Every finding on record at Laurel Park Rehabilitation and Healthcare Center

Based on record review, and staff, family and Medical Director interviews, the facility failed to protect a severely cognitively resident from physical restraint from a private duty Caregiver and chemical restraint. When Resident #199 refused to take medications from the Nurse the private duty Caregiver offered to assist and forced medications into the Resident's mouth, held her hand over the Resident's mouth, to force her to swallow. When Resident #199 became combative, and kicking and spitting out medications the private Caregiver restrained the Resident by placing her leg over Resident #199 legs to prevent her from kicking. The Nurse asked the Caregiver to stop and left the room to call the on-call provider. The Caregiver continued to restrain the Resident until the Nurse returned to the room and administered an intramuscular antipsychotic medication (chemical restraint) to calm her. Resident #199 was assessed and a pea size discoloration on the bottom side of her lip was observed. A reasonable person would expect to be safe from physical and chemical restraints in their own home and could experience anger, anxiety, dehumanization, fear and depressed mood. This deficient practice affected 1 of 1 resident reviewed for restraints (Resident #199). The findings included: Resident #199 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, Alzheimer's disease, dementia with behaviors, anxiety disorder and atrial fibrillation. Resident #199's admission Minimum Data Set, dated [DATE] revealed she was severely cognitively impaired with no behaviors. A skin assessment dated [DATE] by the Nurse Practitioner revealed Resident #199 had three visible bruises on the right upper extremity, with the largest on the inner right arm. With no signs of acute trauma noted otherwise. In a phone interview on 5/20/25 at 10:53 AM Nurse #2 stated the day of the incident Resident #199 call light rang close to 5:00 PM. Nursing Assistant (NA) #4 answered the call light and reported the Resident needed incontinence care and the private caregiver requested the resident's medications. Nurse #2 indicated she prepared the resident's 5:00 PM Risperdal and entered the room and found Resident #199 sitting on the side of her bed, with her fists balled up, swearing. Nurse #2 reported she explained the medications to the Resident, who refused, when the private caregiver approached the bed and indicated she could get Resident #199 to take her medications. Nurse #2 revealed the Resident refused and tried to swat the medication cup out of the Caregiver's hand when she attempted to give Resident #199 her medications. Nurse #2 indicated she took the medication cup back, and held the Residents hand, trying to calm her, when the Resident laid back across the bed. The Caregiver asked for the medication cup and continued to try to give the resident's her medication, including putting medication into the resident's mouth when Resident #199 would open her mouth to scream, and used a C motion to hold her mouth closed (arm under the chin and hand over the nose to swallow). The Resident tried to spit out the medications and the caregiver put her hand over Resident #199's mouth. Nurse #2 reported that the caregiver laid down beside the Resident on the bed and put her left leg over the Residents legs to prevent her from kicking. Nurse #2 stated she told the Caregiver to stop pushing the medications and she left NA #2 and the Caregiver in the room with the Resident while she went to call the on-call Provider. The Nurse revealed that Nurse #9 was at nurses' station and returned to the room with her, where the Caregiver remained in the same position, lying beside the Resident on the bed with her left leg over the Resident's legs Nurse #2 stated after she cleaned the left outer thigh and administered an IM injection of 2.5 mg of Haldol, the Caregiver released Resident #199 and moved to the side. Nurse #2 revealed she disposed of the needle, returned to sit down beside Resident #199 encouraged her to take deep breaths, to calm down, take a sip of water, and offered incontinence care, which she accepted. Nurse #2 stated the caregiver left the room and she and NA #4 provided Resident #199 her incontinence care. Nurse #2 stated Resident #199 was calm and cooperative with her care. Nurse #2 indicated she left NA #4 with Resident #199 to call the DON and Resident Representative to report the incident. Nurse #2 reported the DON told her the Caregiver was not to touch Resident #199, and the Caregiver had to leave the building. Nurse #2 revealed when she returned to Resident#199 the caregiver was outside the room, was told she had to leave, and the Caregiver left the building. Resident #199's progress notes revealed the following note dated 5/13/25 at 6:30 PM, written by Nurse #2. The resident was observed hitting her private duty caregiver, spitting at staff members, attempting to hit staff members, using extreme profanity towards staff members and her private duty caregiver, attempting to scratch and bite staff members and her private duty caregiver, as well as screaming at staff members and her private duty caregiver. This writer contacted the on-call provider and obtained a verbal order to administer 5mg (milligrams) of IM (intramuscular) Haldol, split into two 2.5mg doses 1 hour apart. This writer administered the first dose now IM into the [outer thigh]. In a phone interview on 5/20/25 at 1:41 PM NA #4 indicated she remembered the incident on 5/13/25 as it was the first time she was assigned to Resident #199. She reported the call light was on when she went to check on Resident #199 and the private Caregiver was in the room and requested incontinence care and evening medications. NA # 4 indicated Nurse #2 entered with the medications and she told Nurse #2 to give medications first as she needed to prepare for incontinence care. NA #4 indicated the Resident stated she was not taking the pills and was very aggressive, swearing and saying no to her medications. NA #4 stated the Caregiver indicated to Nurse #2 the Resident would take medications from her and when she (Caregiver) offered, the Resident refused to take the medications from the Caregiver. She reported that the Caregiver placed the pills into Resident #199's mouth and she spit them back out. NA #4 stated the Nurse and Caregiver continued to encourage Resident #199 to take medications when the Caregiver put her knee on the bed beside the Resident and laid her back on the bed. The Resident was kicking her legs, spitting, when the Caregiver laid down beside the Resident and put her leg over the residents' lower legs. Nurse #2 told the Caregiver to stop pushing medications and told me (NA #4) to stay with Resident #199 and she left the room to call the doctor. Nurse #9 returned with Nurse #2 and remained in the room while Nurse #2 gave the Resident an injection in her upper leg. NA #4 reported she left the 2 nurses in the room and saw the Caregiver leave the hall while she was passing out meal trays. NA #4 reported that Nurse #2 never restrained Resident #199, she held her hand and tried to soothe her. In an interview on 5/20/25 at 12:16 PM the Director of Nursing (DON) revealed she was aware of the incident with Resident #199 and the private Caregiver. She stated she received a call from Nurse #2 on 8/13/25 who reported Resident #199 was refusing her medications and the private Caregiver indicated she could get the Resident to accept her medications. Nurse # 2 explained she handed Resident #199's medications to the Caregiver, and the Resident refused the Caregiver. The Caregiver laid down on the bed beside the Resident and put her leg over Resident #199 to keep her from kicking out. At that point Nurse #2 told the Caregiver to Stop and she took the medication cup back from the Caregiver. Nurse #2 left NA #4 in the room with the Resident and went to call the on-call Provider for orders. The DON reported this was reported to her that once the caregiver was removed from the room Resident #199 began to calm down and allowed staff to provide her with incontinence care. The DON revealed Resident #199 was admitted from the hospital with bruising to her arms, and the skin assessment she conducted on 5/13/25 revealed Resident #199 had a new small bruise to lower lip and denied any pain. The DON reported she told Nurse #2 to make sure the Caregiver left the facility, and she was on her way to the facility to assess Resident #199 and interview staff. A skin assessment dated [DATE] at 5:30 PM completed by the Director of Nursing (DON) indicated that Resident #199 had bruising to the right-hand purple in color, bruising to right arm, and resident had a very small bruise to lower lip on right side green/purple in color, resident denies pain to any of these areas. The assessment was completed by the Director of Nursing (DON). Review of Medical Director's Progress Note dated 5/14/25 at revealed Resident #199 was an [AGE] year-old female patient with a past medical history of atrial fibrillation, hypertension, hyperlipidemia, hypothyroidism, and progressing dementia. The Patient does have multiple bruises to bilateral upper extremities and a new small purple area to the underside of her bottom lip on the right side. Patient does not appear to have had any decline with physical functioning since admission here. Range of motion appears to be appropriate with no changes. She is completely awake and alert with no increase in lethargy or sedation noted. No tearfulness or increased depression noted. The patient appears to be at her normal baseline today with no changes. In an interview on 5/21/25 at 1:05 PM the Medical Director stated he was notified of the incident between Resident #199 and private Caregiver on 5/13/25. He revealed he assessed the Resident on 5/14/25 and found she had no memory of the incident, no bruising and no complaint of pain and was smiling. In an interview on 5/21/25 at 4:45 PM the Administrator stated he was notified by Nurse #2 on 5/13/25 at 7:03 PM of the incident with Resident #199 and her private Caregiver. He stated the Resident was refusing her medications and shut her mouth tight when Nurse #2 offered medications. The Caregiver told Nurse #2 it would be easier for her to take medications from her and asked Nurse #2 to let her give the medications. The Caregiver took the medications, when Resident #199 opened her mouth, the Caregiver dumped the medications in her mouth and put her hand over Residents #199 mouth. The Resident refused, trying to kick and bite the staff, when the Caregiver laid the resident back on the bed and lay beside her. As Resident #199 continued to kick out at staff the Caregiver placed her leg over the Resident's leg to stop her from kicking. At this time Nurse #2 stepped in and told the Caregiver to stop and she tried to calm the resident down. Nurse #2 left NA #4 with the Resident and left to call the on-call Provider who gave an order for Haldol IM (intramuscular). The Administrator stated they determined the private Caregiver's behavior was inappropriate and she was banned from the facility. The Administrator stated they notified the State Agency and Law Enforcement of the incident on 5/13/25 and the staff members involved were sent home pending the facility's investigation.

Based on staff interview and review of the Facility Assessment the facility failed to identify any cultural considerations for the resident population, failed to ensure the staffing plan considered specific staffing needs for each unit and shift as required, and failed to evaluate contracted services utilized by the facility to provide necessary care for its residents during normal operations and emergencies which had the potential to affect 88 of 88 residents. The findings included: Review of the Facility Assessment revealed it was revised on 3/12/25. The Facility Assessment did not include any cultural considerations to meet the needs of the residents of the facility. Further review of the Facility Assessment revealed that the staffing plan listed the number of Nurses (Registered Nurse or Licensed Practical Nurse) and Certified Nursing Assistants (CNAs) noted as the desired number FTE (full-time equivalent, the total number of full-time employees working in an organization) of staff and the professional requirement for those staff members. However, the staffing plan did not address staffing needs for each shift and weekends, or address staffing needs in these areas based on changes to the resident population as required. The Facility Assessment did not note if a contract or other agreement was in place related to the provider who was responsible for the provision of goods, medical services, facility management services, emergency services, transportation, and dialysis services for the facility. An interview was conducted with the Administrator on 5/21/25 at 4:12 pm who revealed he thought he had completed the cultural consideration portion of the facility assessment but must have missed it. He reported he was not aware of the requirement to specifically address the nurse staff shift information and emergency staffing plan any further than the FTE information. The Administrator stated he was not aware the contracted services used at the facility had to be included in the Facility Assessment.

