or how involved they are with her care. She is unsure if the nutrition team was monitoring specifically intake and output. During a follow up interview on 4/8/26 at 2:39 p.m., PA-A stated she relied on the pharmacist to know what medication can be given at what times in relation to the tube feeding and on the pharmacy team to tell her if there are any specific medication interactions. PA-A had not directly communicated to the facility consultant pharmacist about R5's medication needs in relation to her tube feedings. During an interview on 4/9/26 at 8:53 a.m., PA-B stated she was the hospitalist who cared for R5 during her 3/6/26 to 3/10/26 hospital admission. PA-B stated she expected the facility providers to manage the calcium levels after discharge as she was a member of the hospital consulting service and infrequently sees R5. PA-B stated medication interactions should be managed by the facility provider and pharmacist; additionally, medication administration times should be assessed by the facility provider and pharmacist. During an interview on 04/09/2026 at 11:54 AM, PA-C stated frequently monitoring of calcium should be complete weekly until R5's calcium levels are stable, then monthly, then every six months. R5 has been on cinacalcet to manage her high calcium levels; she is on a consistent dose, but ongoing monitoring should still be weekly to bi-weekly. PA-C stated the facility providers are responsible for monitoring electrolytes, she would not be requesting electrolyte levels unless she saw R5 again as outpatient or in the hospital. On 4/14/26 at 10:22 a.m., a call was placed to the facility Medical Director; no return call received. A facility policy titled Medical Director Responsibilities dated 4/22/25, the medical director responsibilities included addressing issues related to coordination of medical care an implementation of resident care policies, ensuring the appropriateness and quality of medical care and medically related care, discussing and intervening (as appropriate) with a health care practitioner regarding medical care that is inconsistent with current standards of care.

Based on record review and interview, the facility failed to notify the resident representative/Power of Attorney (POA) about refusal of care and/or treatment for 1 of 1 resident (R5) reviewed for notification of changes.Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). During a record review, R5's dismissal summary from the 2/12/26 hospitalization; the hospital physician stated, R5 is unable to receive and evaluate information effectively and communicate decisions necessary to manager her health. I recommend that the provisions contained in her Power of Attorney for Health Care be activated. During a record review, R5's POA was activated at the facility upon return from the 2/12/26 hospitalization. R5's care plan failed to address R5's refusals of care; additionally, the care plan failed to provide direction, so staff know when to notify provider and POA about refusals of care and medications. R5's orders failed to address R5's refusals of care; additionally, the orders lacked direction, so staff knew when to notify the medical providers and POA about refusals of care and medications. During record review, R5 refused medications or treatment on the following dates after the POA was activated:-3/6/26: refusal to have blood drawn, no POA notification-4/6/26: refused weight measurements, no POA notification-4/7/26 at 5:16 a.m.: refused constipation medication, no POA notification-4/7/26 at 12:22 p.m.: refused constipation medication, no POA notification-4/7/26 at 8:58 p.m.: R5 stated her pain was worse, no POA notification-4/8/26 at 4:58 a.m.: R5 stated her pain had gotten worse, refused all bowel medications, no POA notifications During record review, there was no documentation R5's POA had been notified prior to leaving the facility to go to the emergency room (ER) on 2/12/26 after suffering a fall at the facility. During an interview on 4/7/26 at 3:25 p.m., director of nursing (DON) stated R5's POA was activated when she returned from the hospital on 2/22/26. DON stated the POA was activated when R5 was in the hospital because R5 had increasing periods of confusion and lack of understanding about her medical status. DON confirmed R5 has been intermittently refusing cares or treatments since the beginning of February. DON stated the facility doesn't notify the POA of refusals, probably should if the resident doesn't understand her condition or how the meds work. DON stated it is important to notify the POA about refusal of cares and treatments, so the POA knows the treatments R5 is or isn't receiving. Attempted phone call to speak with R5 POA made on 4/7/26 at 10:45 a.m. During an interview on 4/8/26 at 2:39 p.m., physician assistant (PA)-A stated she was aware R5 had intermittently been refusing medications. PA-A stated she would expect to be notified of ongoing refusals. PA-A stated R5 did not have an order to notify facility providers or POA of refusals of cares or treatments. PA-A stated notification to the POA is important, so the POA understands what treatments R5 isn't getting and why. Additionally, the POA may have some influence with R5 and encourage R5 to accept the cares and treatments. A facility policy titled Change in Condition of the Resident dated 9/20/2022, the facility should immediately inform the resident representative when there is a need to alter treatment or a need to discontinue an existing treatment due to adverse consequences, or to commence a new form of treatment.

Based on observation, interview, and document review, the facility failed to develop and implement a person-centered care plan for 1 of 1 resident (R5) reviewed for comprehensive care plans.Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5 required hydration and nutrition via a feeding tube (g-tube). R5's hospital Discharge summary dated [DATE] noted the following:-Pressure injury to coccyx: red, blanchable: treatment offloading, barrier cream (Zinc, Petroleum) and open to air-Skin problem to left heel: clean, dry, intact: treatment offloading and open to air-Skin problem to right heel: clean, dry, intact: treatment open to air R5's current, undated care plan indicated the following:-urinary incontinence: report changes in skin integrity found during daily care-potential for pressure ulcer development:administer treatments as ordered, and monitor effectivenessfollow facility policies/protocols for the prevention/treatment of skin breakdownmonitor nutritional statusmonitor/document/report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length x width x depth)-The need for a feeding tube/potential complications from that tube. R5 was to have no complications from the feeding tube. Staff were to administer formula and hydration and flushes per order. R5's care plan lacked identification of skin breakdown on R5's coccyx; further lacking goals and interventions for monitoring, treating, and documenting R5's actual skin breakdown. Additionally, R5's care plan lacked identification of R5's refusal of cares and treatments; further lacking goals and interventions to apply when R5 refused cares and treatments. R5's care plan lacked identification of R5's risk for fluid-volume imbalances; further lacking goals and interventions for monitoring, treating and documentation. R5's care plan lacked specific time requirements to elevate the head of the bed (HOB) to 30-45 degrees during and after tube feeding. Lastly, R5's care plan lacked specific symptoms and side effects of hypercalcemia, hypothyroidism, and hyperparathyroidism. R5's February, March, and April 2026 treatment administration record (TAR) noted to Monitor Mepilex dressing to buttock daily and change every 3 days and as needed when soiled beginning on 2/25/26. February, March, and April TAR lacked additional interventions to prevent or mitigate the worsening of skin issues such as position change schedule, heel protectors, barrier creams, toileting program, and pressure offloading interventions. During an interview on 4/7/26 at 11:47 a.m., physician assistant (PA)-A stated R5 is a complicated resident due to her multiple medical problems including hypercalcemia, hypothyroidism, hyperparathyroidism, nausea, vomiting, and gastrectomy tube (g-tube) a device surgically inserted through the belly directly into the stomach to deliver nutrition, fluids, and medications). PA-A stated she would expect to see a care plan for each of these areas. During an interview on 4/7/26 at 3:25 p.m., director of nursing (DON) stated R5 had a Stage I pressure ulcer; her care plan did not reflect any goals or interventions to care for and prevent worsening of the pressure ulcer. DON confirmed R5's care plan only indicated a risk for pressure ulcers; should have identified the actual Stage I pressure ulcer and contain interventions such as encouraging position changes, how often to monitor the coccyx, and treatment directions. The DON stated R5's care plan did not include information about her refusal of cares and treatments. The DON stated this care plan would identify the interventions that could have worked to encourage R5 to follow care and treatment orders. The DON stated R5 did not have a fluid-volume care plan. This care plan would be beneficial so staff could monitor and document fluids; this would be important for the resident since she had a G-tube. The DON stated this resident is complicated, R5's care plan should probably have more detail about her medical conditions so staff could be aware of the symptoms or side effects. The DON stated a complete and comprehensive care plan is important so facility staff could identify, monitor, and treat R5's medical issues. During an interview on 4/8/26 at 2:39 p.m., PA-A stated she would expect a complete and comprehensive care plan; a comprehensive care plan allows the facility to adjust cares and interventions based on R5's needs and desire for treatment. PA-A stated she would specifically expect to see a care plan for skin breakdown, fluid intake-output, refusals of care, and tube feeding care. PA-A stated care plans are important because they can be tied into the treatment and medication tasks the facility staff perform; without a specific care plan, staff might not know how to provide specific types of care. A facility policy titled Comprehensive Care Plan dated 9/23/2022, the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. These objectives will be used to monitor the residents' progress. Alternative interventions will be documented, as needed.

Based on interview and document review, the facility to implement policies and procedures to ensure the State agency (SA) was notified in a timely manner for allegations of abuse for 1 of 1 residents (R32) whose allegations were reviewed.Findings include: R32's significant change in status Minimum Data Set (MDS) assessment, dated 1/24/26, identified R32 had moderately impaired cognition, required maximum staff assistance with dressing, moderate assistance with transfers and displayed no hallucinations, delusions, or rejection of care behaviors. R32's care plan, initiated on 6/20/23, identified R32 as a vulnerable adult at risk for potential abuse due to Alzheimer's disease and identified facility staff are education on reporting abuse and facility staff will follow facility policy and procedures. During an observation on 4/6/26 at 2:08 p.m., R32 was observed playing Bingo in the dining room with other residents and staff. At 3:36 p.m., R32 was observed sitting in her wheelchair in her room. R32 stated she couldn't remember how long she had been at the facility and directed the surveyor to ask her kids. R32 stated staff are nice and if she had any issues with staff, she would know what to do (as she raised her fist). During an interview on 4/7/26 at 12:32 p.m., complainant (C)-A stated they had witnessed nurse aide (NA)-G telling R32 to shut the [expletive] up and you need to stop acting like that. C-A stated she stopped the administrator the day it happened as the administrator was walking passed and she spoke to her. C-A doesn't recall exactly when this happened. C-A reported it to the State Agency as she didn't think anything at the facility was being done. A message was left for R32's power of attorney (POA)-A requesting a call back. A second message requesting a call back was left on 4/7/26 at 1:48 p.m. for R32's POA-A. A return call was not received. Grievances for the past 6 months for the facility were reviewed. No grievances were provided indicating any abuse being investigated for R32. Allegations of abuse reported in the past 6 months requested. No allegations were provided involving R32. R32's progress notes from 2/1/26 to 4/6/26 were reviewed. Progress notes lacked identification of abuse or abuse being investigated. During an interview on 4/7/26 at 4:51 p.m., the administrator stated the expectation was if any staff expected abuse, it would be reported to the administrator or the director of nursing immediately for further investigation. All staff are trained on abuse and the expectations of reporting abuse. If a staff member was talking to a resident, as stated above, that would be considered verbal abuse and would need immediate intervention which included reporting to the State Agency and a full investigation was to occur. She was not aware of this incident until today after surveyor interviewed C-A. She had not recalled if C-A stopped her in the hallway to talk to her or if C-A had told the administrator about any abuse concerns with R32. The administrator stated she had already begun a full investigation and filed a facility reported incident with the State Agency as it was a reportable incident as it would be considered an allegation of verbal abuse. During a follow up interview on 4/8/26 at 1:14 p.m., administrator shared the investigation that had been completed so far which included staff interviews, and review of R32's care plan, progress notes, trauma assessment, and skin checks, along with staff education, all notifications completed, and other resident interviews that had been provided at this time. During a follow up interview on 4/10/26 at 11:29 a.m., C-A stated they had gotten training on reporting abuse prior to initially reporting abuse. C-A stated since 4/7/26, they have gotten additional training on what to say when reporting abuse. C-A stated when they had stopped administrator in the hallway to report concerns of abuse, they didn't tell administrator they had actual concerns about alleged abuse. C-A stated she told the administrator they wanted to talk about R32 and NA-G but didn't tell the administrator what the concerns were. C-A stated she didn't follow back up with the administrator to explain she had concerns about alleged abuse. During an interview on 4/13/26 at 11:38 a.m., NA-G stated they had received education on abuse which included definitions and examples of abuse. The facility had called her in the last couple of days to talk about the incident with R32. During an interview on 4/14/26 at 9:57 a.m., director of nursing (DON) stated the expectation was if abuse was suspected, staff would intervene and communicate to management, and it would be reported immediately. During an interview on 4/14/26 at 11:27 a.m., administrator stated they developed a new procedure following the above noted abuse allegation, as it was determined staff needed additional education on how to report abuse, specifically need to make sure they are saying what they are trying to say. The administrator stated they are also implementing another step that will involve staff writing a statement to ensure nothing gets lost or was missed as it was with this incident. The facility Abuse, Neglect, and Exploitation policy, reviewed 7/15/22, indicated a statement of the facility was to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Furthermore, Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. New employees were to be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation and existing staff were to receive annual education through planned in-services and as needed, which included the reporting process for abuse. The facility was to report all alleged violations to the administrator, State Agency, Adult Protective Serves and to all other required agencies within the specified timeframe.

Based on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complication (i.e., missed orders, insufficient preparation for treatment), ensure contact information for dialysis clinic was on the care plan and ensure orders were accurate for monitoring dialysis site for 1 of 1 residents (R16) reviewed for dialysis care and services. Findings include: R16's quarterly Minimum Data Set (MDS) assessment, dated 2/11/26, identified R16 had intact cognition with no hallucinations, delusions, or rejection of care. R16 required maximum amount of assistance or was dependent on staff for all Activities of Daily Living (ADLs) except showering (which R16 refused) and oral hygiene/eating which required staff set up. In addition, the MDS outline R16 received hemodialysis while a resident at the facility. R16's admission record indicated on 2/18/26, R16's primary diagnosis was end-stage renal disease. A secondary diagnosis, dated 11/21/25, included dependence on renal dialysis. During an interview on 4/6/26 at 4:08 p.m., R16 stated he goes to dialysis three days a week and had been on dialysis for about 8 months. R16 stated his dialysis access site was located on his right upper chest (a central venous catheter (CVC)) and showed the surveyor. R16's dialysis access site was covered with a bandage. R16's care plan, printed 4/7/26, indicated R16 had chronic kidney disease: end stage renal disease and dependence on renal dialysis with the following interventions:Check access site for lack of thrill/bruit, evidence of infection, swelling. or excessive bleeding per facility guidelines. Report abnormalities to MD.Confer with MD (physician) and/or dialysis treatment center regarding changes in medication.Coordinate dialysis care with dialysis treatment center.Dialysis 3 times/week at [general clinic name] M/W/F. Sack Lunch to be sent with.Diet per MD orders. Initiated on 12/3/25Fluid restriction per MD orders.Monitor vital signs as ordered.No blood pressure, IVS, or lab draws from right arm.Obtain labs as ordered and notify MD of results.R16's care plan lacked contact information for dialysis clinic including the phone number and address, the type of dialysis access site R16 had, appropriate monitoring for the type of dialysis access site, and evidence or direction on how or how often the facility would coordinate or collaborate with the offsite dialysis clinic. R16's Order Summary Report, dated 4/7/26, included the following orders:Dialysis - nurse must complete a post-dialysis UDA (assessment) in the afternoon every Monday, Wednesday, Friday with a start date of 11/24/25.Dialysis - nurse must complete a pre-dialysis UDA, print and send with resident to dialysis in the morning every Monday, Wednesday and Friday with a start date of 11/24/25.Do not obtain blood pressure or blood draws on the dialysis access site - right arm with a start date of 11/21/25.Enhanced barrier precautions related to dialysis every shift with a start date of 11/21/25.Fistula/AV Graft Site: Location right IJ (internal jugular vein) - Monitor site for presence of thrill, bruit, and signs and symptoms (s/s)x of infection. Notify MD for any abnormal findings. every shift with a start date of 11/24/25. Although this was initiated as an order, there was no indication R16 actually had a fistula or graft and no evidence the facility had clarified this order for accuracy.Hemo Dialysis (right tunneled catheter) (CVC) three times a week on Monday/Wednesday/Friday for dialysis at 11:00 a.m. with a return pick up time of 3:00 p.m. with a start date of 11/24/25.If the dialysis site is oozing, apply moderate pressure until bleeding subsides. (Do not use pressure dressings or bandages that will restrict blood flow. If bleeding continues, resident to be evaluated by physician for further intervention and dialysis center to be notified.) every shift as needed with a start date of 11/21/25. R16's Medication Administration Record and Treatment Administration Record (MAR/TAR) for March and April 2026 identified:Dialysis - nurse must complete post-dialysis UDA (assessment) in the afternoon every Monday, Wednesday, Friday with a start date of 11/24/25. All of which were documented as completed except 3/20/26 which was blank.Dialysis - nurse must complete pre-dialysis UDA, print and send with resident to dialysis in the morning every Monday, Wednesday and Friday with a start date of 11/24/25. All of which were documented as completed.Hemo Dialysis (right tunneled catheter) three times a week on Monday/Wednesday/Friday for dialysis at 11:00 a.m. with a return pick up time of 3:00 p.m. with a start date of 11/24/25. All of which were documented as completed.Remove dressing to fistula/graft site 4-6 hours post dialysis. Dialysis over at approximately 2-230pm most days, dressing should get removed at approximately 6/630-8pm in the evenings on M/W/F with a start date of 11/24/25 and end date of 4/6/26. Documentation indicated this was completed all days except 4/6/26. Although this was initiated on the TAR, there was no indication R16 actually had a fistula or graft and no evidence the facility had clarified this order for accuracy. The CVC site was not mentioned that staff should be only inspecting the dressing for signs or increased bleeding or infection surrounding the site with specific instructions to call the dialysis center (ESRD) if the dressing needed to be changed or removed, as it would be done weekly in the ESRD setting.If dialysis site is oozing, apply moderate pressure until bleeding subsides. (Do not use pressure dressings or bandages that will restrict blood flow. If bleeding continues, resident to be evaluated by physician for further intervention and dialysis center to be notified.) every shift as needed with a start date of 11/21/25.Fistula/AV Graft Site: Location right IJ - Monitor site for presence of thrill, bruit, and s/sx of infection. Notify MD for any abnormal findings every shift with a start date of 11/21/25 and end date of 4/10/26. Documentation indicated this was completed every day except for the following:3/8/26 night shift: coded with a 9 (9 indicated per chart codes other/see progress note).3/9/26 night shift: coded with a 93/27/26 evening shift: coded with a 93/27/26 night shift: coded with a 93/28/26 day and evening shifts: coded with 2 (2 indicated per chart codes as refused) and night shift was blank.3/29/26 day and evening shifts coded with 2.3/30/26 night shift coded with a 2.3/31/26 day shift: coded with a 2. R16's Post Dialysis Assessments reviewed from 3/1/26 to 4/6/26 and identified the following relevant information. On:4/6/26: dialysis paperwork received (answered yes), weight was dated 3/25/26 at 3:27 p.m., and other vitals dated 4/6/26 at 7:17 a.m. No other pertinent information documented.4/3/26: dialysis paperwork received, weight was dated 3/25/26 at 3:27 p.m. Thrill palpated, and bruit auscultated - both indicated yes. Pertinent information section - notified dialysis regarding sevelamer (medication used to control phosphorus levels for people on dialysis) and side effect.4/1/26: dialysis paperwork received, weight was dated 3/25/26 at 3:27 p.m. No other pertinent information documented.3/30/26: dialysis paperwork received, weight was dated 3/25/26 at 3:27 p.m. Thrill palpated, and bruit auscultated - both indicated no. No other pertinent information documented.3/27/26: dialysis paperwork received, weight was dated 3/25/26 at 3:27 p.m. Temperature from 3/27/26 at 9:28 a.m., and respirations from 3/27/26 at 9:28 a.m. Thrill palpated, and bruit auscultated - both indicated yes. Other pertinent information documented as none.3/25/26: dialysis paperwork received. Temperature from 3/27/26 at 9:09 a.m., and respirations from 3/27/26 9:10 a.m. No other pertinent information documented.3/23/26: dialysis paperwork received. Thrill palpated, and bruit auscultated - both indicated yes. No other pertinent information documented.3/20/26: dialysis paperwork received. All vital signs including weight were dated 3/18/26. Thrill palpated, and bruit auscultated - both indicated yes. No other pertinent information documented.3/18/26: dialysis paperwork received. Thrill palpated, and bruit auscultated - both indicated yes. No other pertinent information documented.3/16/26: dialysis paperwork received. Weight was dated 3/14/26 at 2:09 p.m. Thrill palpated, and bruit auscultated - both indicated no. No other pertinent information documented.3/13/26: dialysis paperwork received. Thrill palpated, and bruit auscultated - both indicated yes. Other pertinent information documented as none.3/11/26: dialysis paperwork received. Weight dated 3/10/26 at 10:07 a.m. and all other vital dated 3/11/26 at 10:13 a.m. Thrill palpated, and bruit auscultated - both indicated yes with radio button answer. No other pertinent information documented.3/9/26: dialysis paperwork received. Weight dated 3/3/26 at 5:56 p.m. and all other vitals dated 3/8/26 at 1:43 p.m. Thrill palpated, and bruit auscultated - both indicated yes with radio button answer. Other pertinent information documented as none.3/6/26: dialysis paperwork received. Weight dated 3/3/26 at 5:56 p.m. and all other vitals dated 3/8/26 at 1:43 p.m. Thrill palpated, and bruit auscultated - both indicated no with radio button answer. The document was signed on 3/8/26.3/5/26: dialysis paperwork received. Weight dated 3/3/26 at 5:56 p.m. and all other vital signs dated 3/4/36 at 4:55 p.m. Thrill palpated, and bruit auscultated - both indicated yes with radio button answer. No other pertinent information documented.3/4/26: dialysis paperwork received. Weight dated 3/3/26 at 5:56 p.m. Thrill palpated, and bruit auscultated - both indicated yes with radio button answer. No other pertinent information documented.3/2/26: dialysis paperwork received. Weight dated 2/26/26 at 12:44 p.m. Thrill palpated, and bruit auscultated - both indicated yes with radio button answer. No other pertinent information documented.There was no evidence to support documentation had been received from the dialysis facility, nor was there evidence R16 had a fistula or graft, either old and non-functioning or new and developing where a bruit and thrill would need to be checked. R16's progress notes, dated 3/1/26 to 4/6/26, were reviewed and identified staff were documenting some vitals and/or were using old data, however, the notes lacked the necessary observations of the current dialysis CVC for most notes. It was unknown if staff were referring to the CVC site as noted below: 3/2/26 at 6:05 p.m., R16 had dialysis treatment. No new orders received. Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/4/26 at 4:55 p.m. Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/4/26 at 3:27 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs: -W [weight] 197.0 lbs on 3/3/26. His blood pressure (BP) was 98/58 millimeters of mercury (mm/hg) on 3/4/26. R16's temperature (T) was 98.4 degrees Fahrenheit (F), pulse (P) 58 (beats per minute (BPM)) and his respirations (RR) were 16 (breaths per minute (bpm)).3/5/26 at 1:32 p.m.: R16 had dialysis treatment. No new orders received. W 197.0 lbs on 3/3/26. His BP was 98/58 mm/hg and on 3/4/26 staff documented his previous T of 98.4 degrees F, P of 58 bpm and RR was16 bpm. Bruit auscultated. Thrill was palpated. No bleeding noted at access site. No new vitals had been obtained.3/6/26 at 5:30 p.m.: R16 had dialysis treatment. No new orders received. Bruit not auscultated. Thrill was not palpated. No bleeding noted at access site.3/9/26 at 5:53 p.m.: R16 had dialysis treatment. No new orders received. Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/11/26 at 6:32 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs: W 205.8 lbs. on 3/10/26. His BP 107/57, T 97.9 degrees F, P 61 bpm, and RR was 16 bpm, were all used from vitals acquired earlier that day. Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/13/26 at 5:58 p.m.: R16 had dialysis treatment. No new orders received. Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/16/26 at 5:27 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs: -W 205.6 lbs was obtained on 3/14/26. His BP 88/68 mm/hg, T was 98.2 F, P was 80 bpm, and RR was 16 and noted as taken on 3/16/26 at 9:42 a.m. Bruit not auscultated. Thrill was not palpated. No bleeding noted at access site.3/18/26 at 5:52 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs: -W 207.7 lbs on 3/18/26 at 4:10 p.m. on Wheelchair scale; BP 84/49 on 3/18/26 at 6:09 p.m. Sitting I/arm; T 98.8 on 3/18/26 at 6:09 p.m.: P 71 on 3/18/26 at 6:09 p.m. and R -16 on 3/18/26 at 6:09 a.m. Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/20/26 at 9:03 a.m.: R16 had dialysis treatment. No new orders received. Vital Signs staff documented were noted to be from 3/18/26, 2 days previously and not upon return from dialysis. Staff continued to document Bruit auscultated. Thrill was palpated. No bleeding noted at access site.3/21/26 at 1:19 p.m., staff mentioned an order note: resident has a tunneled chest catheter and are unable to assess bruit/thrill with catheter. Only if resident had fistula/graft. There was no indication or mention staff had contacted the physician to discontinue the order to check for bruit and thrill on a non-existent fistula or graft.3/22/26 at 6:36 a.m.: order note: resident has a tunneled chest catheter. Unable to assess bruit/thrill as not a fistula or graft. Again, there was no indication or mention staff had contacted the physician to discontinue the order to check for bruit and thrill on a non-existent fistula or graft.3/23/26 at 4:06 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs had been appropriately taken. However, staff still documented Bruit auscultated. Thrill palpated. No bleeding noted at access site.3/25/26 at 3:36 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs had been appropriately taken. This time, staff documented No bleeding noted at access site., however, it was unclear if staff had identified this was the CVC or a non-existent fistula or graft.3/27/26 at 5:58 p.m.: R16 had dialysis treatment. No new orders received. Vital Signs: -W 212.9 lbs on 3/25/26 at 3:37 p.m. on Wheelchair scale; BP 98/67 on 3/27/26 at 5:59 p.m. Sitting I/arm; T 98.2 on 3/27/26 at 9:28 a.m.: P 65 on 3/27/26 at 6:00 p.m. and R -17 on 3/27/26 at 9:28 a.m. Bruit auscultated. Thrill was palpated. No bleeding noted at access site. 3/30/26 through 4/6/26, staff continued to document old vital sign data that had been taken sometimes from almost a week prior and were either documenting Bruit not auscultated. Thrill was not palpated. No bleeding noted at access site. or No bleeding noted at access site.R16's medical record (paper chart and electronic medical record) was reviewed and lacked any summary report after dialysis to include vital signs, weights (pre-dialysis and post-dialysis), medications administered at dialysis, orders, or any overall concerns with R16 during dialysis. Furthermore, R16's medical record lacked facility communication with dialysis center related to medication refusals in a timely manner, changes or declines in condition unrelated to dialysis. During an interview and document review on 4/10/26 at 1:04 p.m., registered nurse (RN)-C stated when a resident goes to dialysis, a pre and post assessment was to be completed. RN-C stated they are familiar with R16. The pre-assessment should be sent with the resident along with the order summary. If R16 doesn't come back with paperwork such as vitals signs, medications administered, a run report, they don't' do anything. She doesn't call the facility herself to follow up as she figured if they [dialysis] didn't send any paperwork then there weren't any concerns. RN-C assesses the site upon return for signs of infection. RN-C stated R16 had a right IJ (internal jugular) catheter for his dialysis catheter which would not have a thrill or bruit, so she doesn't check for a thrill or bruit. RN-C verified the MAR/TAR indicated to check for thrill and bruit and shouldn't. During an interview on 4/10/26 at 1:04 p.m., RN-A stated a pre and post assessment was completed on R16 on dialysis days. RN-A stated if she ever called dialysis, it would be documented in a progress note. RN-A checks R16's catheter site for any signs of infection. RN-A stated she doesn't check for thrill or bruit as R16's dialysis site wouldn't have one due to the type of site. Staff often don't get anything back from dialysis. RN-A stated they send a notebook with R16 that dialysis can write in if needed. RN-A unsure if this was documented in the resident's medical record. During an interview and document review on 4/10/26 at 3:23 p.m., assistant director of nursing (ADON) identified the facility has a legal pad of note paper that was sent back and forth for communication between the facility and dialysis center. The ADON was unsure if any of this was documented in R16's medical record. The dialysis center does not send any paperwork to the facility such as report runs which would include medications, weights before and after treatment, vital signs, etc. The ADON verified the contact information for the dialysis center was not on the care plan. During a follow up interview on 4/13/26 at 10:19 a.m., the ADON verified the contact number for dialysis was not listed on the care plan or on the banner in R16's medical record. She had now asked that any information in the notebook be entered into the medical record. ADON verified this would not necessarily include medical information obtained during dialysis. During an interview on 4/13/26 at 11:06 a.m., the dialysis registered nurse (RN)-D stated they are the dialysis care facility R16 received his treatment at. The facility sends paperwork and notebook with R16 about 50% of the time. The facility had never requested any documentation from the dialysis center, therefore, they have never sent any to the facility. The dialysis center was not updated on medication changes from the facility. If R16 stated his medications were changed, the dialysis center has the capability to access what medications have been filled at pharmacies. RN-D verified they do not send the facility any weights, medications administered during dialysis, pressures on treatments, vitals, etc. During an interview on 4/14/26 at 9:50 a.m., director of nursing (DON) stated the expectation was the facility was communicating effectively with dialysis and receiving information needed to care for the residents. The DON verified the facility was not receiving information needed from the dialysis center such as vitals, weights, medications received, etc. and verified the facility had not been requesting this information. The DON also verified the contact information was not listed on R16's care plan nor on the banner of the electronic medical record and should be. A facility policy titled Hemodialysis, reviewed 9/10/23, identified the facility will ensure that the place of care for dialysis include the dialysis facility name and phone number. Furthermore, the facility was to coordinate and collaborate with the dialysis facility to ensure:a. The residents' needs related to dialysis treatments are met;b. The provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments.c. Documentation requirements are met to ensure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team; andd. There was to be ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff.

Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to standards of care to prevent respiratory infections for 1 of 1 residents (R16) who required oxygen for chronic respiratory failure with hypoxia (a condition where the lungs are unable to adequately oxygenate the blood).Findings include: R16's quarterly Minimum Data Set (MDS) assessment, dated 2/11/26, identified R15 had intact cognition with no hallucinations, delusions, or rejection of care with admission date of 11/21/25. R16's admission record indicated on 2/18/26, R16's primary diagnosis was end stage renal disease with secondary diagnoses of chronic respiratory failure with hypoxia, biventricular heart failure (heart not working correctly), dependency on supplemental oxygen, unspecified right bundle-branch block (condition where electrical conduction in the heart is impaired), thoracis aortic ectasia (dilation or bulging in aorta in the chest), and atrial fibrillation (heart not beating correctly). Additional secondary diagnosis, dated 1/21/25, included: pulmonary hypertension (high blood pressure in the arteries of the lungs that strains the heart), and pleural effusion (buildup of excess fluid between the layers of the pleura surrounding the lungs). During an interview on 4/6/26 at 4:08 p.m., R16 was observed to be sitting in his wheelchair receiving oxygen via nasal canula from an oxygen concentrator at 2 liters(l)/minute. R16's oxygen tubing did not have a date or label on it. R16 was observed to have a portable oxygen tank on the back of his wheelchair with the oxygen tubing with nasal cannula attached wrapped around it with no date on it. R16 was not sure when the oxygen tubing had been changed. R16's care plan, printed 4/7/26, identified R16 was at risk for respiratory impairment related to chronic respiratory failure with hypoxia with an intervention to administer oxygen per MD orders. The care plan lacked any indication on how often the oxygen tubing should be changed or who would be responsible for changing the oxygen tubing. R16's Order Summary Report, dated 4/6/26, included the following orders:- 2L continuous oxygen via nasal cannula. Concentrator and cylinders with contents and regulators with a start date of 2/18/26. The Order Summary Report lacked evidence of an order to change oxygen tubing. R16's medication and treatment administration record (MAR/TAR) for 4/1/26 to 4/14/26 included the following orders:-change oxygen tubing and humidifier bottles weekly. Date tubing in the afternoon every Thursday with a start date of 4/16/26.- Change oxygen tubing and humidifier bottles weekly. Date tubing as needed for visibly soiled or known contamination with a start date of 4/9/26. This order had a start date after survey entrance.-Oxygen at 2L/minute via nasal cannula every shift with a start date of 4/9/26 R16's Medication Administration Record and Treatment Administration Record (MAR/TAR) for March 2026 was reviewed and lacked any order for oxygen use or changing of oxygen tubing or oxygen supplies. R16's task log was reviewed and did not include any change of oxygen tubing. R16's progress notes from 3/1/26 through 4/7/26, made no mention of any oxygen tubing having been changed by staff. Observation and interview ON 4/7/26 at 8:29 a.m., of R16 identified he was observed sitting in his room in his wheelchair and reported he just got done eating. R16's oxygen tubing from the oxygen tank on the back of the chair was observed to be partially on the floor with no date on it. R16's oxygen tubing from the concentrator, which R16 was observed wearing, did not have a date on it. R16 stated the facility will change the tubing when it doesn't fit but couldn't explain what that meant or when the last time the tubing was changed. At 12:17 p.m., R16 was observed in the dining room for lunch. R16 was observed to have oxygen on via nasal cannula from his portable tank located on the back of his wheelchair. The oxygen tubing remained undated or labeled. On 4/8/26 at 9:55 a.m., R16 was observed to be leaving the facility. R16 was observed to have nasal cannula on and receiving oxygen from portable oxygen tank located on the back of his wheelchair. The oxygen tubing remained undated or labeled. On 4/9/26 at 2:53 p.m., R16 was observed propelling self in wheelchair in his room. R16 was observed receiving oxygen via nasal cannula from the portable tank located on the back of his wheelchair. The oxygen tubing, including the nasal cannula, from the oxygen concentrator was noted to be laying in a box on the floor. Neither oxygen tubing was dated or labeled. R16 stated he was unsure when the oxygen tubing was last changed. During an interview on 4/9/26 at 2:54 p.m., NA-C stated they are familiar with R16. Staff put oxygen on and off residents including R16. NA-C stated nursing assistants do not change oxygen tubing. NA-C observed R16's oxygen tubing and verified the set of oxygen tubing (from the oxygen tank or oxygen concentrator) was dated or labeled. NA-C stated they are unsure when it was last changed as it was not dated. During an interview on 4/10/26 at 12:54 p.m., nursing assistant (NA)-A stated they do not change the oxygen tubing for residents. Staff only turn the oxygen on and off and do not adjust any settings. NA-A thought it was the nurse's responsibility to change the tubing as nurse aides have never changed oxygen tubing. During an interview on 4/10/26 at 1:03 p.m., registered nurse (RN)-A stated oxygen tubing and supplies should be changed weekly to prevent infections and the nurses are responsible for this. During an interview and document review on 4/10/26 at 1:04 p.m., RN-C stated oxygen tubing should be changed weekly, and nurses were responsible for ensuring that was completed. RN-C stated there would be an order to change the oxygen tubing. RN-C stated it was expected to date and label the oxygen tubing also. RN-C reviewed R16's medical record and verified the order to change R16's oxygen tubing was entered on 4/9/16 (after survey entrance) and there was no previous order. RN-C stated it was important to change oxygen tubing to prevent infection and prevent build up in the nasal cannula. During an interview on 4/10/26 at 3:21 p.m., the assistant director of nursing (ADON) stated the expectation was oxygen tubing was changed weekly for infection control purposes as not changing it can contribute to respiratory illnesses. The expectation would be for tubing and all supplies to be dated and labeled. The ADON verified there were no additional nursing or physician's orders prior to 4/9/26, to change R16's oxygen tubing or humidifier bottles and there should have been. On 4/14/26 at 9:53 a.m., the director of nursing (DON) stated the expectation would be oxygen tubing would be changed weekly and as needed to help decrease risk of infection as not changing it can put a resident more at risk for infection. This was to be documented on the MAR/TAR. Review of the current, undated Northwest Respiratory Services instruction sheet for oxygen use the facility used for direction for staff, identified staff were to change tubing every month and the nasal cannula every week.