Based on record review, resident and staff interviews, the facility failed to provide written information to residents and resident representatives regarding advance directive and/or an opportunity to formulate an advance directive for 19 of 22 residents reviewed for advance directives (Resident #1, #5, #8, #21, #25, #26, #29, #33, #37, #40, #50, #52, #58, #72, #73, #75, #91, #95, and #302). The findings included: a. Review of Resident #1's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, and hypotension. The review revealed a full code Physician order dated 5/18/25. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive. b. Review of Resident #5's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart failure, Alzheimer's disease, and cystitis. The review revealed a full code Physician order dated 10/29/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive. c. Review of Resident #8's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included hypertension, osteoarthritis, and sleep apnea. The review revealed a do not resuscitate Physician order dated 8/6/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive. d. Review of Resident #21's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included hypertension, diabetes, and chronic obstructive pulmonary disease. The review revealed a full code Physician order dated 9/26/22. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive. e. Review of Resident #25's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included hypertension, and chronic pain syndrome. The review revealed a do not resuscitate Physician order dated 4/4/17. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive. f. Review of Resident #26's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included stroke, diabetes, muscle weakness, and high blood pressure. The review revealed a do not resuscitate Physician order dated 11/17/22. There was no documentation in the record for education regarding a formulation of an advance directive and/or the opportunity to formulate an advance directive. g. Review of Resident #29's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included diabetes, peripheral vascular disease, and hypertension. The review revealed a do not resuscitate Physician order dated 1/17/22. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive. h. Review of Resident #33's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, epilepsy, and dementia. The review revealed a full code Physician order dated 4/29/25. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive. i. Review of Resident #37's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and chronic kidney disease. The review revealed a full code Physician order dated 7/24/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive. j. Review of Resident #40's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and kidney failure. The review revealed a full code Physician order dated 6/28/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. k. Review of Resident #50's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, diabetes, and atrial fibrillation. The review revealed a full code Physician order dated 10/28/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. l. Review of Resident #52's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included hypertension, kidney disease, and heart failure. The review revealed a do not resuscitate Physician order dated 10/9/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. m. Review of Resident #58's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and muscle weakness. The review revealed a full code Physician order dated 5/30/23. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. n. Review of Resident #72's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included seizure disorder, dementia, and heart failure. The review revealed a full code Physician order dated 11/22/23. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. o. Review of Resident #73's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness, and history right hip fracture. The review revealed a full code Physician order dated 4/18/25. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. p. Review of Resident #75's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and kidney failure. The review revealed a full code Physician order dated 3/29/25. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. q. Review of Resident #91's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included diabetes and congestive heart failure. The review revealed a do not resuscitate Physician order dated 4/4/17. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. r. Review of Resident #95's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included depression, sleep apnea, and peripheral neuropathy. The review revealed a do not resuscitate Physician order dated 4/29/25. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. s. Review of Resident #302's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included chronic renal failure. The review revealed a do not resuscitate Physician order dated 5/10/25. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive. An interview was completed on 5/21/25 at 10:47 a.m. with the facility's Admission's Director. The Admission's Director stated she had a blank template for advance directive if someone needed one but that it was not something she discussed with the resident and/or Resident Representative when she completed the admission packet. She stated she reviewed the advance directive from the hospital if the resident had one and verified the code status with the discharge summary. During an interview with the Social Services Director on 5/21/25 at 1:56 p.m. she revealed she had discovered it was her responsibility to provide advance directive education to the resident and/or their Resident Representative a week ago. In an interview with the Administrator on 5/21/25 at 4:25 p.m. he stated the advance directive education was not something identified and had been missed, and he stated the Social Services Director was responsible for ensuring the Advance Directive discussion was completed with the residents and/or Resident Representative on admission and uploaded in the medical record.

Based on observation, staff interview, and record review the facility failed to clean and maintain resident rooms for 6 of 29 resident rooms on 1 of 4 halls (300 Hall) observed for environment (Resident #39's room, Resident #29's room, Resident #8's room, Resident #56's room, Resident #92's room, and Resident #25's room). The findings included: The Resident Council meeting minutes dated 7/11/24 revealed there were residents' concerns about housekeeping needing to do a better job cleaning residents' room. The residents reported the housekeeping staff were not sweeping and mopping around or under beds. The Resident Council meeting minutes dated 11/22/24 revealed there were residents' voiced concerns about housekeeping not cleaning residents' rooms or emptying resident trash cans in room. The Resident Council meeting minutes dated 3/21/25 revealed the residents felt the rooms were not being swept or mopped. The residents voiced concern that the floors in their rooms were sticky. The Resident Council meeting minutes dated 4/11/25 revealed the residents voiced concern that the housekeeping staff were not sweeping underneath the furniture. The Resident Council Meeting minutes dated 5/16/25 revealed the residents' voiced concern that room cleaning wasn't being done. 1a. An observation was conducted on 5/18/25 at 12:56 PM of Resident #39's room. The floor by the bed was sticky and there was a strong urine odor present in the room. An interview conducted with Resident #39 on 05/18/25 at 01:12 PM revealed she had concerns about the staff not cleaning the rooms properly. Resident #39 stated the floors were often sticky and housekeeping did not do a good job of sweeping and mopping the floors. b. An observation was conducted on 05/18/25 at 2:47 PM of Resident #29's room. There were marble sized holes in the wall above the base board by the bathroom door and above the baseboard near the bed by the door. An interview conducted with Resident #29 on 05/18/25 at 02:47 PM revealed she had concerns that the rooms were not being cleaned. She stated housekeeping was not cleaning the rooms properly and her room had a strong urine scent in it. She stated housekeeping did not sweep underneath the beds nor around the furniture. She stated housekeeping needed to do a better job. c. An interview conducted with Resident #8 on 05/21/25 08:54 AM revealed she was concerned with urine smell in her room by her bed. Resident #8 stated housekeeping staff did not do a good job cleaning the rooms because they did not sweep underneath the beds and often left food crumbs underneath them. She reported the housekeeping staff barely scrubbed the floors and that was one of the reasons the floors were so sticky and stained. Resident #8 stated she often had to tell the housekeeper to sweep under the bed and clean the floor underneath her bedside commode. An observation was conducted on 5/21/25 at 8:59 AM of Resident #8's room. The floor in front of the room door in the hall and floor in the room were sticky. There was encrusted brown matter and trash, consisting of hair, dust and bits of paper around the edges of the baseboards. d. An observation was conducted on 5/21/25 at 9:03 AM of Resident # 56's room. There was encrusted brown matter around the edges of baseboard by the door and trash consisting of dust and dirt around the edges of the baseboards. e. An observation was conducted on 5/21/25 at 9:05 AM of Resident # 92's room. There was dark brown matter and trash consisting of dirt, dust and bits of paper in the corners of the room around the edges of baseboards. f. An observation was conducted on 5/21/25 at 9:06 AM of Resident #25's room. There was a broken floor tile by the closet door, dark brown encrusted matter around door, the window frame had missing caulk on the interior side beneath the window exposing an opening about 2 inches in width, to the inside of the wall. There was also damaged drywall paper, the size of a quarter, beneath the bottom of the window. An interview conducted with the Housekeeping Director on 5/21/25 at 10:27 AM revealed she was responsible for ensuring the housekeeping staff maintained the cleanliness of the environment. The Housekeeping Director stated daily cleaning of resident rooms included sweeping, mopping, and cleaning the bathroom. She stated rooms were deep cleaned with all the furniture moved from the wall, cove base cleaned, and the floors swept and mopped. She further stated the rooms were difficult to clean due to the need for replacement of the cove base (a trim that is installed at the base of a wall where it meets the floor) which was stained and had a buildup of wax that had been there for a while. An interview and observation conducted with the Maintenance Director on 5/21/25 at 1:01 PM revealed he was made aware of issues with resident rooms through the facility's online maintenance management system. The Maintenance Director denied being made aware of the broken tile in room [ROOM NUMBER] and exposed area beneath the windowsill. The Maintenance Director stated staff were to enter issues with rooms and equipment in the online system. He further stated the facility used Ambassador Rounds (Management staff assigned to a section of resident rooms to encourage communication with residents and family members) to assist with the cleanliness and reporting of room issues. An interview was conducted with the Administrator on 5/21/25 at 4:58 PM. The Administrator stated the Housekeeping Director was responsible for ensuring the facility is cleaned and Maintenance was responsible for structural repairs. He stated he was made aware by Housekeeping the facility was not accurately using a deep cleaning schedule. The Administrator stated he also expected that Ambassadors would report housekeeping and structural room issues discovered during their rounding each morning during the daily morning meeting for follow up.

Based on observation, record review, and resident and staff interviews, the facility failed to update the care plan to include hearing aids for 1 of 33 residents whose care plans were reviewed (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE]. Review of the medical record revealed Resident #29 was seen by audiology for evaluation and treatment on 9/12/24. A physician's order dated 2/5/25 indicated the hearing aids were to be inserted every morning. A physician's order dated 2/6/25 indicated the hearing aids were to be removed at bedtime. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had moderate cognitive impairment. The resident was coded as having adequate hearing and wore hearing aids. The care plan, updated 3/19/25, did not include a focus area related to hearing loss or the wearing of new hearing aids. An observation of Resident #29 on 05/19/25 at 9:19 AM revealed the resident was not wearing her hearing aids. An interview with Resident #29 on 5/19/25 at 9:20 AM revealed she did have hearing aids, but she did not like wearing them. She stated the hearing aids felt strange in her ears. An interview conducted with Nurse #9 on 5/19/25 at 9:25 AM revealed Resident #29 had just started wearing hearing aids about a month ago and frequently refused to wear them. An interview conducted with the MDS Nurse on 5/21/25 at 4:45 PM revealed she missed the assessment and did not add the hearing aids to the care plan. The MDS nurse stated updates to resident assessments were discussed in the daily morning meeting. An interview conducted with the Director of Nursing on 5/21/25 at 4:50 PM revealed Resident #29 should have had a care plan to reflect she wore hearing aids. The DON stated care plans were reviewed daily during morning clinical meeting. An interview conducted with the Administrator on 5/21/25 at 4:55 PM revealed he expected care plans to be reviewed during morning clinical meeting and updated to reflect the resident's status.