Based on interview and document review, the facility failed to notify the Office of the State Long-Term Cate (LTC) Ombudsman for 2 of 2 residents (R5 and R39) reviewed for hospitalizations and discharges. Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. R5 was independent with eating, required set up/clean up assistance with oral hygiene, and required partial to moderate assistance with toileting, showering/bathing, dressing, and personal hygiene. R5 had occasional urinary incontinence but was always continent of bowel. R5's face sheet indicated R5 was originally admitted to the facility on [DATE]. R5 was hospitalized on [DATE] and 3/6/26. R5's Progress notes lacked any communication with the ombudsman after each hospitalization. Review of the notices to the Ombudsman, provided by the facility, identified the notice sent on 3/8/26 did not include R5's hospitalizations. During an interview on 4/7/26 at 12:52 p.m., ombudsman (OM)-A stated she had received a notification from the facility on 3/8/26; this notification contained information about hospitalizations, transfers, and discharges from November and December. OM-A stated she has not received any other notifications for the months of January, February, and March. During an interview on 4/10/26 at 10:22 a.m., social services (SS)-A stated he is responsible for sending notification to the ombudsman about hospitalizations, transfers, and discharges; these notifications are supposed to be sent monthly. SS-A confirmed he is behind a little with submitting the notifications to the ombudsman. SS-A stated ombudsman notification are important, so residents have advocate if they feel they have been wrongly hospitalized , transferred, or discharged . R39's admission Minimum Data Set (MDS) assessment, dated 2/17/26, identified R39 had moderately impaired cognition and required moderate to maximum staff assistance with activities of daily living (ADLs). R39's diagnoses included: displaced fracture of the base of the left femur, hip fracture, coronary artery disease (heart disease), heart failure (heart not functioning properly), hypertension (high blood pressure), and diabetes mellitus (condition where the body's ability to manage glucose is impaired). R39's progress dated 2/11/26 to 3/6/26 identified a progress note dated 2/11/26 at 10:53 a.m., indicated R39 was admitted to the facility. Another progress noted dated 3/6/26 at 5:43 p.m., indicated R39 discharged home to a new apartment from the facility. The progress notes lacked any communication with ombudsman during planning process of R39's discharge. Review of the notices to the Ombudsman, provided by the facility, identified a notice sent on 3/8/26 did not include R39. During an interview on 4/13/26 at 9:56 a.m., social services (SS)-A stated that he had worked with R39 for her planned discharge. SS-A stated R39 had a case manager who also assisted with the discharge. SS-A stated he had not coordinated with the ombudsman or updated the ombudsman that R39 was planning to discharge prior to discharge. SS-A was unsure if he updated the ombudsman after R39 discharged . If R39 was not on the list provided to surveyors that was sent to the ombudsman's office the beginning of March, then the ombudsman had not been notified. A facility policy titled Transfer and Discharge (including AMA), reviewed 7/15/22, identified for non-emergency transfer or discharges which were initiated by the facility and return not anticipated, a copy of notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman. Furthermore, instances of emergency transfers/discharges, the social services director or designee, shall provide notice of transfer to a representative of the State Long-term Care Ombudsman via monthly list.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R5, R20) reviewed for transmission-based precautions.Findings include: R20's quarterly Minimum Data Set (MDS) assessment, dated 3/12/26, identified R20 had intact cognition with no hallucination, delusions or other behavioral symptoms noted and was dependent on staff for activities of daily living (ADLs) except eating which R20 required maximal staff assistance. The MDS indicated R20 had an indwelling catheter. During an observation on 4/8/26 at approximately 7:20 a.m., RN-A was observed to enter R20's room and performed hand hygiene prior to entering room with hand sanitizer. A plastic bin was observed outside the doorway and inside the bin were personal protective gowns and gloves. Hand sanitizer was available from a dispenser on the wall. On the door, was a single page sign hung indicating Enhanced Barrier Precautions. Signage was orange in color, CDC (Center for Disease Control and Prevention) emblem on the bottom right corner, two stop signs on the upper right and upper left corners of the page and indicated: Everyone must: Clean their hands, including before entering and when leaving the room, and Providers and Staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wounds Care: any skin opening requiring a dressing. R20 was observed sitting in her Broda chair (a type of positioning chair) in her room. R20 was administered her morning oral medications by registered nurse (RN)-A. RN-A performed a respiratory assessment on R20 which included a pulse oximeter reading, and breath sounds. RN-A held R20's inhaler while she did the treatment, then had R20 rinse her mouth and spit in a cup that RN-A was holding. RN-A prepared R20's nebulizer and placed the mask on R20's face. RN-A placed R20's call light pad on her lap and instructed her to turn her call light on when the treatment was completed. RN-A exited R20's room and used hand sanitizer. R20's April medication/treatment administration report (MAR), printed 4/14/26, included the following order: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligram(mg)/3millilter(ml) (a combination of two medications in one solution used to help open airways and prevent worsening of airflow obstruction) - 1 dose inhale orally two times a day related to chronic respiratory failure with hypoxia with a start date of 3/12/26. The record indicated the medication was administered twice a day as ordered as of print date of MAR. -Respiratory assessment prior to nebulizer treatment. Document Respirations, Pulse, O2 Sat, and lung sounds prior to nebulizer treatment two times a day. The record indicated the assessment was completed twice a day as ordered as of the print time of the MAR along with lung sounds being documented with code. -Respiratory assessment after nebulizer treatment. Document Respirations, Pulse, O2 Sat, and lung sounds prior to nebulizer treatment two times a day. The record indicated the assessment was completed twice a day as ordered as of the print time of the MAR along with lung sounds being documented with code. -Change foley catheter monthly and as needed using a 18Fr silicone indwelling catheter 10cc balloon. One time a day once a month on 18 day of the month and as needed using a 18Fr silicone indwelling catheter 10cc balloon with a start date of 3/18/26. -Irrigate foley catheter daily and as needed with 122 cc. can use tap water or sterile water per facility preference one time a day for catheter care with a start date of 2/20/26. -Catheter care every morning and at bedtime for urinary retention with a start date of 1/20/26. R20's order summary report, dated 4/14/26, included the following order: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) mg/3ml - 1 dose inhale orally two times a day related to chronic respiratory failure with hypoxia with a start date of 3/12/26. -Catheter Care every morning and at bedtime for urinary retention starting 1/20/26. -Change foley catheter monthly and as needed using a 18Fr silicone indwelling catheter 10cc balloon. One time a day once a month on 18 day of the month and as needed using a 18Fr silicone indwelling catheter 10cc balloon with a start date of 3/18/26. -Irrigate foley catheter daily and as needed with 122 cc. can use tap water or sterile water per facility preference one time a day for catheter care with a start date of 2/20/26. R20's care plan, initiated on 1/20/26, indicated R20 had indwelling urinary catheter. Interventions were all updated on 3/8/26 and included: administer medications per MD order; catheter care; catheter collection bag place din dignity bag holder on b ed/wheelchair; change urinary collection bag as needed; maintain drainage bag below bladder level; report any changes in amount and color, or odor of urine; report to MD signs of UTI (urinary tract infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, complaints of pain or burning. The care plan lacked identification R20 was on enhanced barrier precautions. During an interview on 4/8/26 at 11:50 a.m., RN-A verified they did administer R20's medications 4/8/26 which included a nebulizer, inhaler, oral medications and performed a respiratory assessment. RN-A stated they did not wear a gown and stated they did not touch R20's catheter which was the reason R20 was on EBP. RN-A stated they should have worn a gown since they did a respiratory assessment with the resident and the EBP sign on the door. R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). During an observation on 4/8/26 at 9:39 a.m., registered nurse (RN)-A prepared R5's morning medication administration. RN-A removed and prepped the above-named medications and put each medication in a medication cup. Prior to medication administration, R5 required enhanced barrier precaution (EBP) due to an indwelling medical device (g-tube). RN-A failed to apply the appropriate personal protective equipment (PPE) prior to providing care. During an interview on 4/8/26 at 10:36 a.m., RN-A stated she should have been wearing the appropriate personal protective equipment (PPE) when providing care or administering medications to R5. She stated R5 required enhanced barrier precautions (EBP) and additional PPE (gown and gloves) were needed due to her g-tube. She stated the appropriate PPE is important to prevent the spread of infection from residents to residents. During an interview on 4/14/26 at 9:55 a.m., director of nursing (DON) stated the expectation would be that if a resident on enhanced barrier precautions, the proper PPE would be worn as this helps stop the transmission of infections. DON stated she would expect proper PPE to be worn for a resident on EBP while a respiratory assessment is being performed along with a setting up and administering a nebulizer treatment. A facility policy titled Enhanced Barrier Precautions, dated 8/8/24, identified the facility will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms and an order for enhanced barrier precautions will be initiated for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, peripherally inserted central catheters (PICCs), hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a [NAME]. Ostomies, such as colostomies or ileostomies, are not defined as a wound for Enhanced Barrier Precautions.

Based on interview and document review, the facility failed to ensure staff completed mandatory communication training for 2 of 10 staff (nursing assistant (NA)-A, licensed practical nurse (LPN)-B) reviewed for training requirements. This had the potential to affect all 34 residents residing in the facility. Findings include: The facility assessment dated [DATE], indicated the facility had developed a training program that included an orientation process and ongoing training for all new and existing staff to ensure the programs meet the regulatory requirements. The assessment indicated all staff were to receive training in communicating effectively. During an interview on 4/13/26 at 10:59 a.m., administrator stated she was responsible for overseeing and ensuring all staff completed the required training. During a follow up interview on 4/14/26 at 11:06 a.m., the administrator was informed the education on effective communication was not found the personal files she had provided for LPN-B and NA-A. Administrator verified the trainings had not been completed at this time for either LPN-B or NA-A. A facility policy regarding required staff training was requested and not received.

Based on interview and document review, the facility failed to ensure appropriate side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure what occurs when a person stands up after sitting or lying down) was completed for 1 of 1 resident (R15) reviewed for unnecessary medication use and who consumed antipsychotic medication.Findings include: Review of the 7/24/24, Olanzapine guidelines, located at: https://www.drugs.com/olanzapine.html#side-effects, identified olanzapine may cause serious side effects such as low blood pressure. Common side effects of olanzapine that affect 5% or more people who take it include postural hypotension (a drop in blood pressure when going from a lying or sitting position to standing). R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had no cognitive impairment and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS recorded R15 consumed antipsychotic, antidepressant, and antianxiety medications. During a record review, R15's orders reflected showed R15 received olanzapine 10 milligrams (mg) every evening before bedtime. Additionally, orthostatic BP laying, sitting, and standing; documented in the electronic medical record on the 9th of every month. During a record review, R15's orders reflected orthostatic BP laying, sitting, and standing; documented in the electronic medical record on the 9th of every month. During a record review of R15's orthostatic blood pressures from October 2025 through April 2026 identified there were no orthostatic blood pressures completed in October, January, March, or April During a record review of R15's pharmacy review and recommendations indicated the following. In:-4/7/26: did not address orthostatic blood pressures not done in March 2026 or April 2026-2/5/26: did not address orthostatic blood pressure not done in January 2026-11/4/26: did not address orthostatic blood pressure not done in October 2026 During an interview on 4/7/25 at 3:25 p.m., director of nursing (DON) stated R15 is currently taking an antipsychotic medication and should have her orthostatic blood pressure completed monthly. Additionally, if orthostatic blood pressures are ordered, it is her expectation they get completed monthly. When the consultant pharmacist performs the monthly review of medications, she would identify when orthostatic blood pressures aren't being completed and would put the reminder to complete them in her monthly recommendations. Lastly, orthostatic blood pressure measurements are important so that staff can identify adverse medication effects as soon as possible. During an interview on 04/15/2026 at 11:46 a.m., pharmacist (PH)-B stated when she completes the medication monthly review, she would review the orders to make sure there was an order to complete orthostatic blood pressures, not necessarily whether they were completed. She would expect nursing to complete the orders as written and document why they weren't done. Since it isn't routine for her to check the actual completion of orthostatic blood pressures, she would not put in the monthly medication review to remind staff to complete them. PH-B stated orthostatic blood pressure monitoring can be important because you can identify medication issues if a resident has positive orthostatic blood pressures. A policy titled Use of Psychotropic Medications, dated 4/27/25 showed the effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: upon physician evaluation, during the pharmacist's monthly medication review, during the MDS review, and in accordance with nurse assessments and medication monitoring parameter consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan. The resident's response to the medications, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.

Based on observation, interview, and document review, the facility failed to monitor daily oral intake and daily output; additionally, the facility failed to develop a system to monitor and assess daily intake and output for 1 of 1 resident (R5) reviewed who required nutritional and hydration support via a gastrostomy tube (g-tube).Findings Include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 required hydration and nutrition via a feeding tube (g-tube). R5's current face sheet identified diagnoses of moderate protein-calorie malnutrition, dysphagia (difficulty swallowing) requiring the placement of a gastrostomy tube (g-tube) for nutrition and medication administration. R5's care plan dated 1/26/26 indicated R5 required tube feeding, hydration, and flushes per order, check tube placement prior to meds and feedings, elevating head of bed 30-45 degrees, care of tube per orders, and report signs of aspiration or intolerance of feeding. R5's care plan lacked identification for a risk in decreased hydration, lacked the specific signs and symptoms of aspiration, lacked resident-specific interventions to mitigate complications when using the g-tube, and lacked guidance and collaboration for monitoring fluid balance and imbalance. R5's current physician orders included tube feedings (Vital Advanced Formula at 100 milliliters (ml)/hour (hr) for 13 hours) via g-tube. R5 received 150 ml water flush in g-tube every 4 hours, including during tube feeding. R5 received 150ml of water flush in g-tube after medication administration for the AM medication pass. R5's orders lacked a clear monitoring system for intake and output including urine output, emesis amounts, amount of bowel movement, and amount of oral intake. R5's nutrition assessments dated 1/22/26, 3/2/26, and 3/16/26: section 30 failed to accurately identify how much oral intake the resident received (to adjust free water amounts), section 36 failed to identify gastrointestinal (GI) concerns such as nausea and vomiting, and section 44 failed to identify the amount of emesis the resident experienced (to know when to adjust free water amounts). R5's electronic medical record lacked collaboration, assessments, and outcome about who would be overseeing and managing daily intake and output in relation to the amount of tube feeding and free water flushes R5 should have received to maintain adequate fluid and nutrition. Additionally, the medical record and testing lacked collaboration and follow up to monitor and assess previously known electrolyte imbalances (high calcium, low potassium, high sodium) with a previously low Albumin level of 3.0 (could indicate malnutrition) on 1/6/26. During an interview on 4/7/26 at 11:31 a.m., R5 stated they give her a lot of water during the day and then in the evening they start her tube feedings; she thinks it is just too much liquid for [her] to handle, and she gets nauseous and vomits at times. R5 stated she wasn't sure who kept track of all that liquid going in, but she felt like it was too much. During observation and interview on 4/7/26 at 11:47 p.m., physician assistant (PA)-A had entered R5's room to evaluate her pressure ulcer; upon entering, the resident was vomiting and handed the emesis bag to the nurse. The emesis bag contained approximately 300ml of vomit; a later record review noted this amount was not documented in a treatment administration record (TAR) nor a progress note. Additionally, the TAR and task list did not contain an option to document any output. PA-A stated R5's GI tract was complicated due to her hyperparathyroidism resulting in high calcium levels; symptom management is the primary treatment option as R5 is no longer a surgical candidate. She was not aware how often nutrition is involved with her care. She was not actively monitoring daily intake and output. She stated she also did not have any laboratory orders for blood draws to assess electrolyte imbalances; the teams in the hospital might be managing that. During an interview on 4/7/26 at 3:25 p.m., director of nursing (DON) stated R5's tube feeding care plan should have been more resident-specific to include aspects of care such as head-of-bed elevation, medication administration, g-tube complications, and symptoms and side effects. The DON acknowledged they should have been monitoring R5's intake and output more closely, especially the emesis amounts. Fluid balance is important for R5 since she is receiving tube feedings and free water flushes. Staff needed to make sure her hydration and nutrition are adequate. A facility g-tube education titled Enteral Nutrition and Drug Administration dated as provided on 12/22/25, this education failed to identify practice standards for medication administration and tube feeding administration.

Based on interview and record review, the facility failed to identify irregularities in monthly drug regimen monitoring review for 1 of 5 residents (R15) reviewed for unnecessary medications who received antipsychotic medications. Additionally, the facility failed to identify potential medication side effects for 1 of 1 resident (R5) reviewed for medication administration.Findings include: R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had no cognitive impairment and demonstrated no hallucinations or delusional thinking during the review period. Further, the MDS recorded R15 consumed antipsychotic, antidepressant, and antianxiety medications. Review of the 7/24/24, Olanzapine guidelines, located at: https://www.drugs.com/olanzapine.html#side-effects, identified olanzapine may cause serious side effects such as low blood pressure. Common side effects of olanzapine that affect 5% or more people who take it include postural hypotension (a drop in blood pressure when going from a lying or sitting position to standing) During a record review, R15's orders reflected showed R15 received olanzapine 10 milligrams (mg) every evening before bedtime. Additionally, orthostatic BP laying, sitting, and standing; documented in the electronic medical record on the 9th of every month. During a record review of R15's orthostatic blood pressures from October 2025 through April 2026 identified there were no orthostatic blood pressures completed in October, January, March, or April. During a record review of R15's pharmacy review and recommendations, the pharmacist failed to address the lack of blood pressure monitoring being completed by staff in the course of their monthly reviews on 11/4/25, 2/5/26, and 4/7/26 for the above-mentioned months. During an interview on 4/7/25 at 3:25 p.m., director of nursing (DON) stated R15 is currently taking an antipsychotic medication and should have her orthostatic blood pressure completed monthly. Additionally, if orthostatic blood pressures were ordered, it was her expectation they should get completed monthly. When the consultant pharmacist performed the monthly review of medications, they were to identify when orthostatic blood pressures weren't being completed and should put the reminder to complete them in her monthly recommendations. Lastly, orthostatic blood pressure measurements are important so that staff can identify adverse medication effects as soon as possible. During an interview on 04/15/2026 at 11:46 a.m., pharmacist (PH)-B stated when she completes the medication monthly review, she would review the orders to make sure there was an order to complete orthostatic blood pressures, not necessarily whether they were completed. Additionally, she would expect nursing to complete the orders as written and document why they weren't done. Lastly, since it isn't routine for her to check the actual completion of orthostatic blood pressures, she would not put in the monthly medication review to remind staff to complete them. PH-B stated orthostatic blood pressure monitoring can be important because you can identify medication issues if a resident has positive orthostatic blood pressures. R5According to the American Society for Parenteral and Enteral Nutrition article, Medication via Enteral Feeding Tubes: A Clinician's Guide, located at https://nutritioncare.org/wp-content/uploads/2026/04/Medications-Via-EN-Tubes.pdf, identified prior to administering medications through a g-tube, medications should be verified for right client, right medication, right dose, right time, right route, and right documentation. When administering medication through a g-tube, medications should be crushed and diluted with 15-20 milliliters (ml) of purified water separately. Additionally, the head of the bed (HOB) should be elevated at least 30-45 degrees during medication administration and for at least 30-60 minutes after medication administration to prevent aspiration and support safe, effective delivery of medication. Further, proper positioning supports breathing, reduces pressure on the abdomen, and improves resident comfort. Lastly, complications from g-tube misuse can lead to nausea, vomiting, abdominal pain, tube clogging, aspiration, and toxicities. R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment with no rejection of care. R5 required hydration and nutrition via a feeding tube (g-tube). R5's care plan indicated the following:-administer tube feeding formula, hydration, and flushes per order-elevate HOB 30-45 degrees (did not provide direction for when and how long to elevate HOB) R5's care plan lacked resident-specific interventions to monitor or prevent recurrence of nausea, vomiting, and abdominal pain; to include the signs and symptoms of hypercalcemia; which include mental status changes, muscle spasms, abdominal pain, and constipation. R5's phyician's order, dated 1/26/26, included tube feedings (Vital Advanced Formula at 100 milliliter (ml)/hour (hr) for 13 hours) via g-tube. R5 received 150 ml water flush in g-tube every 4 hours, including during tube feeding. R5 received 150 ml of water flush in g-tube after medication administration for the AM medication pass. R5's physician's orders included:-levothyroxine (thyroid medication) 88 micrograms (mcg) via g-tube daily (instruction to give on an empty stomach and not with 4 hours of iron supplements or antacids) -prednisone (steroid) 4 milligrams (mg) via g-tube daily (instruction to take with food) -iron-vitamins oral liquid 15 ml via g-tube daily (instruction to take on an empty stomach or with food if it upsets stomach. -folic acid (vitamin) 1 mg via g-tube daily -apixaban (blood thinner) 2.5 mg via g-tube twice daily -metoprolol tartate (blood pressure) 12.5 mg via g-tube twice daily -senna (laxative) 8.6 mg via g-tube twice daily -cinacalcet (overactive parathyroid) 30 mg via g-tube twice daily -omeprazole-syrspend (antacid) SF Akla oral suspension 10 ml daily -ascorbic acid (vitamin C) 500 mg via g-tube daily During an interview on 4/8/26 at 2:39 p.m., physician assistant (PA)-A stated the resident had been experiencing ongoing nausea and vomiting with intermittent abdominal pain since returning from the hospital on 3/10/26. Additionally, she relies on the consultant pharmacist to know what medication can be given at what times in relation to the tube feeding and on the pharmacy team to tell her if there are any specific medication interactions. During an interview on 4/9/26 at 8:53 a.m., PA-B stated she was the hospitalist who cared for R5 during her 3/6/26 to 3/10/26 hospital admission. Additionally, medication interactions should be managed by the facility provider and pharmacist. Further, medication administration times should be assessed by the facility provider and pharmacist. Medications given with other medications or around tube feedings can have side effects for R5 that include nausea, vomiting, abdominal pain, increased absorption, or decreased absorption. During interview on 4/9/26 at 9:59 a.m., pharmacist (PH)-A stated the hours and times of administration are determined by the facility provider, pharmacist, and manufacturer guidelines. Medication interactions should be managed by the facility provider and pharmacist. If medication interactions aren't completed, R5 could experience ineffective medications, medication side effects, and symptom side effects. PH-A stated medications such as prednisone should be taken with food to prevent nausea and vomiting. Medications such as levothyroxine, in this situation, should have been given before the tube feedings were started or several hours after tube feedings have stopped. Levothyroxine should be spaced at least 4 hours from the iron vitamin solution and the omeprazole solution. The medication errors should have been identified by the facility provider and pharmacist upon medication review at time of admission. During an interview on 4/15/26 at 11: 46 a.m., pharmacist (PH)-B stated when a resident has been admitted to the facility, she reviews the discharge summary to verify medications and compare them to the facility medication administration record (MAR). If she notices any discrepancies, she will write a recommendation for the provider to review and determine appropriateness of medication; she would expect response from the provider in one week. PH-B stated she does not evaluate each medication for interactions. PH-B stated she doesn't check when medications are administered in relation to the tube feedings; she would expect nursing to follow the administration directions from the pharmacy. PH-B stated it is important to follow the administration directions from pharmacy; but could not speak to the importance of accurate medication administration timing. A policy titled Use of Psychotropic Medications, dated 4/27/25 showed the effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: upon physician evaluation, during the pharmacist's monthly medication review, during the MDS review, and in accordance with nurse assessments and medication monitoring parameter consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan. The resident's response to the medications, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. A facility policy titled Medication Administration dated January 2026, medications are administered in accordance with written orders of the prescriber. Timing of medication administration must align with manufacturer specifications.

Based on observation, interview and document review, the facility failed to comprehensively assess and care plan to ensure competency and safety with self-administration of medication for 1 of 1 resident (R20) observed to be self-administering medication in their room.Findings include: R20's quarterly Minimum Data Set (MDS) assessment, dated 3/12/26, identified R20 had intact cognition. On 4/8/26 at approximately 7:20 a.m., R20 was observed sitting in her Broda chair (a type of positioning chair) in her room. R20 was administered her morning oral medications by registered nurse (RN)-A along with an inhaler after performing a respiratory assessment. RN-A prepared R20's nebulizer and placed the mask on R20's face. RN-A placed R20's call light pad on her lap and instructed her to turn her call light on when the treatment was completed. R20 stated she always puts the light on when she was finished with the treatment. On 4/8/26 at 7:52 a.m., assistant director of nursing (ADON) told RN-A that she had removed R20 nebulizer mask and performed the post - respiratory assessment. R20's April medication/treatment administration report (MAR), printed 4/14/26, included the following order:-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligram(mg)/3millilter(ml) (a combination of two medications in one solution used to help open airways and prevent worsening of airflow obstruction) - 1 dose inhale orally two times a day related to chronic respiratory failure with hypoxia with a start date of 3/12/26. The record indicated the medication was administered twice a day as ordered as of print date of MAR.The MAR lacked evidence that R20 was able to administer the medication independently after staff set up. R20's order summary report, dated 4/14/26, included the following order:-Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) mg/3ml - 1 dose inhale orally two times a day related to chronic respiratory failure with hypoxia with a start date of 3/12/26.The order summary report lacked an order or evidence that R20 was able to administer the medication independently after staff set up. R20's care plan, with an initiation date of 4/8/26 (after survey entrance) for self-administration of medications/treatments indicated nurse to set up Neb and place mask on resident for resident to complete without supervision. Nurse to return to take mask off and complete [NAME] respiratory assessment when treatment is complete. The care plan lacked evidence of identification of R20 being assessed and able to self-administer nebulizer prior to 4/8/26. R20's entire medical record was reviewed and lacked any assessment, physician order, or care planning which demonstrated R20 had been evaluated for their ability to self-administer medication. During an interview on 4/8/26 at 11:50 a.m., RN-A stated if a resident was cognitively aware, then the resident could be left alone with a nebulizer after set up. RN-A stated we know our residents and who can be left alone with nebulizer treatments. RN-A verified that R20 was left alone in her room with her nebulizer treatment this morning and this was the facility practice. RN-A stated R20 was able to push her call light when the treatment was completed to have the mask removed. RN-A stated a self-administration assessment should be completed for residents who self-administer medications. RN-A verified an assessment had not been completed for R20. During an interview on 4/8/26 at 11:56 a.m., ADON verified she had turned off R20's nebulizer treatment earlier today and removed her nebulizer mask. ADON verified R20 had been in her room alone. ADON stated if a resident was left in their room while completing a nebulizer treatment, it would be expected a self-administration of medication assessment would be completed as this would be self-administration of medication. ADON verified this had not been completed for R20. ADON stated she was going to complete an assessment. During an interview on 4/14/26 at 9:58 a.m., director of nursing (DON) stated the expectation would be if a resident was left with a nebulizer, a self-administration of medication assessment would be completed as it's important because the residents have to have the knowledge and understanding of what the medications is used for and why. DON stated they must be properly assessed. A facility policy titled Medication Administration Self-Administration by resident, reviewed 1/26, identified residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Facilities must adhere to state specific laws and regulations. Furthermore, the document identified an assessment will be conducted to assess the resident's cognitive, physical and visual ability to carry out the responsibility.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to minimize the risk for serious injury, impairment or death, for 1 of 1 resident (R27) reviewed at risk for falls. Although R27 had a history of [REDACTED]. This resulted in an immediate jeopardy (IJ) for R27. The IJ began on 8/1/18, and was identified on 8/29/18 at 4:51 p.m., when it was determined the facility had failed to implement the physician's orders [REDACTED]. R27 sustained a forward fall from the wheelchair 7/29/18, that resulted in cervical [MEDICAL CONDITION] vertebra (C1). Although the physician had ordered safety interventions including a lap belt and recommendations for a wheelchair that could prevent or reduce the risk of another forward fall (wheelchair order 8/3/18), the facility failed to implement the physician orders [REDACTED]. As a result, R27 was diagnosed with [REDACTED]. Findings include: R27's Admission Record indicated R27 had originally been admitted to the facility 10/20/17, with a readmission 3/13/18. The Admission Record included a list of [DIAGNOSES REDACTED]. R27's significant change Minimum Data Set (MDS) an assessment dated [DATE], indicated R27's cognitive skills for daily decision-making was severely impaired and had rejection of care behaviors. The MDS also indicated R27 had unclear speech, sometimes was understood, and sometimes had the ability to understand others. In addition, the MDS indicated R27 had fluctuating signs and symptoms of [MEDICAL CONDITION] that included inattention and disorganized thinking. The MDS further indicated R27 had functional range of motion limitations in both lower extremities, did not ambulate, was dependent on two plus staff for transfers and toilet staff; required extensive assist of two plus staff for bed mobility and dressing, and extensive assist from one staff for locomotion. In addition, the MDS reflected R27 had one fall with major injury and two falls with no injury since the previous assessment. R27's fall Care Area Assessment (CAA) dated 8/13/18, indicated R27 was at risk for falls related to a fall on 7/29/18, that resulted in C1 (1st vertebra of the cervical spine or neck) fracture. The resident also had a history of [REDACTED]. The CAA identified fall risk factors including: [MEDICAL CONDITION] medication use, transfer with mechanical lift, metabolic [MEDICAL CONDITIONS], pressure ulcers, rarely was able to make needs known, and did not use call light. The CAA indicated staff were to monitor R27 for clinical situations that could increase risks such pain and weakness, and were to notify the provider for further evaluation and treatment. The CAA also indicated licensed therapy was evaluating R27's wheelchair positioning and the care plan would address R27's risk for falls. . R27's fall current care plan indicated R27 was at risk for falls related to cognition, being unaware of safety needs, deconditioning/weakness, history of falls and pain. Care plan interventions to prevent falls included: anticipate needs, encourage to use call light- answer promptly and keep in reach, educate on fall prevention measures, use of appropriate footwear, full body mechanical lift, and to review each fall to determine cause and prevent/minimize falls. An additional intervention had been added on 6/26/18, to encourage use of foot pedals in wheelchair as R27 would allow for positioning, to offer support and slow re-positioning if resident is leaning, and to encourage R27 to allow one on one support if accepting. On 7/26/18, an intervention was added to include physical/occupational therapy, treat as indicated. On 8/2/18, the care plan was revised to include will sleep in wheelchair, with approach to encourage to lay down or sit in recliner. On 8/14/18, care plan revision indicated R27 made unsafe choices like refusing to wear neck collar, and directed staff to remind R27 to wear collar to help neck heal. Review of fall incidents and interventions from 6/23-8/24/18 included the following information regarding R27's falls: 6/23/18, Fall Incident Report indicated R27 had an unwitnessed fall from his wheelchair in his room. The interdisciplinary Team review indicated R27 had indicated he was having trouble sitting as straight as he used to in his chair. The review indicated the plan was to seek occupational therapy to evaluate wheelchair and modalities for back pain. 6/26/18, Occupational Therapy (OT) Screen notes indicated nursing reported R27 fell out of wheelchair; note further indicated resident refused to make any necessary changes at that time and would continue to monitor. 7/16/18, Fall Incident report indicated R27 had an unwitnessed fall from his wheelchair near the nurses' station at 10:16 p.m. after he refused assistance from staff multiple times to lie down in bed. The report indicated prior to the fall R27 had been in the wheelchair sleeping and leaning forward. 7/17/18, OT Screen notes indicated R27 had increased behaviors to repositioning and slid forward out of his chair related to fatigue. OT recommended having maintenance tilt the chair slightly back by adjusting front wheels and R27 had refused further therapy intervention. 7/24/18, Fall Incident report indicated R27 had an unwitnessed fall from bed. 7/29/18, Fall Incident report indicated R27 had an unwitnessed fall at 11:15 p.m. from his wheelchair in the hallway. The report indicated prior to the fall R27 had been intermittently falling asleep in his wheelchair and had become combative when staff attempted to put him to bed. Corresponding nursing progress note indicated R27 had fallen head first out of his wheelchair and sustained a large abrasion on his left forehead. The note indicated interventions included: fall mat next to bed, a safety alarm while in wheelchair, and referral to interdisciplinary team. 7/20/18, R27's nursing progress note at 8:56 a.m. indicated R27 had a change in level of consciousness, was not easily aroused, and an order was obtained to send R27 to the emergency room (ER) for further evaluation. 7/30/18, R27's emergency room visit note indicated R27 had a fall on 7/29/18, and was diagnosed with [REDACTED]. The note indicated R27 was discharged back to the facility with a cervical collar. 8/1/18, R27's primary physician visit note indicated R27 had fallen forwards out of his wheelchair which resulted in a C1 fracture and required a cervical collar which was lying on the floor at the time of the visit. The note indicated some medication changes that included the discontinuation of [MEDICATION NAME] and [MEDICATION NAME] (blood pressure medication), and referral to behavioral health clinic. The note further included, SPECIAL RECOMMENDATIONS: need for restraints, he will require a seatbelt for his wheelchair to prevent worse injury to his cervical spine fracture. Physician orders [REDACTED]. The nursing progress note dated 8/1/18, reflected the physician's orders [REDACTED]. 8/1/18, OT's Plan of Care note dated 8/1/18, included: R27 presented with positioning deficits as a result from increased sleepiness/confusion episodes with refusals to transfer out of the wheelchair with subsequent fall forward from wheelchair that resulted in a C1 fracture. The note indicated nursing staff had noticed positioning difficulties with concerns for further falling out of the wheelchair face first. The evaluation indicated R27 required a high back/negatively tilted seat wheelchair related the sleepiness, confusion, refusals, excessive trunk flexion, and forward fall from the wheelchair. R27's OT's Daily Treatment Note dated 8/3/18, indicated the OT was not able to borrow that type of wheelchair from a neighboring nursing facility and was discussed with director of nursing (DON) and licensed social worker (LSW). DON and LSW discussed with the administrator who was going to inquire with other facilities. R27's nursing progress note dated 8/3/18, indicated primary care physician (PCP) was contacted with physical therapy/occupational therapy recommendations for a high-back wheel chair that reclined with a negative tilt seat. The note indicated the PCP responded, They can go ahead, and try, but he fought it the last time. 8/6/18, OT's Daily Treatment Note indicated environment director checked with the therapist on the specifications for the wheelchair, and reported the chair would be ordered today (8/6/18) and be in the building later this week. On 8/10/18, indicated the wheelchair had arrived and was put together. R27 was resistive to sitting in the chair, and once in the chair continued to be very upset, resistive, yelling, and swinging out. The OT indicated the seat on the wheelchair was too high. On 8/13/18, indicated the new high back wheelchair does not drop making it too tall for R27. The note further indicated R27 really needed a negatively tilted seat to decrease risk for falls from the wheelchair. On 8/15/18, indicated the wheelchair was returned to the supplier and on 8/16/18, the OT note indicated therapy would be placed on hold until appropriate wheelchair arrived. 8/22/18, R27's Fall Incident Report indicated R27 had an unwitnessed fall from his wheelchair in the dining room area. The report indicated R27 did not have his cervical collar on at the time of the fall, did not have any apparent injuries, and was sent to the emergency room . A computer tomography (CT) scan of the cervical spine was performed and indicated there was widening of the C1 fracture now at 11 millimeters (mm) compared with the 7 mm on the preceding study (7/29/18). 8/24/18, OT's Therapy Screen dated 8/24/18, indicated wheelchair positioning was in progress. On 8/27/18, at 1:46 p.m. R27 was observed in a regular wheelchair, located outside the front entrance to the facility. R27 had a safety alarm attached to his back, was not wearing the cervical collar, did not have a seat belt on, did not have a means to call staff such as a call light, and was not being directly supervised. R27 had his head down and was slightly leaned forward. At 1:55 p.m. nursing assistant (NA)-B was observed to bring a cup of water outside to R27, and to immediately return inside of the facility while R27 continued to sit outside. At 2:02 p.m. NA-B, walked to the door and looked at R27 who was sitting with his head down, then NA-B walked down the hallway. At 2:25 p.m. an unidentified staff member was observed to go outside and push R27's wheelchair back into the facility. On 8/28/18, at 8:23 a.m. R27 was observed seated in his regular wheelchair located in the dining room at a table. R27 had a cervical collar on, and a safety alarm was attached to his back. At 10:00 a.m., R27 was observed to continue to sit in his wheelchair in the dining room, his eyes were closed, and an unidentified staff member encouraged repositioning; R27 became agitated and the staff person walked away. At 11:00 a.m. R27 was observed to be seated in his wheelchair in the dining room without his cervical collar on. R27 was agitated and was refusing to go to a medical appointment. On 8/29/18, at 8:00 R27 was observed seated in his wheelchair in the dining room without the cervical collar on. R27's safety alarm was not attached and was dangling from the wheelchair. Although staff were observed in the dining room vicinity, R27 was not directly supervised. At 8:21 a.m. an unidentified staff member sat down by R27 to assist a neighboring resident with eating. At 8:49 a.m. NA-A was observed to clip the safety alarm to R27's back. At 9:10 am. R27 wheeled himself out of the dining room to his room. From 9:38 a.m. until 10:19 a.m. R27 was observed to sit in his wheelchair intermittently closing his eyes, head down, and would occasionally lean forward until he opened his eyes, and sit back up straight. R27 was observed to sit like that for periods ranging from 1 to 5 minutes. During this observation time, NA-A and NA-B periodically walked by the doorway and glanced inside the room. During interviews on 8/29/18, at 12:11 p.m., NA-A stated to prevent R27 from falling staff would encourage him to sit in the recliner if he was sleeping or leaning forward in his wheelchair, or they would try to find something to keep him awake. NA-A stated a safety alarm was placed on his chair when he started leaning forward more to alert staff when he would lean forward. NA-A also stated therapy had trialed a different wheelchair but could not move the chair by himself, so the chair had been switched back, and then at the beginning of the month another chair was attempted however, the seat was too high so the chair was switched out again, and they were waiting for the other chair to arrive. NA-A stated a seat belt had not been trialed. NA-A stated there was not a set schedule on how frequently she checked on R27, but said she looked in on him every time she passed by his room, and R27 was supposed to be repositioned every 2 hours. NA-A stated R27 liked to sit outside, could take himself outside, staff would bring water out frequently, and could be outside unsupervised because he sat in front of the business office window and there was usually someone there. NA-A indicated R27 did not like the cervical collar, often refused, and would take it off by himself. On 8/29/18, at 12:16 p.m. NA-B stated she checked on R27 every time she walked by him and if he was sleeping or leaning would suggest the recliner or bed, however, often refused repositioning. NA-B stated R27 was supposed to have a safety alarm on. NA-B then indicated a different wheelchair was attempted however, R27 did not like it and was unwilling to use it. NA-B stated a seat belt had not been trialed. NA-B indicated R27 could sit outside by himself without direct supervision and stated the business office is right there and can see him where he sits. NA-B indicated R27 did not like the cervical collar, often refused, and would take it off by himself. On 8/29/18, at 12:20 p.m. licensed practical nurse (LPN)-A stated R27 was at high risk for falls. LPN-A also stated there was no set frequency on how often staff were to check on R27 however, staff checked on him every time they passed by his room. LPN-A stated a different wheelchair was attempted however, the wrong one was sent, and the replacement had not yet arrived. LPN-A confirmed R27 had a tendency to fall asleep and lean forward; the other day I had to sit outside with him for a couple of hours just to hold him up so he wouldn't fall out of the chair. LPN-A indicated R27 could sit outside by himself, and staff would let the business office know when he went outside. LPN-A stated a seat belt had not been trialed. LPN-A indicated R27 did not like the cervical collar, often refused, and would take it off himself. On 8/29/18, at 12:21 p.m. LPN-B stated she had not worked on the hallway where R27's bedroom was located for a couple of weeks, was aware R27 had a fall that resulted in a spinal fracture, stated an unawareness of fall interventions without having to look at the care plan. LPN-B was not aware R27 had not gotten a new wheelchair or a safety alarm had been applied. LPN-B indicated R27 was not cooperative, and should almost be 1:1 supervision so he didn't fall. On 8/29/18, at 2:13 p.m. director of nursing (DON) stated when R27 started to lean forward a wheelchair that reclined was trialed, however, R27 refused to use it, so padded armrests were added to the wheelchair to assist with positioning. DON confirmed the physician had ordered a seat belt for the wheelchair on 8/1/18, and stated she had notified the administrator of the restraint order. DON indicated at the time of the physician order [REDACTED]. DON stated the physician was not immediately notified of the therapy recommendation for the high back wheelchair. DON confirmed R27's seat belt order was never implemented and R27's wheelchair was the one the falls had occurred from. DON also indicated the physician was not immediately notified of the therapy recommendation for the high back wheelchair with the negative tilt recommendation and had not communicated with R27's doctor (DR)-A when there was a delay in obtaining the wheelchair and interventions were not put into place while the facility was waiting to procure the wheelchair. On 8/29/18, at 2:29 p.m. the administrator confirmed the DON had communicated the physician's orders [REDACTED]. The administrator also stated the order was communicated with the therapy department director in order to determine the type of seat belt to use with the appropriate chair. The administrator stated the facility did not use a specific time span for observation of R27, but used terminology such as occasionally, frequently or very frequently. Administrator indicated the times a resident was checked were not recorded. The administrator defined occasionally as every 30 to 45 minutes and very frequently was every 15 minutes. Administrator indicated NAs may not be able to articulate time duration of frequently and very frequently) as she stated. Administrator stated R27 should be frequently checked on by staff. The staff were usually in the general location when he is out in common areas and knew to check on him while he was in his room when passing by his room. Administrator indicated R27 had rejection of care behaviors that were difficult to manage. On 8/30/18, at 8:14 a.m. during an interview with R27's primary doctor (DR)-A, DR-A stated he had anticipated more falls to occur without an intervention such as a seatbelt which was medically necessary to keep R27 safe. DR-A stated the forward fall (incident on 8/22/18) probably played a part in the worsening of the (C1) fracture along with other factors such as R27's refusals to consistently wear the neck brace, and repositioning while lying in bed. DR-A stated the facility had trialed different wheelchairs however, R27 had been resistive to the chairs and did not tolerate them. DR-A stated he was not aware the facility had not activated the orders for the seat belt and/or the specialized wheelchair yet. DR-A stated he would have expected to have been notified sooner about the inability to implement these measures, so something else could have been put in place. On 8/30/18, at 8:36 a.m. certified occupational therapy assistant (COTA)-A stated she had worked with R27 regarding the reclining chair when he was leaning. COTA-A indicated R27's recommended chair had still not arrived. COTA-A acknowledged not having been aware the physician had ordered a seatbelt to be used 8/1/18. On 8/30/18, at 8:58 a.m. physical therapy assistant (PTA)-A and the director of rehab department, stated the facility was still waiting for the high back negative tilt wheelchair to arrive. PTA-A stated the therapy department was not aware of the order for the seatbelt, and they would not be the ones who would apply it to the wheelchair. PTA-A stated therapy would only assess the stability of the chair in relation to forward gravity. The IJ which began on 8/1/18, was removed on 8/30/18, at 3:20 p.m. when it could be verified the facility had implemented a removal plan including: demonstrating 1:1 supervision of R27 until an appropriate wheelchair was obtained and a seat belt applied per DR-A's order, R27's fall risk care plan was revised and implemented, and the fall risk assessments and care plans had been updated for all other at risk residents. Additionally, therapy screens were completed for wheelchair positioning for all residents, and education was provided to the DON and licensed nursing staff related to incident procedures, investigation and implementation of physician orders. All staff were educated to the facility policies/procedures, and a quality assurance program was implemented to monitor incidents and accidents to reduce safety risks. The facility's 2/2017, Fall Prevention and Management Guidelines included: the facility will maintain a fall prevention and management program. In as much as it is in the power of the facility, the facility will prevent and/or manage the resident's risk for falls. The facility will implement a fall program for residents determined to be at risk for falls in order to better manage these factors and prevent and/or manage, as is possible, the resident from falling and/or sustaining injuries related to falling. Other components of the Fall Prevention and Management Guidelines included: staff to complete comprehensive assessments and re-assessments non-pharmacological interventions necessary such as use of devices including enablers and restraints.