Based on record review, and staff, resident, Pharmacist and Medical Director interviews, the facility failed to have effective systems in place to ensure intravenous (a soft, flexible tube placed inside a vein used to give medicine or fluids) antibiotic medication was available as ordered for a newly admitted resident for 1 of 2 residents reviewed for IV antibiotic therapy (Resident #95). The findings included: Review of the hospital Discharge summary dated [DATE] revealed Resident #95 had an order to administer cefazolin (antibiotic) solution 2 grams intravenous (IV) every 8 hours for 42 days. Resident #95 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection) of the left ankle and foot. The Admission/readmission assessment dated [DATE] at 8:52 pm completed by Nurse #3 revealed Resident #95 had a bone infection of the left lower extremity and had IV access in the left arm. Resident #95 had a physician order dated 4/29/25 for cefazolin solution injection 2 grams; administer 2 grams intravenously every 8 hours for bone infection for 42 days. The medication was scheduled to be administered at 6:00 am, 2:00 pm, and 10:00 pm. Review of the Medication Administration Record (MAR) for April 2025 revealed the following: 4/29/25 at 10:00 pm the cefazolin administration was noted as 9 by Nurse #3. Further review of the MAR revealed 9 was identified as other see nurse note. The MAR administration note dated 4/29/25 at 9:46 pm by Nurse #3 revealed the cefazolin was on order. 4/30/25 at 6:00 am the cefazolin administration had no administration documentation noted on the MAR by Nurse #1. No further documentation was noted in the medical record. 4/30/25 at 2:00 pm the cefazolin administration was noted as 9 by Nurse #4. The MAR administration note dated 4/29/25 at 2:18 pm by Nurse #4 revealed the cefazolin was awaiting from pharmacy. 4/30/25 at 10:00 pm the cefazolin administration was noted as 9 by Nurse #2. The MAR administration note dated 4/29/25 at 10:44 pm by Nurse #2 revealed the cefazolin medication schedule was updated. The nursing progress note dated 4/30/25 at 9:40 pm by Nurse #2 revealed she contacted the pharmacy regarding Resident #95's cefazolin. Nurse #2 further noted the pharmacy stated Resident #95's cefazolin was not sent in the earlier delivery but it would be sent to the facility on the next run and should arrive around midnight. Nurse #2 informed the pharmacy that Resident #95 needed his medication as soon as possible and that it was a delay in care. Review of the emergency dose kit (a kit that provided certain medications for residents until available from pharmacy) medication list revealed IV cefazolin was not available in the emergency dose kit. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #95 was cognitively intact and was coded for the use of antibiotic medication and had intravenous access. During an interview on 5/18/25 at 12:39 pm Resident #95 revealed he was worried about his bone infection because he missed several doses of his IV antibiotic when he was admitted to the facility. He stated he was not sure why he didn't get the IV antibiotic for the first few days of his admission, but he stated he told a nurse (unsure of the name) that he needed to have his antibiotic as it was ordered. A telephone interview was conducted on 5/21/25 at 11:32 am with Nurse #3 who was assigned to Resident #95 at the time of the admission. Nurse #3 stated Resident #95 arrived at the facility later in the evening on 4/29/25 and she confirmed the admission medication orders at that time. Nurse #3 stated normally the resident medications would be delivered to the facility the next day when the resident arrived late in the evening. Nurse #3 stated she was not sure what time the pharmacy delivered medications to the facility but she did not have the cefazolin to administer to Resident #95 on 4/29/25 at 10:00 pm. An interview was conducted with Nurse #1 who was assigned to Resident #95 on 4/30/25 for 6:00 am dose of cefazolin. Nurse #1 stated Resident #95's cefazolin was not available at the facility so she contacted the pharmacy and she was told it would be out for delivery to the facility later in the day. Nurse #1 stated the pharmacy normally made a delivery to the facility between 1:00 am and 3:00 am but the medication was not in the delivery so she was unable to administer it to Resident #95 on 4/30/25 at 6:00 am. During an interview on 5/20/25 at 2:28 pm with Nurse #4 she revealed the pharmacy normally would deliver IV antibiotics on the same night the resident was admitted but she stated at times it would take several days to receive IV antibiotics. Nurse #4 stated she did not call the pharmacy to check on the delivery date or time for Resident #95's IV cefazolin 2:00 pm dose on 4/30/25 because he was just admitted the night before and she expected it to be delivered later that day. A telephone interview was conducted with Nurse #2 on 5/20/25 at 11:16 am who revealed when she returned to work on 4/30/25 and saw that the IV cefazolin had not yet been received at the facility and that Resident #95 had missed several doses she contacted the Director of Nursing (DON) and the Pharmacy. Nurse #2 reported that when she called the pharmacy they were unable to tell her why the IV cefazolin was not sent out to the facility but she was told the antibiotic was on the evening delivery and would be available for the 10:00 pm dose on 4/30/25. Nurse #2 stated when the IV medication was still not available for the 10:00 pm dose she called the pharmacy back and told the Pharmacist that Resident #95's care had been delayed due to not having the IV antibiotics as ordered and they stated it would be delivered the next day. Nurse #2 stated she notified the provider and changed the medication administration schedule to start on 5/01/25 when the next expected shipment from pharmacy arrived to ensure all 42 doses would be administered. An interview was conducted with the admission Director on 5/20/25 at 8:46 am who revealed the facility was notified of Resident #95's admission date of 4/29/25 and that the IV cefazolin was needed. The admission Director stated the facility should have been able to obtain Resident #95's IV antibiotic medication when he was admitted . A telephone interview was conducted on 5/20/25 at 3:26 pm with the Pharmacist who revealed the cut-off time for intravenous antibiotics to be sent out for new admissions on the evening delivery was 5:30 pm. He stated if a resident admitted after that time the IV medication would be sent on the first delivery of the next day. The Pharmacist stated Resident #95's cefazolin should have been sent to the facility on the first delivery run on 4/30/25. He stated the delay in the delivery of Resident #95's cefazolin could have been due to an issue with the pharmacy medication log (used to track lot numbers and expiration dates of medications sent to facilities) being incorrectly completed by pharmacy staff or being shorthanded at the pharmacy on 4/30/25. The Pharmacist stated one or both of those reasons could have contributed to the delay of Resident #95's IV cefazolin being available for administration. An interview was conducted on 5/21/25 at 12:53 pm with the Medical Director, who was assigned as the medical provider for Resident #95 at the facility, revealed when medication was not available at the facility for a resident the nurse should contact the pharmacy and the pharmacy would have to be able to provide information about when to expect the medication. The Medical Director stated there should be a better system in place between the pharmacy and the facility to ensure all newly admitted resident medications were available to be administered as ordered. The DON was interviewed on 5/21/25 at 2:29 pm. She revealed the facility had some difficulty obtaining medications timely from the pharmacy for new admissions. The DON stated that when new admissions arrive at the facility the orders were confirmed by the nurse assigned to the resident and that would send the orders to the pharmacy. The DON stated the new admission medications were normally delivered on the same day of admission except for the residents that admitted later in the evening and most often would arrive the next day. She stated the facility had an emergency dose kit which had many common medications that could be used for new admissions until their specific medications arrived at the facility. The DON stated she was not aware if the IV cefazolin was a medication that was available in the emergency dose kit. An interview was conducted on 5/21/25 at 3:01 pm with the Administrator who revealed he was not aware of any issues regarding IV medications from the pharmacy not being delivered timely for new admissions. The Administrator stated the DON was responsible to ensure that Resident #95's IV cefazolin was available and administered as ordered.

Based on observation, record review, resident, staff, and physician interviews, the facility failed to obtain a physician order for the use and care of an indwelling urinary catheter for 1 of 2 residents reviewed for urinary catheter (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder (a condition where the nerves and muscles that control urination were not working properly causing urinary retention) and a history of a spinal fracture. Resident #1's care plan last revised on 4/30/25 revealed he had an indwelling urinary catheter due to neuromuscular dysfunction of the bladder with interventions which included positioning the catheter bag and tubing below the level of the bladder and away from entrance room door. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and was coded for the use of an indwelling urinary catheter. A hospital Discharge summary dated [DATE] revealed Resident #1 had an indwelling urinary catheter in place during his hospital stay and at the time of discharge. Record review of the Physician's orders revealed no order for Resident #1's indwelling urinary catheter or for the care of the indwelling urinary catheter. An observation on 5/18/25 at 2:49 pm revealed Resident #1 was in bed with the indwelling urinary catheter drainage bag hung from the lower rail on the Resident's bed and below the level of the bladder. An interview was completed on 5/18/25 at 2:55 pm with Resident #1. The Resident stated he has had the indwelling urinary catheter for many years. Resident #1 stated the facility's nursing staff cared for the indwelling urinary catheter on all shifts. An interview was completed on 5/21/25 at 10:55 am with Nurse #6. The Nurse stated she readmitted Resident #1 to the facility on 5/15/25 during her 3:00 pm to 11:00 pm shift. Nurse #6 verified Resident #1 was readmitted to the facility with an indwelling urinary catheter. Nurse #6 stated she reviewed the hospital discharge summary sent with Resident #1 and entered the medications listed on it. Nurse #6 stated she reviewed the medications with the Physician and the oncoming 11:00 pm to 7:00 am nurse. Nurse #6 indicated she did not know how to reactivate the discontinued orders for the indwelling urinary catheter and the care of it and believed the oncoming 11:00 pm to 7:00 am nurse was going to reactivate the indwelling urinary catheter orders. An interview was completed on 5/21/25 at 11:54 am with Nurse #1. The Nurse stated she reviewed Resident #1's discharge medications with Nurse #6 on 5/15/25 for correct dosages and amounts. Nurse #1 stated it was Nurse #6's responsibility to reactivate/enter the orders for the indwelling urinary catheter and the care of it. Nurse #1 stated she was unaware Nurse #6 did not know how to reactivate discontinued orders. An interview was completed on 5/21/25 at 12:35 pm with the Medical Director. He revealed an indwelling urinary catheter required a Physician order. The Medical Director stated the order for Resident #1's indwelling urinary catheter should have been entered upon readmission. An interview was completed on 5/21/25 at 5:09 pm with the Director of Nursing (DON). The DON revealed a Physician order was required for Resident #1's indwelling urinary catheter. The DON was unable to state why the order was not entered or reactivated when Resident #1 was readmitted with the indwelling urinary catheter. The DON stated new admissions and readmissions were reviewed during the facility's daily clinical morning meeting. The DON stated Resident #1's omitted indwelling urinary catheter Physician order was an oversite during the clinical morning meeting. An interview was completed on 5/21/25 at 5:13 pm with the Administrator. The Administrator stated nursing was required to ensure that Physician orders were in place to properly care for Resident #1's indwelling urinary catheter.

Based on record reviews, and staff and resident interviews, the facility failed to hold a care plan meeting or invite the resident to participate in the care planning process for 2 of 26 residents whose care plans were reviewed (Resident #26 and Resident #37). The findings included: 1. Resident #26 was admitted to the facility on [DATE]. Resident #26's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderate cognitive impairment. Resident #26 was coded for active participation in the assessment and goal setting. Resident #26's care plans were noted as last reviewed or revised on 3/5/2025. Review of Resident #26's electronic medical record revealed no documentation that a care plan meeting was held or that Resident #26 was invited to participate in a care plan meeting during the time between the 12/4/2024 and 3/5/25 care plan meetings. An interview was completed on 5/18/2025 at 2:24 pm with Resident #26. Resident #26 stated she was unable to recall when she last was invited or attended a care plan meeting. Resident #26 stated she would like to have the opportunity to attend her care plan meetings when she felt up to it. An interview was completed on 5/20/2025 at 3:36 pm with the Social Worker. The Social Worker revealed Resident #26's last scheduled care plan meeting was in December 2024. The Social Worker stated Resident #26 declined to attend. The Social Worker stated the next care plan meeting should have been scheduled in March 2025, but she was behind in scheduling care plan meetings and had not scheduled one. The Social Worker stated at the beginning of each month she reviewed the list of residents that had care plans and MDS assessments due for review and scheduled the care plan meetings with residents and their representatives accordingly. An interview was completed on 5/21/2025 at 4:46 pm with the MDS Nurse. The MDS Nurse stated she sent out an email of the upcoming month's MDS assessments that were due for review to the Social Worker so she would know what residents required a care plan meeting to be scheduled. The MDS Nurse stated long-term resident care plan meetings were held quarterly (every 3 months). An interview was completed on 5/21/2025 at 5:03 pm with the Director of Nursing (DON). The DON stated it was the Social Workers' responsibility to schedule care plan meetings and was unsure why the meetings were not being held timely. An interview was completed on 5/21/2025 at 5:17 pm with the Administrator. The Administrator explained the Social Worker had gotten behind with conducting care plan meetings and was currently working to get caught up. 2. Resident #37 was admitted to the facility on [DATE]. Resident #37's most recent quarterly MDS assessment dated [DATE] revealed Resident #37 was cognitively intact. Resident #37 was coded for active participation in the assessment and goal setting. Review of Resident #37's electronic medical record revealed no documentation that a care plan meeting was held or that Resident #37 was invited to participate in a care plan meeting. An interview was completed on 5/19/2025 at 9:24 am with Resident #37. Resident #37 stated she was unable to recall ever having a care plan meeting since her admission to the facility in 2023. An interview was completed on 5/19/2025 at 3:36 pm with the Social Worker. The Social Worker stated Resident #37 attended her scheduled care plan meeting in October 2024. The Social Worker revealed it was her responsibility to schedule and invite residents and their representatives to the care plan meetings. The Social Worker stated she was behind in scheduling care plan meetings for the current year. An interview was completed on 5/21/2025 at 1:37 pm with the DON. The DON stated it was the responsibility of the Social Worker to schedule and invite participants to care plan meetings. The DON stated she was unaware the Social Worker was late in scheduling care plan meetings. An interview was completed on 5/21/2025 at 5:17 pm with the Administrator. The Administrator explained the Social Worker had gotten behind with conducting care plan meetings and was currently working to get caught up.

Based on observation, record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of smoking and elopement alarms for 1 of 26 residents whose MDS assessments were reviewed (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances and bipolar disorder. Review of the Safe Smoking Screening assessment dated [DATE] revealed Resident #33 was assessed and determined to require supervision while smoking. The assessment further noted the care plan was updated to reflect Resident #33's smoking status. Resident #33 had a physician order dated 4/29/25 for wander guard (elopement alarm) device, check placement every shift. The nursing progress note dated 4/29/25 at 3:32 pm revealed Resident #33 had a wander guard placed on the right ankle. The care plan initiated on 4/29/25 revealed Resident #33 had a care plan in place for smoking with an intervention which included supervision while smoking. The care plan further revealed Resident #33 was an elopement risk related to dementia with an intervention for wander guard as ordered. Review of the MDS admission assessment dated [DATE] revealed Resident #33 had moderate cognitive impairment and used a wheelchair for mobility. Resident #33 was not coded for tobacco use and was not coded for use of the wander/elopement alarm. An observation and interview were conducted on 5/18/25 at 1:59 pm with Resident #33 who was observed in bed with a wander guard in place. Resident #33 reported he was a smoker at the facility. An interview was conducted on 5/21/25 at 3:08 pm with the MDS Nurse who revealed she did not see Resident #33's wander guard and did not see the order so she did not code the resident for use of a wander guard on the assessment. The MDS Nurse further noted that she was aware of Resident #33's smoking status and had entered a care plan for smoking but just missed the area of tobacco use when she coded the MDS assessment. During an interview on 5/21/25 at 4:23 pm with the Administrator he revealed the MDS Nurse was responsible to ensure Resident #33's assessment was coded correctly.

Based on record review, staff and resident interviews, and Physician interviews, the facility failed to administer scheduled intravenous (a soft, flexible tube placed inside a vein used to give medicine or fluids) antibiotic medication which resulted in 4 doses of the antibiotic being missed for 1 of 2 residents reviewed for IV antibiotic therapy (Resident #95). The findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (bone infection) of the left ankle and foot. Resident #95 had a physician order dated 4/29/25 for cefazolin (antibiotic) solution injection 2 grams; administer 2 grams intravenously every 8 hours for bone infection for 42 days. The medication was scheduled to be administered at 6:00 am, 2:00 pm, and 10:00 pm. Review of the Medication Administration Record (MAR) for April 2025 revealed the Resident #95's cefazolin was not administered on the following dates: 4/29/25 at 10:00 pm noted as on order by Nurse #3. 4/30/25 at 6:00 am noted as not administered, no further documentation by Nurse #1. 4/30/25 at 2:00 pm noted as awaiting from pharmacy by Nurse #4. 4/30/25 at 10:00 pm noted as not administered and medication schedule updated by Nurse #2. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #95 was cognitively intact and was coded for the use of antibiotic medication and had intravenous access. During an interview on 5/18/25 at 12:39 pm Resident #95 revealed he missed several doses of his antibiotic when he was admitted to the facility. A telephone interview was conducted on 5/21/25 at 11:32 am with Nurse #3 who was assigned to Resident #95 at the time of the admission on [DATE]. Nurse #3 stated she did not have the cefazolin to administer to Resident #95 on 4/29/25 at 10:00 pm since he was a new admission and the pharmacy had not yet delivered the medication. An interview was conducted on 5/21/25 at 11:48 am with Nurse #1 who was assigned to Resident #95 on 4/30/25 for the 6:00 am dose of cefazolin. Nurse #1 revealed Resident #95's cefazolin was not delivered to the facility by the pharmacy so she was unable to administer the medication to Resident #95. Nurse #1 stated she contacted the pharmacy and was advised that the medication would arrive later in the day. During an interview on 5/20/25 at 2:28 pm with Nurse #4 who was assigned to Resident #95 on 4/30/25 and documented the 2:00 pm noted as awaiting from pharmacy. Nurse #4 revealed the cefazolin was not yet delivered to the facility and she was not able to administer the antibiotic to Resident #95. Nurse #4 stated the facility had a backup box (medication dispensing machine) but she did not think cefazolin was one of the medications that was available. She stated she did not call the pharmacy to check on the delivery because Resident #95 was just admitted the night before and she expected it to be delivered later that day. A telephone interview was conducted with Nurse #2 on 5/20/25 at 11:16 am who was assigned to Resident #95 on 4/30/25 for the 10:00 pm dose of cefazolin. Nurse #2 reported that Resident #95's cefazolin was not available for administration on 4/30/25 at 10:00 pm. She stated she called the pharmacy and was notified that Resident #95's cefazolin would be delivered the next day. Nurse #2 stated she notified the provider and changed the medication administration schedule to start on 5/01/25 when the next expected shipment from pharmacy arrived to ensure all 42 doses of the cefazolin would be administered to Resident #95. An interview was conducted on 5/21/25 at 12:53 pm with the Physician who revealed he was made aware of the medication not being available for Resident #95 and that the cefazolin order was adjusted. He stated he did not feel the missed doses of cefazolin harmed Resident #95 in the grand scheme of his care and treatment. The Physician stated as long as the order was adjusted to ensure the total number of the prescribed doses were in place, he did not feel the missed doses were detrimental to Resident #95's care. The Physician stated there should be a better system in place between the pharmacy and the facility to ensure all newly admitted resident medications were available to be administered as ordered. The DON was interviewed on 5/21/25 at 2:29 pm. The DON revealed that new admission orders were not able to be activated until the resident arrived at the facility and once activated the orders were submitted to the pharmacy to be reviewed and delivered. The DON stated the new admission medications were normally delivered on the same day of admission except for the residents that admitted later in the evening. She stated for those residents that admitted late in the evening there could be a delay until the next day for some of the prescribed medications. The DON stated she was aware of the missed doses of Resident #95's cefazolin and that the order was updated to add the missed doses. An interview was conducted on 5/21/25 at 3:01 pm with the Administrator who revealed the DON was responsible to ensure that Resident #95's IV cefazolin was available to be administered as ordered.