Based on observation, interview and document review, the facility failed to complete a comprehensive reassessment to determine repositioning needs to prevent decline in current pressure ulcers or development of new pressure ulcers for 1 of 3 residents (R27) reviewed for pressure ulcers. The lack of reassessment and failure to implement timely repositioning resulted in harm, when R27 experienced recurrence of stage II pressure ulcer development. Findings include: The facility's 6/2017 Pressure Ulcer/Injury, Prevention policy, identified pressure ulcer stages to include: Stage 1- an observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area of the body may include changes in one or more of the following parameters: skin temperatures (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching), and/or defined area of persistent redness in lightly pigmented skin, whereas darker skin tones, the ulcer may appear with persistent, red, blue, or purple hues. Stage 2- partial thickness loss of dermis presenting as a shallow open ulcer with red/pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister. Stage 3-Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. (MONTH) include undermining or tunneling. R27's Admission Record dated 8/30/18, included [DIAGNOSES REDACTED]. R27's Significant Change Minimum Data Set (MDS) an assessment dated [DATE], indicated R27's cognitive skills for daily decision-making was severely impaired and had rejection of care behaviors. The MDS also indicated R27 had unclear speech, sometimes was understood, and sometimes had the ability to understand others. In addition, the MDS indicated R27 had fluctuating signs and symptoms of [MEDICAL CONDITION] that included inattention and disorganized thinking. The MDS further indicated R27 had functional range of motion limitations in both lower extremities, did not ambulate, was dependent on two plus staff for transfers and toilet staff; required extensive assist of two plus staff for bed mobility and dressing, and extensive assist from one staff for locomotion. In addition, the MDS reflected R27 had an indwelling urinary catheter and always incontinent of bowel. The MDS also indicated R27 had two stage I pressure ulcers, and one stage II pressure ulcer; interventions included: pressure reducing device for chair and bed, turning and repositioning program, nutrition/hydration intervention, pressure ulcer care, and application of non-surgical dressings. R27's pressure ulcer Care Area Assessment (CAA) dated 8/13/18, indicated R27 had developed two pressure ulcers on his scrotum and had several open areas related to moisture associated skin damage and history of picking at his skin. In addition, the CAA indicated the pressure areas were not healing so the physician had initially ordered a male incontinence device however, R27 was not cooperative and on 7/6/18, an indwelling catheter was inserted. The CAA indicated R27 required pressure reducing devices for chair and bed, and a nutritional supplement was added. The CAA further indicated R27 required a turning program. R27's care plan dated 8/16/18, indicated R27 had one stage II and two stage I pressure ulcers on his scrotum, and a history of surgical wound to right hip that had reopened. The care plan further indicated R27 was receiving suppressive antibiotics for [MEDICAL CONDITION] (MRSA) colonization. Interventions were identified to include: Apply alternating pressure air mattress to bed if indicated and chair cushion to wheelchair, both initiated 7/25/18. Assess and measure all skin integrity areas weekly initiated 7/26/18. Encourage frequent repositioning in bed and chair initiated 8/10/18. Interventions that had been initiated 10/5/17 included: Follow pressure ulcer prevention guideline to prevent additional skin problems, monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately, provide treatment to wound(s) per current treatment order, and assess wound(s) for signs and symptoms of infection with each dressing change/treatment. The care plan also included a problem related to rejection of care which was dated 11/7/18. The care plan indicated R27 sometimes rejected care which include transfers, going to bed, and toileting, related to cognitive impairment/communication skills. Interventions included for staff to: Have another staff member approach with cares initiated 5/2/18, and help make good choices by informing of risks and benefits initiated 5/7/18, and to re-approach at a different time as necessary. Although information regarding R27's skin reassessment to determine risk for pressure ulcer(s) development, and assessment to determine skin response to time and pressure over bony prominences (off load) in order to determine frequency for repositioning/offload, none was provided by staff, or found in R27's records. Skin Review notes dated 6/27/18, indicated a [MEDICATION NAME] dressing was applied to open areas on right buttocks. On 7/4/18, identified a stage III pressure ulcer to the front of scrotum that measured 7 centimeters (CM) by 2 cm. On 7/11/18, included: two pressure ulcers to scrotum one measured 4.0 cm by 1.0 cm and with scant amount of drainage and the other measured 2.0 cm by 2.2 cm. Both were open to air with barrier cream applied. The note further indicated R27 had a pressure area on the bottom about the size of a quarter but did not identify where on the bottom or the pressure ulcer stage. On 8/8/18, the Skin Review notes indicated R27 had a stage II on the front of his scrotum that measured 2.0 cm x 1.5 cm with no depth, had a stage I ulceration measuring 1.0 cm by 0.5 cm with no depth (location was not identified), and had multiple open areas on the coccyx, right hip, and left and right medial buttocks from where R27 had scratched and picked (measurements were not indicated). The Skin Review note from 8/15/18, indicated R27 had multiple open areas to the coccyx related to picking, right hip had multiple open areas with greenish drainage, right and left buttock had multiple open areas from picking, and scrotum had two pressure ulcers (documentation did not include staging of pressure ulcers or measurements of impaired skin integrity). Skin Review notes from 8/22/18, indicated left buttock stage III pressure ulcer 2.0 cm x 2.5 cm (depth not indicated). Right hip infected surgical site 6 cm x 5 cm (no depth indicated); middle had jelly bean like blister 2 cm x 1.3 cm., and multiple scratches on buttocks and hips. The Skin Review notes from 8/29/18, indicated R227 had an infected right hip surgical wound measuring 6.3 cm x 3 cm raised 0.5 cm with yellow green odor; and had a black area inside the wound 2.6 cm x 4 cm x 1.2 cm In addition, the notes indicated the resident had a left inside buttock pressure ulcer (not staged) 1.6 cm x 1.2 cm x 0.2 cm, inside right buttock pressure ulcer 2.7 cm x 1.2 cm x 0.5 cm with no drainage, that was pink in color (not staged). During an interview with registered nurse (RN)-A on 8/28/18, at 2:00 p.m. RN-A stated nurses would have completed a tissue tolerance test in the past (a method for determining how long tissue over bony prominences could sustain pressure) however, had stopped doing the tissue tolerance tests this past spring (2018). RN-A stated repositioning schedules were now determined by diagnosis, skin condition, and the Braden Scale (evaluation to predict pressure ulcers). RN-A also stated residents should be repositioned at least every two hours. During continuous observation of R27 on 8/29/18, beginning at 8:00 a.m., and ending at 10:30 a.m., R27 was observed to sit in his wheelchair without being reminded or assisted to reposition or offload. At 8:00 a.m. R27 sat in his wheelchair in the dining room. The wheelchair was observed to have a pressure reducing cushion. At 8:49 a.m. nursing assistant (NA)-A told R27 she would set him up to shave in a little bit. R27 then wheeled himself back to his room at 9:10 a.m. At 9:27 a.m. R27 continued to sit in his wheelchair in his room. Although NA-A entered the resident's room at 10:00 a.m., NA-A did not offer R27 repositioning/offloading. At 10:03 a.m. R27 was observed to sit in his wheelchair with his eyes closed leaning forward in a hunched position. At 10:30 a.m. NA-A and licensed practical nurse (LPN)-A asked R27 if they could lay him down and check his incontinent garment. R27 stated something that was not understandable, but was agreeable to lie down. NA-A and LPN-A transferred R27 into bed using a full body mechanical lift. An air mattress was observed on the bed. R27 had an absorbent dressing to right hip dated 8/29/18, that was ¾ saturated with drainage, an intact wound dressing to the lower left buttock dated 8/29/18, and an uncovered open wound on the mid right buttock. Following the dressing change for R27 on 8/29/18 at 10:30 a.m. LPN-A stated she had done a skin evaluation and completed R27's dressing changes at 6:30 a.m. that morning. LPN-A stated the wound to the right buttock had not been present during that dressing change, but there is now a stage II pressure ulcer. NA-A, present during the interview with LPN-A, also said she had not seen the right buttock pressure ulcer that morning at 6:30 a.m. when LPN-A had conducted the dressing change/treatment. When asked when R27 had gotten up into the wheelchair, NA-A and LPN-A stated R27 had been gotten up in his wheelchair that morning at approximately 7:00 a.m. NA-A stated R27 was normally repositioned when he allowed, which was supposed to be every two hours. NA-A verified R27 had not been repositioned every two hours that morning. On 8/29/18 at 10:46 a.m., the director of nursing (DON) observed R27's newly developed open pressure area located on the resident's mid right buttock. The DON stated the wound was a stage II pressure ulcer and stated the ulcer was recurrent, because R27 used to have a stage II in the same location that had been healed for a couple of weeks. LPN-A was present during the interview and stated the ulcer measurements were 1.6 cm x 1.2 cm. During interview on 8/29/18 at 12:16 p.m., NA-B stated R27 was checked on frequently, and stated if he was sleeping or leaning they would offer to transfer him to his bed or recliner. NA-B stated R27 should be repositioned every two hours but often refused. During interview on 8/29/18 at 12:21 p.m. LPN-B stated R27 could be very uncooperative, and often times refused repositioning but should still be offered repositioning every couple of hours. The DON verified during interview 8/29/18 at 2:51 p.m., the care plan did not reflect a turning/repositioning program. The DON stated repositioning is determined by the resident's skin condition, co-morbidities, and the Braden Scale for predicting pressure ulcers completed upon admission. The DON also stated R27 should be repositioned, or at least offered repositioning, every 2 hours. She stated if R27 refused the staff were supposed to document the refusal. At 2:53 p.m. on 8/29/18, registered nurse (RN)-F, a consultant, acknowledged the facility staff did not do tissue tolerance (off loading assessments) because it was a thing of the past. RN-F stated repositioning/offloading needed to be individualized and should be based on the results of a skin assessment, Braden risk score, and vulnerabilities. RN-F also stated upon admission all diabetics are given an air-mattress and their heels are floated. At 10:19 a.m. on 8/29/18, LPN-A stated she performed the weekly wound evaluations, did the measurements, applied the wound dressings, and would report any changes to the DON. LPN-A stated the DON would then determine the wound type and update the care plan. LPN-A was unaware if the facility had a skin protocol or standing orders for wound treatments. LPN-A stated R27 should be repositioned/offloaded or offered repositioning every two hours. During a follow up interview with the DON, at 10:57 a.m. on 8/29/18, the DON stated if NAs reported to the assigned hallway nurses any new skin concerns; the nurse would then clean and measure the wound, inform the physician, and RNs would assess the wound and determined wound type and stage. The DON stated there was a skin care management program that provided descriptions of the wounds, staging, and dressing types. The DON stated, except for care conferences, there was no system in place to routinely review current care plan interventions for effectiveness and appropriateness in order to determine new interventions. However, the DON stated the facility was working on implementation of a Skin Integrity Management Program and training of nurses which included an assessment to determine pressure ulcer risks and repositioning schedules. The facility's 6/2017 policy Pressure Ulcer/Injury, Prevention included the following procedure: Assess for risk of pressure ulcer/injury development; identify high and low risk residents, develop a care plan to eliminate or minimize risk factors including: D) pressure relief measures, E) resistance or refusal of care: explain care plan approaches to resident, establish a turning and repositioning schedule in bed and chair to meet the resident's needs, position with appropriate surfaces to protect bony prominences, check skin status each shift, report changes or problems promptly to supervisor. Documentation Guidelines include: Date, time, approaches to prevent pressure ulcer/injury development. Care Plan Documentation Guidelines: Identify and treat underlying cause of pressure ulcer/injury, identify frequency of positioning and record behavior management if appropriate.