Based on record review, and staff and Resident Representative interviews, the facility failed to notify the resident, Resident Representative and Ombudsman in writing of the reason for transfer/discharge to the hospital and failed to fully complete the bed hold policy document when a resident transferred to the hospital. The deficient practice affected 3 of 3 residents reviewed for hospitalization (Resident #72, Resident #21, Resident #52). The following included: 1. Resident #72 was admitted to the facility on [DATE]. A review of Resident #72's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. A review of Resident #72's nursing progress notes revealed she was discharged to the hospital on 4/30/25 and returned on 5/15/25. a. A review of the bed hold policy dated 4/30/25 revealed Resident #72's Resident Representative had signed the document. Further review of the bed hold policy revealed there were no dates of hospitalization completed and bed hold accept, or decline had not been marked. An interview conducted with the Business Office Manager (BOM) on 05/21/25 at 10:50 AM revealed the bed hold form was prefilled with the dollar amount to hold a bed. The BOM stated she was not responsible for doing anything with the bed hold policy unless the resident or Resident Representative wanted to hold the bed. The BOM stated then she would talk to the Resident Representative about payment. The BOM further stated nursing sent the form with the resident automatically when they went to the hospital. The BOM stated she believed Admissions was supposed to follow up with the resident or Resident Representative to see if they wanted to pay for the bed hold. b. Review of the April 2025 transfer/discharge list revealed no documentation had been sent to the Ombudsman for residents who transferred to the hospital in the month of April. An interview conducted with the Social Worker on 05/20/25 at 12:10 PM revealed she fell behind and had not sent the discharge/transfer list to the Ombudsman for any April discharges yet. The Social Worker stated she normally sent the transfer/discharge list the first week of each month. c. Further review of Resident #72's medical record did not reveal documentation that a written transfer/discharge notice was provided to the resident or Resident Representative when Resident #72 transferred to the hospital on 4/30/25. An interview conducted with Resident #72's Resident Representative on 05/21/25 at 3:30 PM revealed he did not receive a written notice but was told by phone when Resident #72 went to the hospital. An interview conducted with the admission Coordinator on 5/20/25 at 3:38 PM revealed she was not responsible for sending out a written notice of transfer/discharge. An interview conducted with the Social Worker on 5/20/25 at 3:40 PM revealed she was not aware that she needed to send a written notice of transfer/discharge to the resident or Resident Representative when a resident was transferred to the hospital. An interview conducted with the Administrator on 5/21/25 at 4:55 PM revealed he expected that a follow up phone call would be made to the Resident Representative to discuss the bed hold policy and follow up documentation. The Administrator further stated he expected that written notification of transfer/ discharge would be provided to the resident and Resident Representative for residents transferred to the hospital and documentation sent to the Ombudsman. 2. Resident #21 was admitted to the facility on [DATE]. A review of Resident #21's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of a nurse's note dated 9/17/24 revealed Resident #21was sent out to the emergency department for evaluation and the Resident Representative was notified. A review of Resident #21's nursing progress notes revealed she was discharged to the hospital on 9/18/24 and returned on 9/26/24. Further review of Resident #21's medical record did not reveal documentation that a written transfer/discharge notice was provided to the resident and Resident Representative when Resident #21 transferred to the hospital on 9/17/24. An interview conducted with the admission Coordinator on 5/20/25 at 3:38 PM revealed she was not responsible for sending out written notices of transfer/discharge. An interview conducted with the Social Worker on 5/20/25 at 3:40 PM revealed she was not aware that she needed to send a written notice of transfer/discharge to the resident or Resident Representative when transferred to the hospital. An interview conducted with the Administrator on 5/21/25 at 4:55 PM revealed he expected that written notification of transfer/ discharge would be sent to the resident and Resident Representative for residents transferred to the hospital. 3. Resident #52 was admitted to the facility on [DATE]. A review of Resident #52's quarterly MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment. A review of Resident #52's nursing progress notes revealed she was discharged to the hospital on 8/9/24 and returned on 8/12/24. Further review of Resident #52's medical record did not reveal documentation that a written transfer/discharge notice was provided to the resident and Resident Representative when Resident #52 transferred to the hospital on 8/9/24. An interview conducted with the admission Coordinator on 5/20/25 at 3:38 PM revealed she was not responsible for sending out written notices of transfer/discharge. An interview conducted with the Social Worker on 5/20/25 at 3:40 PM revealed she was not aware that she needed to send a written notice of transfer/discharge to the resident and Resident Representative when transferred to the hospital. An interview conducted with the Administrator on 5/21/25 at 4:55 PM revealed he expected that written notification of transfer/ discharge would be sent to the resident and Resident Representative for residents transferred to the hospital.

Based on record review, staff interviews, resident and Responsible Party (RP) interviews, the facility failed to provide the resident or the RP a written summary of the baseline care plan and medication list for 2 of 4 residents reviewed for care planning (Resident #75 and Resident #91). The findings included: 1. Resident #75 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #75 had severe cognitive impairment. Resident 75's electronic health record revealed no documentation that Resident #75 or his RP received a written summary of the baseline care plan and medications. During an interview on 5/18/25 at 12:23 pm with Resident #75's RP she revealed was at the facility almost every day and she had not been given any information regarding the plan of care or medications for Resident #75. An interview was conducted with the Social Worker on 5/20/25 at 12:04 pm who revealed she was responsible to provide a written summary of the care plan and medication list to the resident and/or their RP. The Social Worker stated she attempted to have the baseline care plan and medication list given to Resident #75 and his RP within 72 hours of admission but she had fallen behind with the process. An interview was conducted on 5/21/25 at 3:41 pm with the Director of Nursing (DON), who revealed the Social Worker was responsible to provide residents and/or their RP with a written summary of the baseline care plan and medication list. The DON stated she was not aware the Social Worker had not provided the information to Resident #75's RP regarding the baseline care plan and medications. During an interview on 5/21/25 at 4:24 pm the Administrator stated that the Social Worker was responsible to ensure the baseline care plan process was completed as required, but he stated the Social Worker just fell off track. 2. Resident #91 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #91 was cognitively intact. Review of the electronic health record revealed no documentation that Resident #91 received a written summary of his baseline care plan and medications. During an interview on 5/18/25 at 2:38 pm, Resident #91 revealed he had not received any documentation about his plan of care or medications since he was admitted to the facility. An interview was conducted with the Social Worker on 5/20/25 at 12:04 pm who revealed she was responsible to provide a written summary of the care plan and medication list to Resident #91. The Social Worker stated she attempted to have the baseline care plan and medication list given to Resident #91 within 72 hours of admission but she had fallen behind in the process. An interview was conducted on 5/21/25 at 3:41 pm with the Director of Nursing (DON), who revealed the Social Worker was responsible to provide Resident #91 with a written summary of the baseline care plan and medication list. The DON stated she was not aware the Social Worker had not provided the information to Resident #91 regarding the baseline care plan and medications. During an interview on 5/21/25 at 4:24 pm the Administrator stated that the Social Worker was responsible to ensure the baseline care plan process was completed as required, but he stated the Social Worker just fell off track.

Based on observations, and staff interviews the facility failed to maintain 2 of 4 skillets and 9 of 15 baking sheets free from grease build up and failed to maintain one ice scoop holder free of standing water and mold. These practices had the potential to affect ice and food served to residents. The facility census was 91 residents. Findings included: 1. An observation of the kitchen dishware on 5/19/24 at 10:20 AM revealed: - 2 skillets hung up, ready for use with grease build up on the bottom of the skillets - 3 baking sheets with dark grease built up under the rims were observed stacked on the drying rack ready for use A second observation of the kitchen dishware on 5/21/24 at 9:33 AM revealed: - 2 skillets hung up, ready for use with grease build up on the bottom of the skillets - 3 baking sheets with dark grease built up under the rims were observed stacked on the drying rack ready for use A third observation of the kitchen dishware on 5/22/24 at 9:57 AM revealed: - 2 skillets hung up, ready for use with grease build up on the bottom of the skillets - 9 baking sheets with dark grease built up under the rims were observed stacked on the drying rack ready for use In an interview on 5/22/24 at 10:21 AM the Administrator indicated if staff could not clean the baking sheets and fry pans then they would purchase new ones. 2. An observation on 5/21/24 at 9:43 AM of the hall ice machine revealed the ice scoop holder with a film of pink water and mold on the bottom of the ice scoop holder. In an interview on 5/21/24 at 9:58 AM the Certified Dietary Manager (CDM) indicated staff on the hall were responsible for the hall ice machine and scoop holder, but he would clean it immediately. In an interview on 5/22/24 at 10:21 AM the Administrator indicated that all staff were responsible for the ice machine and ice scoop holder. She indicated staff should see if the ice scoop holder was removable and washed on a daily basis.

Based on record review, resident interviews and staff interviews, the facility failed to conduct and document a care plan meeting with a cognitively intact (Resident #86) and moderately impaired (Resident #38) residents newly admitted to the facility and failed to conduct and invite a cognitively intact resident to participate in care plan meetings after two annual Minimum Data Set (MDS) assessments and three quarterly MDS assessments (Resident #26) for 3 of 6 residents reviewed for care planning. Findings included: 1. Resident # 86 was admitted to the facility on [DATE] with diagnoses including multiple fractures. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #86 was cognitively intact. Resident #86's baseline care plan was signed by the Assistant Director of Nursing as completing the plan on 5/3/2024. The MDS Nurse signature was not dated and the Director of Nursing signed the baseline care plan on 5/21/2024. Resident # 86's comprehensive care plan dated 5/4/2024 indicated he was on pain medication due to fractures of the humerus and femur bones. On 5/9/2024, the care plan was updated to include a focus indicating Resident #86 had acute pain post a fall resulting in a humerus and femur fracture. In an interview with Resident #86 on 5/19/2024 at 11:49 a.m., he stated the facility had not held a care plan meeting with him since his admission. In an interview with Admission Director on 5/22/2024 at 8:31 a.m., she stated she was unable to locate documentation that a care plan meeting was held for Resident #86 after his admission. She said Admission Director or the Social Worker (who was no longer employed at the facility) scheduled the 72-hour care plan meetings for newly admitted residents and recorded scheduled care plan meetings on a calendar. The Admission Director was unable to provide documentation when a care plan meeting was scheduled for Resident #86. In an interview with the Administrator (who was in the Admission Director's office) on 5/22/2024 at 8:31 a.m., she stated Resident #86 should have received a 72-hour care plan meeting after his admission to the facility. She explained there was no documentation of care plan meetings in residents' electronic medical record (EMR) because there was no one assigned to document care plan meetings into resident EMR. Nursing documentation dated 5/21/2024 at 2:15 p.m. by the MDS Nurse recorded a 72-hour care plan meeting was attempted, and the facility was unsuccessful in reaching Resident #86's contact person. In an interview with the MDS Nurse on 5/22/2024 at 9:38 a.m., she explained there was no 72-hour care plan meeting conducted for Resident #86 after his admission. She stated a 72-hour care plan meeting was held on 5/21/2024 and she attempted to contact Resident #86's contact person. She explained she signed the baseline care plan on 5/21/2024 as documentation a care plan meeting was held. She said the Admission Director was responsible for setting up the initial 72-hour care plan meeting. 2. Resident #38 was admitted to the facility on [DATE] with diagnoses including stroke. There were no signatures for Resident #38, Resident #38's Representative or staff recorded on Resident #38's baseline care plan dated 1/13/2024. The baseline care plan indicated Resident #38 understood and communicates with staff easily. Resident #38's comprehensive care plan was updated on 3/15/2024 that reflected Resident #38 had a terminal prognosis. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was moderately cognitively impaired. There was no documentation in Resident #38's electronic medical record (EMR) that a care plan meeting had been held following admission to the facility for Resident #38. In an interview with Resident #38 on 5/19/2024 at 10:58 a.m., she stated the facility had not conducted a care plan meeting with her to discuss her care, and she was not aware of the facility having a care plan meeting with Resident #38's Representative. An attempt on 5/22/2024 to reach Resident #38's Representative was unsuccessful. In an interview with Admission Director/Social Worker on 5/21/2024 at 2:11 p.m., she stated since March 2024 she had been responsible for scheduling the 72-hour care plan meetings after admission and thought a care plan meeting was held for Resident #38. In a follow up interview with Admission Director on 5/22/2024 at 8:31a.m., she stated she was unable to locate any documentation that a 72-hour care plan meeting was held for Resident #38. In an interview with the Administrator on 5/22/2024 at 8:31 a.m., she explained 72-hour care plan meeting should be held with new admissions at the facility. She explained there was no documentation of a care plan meeting for Resident #38 because there was no one assigned the responsibility to document a care plan meeting was held into residents' EMR. 49502 3. Resident #26 was admitted to the facility on [DATE] with diagnosis including stroke. Resident #26's electronic medical record revealed the last documented care plan meeting occurred on 2/1/21. Minimum Data Set (MDS) assessments were completed for Resident #26 on the following dates: 4/25/23 (annual), 7/26/23 (quarterly), 10/26/23 (quarterly), and 1/26/24 (quarterly). The annual MDS assessment dated [DATE] revealed Resident #26 was cognitively intact. In an interview with Resident #26 on 5/19/24 at 11:51 am, he stated he had not attended or been invited to a care plan meeting since 2021. During an interview with the MDS Coordinator on 5/21/24 at 2:57 pm, she stated the Social Worker, who left the facility in March 2024, was responsible for creating and maintaining the care plan meeting calendar, sending out care plan meeting invitations, and holding care plan meetings quarterly. In an interview with the Administrator on 5/21/24 at 3:20 pm, she stated the previous Social Worker was responsible for scheduling the care plan meetings. She further stated when she started her position as administrator at the facility, she was unaware the care plan meeting had not been done. She further revealed the Admissions Director was working on scheduling care plan meetings that needed to be completed.