Based on observation, interview and document review, the facility failed to follow the care plan related to transfers for 2 of 3 residents (R9 & R14) that resulted in actual harm for R9 when the resident was lowered to the floor and sustained a spiral femur fracture. The facility also failed to follow the care plan for activities of daily living (ADL's) for 1 of 3 residents (R12), and failed to monitor bruising for 1 of 1 resident (R38) reviewed for bruises of unknown origin. Findings include: R9 was admitted on [DATE]. Review of R9's admission record identified [DIAGNOSES REDACTED]. R9's Minimum Data Set (MDS) significant change assessment dated [DATE], identified a Brief Interview for Mental Status score of 00 indicating severe cognitive impairment. The Care Area Assessment (CAA) identified R9 at risk for falls and fall related injuries and the need for extensive assistance of 2 staff with transfers. Review of R9's care plan, revised 3/25/16, identified R9 had physical functioning ADL(activities of daily living) deficit with interventions to include R9 should have transfer assist of one staff and EZ stand lift or use 2 staff as needed (PRN). Review of the quarterly interdisciplinary resident review dated 8/15/16, identified ADL's included transfers with the use of stand lift. The certified nursing assistant (NA) care sheet, updated 8/23/16, identified R9 required the EZ stand and 1 staff assist for transfers. Review of R9's nursing notes dated 8/21/16, at 9:54 p.m. identified R9 was being transferred from the commode to the bed with a transfer belt and slid down on the floor next to her bed. The incident report dated 8/21/16, under the IDT (interdisciplinary team) review and recommendations, identified the care plan intervention of 1 assist w/ (with) EZ stand for transfers was not followed at the time of the fall. Education was provided to the NA assisting R9. R9 would remain an EZ stand for transfers. Further review of the nurses notes identified R9 transferred to the hospital 8/23/16 with a spiral [MEDICAL CONDITION] femur. During interview on 8/24/16, at 3:05 p.m. nursing assistant (NA)-H stated she transferred R9 on 8/21/16 when R9 was lowered to the floor. NA-H stated while she was transferring R9 between the commode and bed, R9's right heel caught on the commode as she was turning her and R9, fell into me and I slid her to the floor. NA-H stated staff were supposed to use the EZ stand lift to transfer R9. NA-H stated she used the transfer belt at times to transfer R59 between the commode or wheelchair and the bed. NA-H also stated she was aware the EZ stand was supposed to be used for R9 when transferring. NA-H stated, I screwed up big by not using it. When asked if there was any special reason she used the transfer belt and not the stand NA-H she stated both lifts were in use and they were short-staffed. During interview with the director of nursing (DON) on 8/23/16, at 3:12 p.m., the DON verified NA-H did not follow R9's care plan for transfers. During interview on 8/25/16, at 11:53 a.m. licensed practical nurse (LPN)-B verified NA- H did not follow the care plan. NA-H stated she thought she could just transfer R9 with the belt since R9 was right by the bed. NA-H then stated R9's foot got caught on the commode when she was turning her and R9 fell in a direction towards NA-H. On 8/23/16, at 8:35 a.m. a note identified R9 was transferred with a full body lift. A note from 8/23/16, at 9:30 a.m. identified R9 was having pain in her right thigh with the area being swollen, having a large hematoma and tender to touch and movement. R9 was transferred to the hospital at 10:50 a.m. on 8/23/16. A note from the emergency room (ER) visit dated 8/23/16, at 11:07 a.m. identified R9's right leg was shortened and externally rotated. A note from 8/23/16, at 13:06 (1:06 p.m.) from the ER identified that R9's physician had contacted the facility and stated R9 had sustained a spiral [MEDICAL CONDITION] femur. An admission note from the hospital dated 8/23/16, at 16:02 (4:02 p.m.)identified R9 had a severe right femur fracture. The note indicated can see femur close to skin and R9 demonstrated non- verbal indicators of pain and had a very swollen right femur/hip area. During observation of cares on 8/22/16, at 4:58 p.m. R12 was observed in her room with long, jagged fingernails with dark brown substance underneath on both hands. R12 confirmed her nails were long and soiled and stated she needed to have her nails cut as they were too long. On 8/24/16, at 10:25 a.m. R12 was observed lying in bed. During the observation R12 was noted to continue to have long, jagged fingernails that were soiled underneath. R12 was further noted have a black/brown substance on her left thumb cuticle. R12 was interviewed during the observation and stated she needed to have her nails cut and that staff were going to do it sometime later in the day. On 8/24/16, at 4:00 p.m. R12's nails remained long, jagged and dirty with the black/brown substance remaining on the left thumb. R12 stated, staff had not come to her room to cut her nails and she wasn't sure when they would. On 8/25/16, at 7:31 a.m. R12 was observed in her room with nails remaining long, jagged and dirty with the black/.brown substance still present on the left thumb cuticle. R12 also stated her nails were too long and she needed them cut. R12's quarterly minimum data set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) assessment score of 11 indicating moderate cognitive impairment. The MDS also identified that R12 required extensive assistance with personal hygiene. Review of R12's current resident care sheet identified R12 received a weekly bed bath on Friday mornings and had a splint to the left hand that was to be removed daily for hygiene. Review of R12's bath schedule for 8/19/16, indicated R12 had received a bath. The bath schedule identified staff were to PLEASE REMEMBER TO DO NAIL CARE!! The care plan revised 8/24/16, identified R12 required assistance of one staff with personal hygiene and nail care as needed (PRN). R12 also had an order to remove her palm guard in the A.M. with cares and complete hand hygiene which was indicated on the order review report dated 8/1/16-8/31/16. When interviewed on 8/25/16, at 10:58 a.m. nursing assistant (NA)-A stated R12 got a bed bath on Fridays and staff were supposed to do her nails. She stated at times the nail cares did not get done because she received a bed bath instead of a tub bath. NA-A verified it did not look like R12's nail care had been completed with her bed bath on Friday. NA-B verified R12's nails were long, jagged and dirty. NA-B stated she would clean and trim R12's nails right away. NA-B also stated, I tell my director that they need to do nails with a bed bath too and they don't always do it. When interviewed on 8/25/16, at 11:00 a.m. the DON confirmed R12's care plan was not followed for nail care. Review of the facility policy for Bed bath, last reviewed 12/7/15, included: PROCEDURE: 14. Care of fingernails and toenails is part of the bath. Be certain nails are clean. R14 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R14 required extensive assistance with toilet use, dressing, and personal hygiene, and supervision with one person physical assistance with bed mobility, transfer, and locomotion off the unit. R14's care plan last revised 4/4/16, indicated a risk for falls. Interventions included: Bed and W/C (wheelchair) alarms in place and checked daily for proper functioning. Review of the nursing assistant assignment sheet identified R14 utilized a bed and chair alarm for safety. When interviewed on 8/24/16, at 3:20 p.m. nursing assistant (NA)-D stated R14 required assistance with transfers and toileting though would not always ask staff for assistance. NA-D stated that when R14 is in bed, she would often refuse cares as she just wanted to rest and not be disturbed. NA-D was unsure if the resident utilized an alarm when up in her w/c. On 8/25/16, at 9:53 a.m. R14 was observed lying in bed crossways and appeared to be sleeping. The resident's head was positioned up against the wall with her legs/feet hanging off the exit side of the bed. R14's w/c was observed positioned next to the bed by the resident's feet with brakes off; no bed or chair alarm was visualized. At 10:05 a.m., NA-A stated R14 had probably transferred herself into bed. NA-A confirmed an alarm was not in place on the chair nor in the bed and should have been. NA-A stated she wasn't working on the resident's hall today but confirmed she had observed the resident utilizing a TABS clip alarm the day before while up in her w/c. NA-A searched R14's room for an alarm but was unable to locate one; NA-A stated the resident had been known to hide or throw away the alarms in the past. NA-A also attempted to reposition the resident in bed but the resident refused and yelled at NA-A to leave her alone. NA-A positioned R14's w/c next to the bed with the brakes locked then exited the room to alert the assistant director of nursing (ADON) that R14 was in need of a bed alarm. Shortly afterwards the ADON and NA-B entered R14's room with a sensor pad alarm. NA-B attempted to reposition R14 in bed while the ADON placed the sensor pad underneath the resident. The ADON was able to place the sensor alarm underneath the resident though R14 continued to refuse repositioning. NA-B stated the resident had refused morning cares earlier though was unsure who had assisted the resident in getting up for the day; NA-B was unsure if R14 had utilized an alarm earlier. NA-B searched R14's room and was unable to locate an alarm. The ADON confirmed the resident was to utilize an alarm when in her w/c and in bed per the plan of care. R38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R38's 14-day admission data set (MDS) included a brief interview for mental status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS further indicated R38 required total dependence with transfers and bathing, and extensive assistance with bed mobility, locomotion on/off unit, dressing, toilet use, and personal hygiene. The care plan included a focus of altered skin integrity non pressure initiated 8/1/16. Interventions included: Conduct weekly skin inspection. Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. Skin assessment to be completed per Living Center Policy. Review of the Weekly Skin Reviews dated 8/9/16 and 8/23/16 indicated: Skin Intact. The skin reviews did not include evidence of other skin conditions including bruising. Review of the nursing progress note by registered nurse (RN)-A dated 8/10/16, at 23:25 (11:25 p.m.) included the following: Noted bruising on left arm from shoulder to elbow. Area soft and resident denies pain to touch. Continues to need full lift for transfers and remains incontinent of both bladder and stool. The note did not include measurements of the left arm bruising nor evidence of notification to the physician or other nursing staff. A subsequent nursing progress note by RN-A dated 8/14/16 at 23:13 (11:13 p.m.) included: Did request prn [MEDICATION NAME] at HS (hour of sleep) for left upper arm pain, that was effective. Further review of R38's medical record did not include evidence of the bruising until a nursing progress note dated 8/17/16 at 02:42 (2:42 a.m.). The progress note indicated: Type: SBAR - Change of Condition Situation: 0100 (1:00 a.m.) CNAs (certified nursing assistants) discovered lg. (large) dk. (dark) purple bruised area on posterior aspect of L (left) upper arm extending from L shoulder to L elbow and a smaller bruised area on lateral L [MEDICATION NAME] area of res.'s (resident's) body that appear to be new and were not present on admission assessment paper form 7/19/16. There is a brief notation in a Gen. (general) Note dated 8/10/16 @ (at) 2325 re: a L upper arm bruise from shoulder to elbow, no measurement. Background: Last fall here at this facility is on 7/29/16. Res. is on ASA (aspirin) 325 mg p.o. (by mouth) daily for MI ([MEDICAL CONDITION] infarction) prevention, has not be on p.o. or injectable anticoagulation therapy here at GLC (Golden Living Center) since admission. Most recent admission here has (sic) for post hip fx (fracture) rehab. (rehabilitation). Medical hx (history) list does not include platelet or blood clotting factors pathology. Noted to have increased mental confusion on 8/16/16. Elderly male 96 y.o. (years old). Assessment: measurements - posterior L upper arm, 28 cm (centimeters) L (long) x (by) 12 cm W (wide) is dk. purple and soft. Lateral L [MEDICATION NAME] 8 cm L x 10 cm W is a lighter purple, soft. No palpable firm areas on either location. This writer is unable to find a lab report in paper chart re: a CBC (complete blood count) or platelet count result. Response: This writer initiated a Temporary Problem for communication to lic (licensed) nursing staff for on-going assessment and charting. This writer will fax a note re: this issue to Dr. (physician name) at local clinic. This writer is not certain that bruising is new occurrence due to the notation in the 8/10/16 General Note/Progress Notes in PCC (point click care). When interviewed on 8/24/16, at 4:16 p.m. RN-A stated when a new skin condition for a resident is identified the charge nurse would assess the resident and initiate an SBAR (situation, background, assessment, recommendation) note. The nurse would then notify the physician, create a temporary care plan, and pass on the resident's change in condition in report to the next shift. RN-A stated a bruise of unknown origin, if suspicious, would be reported to the state. RN-A further stated if bruising was occurring frequently or if a larger bruise or hematoma of unknown origin was identified and not explainable would also be reported to the state. Surveyor reviewed the 8/10/16 progress note written by RN-A pertaining to R38's left arm bruising. RN-A confirmed the resident had large bruising to the left upper arm that extended from the shoulder to the elbow. RN-A stated the resident had a history of [REDACTED]. RN-A stated she should have completed an SBAR note and notified the physician and confirmed that had not been done. RN-A further verified the bruising had not been passed on to the next shift, investigated for possible causes nor reported to the state agency when identified on 8/10/16. When interviewed on 8/26/16, at 8:46 a.m. the DON stated she was unaware of R38's left arm bruising first identified on 8/10/16 and subsequently on 8/17/16. DON stated R38 was prone to bruising as had fallen many times prior to admission to the facility and was identified with many bruises upon admission. DON reviewed R38's medical record and confirmed the resident was not admitted with the left arm bruising. DON confirmed the large area of bruising of unknown origin to R38's left arm should have been assessed with [REDACTED].

Based on observation, interview and document review, the facility failed to assess for pain and provide the necessary care and services for 1 of 3 residents (R9) in the sample who fell and sustained a femur fracture which resulted in actual harm, significant pain to R9, due to the facility's failure to assess and provide medical care in a timely manner as required. Also the facility failed to provide non pressure related skin care to 1 of 1 resident (R38) who had bruising of unknown origin and failed to ensure services were coordinated with the hospice agency for 1 of 1 residents (R28) receiving hospice care. Findings include: R9's admission record identified [DIAGNOSES REDACTED]. R9 was observed on 8/22/16, at 5:24 p.m. sitting in her room in her wheelchair restless and moaning. An interview was attempted about her restlessness and moaning but R9 was unable to respond appropriately to questions. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R9 with a Brief Interview for Mental Status (BIMS) score of 00 indicating R9 had severe cognitive impairment. The Care Area Assessment (CAA) associated with the MDS identified R9 was at risk for falls and fall related injuries and required extensive assistance of 2 staff with transfers. Review of R9's care plan revised 3/25/16, identified a physical functioning ADL (activities of daily living)/deficit with interventions that included transfers with assist of one staff and EZ stand lift (mechanical lift) or use 2 staff PRN (as needed). Review of the quarterly interdisciplinary resident review dated 8/15/16, identified R9 required ADL assistance including transfers with stand lift. The certified nursing assistant (NA) care sheet updated 8/23/16, identified R9 requiring the EZ stand and 1 assist for transfers. During review of the nurses notes the following entries were noted: On 8/21/16, at 9:54 p.m. the note identified a change of condition situation had occurred. It was documented in the note that R9 was being transferred from the commode to the bed with a transfer belt and slid down on the floor next to her bed. The note further identified minimal pain to right side and that R9 had reddish colored bruises on her right upper back under her right arm. The note also identified R9 stated she had pain all over. On 8/22/16, at 8:53 a.m. a note identified that R9 had complained of right thigh pain at 6:00 a.m., and was unable to stand and required staff to use a full lift to transfer R9. On 8/22/16, at 4:31 p.m. a note identified R9 was complaining of pain to her right thigh while transferring in the EZ stand (mechanical lift device). On 8/22/16, at 10:28 p.m. a note identified R9 was having marked weakness when attempting to utilize the EZ stand and was not able to transfer safely. The note further indicated a full lift was used to transfer R9 back to bed at bedtime. R9 was noted to have a 6 centimeter (cm) red scrape below her left rib cage, on the outer aspect of her left chest. An addendum to the note at 11:27 p.m. clarified the scrape was on the right not the left. The note also identified R9 had a large light purple hematoma (bruise) that was raised and staff were able to cup their palm around the entire hematoma, The hematoma was identified as being firm to touch and measured 6 cm by 12 cm. R9's upper trochanter area was warm to touch. R9 was noticed to wince in pain with use of the lift as well as when rolled gently in bed. On 8/23/16, at 8:35 a.m. a note identified R9 was transferred with a full body lift. A note from 8/23/16, at 9:30 a.m. identified R9 was having pain in her right thigh with the area being swollen, having a large hematoma and tender to touch and movement. R9 was transferred to the hospital at 10:50 a.m. on 8/23/16. A note from the emergency room (ER) dated 8/23/16, at 11:07 a.m. identified R9's right leg was shortened and externally rotated. A note from 8/23/16, at 13:06 (1:06 p.m.) from the ER identified that R9's physician had contacted the facility and stated R9 had sustained a spiral [MEDICAL CONDITION] femur. An admission note from the hospital dated 8/23/16, at 16:02 (4:02 p.m.)identified R9 had a severe right femur fracture. The note indicated can see femur close to skin and R9 demonstrated non- verbal indicators of pain and had a very swollen right femur/hip area. During interview on 8/23/16, at 11:01 a.m. nursing assistant (NA)-I stated she did not get R9 up that morning. NA-I stated night shift got R9 up. NA-H stated when she transferred R9 to the wheel chair that day she used a full body lift rather than the EZ stand as R9 was sore on the right side. During interview on 8/23/16, at 2:25 p.m. NA-J stated R9 utilized an EZ stand lift. NA-J stated the instructions to use the EZ stand lift was indicated on the NA care sheet that the aides carry with them. During interview on 8/23/16, at 2:32 p.m., NA-D stated she was working the evening shift on 8/22/16. NA-D stated when she went to get R9 up out of her recliner with the EZ lift, R9 was leaning way to the left putting all of her weight on the left side, which was not usual for R9. NA-D stated R9 could not stand and was wincing with pain. NA-D stated at that time she notified the nurse immediately. NA-D stated that when she went in to put R9 to bed later that evening she again attempted to use the EZ lift and R9 would not put any weight on her right leg and was very pale and weak. NA-D stated staff then used a full body lift to get R9 into bed. NA-D stated she again told the nurse of R9's condition and the nurse then went to check on R9 and took vital signs (vs). During interview on 8/24/16, at 11:21 a.m. the assistant director of nursing (ADON) stated that when R9 was unable to transfer her typical way, going from an EZ lift to a full body lift, the situation should have been looked into and warranted further investigation. The ADON stated,This would be considered a change of condition for (R9) and she should have been reassessed. The ADON further stated she was not aware of R9's condition until they were going to send her to the hospital. During interview on 8/24/16, at 3:05 p.m. NA-H stated she was transferring R9 from the commode to the bed on 8/21/16 and utilized a transfer belt. During the transfer R9 got her heel caught on the commode and when NA-H went to turn to get resident onto the bed, R9 fell into her and NA-H slid R9 to the floor. NA-H stated R9 grabbed her right leg and complained of pain. During interview on 8/24/16, at 3:32 p.m. registered nurse (RN)-C stated she was working the day shift on 8/22/16. RN-C stated that at approximately 10:00 a.m. an aide told her R9 was having trouble keeping her feet on the EZ lift. RN-C stated that NA-A had reported to her that R9 was moaning and groaning a lot and complaining of her leg hurting. During interview on 8/24/16, at 2:55 p.m. RN-A stated she had worked the evening of 8/22/16. RN-A stated she was told in report that R9 was transferring poorly during the day. RN-A stated the aides didn't feel safe transferring R9 with the EZ stand lift. RN-A stated staff asked her to go look at R9 which she did and she took R9's VS which were fine. RN-A further stated R9 was grimacing and appeared to be in a lot of pain when she was assisted into bed. RN-A also stated, at around 10:00 p.m. she notice R9's right leg was out of sync and she noted the huge hematoma on R9's thigh and the huge scrape on her side. RN-A stated R9 had facial grimaces while staff were turning her stating,She was weaker and having a lot of pain. RN-A stated she did not check to see if one leg was shorter than the other but documented and reported off to the night shift her findings. During interview on 8/25/16, at 6:27 a.m. NA-K stated she had worked the night of the 8/21/16. NA-K stated it was not reported to the NA's that R9 had an incident on the evening shift. NA-K stated R9's leg was swollen and sore and R9 asked for a pain med during the night. NA-K stated when she went to get R9 up in the morning with the EZ lift, R9 was crying and moaning in pain and could not transfer NA-K stated the nurse went in and gave R9 a pain medication and stated she was going to look at R9's leg in the morning. NA-K stated when she sat R9 up R9 complained of pain and started moaning and could not bear weight on her right leg. NA-K stated,Her leg hurt really bad and she wouldn't put pressure on it, it was swollen at that time. During interview on 8/25/16, at 6:40 a.m. NA-L stated R9 complained of pain when she was rolled over. NA-L also stated R9's leg was swollen and painful with movement and stated, Anytime we rolled her she grimaced and complained of pain. During interview on 8/25/16, at 9:37 a.m. NA-A stated she had worked the day shift 8/22/16. NA-A stated R9 was very restless and tired and would not open her eyes when her name was called which would be unusual for R9. NA-A stated she used the EZ stand as that is what the care plan indicated. NA-A stated R9 had a lot of pain with the transfers which was reported to the nurse. NA-A stated R9 was different than her normal, was not transferring well and kept repeating she had pain. During interview on 8/25/16, at 11:30 a.m. R9's daughter (FA)-A stated she was at the hospital when her mother was transferred on 8/23/16. FA-A stated her mother was in so much pain it was excruciating to watch. FA-A stated she had seen the x-ray of her mother's right leg and the surgeon had pointed out that the femur was broken at an angle and it was over-lapping 3 inches. The daughter also stated, How did they not notice this, Her foot was sideways and 3 inches shorter? I don't know how they could even try to stand her up! During interview on 8/25/16, at 11:53 a.m. LPN-B stated she was on duty when R9 was lowered to the floor. LPN-B stated she did not notice bruising, did a little range of motion and didn't think the right leg appeared to be fractured. During interview on 8/26/16, RN-D stated R9 was having pain the morning of 8/22/16. RN-D stated R9 may have had more pain in the right lower extremity and stated,She will have pain after a fall. RN-D stated NA-K had caught her at the end of the shift and reported R9 had pain and difficulty transferring. RN-D further stated that on the night of 8/22/16 to 8/23/16, the NA's reported R9 was having pain in her right leg with repositioning. NA-D stated she gave R9 Tylenol in the morning before she got up. During interview with the ADON on 8/24/16, at 11: 21 a.m. the ADON verified the physician should have been notified sooner of R9's increased pain and inability to transfer. The ADON verified the documentation identified R9 had been demonstrating pain, had swelling of her leg, and was restless from 8/21/16 to 8/23/16. The facility policy Notification of Change in Resident Health Status last reviewed 11/11/15, identified the facility would consult the residents physician, nurse practitioner or physician assistant when there was: (A) An accident which results in injury and had the potential for requiring physician intervention. R38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R38's 14-day admission data set (MDS) included a brief interview for mental status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS further indicated R38 required total dependence with transfers and bathing, and extensive assistance with bed mobility, locomotion on/off unit, dressing, toilet use, and personal hygiene. The care plan included a focus of altered skin integrity non pressure initiated 8/1/16. Interventions included: Conduct weekly skin inspection. Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. Skin assessment to be completed per Living Center Policy. Review of the Weekly Skin Reviews dated 8/9/16 and 8/23/16 indicated: Skin Intact. The skin reviews did not include evidence of other skin conditions including bruising. Review of the nursing progress note by registered nurse (RN)-A dated 8/10/16, at 23:25 (11:25 p.m.) included the following: Noted bruising on left arm from shoulder to elbow. Area soft and resident denies pain to touch. Continues to need full lift for transfers and remains incontinent of both bladder and stool. The note did not include measurements of the left arm bruising nor evidence of notification to the physician or other nursing staff. A subsequent nursing progress note by RN-A dated 8/14/16 at 23:13 (11:13 p.m.) included: Did request prn [MEDICATION NAME] at HS (hour of sleep) for left upper arm pain, that was effective. Further review of R38's medical record did not include evidence of the bruising until a nursing progress note dated 8/17/16 at 02:42 (2:42 a.m.). The progress note indicated: Type: SBAR - Change of Condition Situation: 0100 (1:00 a.m.) CNAs (certified nursing assistants) discovered lg. (large) dk. (dark) purple bruised area on posterior aspect of L (left) upper arm extending from L shoulder to L elbow and a smaller bruised area on lateral L [MEDICATION NAME] area of res.'s (resident's) body that appear to be new and were not present on admission assessment paper form 7/19/16. There is a brief notation in a Gen. (general) Note dated 8/10/16 @ (at) 2325 re: a L upper arm bruise from shoulder to elbow, no measurement. Background: Last fall here at this facility is on 7/29/16. Res. is on ASA (aspirin) 325 mg p.o. (by mouth) daily for MI ([MEDICAL CONDITION] infarction) prevention, has not be on p.o. or injectable anticoagulation therapy here at GLC (Golden Living Center) since admission. Most recent admission here has (sic) for post hip fx (fracture) rehab. (rehabilitation). Medical hx (history) list does not include platelet or blood clotting factors pathology. Noted to have increased mental confusion on 8/16/16. Elderly male 96 y.o. (years old). Assessment: measurements - posterior L upper arm, 28 cm (centimeters) L (long) x (by) 12 cm W (wide) is dk. purple and soft. Lateral L [MEDICATION NAME] 8 cm L x 10 cm W is a lighter purple, soft. No palpable firm areas on either location. This writer is unable to find a lab report in paper chart re: a CBC (complete blood count) or platelet count result. Response: This writer initiated a Temporary Problem for communication to lic (licensed) nursing staff for on-going assessment and charting. This writer will fax a note re: this issue to Dr. (physician name) at local clinic. This writer is not certain that bruising is new occurrence due to the notation in the 8/10/16 General Note/Progress Notes in PCC (point click care). Further review of the nursing progress notes dated 8/17/16 and 8/18/16 included charting on R38's left upper arm and left [MEDICATION NAME] bruising. The medical record did not include monitoring of the bruising after 8/18/16. Review of electronic treatment administration record (eTAR) dated 8/2016 did not include monitoring of R38's bruising. When interviewed on 8/24/16, at 4:16 p.m. RN-A stated when a new skin condition for a resident is identified the charge nurse would assess the resident and initiate an SBAR (situation, background, assessment, recommendation) note. The nurse would then notify the physician, create a temporary care plan, and pass on the resident's change in condition in report to the next shift. Surveyor reviewed the 8/10/16 progress note written by RN-A pertaining to R38's left arm bruising. RN-A confirmed the resident had large bruising to the left upper arm that extended from the shoulder to the elbow. RN-A stated the resident had a history of [REDACTED]. RN-A stated she should have completed an SBAR note and notified the physician and confirmed that had not been done. RN-A further verified the bruising had not been passed on to the next shift nor investigated for possible causes when identified on 8/10/16. When interviewed on 8/26/16, at 8:46 a.m. the director of nursing (DON) stated when a new skin issue is identified the nurse should investigate the source of the skin issue, notify the physician, complete an SBAR note, and add the skin issue to the temporary problem list to pass on to the next shift. Nursing assistants (NA's) are also to let the charge nurse know as soon as they identify a new skin concern. Bruises are initially measured though nursing wouldn't necessarily measure again, but would monitor and indicate if the bruising was getting better or worse; wounds were measured weekly - bruises not necessarily unless there was a significant change. DON stated she was unaware of R38's left arm bruising first identified on 8/10/16 and subsequently on 8/17/16. DON stated R38 was prone to bruising as had fallen many times prior to admission to the facility and was identified with many bruises upon admission. DON reviewed R38's medical record and confirmed the resident was not admitted with the left arm bruising. DON confirmed the large area of bruising of unknown origin to R38's left arm should have been assessed with [REDACTED]. On 8/26/16, at 9:19 a.m. surveyor and DON observed R38 seated in w/c in room with 2 male visitors. DON attempted to remove R38's left arm from his long sleeve shirt but resident became resistive and thus attempt was stopped. Surveyor and DON were able to visualize a portion of the left arm bruising from below R38's left shoulder to the mid upper arm; dark reddish purple bruising noted that surrounded the posterior portion of the resident's upper arm and continued to extend towards the elbow. DON confirmed the bruising continued to be significant and would re-attempt to visualize and measure the bruising at a later time. When interviewed on 8/26/16, at 9:37 a.m. the DON reviewed the nursing temporary problem communication book which identified R38's bruising dated 8/17/16. The form indicated that the shift responsible for documentation indicated all. DON stated with this communication tool the expectation was that nursing would be monitoring and making a chart note daily related to the status of the bruising until healed. DON confirmed R38's bruising had not been monitored daily per the progress notes nor had been added to the eTAR for continued monitoring. On 8/26/16, at approximately 1:00 p.m. the DON provided measurements of R38's left arm bruising; left posterior upper arm bruising measured 28 centimeters (cm) long x 16 cm wide. The bruising had increased from the last measurement on 8/17/16. A policy on skin was requested but not provided. R28's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated she required total staff assistance in activities of daily living and had moderate cognitive impairment. R28's care plan dated 6/2/16, identified that R28 received hospice centered care and staff were to coordinate the care plan with Hospice, keep the family informed of change in condition and to notify hospice of any change in condition or medication changes. The hospice care plan dated 5/18/16 indicated a goal of pain management with weekly and as needed nurse visits and social work visits every 6 weeks and as needed. During an observation on 8/24/16, at 9:07 a.m. R28 was sitting up in her recliner chair eating her breakfast. She was alert, neatly dressed and appeared comfortable. During an interview on 8/24/16, at 9:25 a.m. R28 indicated she had not been on hospice care for long and did not know when they would be coming. During an interview on 8/24/16, at 9:30 a.m. licensed practical nurse (LPN)-A indicated if there was something out of the norm she would talk to the ADON and she would assess whether to call hospice. LPN-A further indicated hospice visits weekly but that she did not know when they come. During an interview on 8/24/16, at 9:51 a.m. the assistant director of nursing (ADON) verified there was no contact information regarding how and when to contact hospice in R28s chart or on the bulletin board in the nursing office. She further verified they did not know when hospice was coming. They had asked for a schedule in the past but were not provided one. During a phone interview on 8/24/16, at 12:12 p.m. the triage hospice nurse indicated they would bring out contact information and stated, They had to have removed it. She further verified that hospice would notify the facility on the day of the visit as there are patient schedule changes within the organization from day to day. The triage nurse indicated they tried to see R28 on Thursdays. During interview on 8/24/16, at 3:44 p.m. the administrator indicated that she would expect the hospice to let them know of the schedule and often the hospice would call the morning of the visit. She stated, We do not have conversations with hospice unless we see them. They have lost all their staff. During interview on 8/24/16, at 3:51 p.m. the director of nursing (DON) indicated she would expect a visit schedule be provided by the hospice organization. In addition the DON verified there were no contact numbers for hospice posted on the chart or in the nursing office should hospice need to be contacted. A hospice policy was requested from the facility but was not provided.

Based on observation, interview and document review ,the facility failed to provide services in a manner that promoted safety for 2 of 3 residents (R9 & R14) in the sample who were identified at risk for falls. The failure of the facility to provide services in a safe manner resulted in harm to R9 who sustained a right femur fracture. Findings include: R9's admission record identified [DIAGNOSES REDACTED]. R9 was observed on 8/22/16, at 5:24 p.m. sitting in her room in her wheelchair restless and moaning. An interview was attempted about her restlessness and moaning but R9 was unable to respond appropriately to questions. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R9 with a Brief Interview for Mental Status (BIMS) score of 00 indicating R9 had severe cognitive impairment. The Care Area Assessment (CAA) associated with the MDS identified R9 was at risk for falls and fall related injuries and required extensive assistance of 2 staff with transfers. Review of R9's care plan revised 3/25/16, identified a physical functioning ADL/deficit with interventions that included transfers with assist of one staff and EZ stand lift or use 2 staff PRN (as needed). Review of the quarterly interdisciplinary resident review dated 8/15/16, identified R9 required ADL assistance including transfers with stand lift. The certified nursing assistant (NA) care sheet updated 8/23/16, identified R9 requiring the EZ stand and 1 assist for transfers. During review of the nurses notes the following entries were noted: On 8/21/16, at 9:54 p.m. the note identified a change of condition situation had occurred. It was documented in the note that R9 was being transferred from the commode to the bed with a transfer belt and slid down on the floor next to her bed. The note further identified minimal pain to right side and that R9 had reddish colored bruises on her right upper back under her right arm. The note also identified R9 stated she had pain all over. On 8/22/16, at 8:53 a.m. a note identified that R9 had complained of right thigh pain at 6:00 a.m., and was unable to stand and required staff to use a full lift to transfer R9. On 8/22/16, at 4:31 p.m. a note identified R9 was complaining of pain to her right thigh while transferring in the EZ stand (mechanical lift device). On 8/22/16, at 10:28 p.m. a note identified R9 was having marked weakness when attempting to utilize the EZ stand and was not able to transfer safely. The note further indicated a full lift was used to get R9 back to bed at bedtime. R9 was noted to have a 6 centimeter (cm) red scrape below her left rib cage, on outer aspect of left chest. An addendum to the note on 11:27 p.m. clarified the scrape was on the right not the left. The note also identified R9 had a large light purple hematoma (bruise) that was raised and staff were able to cup their palm around the entire hematoma, The hematoma was identified as being firm to touch and measured 6 cm by 12 cm. R9's upper trochanter area was warm to touch. R9 was noticed to wince in pain with use of the lift as well as when rolled gently in bed. On 8/23/16, at 8:35 a.m. R9 a note identified R9 was transferred with a full body lift. A note from 8/23/16, at 9:30 a.m. identified R9 was having pain in her right thigh with the area being swollen, having a large hematoma and tender to touch and movement. R9 was transferred to the hospital at 10:50 a.m.,. A note from the emergency room (ER) dated 8/23/16, at 11:07 a.m. identified R9's right leg was shortened and externally rotated. A note from 8/23/16, at 13:06 (1:06 p.m.) from the ER identified that R9's physician had contacted the facility and stated R9 had sustained a spiral fracture of the right femur. An admission note from the hospital dated 8/23/16, at 16:02 (4:02 p.m.) identified R9 had a severe right femur fracture. The note indicated can see femur close to skin and R9 demonstrated non- verbal indicators of pain and had a very swollen right femur/hip area. During interview on 8/23/16, at 2:25 p.m. NA-J stated R9 utilized an EZ stand lift. NA-J stated the instructions to use the EZ stand lift was indicated on the NA care sheet that the aides carry with them. During interview on 8/23/16, at 2:32 p.m., NA-D stated she was working the evening shift on 8/22/16. NA-D stated when she went to get R9 up out of her recliner with the EZ lift, R9 was leaning way to the left putting all of her weight on the left side, which was not usual for R9. NA-D stated R9 could not stand and was wincing with pain. NA-D stated at that time she notified the nurse immediately. NA-D stated that when she went in to put R9 to bed later that evening she again attempted to use the EZ lift and R9 would not put any weight on her right leg and was very pale and weak. NA-D stated staff then used a full body lift to get R9 into bed. NA-D stated she again told the nurse of R9's condition and the nurse then went to check on R9 and took vital signs (vs). During interview on 8/24/16, at 11:21 a.m. the assistant director of nursing (ADON) stated that when R9 was unable to transfer her typical way, going from an EZ lift to a full body lift, the situation should have been looked into and warranted further investigation. The ADON stated,This would be considered a change of condition for (R9) and she should have been reassessed. The ADON further stated she was not aware of R9's condition until they were going to send her to the hospital. During interview on 8/24/16, at 3:05 p.m. NA-H stated she was transferring R9 from the commode to the bed on 8/21/16 and utilized a transfer belt. During the transfer R9 got her heel caught on the commode and when NA-H went to turn to get resident onto the bed, R9 fell into her and NA-H slid R9 to the floor. NA-H stated R9 grabbed her right leg and complained of pain. During interview on 8/24/16, at 2:55 p.m. RN-A stated she had worked the evening of 8/22/16. RN-A stated she was told in report that R9 was transferring poorly during the day. RN-A stated the aides didn't feel safe transferring R9 with the EZ stand lift. RN-A stated staff asked her to go look at R9 which she did and she took R9's vital signs. which were fine. RN-A further stated R9 was grimacing and appeared to be in a lot of pain when she was assisted into bed. RN-A also stated, at around 10:00 p.m. she notice R9's right leg was out of sync and she noted the huge hematoma on R9's thigh and the huge scrape on her side. RN-A stated R9 had facial grimaces while staff were turning her stating,She was weaker and having a lot of pain. RN-A stated she did not check to see if one leg was shorter than the other but documented and reported off to the night shift her findings. During interview on 8/25/16, at 6:27 a.m. NA-K stated she had worked the night of the 8/21/16. NA-K stated it was not reported to the NA's that R9 had an incident on the evening shift. NA-K stated R9's leg was swollen and sore and R9 asked for a pain med during the night. NA-K stated when she went to get R9 up in the morning with the EZ lift, R9 was crying and moaning in pain and could not transfer NA-K stated the nurse went in and gave R9 a pain medication and stated she was going to look at R9's leg in the morning. NA-K stated when she sat R9 up R9 complained of pain and started moaning and could not bear weight on her right leg. NA-K stated,Her leg hurt really bad and she wouldn't put pressure on it, it was swollen at that time. During interview on 8/25/16, at 9:37 a.m. NA-A stated she had worked the day shift 8/22/16. NA-A stated R9 was very restless and tired and would not open her eyes when her name was called which would be unusual for R9. NA-A stated she used the EZ stand as that is what the care plan indicated. NA-A stated R9 had a lot of pain with the transfers which was reported to the nurse. NA-A stated R9 was different than her normal, was not transferring well and kept repeating she had pain. During interview on 8/25/16, at 11:30 a.m. R9's daughter (FA)-A stated she was at the hospital when her mother was transferred on 8/23/16. FA-A stated her mother was in so much pain it was excruciating to watch. FA-A stated she had seen the x-ray of her mothers right leg and the surgeon had pointed out that the femur was broken at an angle and it was over-lapping 3 inches. The daughter also stated, How did they not notice this, Her foot was sideways and 3 inches shorter? I don't know how they could even try to stand her up! During interview on 8/25/16, at 11:53 a.m. LPN-B stated she was on duty when R9 was lowered to the floor. LPN-B stated she did not notice bruising, did a little range of motion and didn't think the right leg appeared to be fractured. During interview on 8/26/16, RN-D stated R9 was having pain the morning of 8/22/16. RN-D stated R9 may have had more pain in the right lower extremity and stated,She will have pain after a fall. RN-D stated NA-K had caught her at the end of the shift and reported R9 had pain and difficulty transferring. RN-D further stated that on the night of 8/22/16 to 8/23/16, the NA's reported R9 was having pain in her right leg with repositioning. NA-D stated she gave R9 Tylenol in the morning before she got up. The facility policy Notification of Change in Resident Health Status last reviewed 11/11/15, identified the facility would consult the residents physician, nurse practitioner or physician assistant when there was: (A) An accident which results in injury and had the potential for requiring physician intervention. R14 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R14 required extensive assistance with toilet use, dressing, and personal hygiene, and supervision with one person physical assistance with bed mobility, transfer, and locomotion off the unit. R14's care plan last revised 4/4/16, indicated a risk for falls. Interventions included: Bed and W/C (wheelchair) alarms in place and checked daily for proper functioning. Review of the nursing assistant assignment sheet identified R14 utilized a bed and chair alarm for safety. When interviewed on 8/24/16, at 3:20 p.m. nursing assistant (NA)-D stated R14 required assistance with transfers and toileting though would not always ask staff for assistance. NA-D stated that when R14 is in bed, she would often refuse cares as she just wanted to rest and not be disturbed. NA-D was unsure if the resident utilized an alarm when up in her w/c. On 8/25/16, at 9:53 a.m. R14 was observed lying in bed crossways and appeared to be sleeping. The resident's head was positioned up against the wall with her legs/feet hanging off the exit side of the bed. R14's w/c was observed positioned next to the bed by the resident's feet with brakes off; no bed or chair alarm was visualized. At 10:05 a.m., NA-A stated R14 had probably transferred herself into bed. NA-A confirmed an alarm was not in place on the chair nor in the bed and should have been. NA-A stated she wasn't working on the resident's hall today but confirmed she had observed the resident utilizing a TABS clip alarm the day before while up in her w/c. NA-A searched R14's room for an alarm but was unable to locate one; NA-A stated the resident had been known to hide or throw away the alarms in the past. NA-A also attempted to reposition the resident in bed but the resident refused and yelled at NA-A to leave her alone. NA-A positioned R14's w/c next to the bed with the brakes locked then exited the room to alert the assistant director of nursing (ADON) that R14 was in need of a bed alarm. Shortly afterwards the ADON and NA-B entered R14's room with a sensor pad alarm. NA-B attempted to reposition R14 in bed while the ADON placed the sensor pad underneath the resident. The ADON was able to place the sensor alarm underneath the resident though R14 continued to refuse repositioning. NA-B stated the resident had refused morning cares earlier though was unsure who had assisted the resident in getting up for the day; NA-B was unsure if R14 had utilized an alarm earlier. NA-B searched R14's room and was unable to locate an alarm. The ADON confirmed the resident was to utilize an alarm when in her w/c and in bed per the plan of care.