Based on record review and staff interviews, the facility failed to develop and implement an individualized person-centered baseline care plan that included the use of insulin (a medication used to lower the blood glucose [sugar] in the blood) and anticoagulants (a medication use to prevent clotting of the blood) for 1 of 5 residents reviewed for unnecessary medications (Resident #293). Findings included: Resident # 293 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, pulmonary embolism (blockage of a blood vessel) and deep vein thrombosis (blood clot in the blood vessel). Physician's orders dated 5/10/2024 included Apixaban (a medication used to thin the blood) 5 milligrams (mg) twice a day and Humalog 100 units per milliliter sliding scale insulin subcutaneously (under the skin) before meals for blood glucose readings: 0 -150 give 0 units; 151 - 200 give 2 units; 201 - 250 give 4 units; 251 - 300 give 6 units; 301 - 350 give 8 units; 351 - 400 give 10 units and call MD if over 400. The admission Minimum Data Set (MDS) assessment dated [DATE] and was recorded as in progress. Medications on the MDS assessment were not completed. Resident #293's May 2024 electronic Medication Administration Record (MAR) recorded Apixaban was administered twice a day and Humalog sliding scale insulin was administered three times from 5/10/2024 to 5/13/2024. The baseline care plan form dated 5/13/2024 indicated Resident #293 was cognitively intact and had a diagnosis of Diabetes Mellitus. The medication section included a place to indicate when insulin or anticoagulant medications were received, but these were not marked. In an interview on 5/21/2024 at 2:54 p.m. with Nurse #3, she stated Resident #293 was receiving the medications, Apixaban and Humalog insulin, on admission and both of these medications should have been marked on her baseline care plan. She said she did not have a reason why she did not mark Resident #293 was taking insulin and an anticoagulant on the baseline care plan. In an interview on 5/21/2024 at 2:49 p.m. with the Assistant Director of Nursing, she stated she reviewed Resident #293's baseline care plan and signed the information was correct on Resident #293's baseline care plan. She explained based on the physician's orders for Apixaban and Humalog insulin, Resident #293's baseline care plan was not accurate, and insulin and anticoagulant medications should have been marked on the baseline care plan. In an interview on 5/22/2024 at 9:18 a.m. with the Director of Nursing, she explained when Nurse #3 completed the baseline care plan the medications, Insulin and Apixaban, should have been marked since Resident #293 had an order for the medications and was receiving the medications. She stated during Resident #293's 72-hour care plan meeting the baseline care plan was reviewed and could have been corrected if identified as inaccurate during the care plan meeting.

Based on record review and staff interviews the facility failed to implement an individualized person-centered care plan for a resident with impaired vision for 1 of 5 residents reviewed for nutrition (Resident #36). The findings included: Resident #36 was readmitted to the facility on [DATE]. A physician order dated 2/27/24 for Resident #36 revealed that all food was to be placed in individual bowls at all meals to increase with self-feeding secondary to decreased vision. The Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #36 was cognitively intact, had highly impaired vision, and required setup help for eating. Review of Resident #36's active care plan (last revised on 2/27/24) revealed she had malnutrition risk related to history of coronary artery disease, stroke, mixed hyperlipidemia, vertigo, and hypertension. Interventions included: provide food in bowls to assist with completion of meals related to visual deficits. An observation on 5/20/24 at 12:24 PM revealed Resident #36 was observed to have the lunch meal served on a flat plate. The meal ticket stated all food was to be served in bowls. Only the dessert item was placed in a bowl. Resident #36 stated that her lunch meal should have been served in bowls. A new meal placed in bowls was offered to Resident #36, but she declined. An observation and interview with the Director of Rehab took place on 5/20/24 at 9:20 AM, and he confirmed that Resident #36's lunch meal was served on a flat plate. The Director of Rehab stated that he had ordered all food for all meals to be served in bowls, so that Resident #36 had an easier time eating due to blindness in both eyes. He further stated that the food should have been served in separate bowls because Resident #36 could not see the food items. The Director of Rehab indicated that he notified the previous Dietary Manager (DM) back in February 2024 about the new order for adaptive equipment. He stated he was going to go to the kitchen and notify the current DM that Resident #36's lunch was not served in bowls. On 5/21/24 at 10:03 AM, Nurse Aide (NA) #1 was interviewed. She stated that Resident #36's food was usually served in bowls, and if not, she would notify the kitchen. NA #1 confirmed that she saw Resident #36's lunch meal was not served in bowls, but the Director of Rehab went to the kitchen to notify the staff before she could. During an interview with the MDS Nurse on 5/21/24 at 1:28 PM, she revealed that Resident #36's care plan included meals should be served in bowls due to impaired vision. She stated that nursing staff should have double checked Resident #36's lunch meal before it was served to her. The MDS Nurse indicated that Resident #36 should have received food in bowls to make eating easier for her due to highly impaired vision as stated in the care plan. An interview was conducted with the Director of Nursing (DON) on 5/21/24 at 1:36 PM. She stated that if Resident #36's meal was not served in bowls as stated in the care plan, the nursing staff should have ensured the meal served was as ordered. The Administrator was interviewed on 5/21/24 at 1:56 PM. She stated that that the plan of care should have been followed, and Resident #36's lunch meal should have been provided in bowls.

Based on record review, observations and staff interviews, the facility failed to obtain a physician order on a resident's medical record for the use of supplemental oxygen and apply signage indicating the use of oxygen outside the resident's room for 1 of 2 residents reviewed for oxygen use (Resident #292). Findings included: Resident #292 was admitted to the facility on [DATE] with diagnoses including chronic heart failure and chronic respiratory failure. Discharge orders dated 5/2/2024 included the use of supplemental oxygen to maintain oxygen saturation greater than or equal to 90%. Nursing documentation dated 5/2/2024 recorded Resident #292 on arrival to the facility at 4:40p.m. was receiving oxygen at 2 liters per minute vis nasal cannula. The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #292 was cognitively intact and the use of oxygen. Further nursing documentation dated 5/8/2024 recorded Resident #292's oxygen saturation decreased to 80%. The physician was notified and Resident #292's oxygen was increased to 3 liters per minute to maintain an oxygen saturation of 96%. A physician progress note dated 5/9/2024 at 8:27 a.m. recorded Resident #292's oxygen saturation was 80% overnight and was placed on 3 liters per minute of oxygen with oxygen saturation increasing to 96%. The physician's note further recorded oxygen was ordered as needed to maintain oxygen saturation above 90%. The care plan dated 5/16/2024 indicated Resident #292's was using oxygen therapy due to congestive heart failure, ineffective gas exchange and respiratory illness. Interventions included giving medications as ordered by the physician. There was no physician order for the use of oxygen therapy in Resident #292's medical record. On 5/19/2024 at 12:07 p.m., there was no signage outside Resident #292's room indicating the use of oxygen. Resident #292 was observed wearing oxygen via nasal cannula at 3.5 liters per minute. On 5/21/2024 at 3:26 p.m. in an interview with Nurse #3, she explained Resident #292 used oxygen continuously and she did not recognize on 5/19/2024 (as nurse assigned to Resident #292) there was no Oxygen in use, no smoking signage outside his door. She stated an Oxygen in use, no smoking sign should have been placed outside Resident #292's door when he was admitted or when nursing staff recognized signage was not outside the door. After reviewing Resident #292's orders, Nurse #3 stated there was no order for the use of 3.5 liters per minute of oxygen for Resident #292 in the physician's orders. She explained the nursing staff could administer up to 2 liters per minute of oxygen when residents were in distress but usually called the physician for an order when oxygen was needed. She explained any nurse could enter a physician order for the use of oxygen and stated she did not know why there was not an order in Resident #262's electronic medial record (EMR) for the use of oxygen. On 5/22/2024 at 11:04 a.m. in an interview with the Director of Nursing, she stated oxygen orders came with discharge orders for Resident #292 and an order for the use of oxygen should have been entered by the nursing staff into the EMR for Resident #292. She further stated when physician was called and supplemental oxygen was increase, the nursing staff should had entered an order into Resident #292's EMR. She explained the nursing staff was responsible to ensure an Oxygen in use, no smoking sign was outside Resident #292's door due to oxygen in use.

Based on observations, record review, and staff interviews, the facility failed to provide all food in bowls as ordered by the physician for 1 of 1 residents requiring adaptive equipment for meals (Resident #36). Findings included: Resident #36 was readmitted to the facility on [DATE]. A physician order dated 2/27/24 for Resident #36 revealed that all food was to be placed in individual bowls at all meals to increase with self-feeding secondary to decreased vision. The Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #36 was cognitively intact, had highly impaired vision, and required setup help for eating. An observation on 5/20/24 at 12:24 PM revealed Resident #36 was observed to have the lunch meal served on a flat plate in her room. The meal ticket stated all food was to be served in bowls. Only the dessert item was placed in a bowl. Resident #36 stated that her lunch meal should have been served in bowls. A new meal placed in bowls was offered to Resident #36, but she declined. An observation and interview with the Director of Rehab took place on 5/20/24 at 12:30 PM, and he confirmed that Resident #36's lunch meal was served on a flat plate. The Director of Rehab stated that he had ordered all food for all meals to be served in bowls, so that Resident #36 had an easier time eating due to blindness in both eyes. He further stated that the food should have been served in separate bowls because Resident #36 could not see the food items. The Director of Rehab indicated that he notified the previous Dietary Manager (DM) back in February 2024 about the new order for adaptive equipment. He stated he was going to go to the kitchen and notify the current DM that Resident #36's lunch was not served in bowls. The DM was interviewed on 5/20/24 at 2:55 PM. He stated he began at the facility in early March 2024. The DM indicated that he was aware of the order to provide food in bowls at all meals for Resident #36. He stated the Director of Rehab notified him that her lunch meal was not served in bowls. The DM revealed that he went to Resident #36's room to offer a new meal in bowls, and she declined. The original order was for a divided plate, but therapy requested bowls because she was able to handle the food better. The DM stated this had not been an issue before, and Resident #36 never previously complained to him about not receiving food in bowls at meals. On 5/21/24 at 10:03 AM, Nurse Aide (NA) #1 was interviewed. She revealed that Resident #36's food was usually served in bowls, and if not, she would notify the kitchen. NA #1 stated that this has happened once or twice previously. She confirmed that she saw Resident #36's lunch meal was not served in bowls, but the Director of Rehab went to the kitchen to notify the staff before she could. During an interview with the MDS Nurse on 5/21/24 at 1:28 PM, she revealed that nursing staff should have double checked Resident #36's lunch meal before it was served to her. The MDS Nurse indicated that Resident #36 should have received food in bowls to make eating easier for her due to highly impaired vision. An interview was conducted with the Director of Nursing (DON) on 5/21/24 at 1:36 PM. She revealed that someone in the kitchen should have provided the correct adaptive equipment for Resident #36's lunch meal. If the meal was not served in bowls as ordered, the nursing staff should have looked at the meal ticket and if it was not correct, they should have corrected immediately with kitchen assistance. The Administrator was interviewed on 5/21/24 at 1:56 PM. She revealed that that the plan of care should have been followed, and Resident #36's lunch meal should have been provided in bowls.

Based on record review, staff, and the facility ' s Quality Assessment and Assurance (QAA) Committee, the facility failed to maintain implemented procedures and monitor interventions the committee put into place following the 7/14/20 complaint investigation survey, 9/20/20 complaint survey, 5/10/21 complaint survey, and the 3/30/22 recertification and complaint investigation and survey. This was for 5 deficiencies cited on the current recertification and complaint investigation survey of 3/2/23. A deficiency was cited on 3/30/22 in the area of safe/clean/ homelike environment (F584). A deficiency was cited on 9/20/20, 5/10/21, and 3/30/22 in the area of accuracy of assessments (F641). A deficiency was cited on 5/10/21 and 3/30/22 in the area of develop/implement comprehensive care plan (F656). A deficiency was cited on 7/14/20 in the area of bowel and bladder incontinence, catheter, urinary tract infection (F690). A deficiency was cited on 5/10/21 in the area of influenza pneumococcal immunizations (F883). The continued failure during two or more surveys of record shows a pattern of facility ' s inability to sustain an effective QAA committee. The findings included: This tag was cross referenced to: F584 Based on observation and staff interviews the facility failed to provide a clean and sanitary environment by failing to clean a tube feeding pump and pole for 1 of 1 resident observed with a tube feeding pump and pole. (Resident #34) The facility also failed to provide a safe and sanitary environment when food and other debris was found lodged in 1 of 1 resident ' s HVAC (system used to heal and cool an area) unit. (Resident #15) During the recertification and complaint survey dated 3/30/22 the facility was cited at F584 for failing to clean a feeding pump and feeding pump pole. F641 Based on observation and staff interviews the facility failed to provide a clean and sanitary environment by failing to clean a tube feeding pump and pole for 1 of 1 resident observed with a tube feeding pump and pole. (Resident #34) The facility also failed to provide a safe and sanitary environment when food and other debris was found lodged in 1 of 1 resident's HVAC (system used to heal and cool an area) unit. (Resident #15) During the recertification and complaint survey dated 3/30/22 the facility was cited at F641 for failing to accurately code the Minimum Data Set (MDS) assessment for a resident. During the complaint investigation survey dated 5/10/21 the facility was cited at F641 when the facility failed to accurately code a minimum data set assessment for a resident. During the complaint investigation survey dated 9/20/20 the facility was cited at F641 for failing to accurately code the MDS in the areas of skin conditions and pain. F656 Based on observation, record review, resident and staff interview the facility failed to develop an individualized person-centered care plan for 3 of 32 residents whose care plans were reviewed. (Resident #48, Resident #36, Resident #14) During the recertification and complaint survey dated 3/30/22 the facility was cited at F656 when the facility failed to implement a communication deficit care plan and failed to care plan a resident ' s urinary catheter. During the complaint investigation survey dated 5/10/21 the facility was cited at F656 failed to implement care plan interventions for resident at risk for potential accidents/falls. F690 Based on observations, record review, staff interviews, and physician interviews, the facility failed to maintain an indwelling urinary catheter drainage bag below the bladder to allow for proper drainage and reduce risk for urinary tract infection (Resident #42) and failed to obtain a physician order for indwelling urinary catheter for 2 of 2 residents (Resident #42 and Resident #170) reviewed for urinary catheter. During the complaint investigation survey dated 7/14/20 the facility was cited at F690 for failing to keep a urinary catheter drainage bag from coming in contact with the floor. F883 Based on record reviews and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations upon admittance into the facility (Resident #47) and offer annual influenza vaccine (Resident #40) for 2 of 5 residents reviewed for immunizations. During the complaint investigation survey dated 5/10/21 the facility was cited at F883 for failing to offer a resident the influenza vaccine, administer the influenza vaccine to a resident after informed consent was signed, and offer a resident the 23 Valent Pneumococcal Polysaccharide vaccine. An interview was conducted with the Administrator on 3/2/23 at 5:51 PM. The Administrator stated that the Quality Assurance Performance Improvement meeting was held monthly to discuss various concerns in the facility. She stated that performance improvement plans were based on concerns the facility received in self-audits, daily rounds and observations, and pharmacy reports. The Administrator stated the staff were constantly being educated through in-services and all staff meetings about the performance improvement plans and the facility ' s progress. The Administrator stated that the facility had faced a lot of staff turnover and she felt this change had directly affected the facility ' s ongoing performance improvement plan

Based on record reviews and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations upon admittance into the facility (Resident #47) and offer annual influenza vaccine (Resident #40) for 2 of 5 residents reviewed for immunizations. The Findings included: The facility policy for Pneumococcal Vaccine with the revised date October 28,2020 read in part Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. The resident's medical record shall include documentation that indicates at a minimum the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. The facility policy for Influenza Vaccine with the revised date October 27, 2020, read in part Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during the time period, or refuses to receive the vaccine. It further read, the resident's medical record will include documentation that the resident received or did not receive the immunization due to medical contraindication or refusal. 1. Resident #47 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and hypertension. The quarterly MDS assessment dated [DATE] revealed Resident #47 had severe cognitive impairment and was coded as not receiving his pneumococcal vaccine. Review of Resident #47's immunization record revealed no documentation that he or his responsible party had been offered, given, or refused the pneumococcal vaccine. An interview was completed with the Infection Control Nurse on 3/2/23 at 3:04pm. The Nurse indicated she was new to the position and facility and had no information regarding the pneumococcal or influenza vaccinations. An interview was completed with Administrator #2 on 3/2/23 at 4:54pm. She revealed there had been a change in leadership at the facility which led to a miscommunication to nursing staff, that resulted in residents not receiving vaccinations. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses that included history of a stroke and high blood pressure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had severe cognitive impairment and was coded as receiving his last influenza vaccine on 10/21/21. Review of Resident #40's immunization record revealed no documentation that he or his responsible party had been offered, given, or refused the influenza vaccine. An interview was completed with the Infection Control Nurse on 3/2/23 at 3:04pm. The Nurse indicated she was new to the position and facility and had no information regarding the pneumococcal or influenza vaccinations. An interview was completed with Administrator #2 on 3/2/23 at 4:54pm. She revealed there had been a change in leadership at the facility that led to a miscommunication to nursing staff, which resulted in residents not receiving vaccinations.