Based on observation, interview and document review, the facility failed to notify the physician of pain/injury following a fall for 1 of 3 residents (R9) who had a fall that resulted in harm evidenced by pain related to a [MEDICAL CONDITION] for R9. Further, the facility failed to notify the physician of significant bruising for 1 of 1 resident (R38) with significant bruising of unknown origin when initially identified. Findings include: R9's admission record identified [DIAGNOSES REDACTED]. R9 was observed on 8/22/16, at 5:24 p.m. sitting in her room in her wheelchair. She was restless and moaning. An interview was attempted about her restlessness and moaning but R9 was unable to respond appropriately to questions. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R9 with a Brief Interview for Mental Status (BIMS) score of 00 indicating R9 had severe cognitive impairment. The Care Area Assessment (CAA) associated with the MDS identified R9 was at risk for falls and fall related injuries and required extensive assistance of 2 staff with transfers. During review of the nurses notes the following entries were noted: On 8/21/16, at 9:54 p.m. the note identified a change of condition situation had occurred. It was documented in the note that R9 was being transferred from the commode to the bed with a transfer belt and slid down on the floor next to her bed. The note further identified minimal pain to the right side and that R9 had reddish colored bruises on her right upper back under her right arm. The note also identified R9 stated she had pain all over. On 8/22/16, at 8:53 a.m. a note identified that R9 had complained of right thigh pain at 6:00 a.m., and was unable to stand and required staff to use a full lift to transfer R9. On 8/22/16, at 4:31 p.m. a note identified R9 was complaining of pain to her right thigh while transferring in the EZ stand (mechanical lift device). On 8/22/16, at 10:28 p.m. a note identified R9 was having marked weakness when attempting to utilize the EZ stand and was not able to transfer safely. The note further indicated a full lift was used to transfer R9 back to bed at bedtime. R9 was noted to have a 6 centimeter (cm) red scrape below her left rib cage, on the outer aspect of her left chest. An addendum to the note on 11:27 p.m. clarified the scrape was on the right not the left. The note also identified R9 had a large light purple hematoma (bruise) that was raised and staff were able to cup their palm around the entire hematoma, The hematoma was identified as being firm to touch and measured 6 cm by 12 cm. R9's upper trochanter area was warm to touch. R9 was noticed to wince in pain with use of the lift as well as when rolled gently in bed. On 8/23/16, at 8:35 a.m. a note identified R9 was transferred with a full body lift. A note from 8/23/16, at 9:30 a.m. identified R9 was having pain in her right thigh with the area being swollen, having a large hematoma and tender to touch and movement. R9 was transferred to the hospital at 10:50 a.m. on 8/23/16. A note from the emergency room (ER) dated 8/23/16, at 11:07 a.m. identified R9's right leg was shortened and externally rotated. A note from 8/23/16, at 13:06 (1:06 p.m.) from the ER identified that R9's physician had contacted the facility and stated R9 had sustained a spiral [MEDICAL CONDITION] femur. An admission note from the hospital dated 8/23/16, at 16:02 (4:02 p.m.)identified R9 had a severe right femur fracture. The note indicated can see femur close to skin and R9 demonstrated non- verbal indicators of pain and had a very swollen right femur/hip area. During interview on 8/23/16, at 11:01 a.m. nursing assistant (NA)-I stated she did not get R9 up that morning. NA-I stated night shift got R9 up. NA-H stated when she transferred R9 to the wheel chair that day she used a full body lift rather than the EZ stand as R9 was sore on the right side. During interview on 8/23/16, at 2:25 p.m. NA-J stated R9 utilized an EZ stand lift. NA-J stated the instructions to use the EZ stand lift were indicated on the NA care sheet that the aides carry with them. During interview on 8/23/16, at 2:32 p.m., NA-D stated she was working the evening shift on 8/22/16. NA-D stated when she went to get R9 up out of her recliner with the EZ lift, R9 was leaning way to the left putting all of her weight on the left side, which was not usual for R9. NA-D stated R9 could not stand and was wincing with pain. NA-D stated at that time she notified the nurse immediately. NA-D stated that when she went in to put R9 to bed later that evening she again attempted to use the EZ lift and R9 would not put any weight on her right leg and was very pale and weak. NA-D stated staff then used a full body lift to get R9 into bed. NA-D stated she again told the nurse of R9's condition and the nurse then went to check on R9 and took vital signs (VS). During interview on 8/24/16, at 11:21 a.m. the assistant director of nursing (ADON) stated that when R9 was unable to transfer her typical way, going from an EZ lift to a full body lift, the situation should have been looked into and warranted further investigation. The ADON stated, This would be considered a change of condition for R9. During interview on 8/24/16, at 3:05 p.m. NA-H stated she was transferring R9 from the commode to the bed on 8/21/16 and utilized a transfer belt. During the transfer R9 got her heel caught on the commode and when NA-H went to turn to get the resident onto the bed, R9 fell into her and NA-H slid R9 to the floor. NA-H stated R9 grabbed her right leg and complained of pain. During interview on 8/24/16, at 3:32 p.m. registered nurse (RN)-C stated she was working the day shift on 8/22/16. RN-C stated that at approximately 10:00 a.m. an aide told her R9 was having trouble keeping her feet on the EZ lift. RN-C stated that NA-A had reported to her that R9 was moaning and groaning a lot and complaining of her leg hurting. During interview on 8/24/16, at 2:55 p.m. RN-A stated she had worked the evening of 8/22/16. RN-A stated she was told in report that R9 was transferring poorly during the day. RN-A stated the aides didn't feel safe transferring R9 with the EZ stand lift. RN-A stated staff asked her to go look at R9 which she did and she took R9's v.s. which were fine. RN-A further stated R9 was grimacing and appeared to be in a lot of pain when she was assisted into bed. RN-A also stated, at around 10:00 p.m. she notice R9's right leg was out of sync and she noted the huge hematoma on R9's thigh and the huge scrape on her side. RN-A stated R9 had facial grimaces while staff were turning her stating,She was weaker and having a lot of pain. RN-A stated she did not check to see if one leg was shorter than the other but documented and reported off to the night shift her findings. During interview on 8/25/16, at 6:27 a.m. NA-K stated she had worked the night of the 8/21/16. NA-K stated it was not reported to the NA's that R9 had an incident on the evening shift. NA-K stated R9's leg was swollen and sore and R9 asked for a pain med during the night. NA-K stated when she went to get R9 up in the morning with the EZ lift, R9 was crying and moaning in pain and could not transfer NA-K stated the nurse went in and gave R9 a pain medication and stated she was going to look at R9's leg in the morning. NA-K stated when she sat R9 up R9 complained of pain and started moaning and could not bear weight on her right leg. NA-K stated,Her leg hurt really bad and she wouldn't put pressure on it, it was swollen at that time. During interview on 8/25/16, at 6:40 a.m. NA-L stated she worked Monday (8/22/16) and R9 complained of pain when she was rolled over. NA-L also stated R9's leg was swollen and painful with movement and stated, Anytime we rolled her she grimaced and complained of pain. During interview on 8/25/16, at 9:37 a.m. NA-A stated she had worked the day shift 8/22/16. NA-A stated R9 was very restless and tired and would not open her eyes when her name was called which would be unusual for R9. NA-A stated she used the EZ stand as that is what the care plan indicated. NA-A stated R9 had a lot of pain with the transfers which was reported to the nurse. NA-A stated R9 was different than her normal, was not transferring well and kept repeating she had pain. During interview on 8/25/16, at 11:53 a.m. LPN-B stated she was on duty when R9 was lowered to the floor. LPN-B stated she did not notice bruising, did a little range of motion and didn't think the right leg appeared to be fractured. During interview on 8/26/16, at 8:35 a.m. RN-D stated R9 was having pain the morning of 8/22/16. RN-D stated R9 may have had more pain in the right lower extremity and stated,She will have pain after a fall. RN-D stated NA-K had caught her at the end of the shift and reported R9 had pain and difficulty transferring. RN-D further stated that on the night of 8/22/16 to 8/23/16, the NA's reported R9 was having pain in her right leg with repositioning. RN-D stated she gave R9 Tylenol in the morning before she got up. During interview with the ADON on 8/24/16, at 11: 21 a.m. the ADON verified the physician should have been notified sooner of R9's increased pain and inability to transfer. The ADON verified the documentation identified R9 had been demonstrating pain, had swelling of her leg, and was restless from 8/21/16 to 8/23/16. R38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R38's 14-day admission data set (MDS) included a brief interview for mental status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS further indicated R38 required total assistance with transfers and bathing, and extensive assistance with bed mobility, locomotion on/off unit, dressing, toilet use, and personal hygiene. The care plan included a focus of altered skin integrity, non pressure, initiated 8/1/16. Interventions included: Conduct weekly skin inspection. Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. Skin assessment to be completed per Living Center Policy. Review of the Weekly Skin Reviews dated 8/9/16 and 8/23/16 indicated: Skin Intact. The skin reviews did not include evidence of other skin conditions including bruising. Review of the nursing progress note by registered nurse (RN)-A dated 8/10/16, at 23:25 (11:25 p.m.) included the following: Noted bruising on left arm from shoulder to elbow. Area soft and resident denies pain to touch. Continues to need full lift for transfers and remains incontinent of both bladder and stool. The note did not include measurements of the left arm bruising nor evidence of notification of the physician or other nursing staff. A subsequent nursing progress note by RN-A dated 8/14/16 at 23:13 (11:13 p.m.) included: Did request prn [MEDICATION NAME] at HS (hour of sleep) for left upper arm pain, that was effective. Further review of R38's medical record revealed no further mention of the bruising until a nursing progress note dated 8/17/16 at 02:42 (2:42 a.m.). The progress note indicated: Type: SBAR - Change of Condition Situation: 0100 (1:00 a.m.) CNAs (certified nursing assistants) discovered lg. (large) dk. (dark) purple bruised area on posterior aspect of L (left) upper arm extending from L shoulder to L elbow and a smaller bruised area on lateral L [MEDICATION NAME] area of res.'s (resident's) body that appear to be new and were not present on admission assessment paper form 7/19/16. There is a brief notation in a Gen. (general) Note dated 8/10/16 @ (at) 2325 re: a L upper arm bruise from shoulder to elbow, no measurement. Background: Last fall here at this facility is on 7/29/16. Res. is on ASA (aspirin) 325 mg p.o. (by mouth) daily for MI ([MEDICAL CONDITION] infarction) prevention, has not be on p.o. or injectable anticoagulation therapy here at GLC (Golden Living Center) since admission. Most recent admission here has (sic) for post hip fx (fracture) rehab. (rehabilitation). Medical hx (history) list does not include platelet or blood clotting factors pathology. Noted to have increased mental confusion on 8/16/16. Elderly male 96 y.o. (years old). Assessment: measurements - posterior L upper arm, 28 cm (centimeters) L (long) x (by) 12 cm W (wide) is dk. purple and soft. Lateral L [MEDICATION NAME] 8 cm L x 10 cm W is a lighter purple, soft. No palpable firm areas on either location. This writer is unable to find a lab report in paper chart re: a CBC (complete blood count) or platelet count result. Response: This writer initiated a Temporary Problem for communication to lic (licensed) nursing staff for on-going assessment and charting. This writer will fax a note re: this issue to Dr. (physician name) at local clinic. This writer is not certain that bruising is new occurrence due to the notation in the 8/10/16 General Note/Progress Notes in PCC (point click care). When interviewed on 8/24/16, at 4:16 p.m. RN-A stated when a new skin condition for a resident is identified the charge nurse would assess the resident and initiate an SBAR (situation, background, assessment, recommendation) note. The nurse would then notify the physician, create a temporary care plan, and pass on the resident's change in condition in report to the next shift. RN-A stated a bruise of unknown origin, if suspicious, would be reported to the state. RN-A further stated if bruising was occurring frequently or if a larger bruise or hematoma of unknown origin was identified and not explainable it would also be reported to the state. Surveyor reviewed the 8/10/16 progress note written by RN-A pertaining to R38's left arm bruising. RN-A confirmed the resident had large bruising to the left upper arm that extended from the shoulder to the elbow. RN-A stated the resident had a history of [REDACTED]. RN-A stated she should have completed an SBAR note and notified the physician and confirmed that had not been done. RN-A further verified the bruising had not been passed on to the next shift, investigated for possible causes nor reported to the state agency when the bruising was identified on 8/10/16. When interviewed on 8/26/16, at 8:46 a.m. the director of nursing (DON) stated when a new skin issue was identified the nurse should investigate the source of the skin issue, notify the physician, complete an SBAR note, and add the skin issue to the temporary problem list to pass on to the next shift. Nursing assistants (NA's) are also to let the charge nurse know as soon as they identify a new skin concern. Bruises are initially measured though nursing wouldn't necessarily measure again, but would monitor and indicate if the bruising was getting better or worse; wounds were measured weekly - bruises not necessarily unless there was a significant change. DON further stated if a large or suspicious bruise of unknown origin was not explainable, she would expect it to be reported immediately to the state. DON stated she was unaware of R38's left arm bruising first identified on 8/10/16 and subsequently on 8/17/16. DON stated R38 was prone to bruising as had fallen many times prior to admission to the facility and was identified with many bruises upon admission. DON reviewed R38's medical record and confirmed the resident was not admitted with the left arm bruising. DON confirmed the large area of bruising of unknown origin to R38's left arm should have been assessed with [REDACTED]. The policy titled Notification of Change in Resident Health Status last reviewed 11/11/15, included: The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: (A) An accident which results in injury and has the potential for requiring physician intervention.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for pain management and anxiety relief for 1 of 2 (R71) residents in the sample who was designated as receiving hospice services to control pain, to decrease anxiety due to breathing difficulty and declining health status. This resulted in actual harm for R71. Findings include: R71 did not receive pain or anxiety medication timely to control chronic pain and anxiety. R71 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was still in the fourteen day assessment period for the comprehensive Minimum Data Set (MDS) an assessment tool. A comprehensive pain assessment had not been completed prior to the initial record review on 8/30/11, at 2:50 p.m. On 8/30/11, at 3:10 p.m. the resident and her daughter were interviewed during which they both established that they felt there was a communication deficit in the facility. R71 then went on to say that about 15 minutes prior to my interview with her she put her call light on and the call light was promptly answered by a nursing assistant (NA) where R71 asked for pain medication and medication for anxiety. After the NA answered the call light, the NA stated she would report the request to the nurse. This nurse was licensed practical nurse (LPN)-A. The resident continued to say that she waited another 10-15 minutes and nobody came back to her with the medications or other instructions. After waiting another 10-15 minutes (total of 20 to 30 minutes from the time R71 reported the need for pain and anxiety medication to the staff) there was no response so she put the call light back on, the NA again answered the call light and told the R71 she would again report to LPN-A that R71 ' s request for pain medication and anxiety medication. The nursing assistant then reported back to the resident that the nurse had told the nursing assistant to tell the resident she could not have any pain medication or medication for anxiety until 4:00 p.m. The licensed nurse had not assessed the hospice patient ' s current pain or anxiety needs to offer non-pharmacological interventions or inform the physician that the medication regimen was not effective to relieve pain between medications for this hospice resident. Review of a pain evaluation completed 8/30/11 at 4:00 p.m. established that the patient had reported moderate to severe pain in her upper and lower back and ribs rating the pain at a " 9 " on a scale of 1-10. The pain evaluation identified " Current pain treatment plan: Effective " . The evaluation did not identify pain history or effective non-pharmacological interventions. During an interview with R71 during the aforementioned incident on 8/30/11, at 3:10 p.m. R71 reported that she rated her pain at a 5 on a 1-10 scale with 10 being the worst pain. The resident was observed during this interview to appear anxious and short of breath. R71 was observed seated on her bed with her face within 4 inches of a circular fan gasping for breath while talking. Review of the resident ' s current physician orders [REDACTED]. The first order was for [MEDICATION NAME] 5/500 one tablet scheduled three times a day. There was also an order [REDACTED].[REDACTED]. According to the physician orders [REDACTED].) Review of the resident ' s anxiety medication revealed that the resident had 2 different orders for anxiety medication. The first order was for [MEDICATION NAME] 1 mg scheduled four times a day. There was also an as needed order prescribed for [MEDICATION NAME] 1 mg every 2 hours for increased anxiety characterized as shortness of breath which occurs with activity. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) LPN-A was interviewed on 8/30/11 at 3:28 p.m. during which she confirmed she was assigned to R71 ' s cares for the day and that the nursing assistant had reported to her twice that R71 had requested medication for pain and anxiety, however, LPN-A had not personally assess R71 ' s pain or anxiety or get back to R71 about giving the resident her pain and anti-anxiety medication. The nurse stated that she should have assessed the resident for pain and anxiety symptoms and provided the resident with the requested medication or notified hospice if medication was not yet available due to the time frames specified by the physician orders. LPN-A confirmed that R71 could have had medication for anxiety at 2:00 p.m. and that it was not given when the resident had requested it at 3:00 p.m. R71 was again interviewed on 8/31/11, at 7:13 a.m. during which it was noted that the residents call light was on. The resident said that she had been waiting for pain medication and anxiety medication again and had been waiting for quite some time. Further interview with the resident established that R71 had put her call light on several times in a row and the NA would answered the light and reported the request for medication to the medication nurse, but there would be no response for a while, and this went on for 45 minutes until this surveyor interviewed the resident and reported the residents concern to the nurse. During this interview with R71, she stated that she felt worthless and stupid when her requests for medication were not responded to. Also R71 had been observed to be short of breath during this interview. On 8/31/11 at 7:23 a.m. LPN-C was interviewed during which she stated that she did not know why the resident had to wait over 45 minutes and a surveyor request to be assessed for pain and anxiety symptoms, but that she had just got on shift and the night nurse had not addressed the pain or anxiety needs. LPN-C then confirmed that the resident could have received an as needed dose of [MEDICATION NAME] 5/500 (pain medication) and [MEDICATION NAME] 1 mg (antianxiety) at 6:15 p.m. per physician order. During an interview with the Administrator on 8/31/11, at 9:58 a.m. she stated that when the resident call light is put on the nursing assistant answers the light as soon as possible. And if services from a licensed nurse are requested then the nursing assistant will report the request to the licensed nurse. The licensed nurse should then assess the patient in a timely manner which should be in 10-15 minutes.