Based on record review, staff interviews, observations, and physician interview the facility failed to provide supervision to prevent a cognitively impaired resident who had been identified as a wandering risk from exiting the facility for one of two residents reviewed for supervision to prevent accidents. Resident #3, who was cognitively impaired, exited the facility without staff knowledge and was found approximately an hour later at a credit union adjacent to a 4-lane highway, 0.2 miles or 1,056 feet away from the facility. After Resident #3 was observed outside by a staff member, he was left unattended outside while confirmation and assistance was sought from other staff members. The findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses, one of which included Alzheimer's disease. Review of a wandering assessment dated [DATE] revealed Resident #3 was assessed as a high risk for wandering. A physician's order was initiated on 9/12/2020 for Resident #13 to have a wander or elopement alarm to the ankle and to have the placement checked every shift for monitoring. Review of Resident #3's annual Minimum Data Set (MDS) assessment completed 2/9/2021 revealed he was coded as severely cognitively impaired. Resident #3 was coded as having no wandering behaviors, used a wheel chair for locomotion, and did not use a wandering/elopement alarm. Review of Resident #3's care plan, completed 2/17/2021, revealed the resident had a focus area for being an elopement risk relative to having a diagnosis of Alzheimer's disease and confusion. The care plan goal specified the resident's safety was to be maintained through the next review date. Listed interventions included: checking placement and function of safety monitoring device on the right ankle every shift, seeking of placement for resident at a facility in a secure unit, and reorientation/validation/redirection of resident as needed. There was no nursing progress note dated 4/10/2021 written by Nurse #1. Review of the nursing progress notes revealed a note written by the Administrator on 4/10/2021 which indicated the Administrator spoke with the responsible party for Resident #3 and informed her of the elopement of Resident #3 from the facility and his safe return. The same progress note revealed the Administrator contacted the physician for Resident #3 and left a voice mail. A nursing progress note dated 4/10/2021 written by the Director of Nursing (DON) revealed, Staff was notified by another staff member that resident was seen outside the building at 11:25 AM. Staff immediately responded, staff immediately assessed the resident with no injuries. Resident was assisted to the building by staff. Resident was placed on one on one supervision for additional precautions. An interview was conducted with Nurse #1 on 4/30/2021 at 9:47 AM. Nurse #1 described and explained how on 4/10/2021 Resident #3 was thought to have exited the facility. Nurse #1 stated at approximately 10:30 AM Resident #5 was at the front door of the facility and shouted to her requesting for the door to be unlocked. Nurse #1 was behind the nurses' desk at the medication cart at the end of the front hallway with a view of the front door. Nurse #1 explained that Resident #5 had a medical appointment outside of the facility and could transport himself. Nurse #1 questioned Resident #5 if he had notified his nurse (CMA #1) he was leaving the facility to which he replied he had. Nurse #1 pushed the key pad at the nurses' station to remotely open the front door and returned to where she could visualize Resident #5 ambulate through the door. Nurse #1 revealed she did not see Resident #3 sitting to the side next to the front door. Nurse #1 revealed she saw Resident #5 leave through the front door. Nurse #1 indicated she did not see the door close or hear an alarm go off at the front door because she returned to her nursing duties. Nurse #1 stated she went to have lunch in her vehicle in the facilty parking lot at approximately 11:30 AM returning at approximately 12:00 PM and was notified at that time of the elopement of Resident #3. Nurse #1 confirmed she was the only nurse working in the facility on 4/10/2021, but was available by phone if she needed to return inside the building. Nurse #1 also confirmed she performed a physical assessment of Resident #3 for injuries upon her return to the facility, finding no injuries to the resident. An interview was conducted on 4/29/2021 at 7:13 PM with dietary aide (DA #1) who observed Resident #3 outside of the building unaccompanied. DA #1 revealed on 4/10/2021 at approximately 11:24 AM, she came out a side door of the facility by the dumpster to take out garbage and to take care of an emergency phone call prior to the start of tray line service. DA #1 stated she was unable to address the phone call because she observed Resident #3 in a wheel chair near the credit union parking lot. DA #1 stated she called to Resident #3, but he did not respond. DA #1 stated she was unsure if this was a resident from the facility or not due to many older people frequently in the area of the facility. DA #1 indicated she went back into the facility to confirm with and notify the nursing staff of Resident #3 being outside the facility. DA #1 then went back to the facility kitchen because she was needed for the start of the tray line service. An interview was conducted with HK #1 on 4/30/2021 at 11:29 AM. HK #1 explained her primary duties were in the laundry across from the kitchen. HK #1 stated on 4/10/2021 she was in the laundry room when DA #1 came through the outside door asking her if residents of the facility were allowed to go to the credit union on their own. HK #1 indicated DA #1 thought she saw a resident from the facility at the drive through of the credit union. HK #1 revealed DA #1 described the resident to her, and she immediately was able to identify Resident #3 as the resident who was outside. HK #1 and DA #1 both agreed nursing staff should be alerted. HK #1 stated DA #1 went to alert the nursing staff while she stayed in the laundry. HK #1 stated soon after, NA #1 came running to the back door. HK #1 then went outside to assist NA #1 in the search for the resident. HK #1 revealed the four staff members, HK #1, NA #2, NA #1, and CMA #1 converged in the facility parking lot at the same time and observed Resident #3 stuck in the grass near the credit union. HK #1 revealed the four staff members went to Resident #3 through the muddy grass and asked him how he got outside. HK #1 stated the resident replied he was going to get his car. HK #1 stated she returned to the laundry room through the grass while CMA #1, NA #1, and NA #2 assisted Resident #3 in returning to the facility. An interview was conducted with a Certified Medication Aide (CMA #1) on 4/29/2021 at 7:27 PM. CMA #1 recalled she gave medications to Resident #3 at approximately 9:30 AM on 4/10/2021 and watched him propel to the front lobby after telling her he was going to get his truck. CMA #1 revealed DA #1 came to the nurses' station at 11:30 AM, described Resident #3, and announced he was outside. CMA #1 stated two other nurse aides (NA #1 and NA #2), herself, and a housekeeper (HK #1) went outside to search for Resident #3. CMA #1 described how the Resident #3 was found stuck in the muddy median area next to the credit union drive through with his wheel chair wedged between a concrete pass through. CMA #1 stated Resident #3 indicated he was uninjured but needed to get to the bank and then on to work. CMA #1 revealed the nurse aides (NA #1 and NA #2) helped her dislodge the wheelchair and propel Resident #3 along the highway back to the facility. CMA #1 confirmed Resident #3 was wearing a wander/elopement alarm which sounded when he was brought back into the facility through the front door. An interview was conducted with NA #1 on 4/30/2021 at 10:35 AM. NA #1 confirmed she was assigned to monitor and provide care for Resident #3 on 4/10/2021 on the 7:00 AM to 3:00 PM shift. NA #1 relayed she set up the breakfast tray for Resident #3 at approximately 8:20 AM and gave him a bath after 9:00 AM. NA #1 stated at approximately 9:45 AM Resident #3 came out of his room and as was his usual practice propelled himself to the front lobby. NA #1 stated she went on her break at approximately 11:00 AM and upon her return a dietary employee (DA #1) came to the nurses' station and indicated Resident #3 was outside. NA #1 described the retrieval of Resident #3 with the assistance of CMA #1, HK #1, NA #2 and herself. NA #1 indicated she and HK #1 went out of the facility side door and CMA #1 and NA #2 went out the front door in search of Resident #3. NA #1 explained CMA #1, NA #2, HK #1, and herself all saw Resident #3 at the same time over at the credit union. NA #1 confirmed Resident #3 was found in his wheel chair stuck in the mud in a walkway next to the credit union. NA #1 stated it was thought that Resident #3 came through the front parking lot and crossed through the grassy area to get to the credit union as evidence by the wheel chair tracks in the muddy grass. NA #1 explained how Resident #3 was stood up and the wheel chair dislodged from the barrier and put in the road next to the credit union. NA #1 explained how Resident #3 was pushed in his wheel chair by CMA #1 through the parking lot and onto the highway with NA #1 and NA #2 waiving off traffic to return the resident to the facility. An interview was conducted with NA #2 on 4/30/2021 at 11:14 AM, who confirmed the description of events on 4/10/2021 as described by NA #1. A review of Resident #3's treatment administration record (TAR) from April 2021 revealed an order for a wander/elopement alarm on the ankle of Resident #3 was to have the placement checked every shift for monitoring. The April TAR revealed the placement of the wander/elopement alarm was checked every shift to include the night shift on 4/9/2021 and day shift on 4/10/2021 and was on Resident #3. A review of the weather conditions, per Weather Underground web site, revealed the following data for [NAME] City, North Carolina on 4/10/2021 at 10:30 AM were 65 degrees Fahrenheit (F) partly cloudy with no wind or precipitation. The conditions at 11:30 AM were 70 degrees F, with fair conditions. An interview was conducted with the responsible party (RP) for Resident #3 on 4/30/2021 at 11:58 AM. The RP stated on 4/11/2021 she received a phone call from the DON and the Administrator letting her know Resident #3 attempted to get out of the facility but he was fine. The RP stated she visited Resident #3 on 4/12/2021 and was notified by the nursing staff Resident #3 was let out of the facility on 4/10/2021 by another resident leaving for a medical appointment and had propelled himself to the credit union. The RP stated she did not have any other information but was concerned Resident #3 could have been injured because the facility was located next to a highway. The DON and the Administrator were interviewed, and observations of the nursing/ front door area was made on 4/29/2021 at 9:15 AM. A device to unlock the front door was observed to be to the left on the desk at the nurses' station. The device had a button to unlock the front door when pressed allowing the person at the front door to either push the door open or press the handicap button automatically opening the door. The Administrator explained the wander/elopement alarm on Resident #3 prevented the front door from opening and sounded an alarm as the resident approached the door. The Administrator clarified if the door was already open, then only an alarm would sound as the resident went to the door, allowing Resident #3 to exit if the alarm went unnoticed. It was observed at the time of the interview from the nurses desk the front door was visible down the front hallway but, the area to the left of the front door was not visible. The Administrator explained the facility investigation revealed it was likely Resident #3 was able to exit the facility while following Resident #5, for which the door was opened, so he could drive himself to a medical appointment. The Administrator explained Nurse #1 let Resident #5 out the door but was unable to visualize where Resident #3 was sitting to the left of the front door. The Administrator confirmed there was not a front desk receptionist sitting in the lobby on 4/10/2021 due to it being the weekend. The DON stated Resident #3 was coherent enough upon his return to the facility and he told her he left the building behind the man who drove away. The physician for Resident #1 (MD #1) was interviewed on 4/30/2021 at 8:49 AM. MD #1 denied having any knowledge of Resident #3 eloping from the facility on 4/10/2021. MD #1 stated he thought Resident #3 was an easy going guy who sometimes spoke of wanting to go home. MD #1 stated to his knowledge the facility was checking the wander/elopement alarms on the residents every shift to include Resident #3. Resident #3 was observed on 4/30/2021 at 11:29 AM propelling himself with his feet down the hallway. He had a wander/elopement alarm on his right ankle. Observations were made on 4/30/2021 at 2:06 PM of the location and distance Resident #3 was from the facility when he was found on 4/10/2021. The credit union drive through where Resident #3 was found was observed to be 0.2 miles or 1,056 feet from the front entrance of the facility. Resident #3 had to propel himself across 3 parking lots and 2 grass medians adjacent to a 4-lane highway to get to the credit union drive through. The maintenance supervisor was interviewed on 5/6/2021 at 11:14 AM. The maintenance supervisor revealed he was contacted on 4/10/2021 and notified a resident had eloped from the facility. The maintenance supervisor stated he checked the wander/elopement alarm system on 4/10/2021 after he was alerted Resident #3 had eloped from the facility and found it to be functioning properly. The maintenance supervisor additionally revealed a video tape surveillance tape of the facility lobby had revealed Resident #5 had pushed the handicap door button for both front entrance doors and had exited the facility. The maintenance supervisor stated the video did not have any sound but Resident #3 was seen to be looking at the birds in the front lobby, turned himself around when the front door opened, hesitated, and then propelled himself out the front doors that remained open long enough for him to escape. The maintenance supervisor revealed the video tape surveillance was no longer available for viewing or for confirmation of the time of the elopement. The maintenance supervisor stated every Tuesday a maintenance assistant checked the functionality of the wander/elopement alarms on the residents and on the doors of the facility documenting this in a book at the nurse's station. The corrective action provided by the facility was completed on 4/11/2021. Problem Identified: Resident #3 was admitted to The Citadel at [NAME] City on 1/31/2020. At 10:30 AM on 4/10/2021, Resident #3 exited the building via the front door. At 11:30 AM, the resident was observed by Dietary Aide #1/Dietary Staff Member #1 to be sitting in his wheelchair in the field between the facility and the State Employees Credit Union next door. The Dietary Aide #1/Dietary Staff Member #1 notified Nurse Aide NA #1. The Nurse Aide NA #1, Nurse Aide NA #2, Certified Medication Aide CMA #1, and Laundry Aide/Housekeeper #1 immediately responded and assisted Resident #3 back into the building. Our investigation on 4/10/2021 showed that prior to this event, Resident #3 was last seen by Housekeeper #2 in the front lobby watching the birds in the bird cage. The front door was locked and secured; it can only be unlocked by entering the code on the keypad at the door or by pushing the unlock button from the remote-control keypad at the nurse's station. Resident #5 approached the door to go out for his [CONDITION(S)] appointment. He yelled down the hallway and asked Nurse #1 who was at the nurse's station to unlock the door so he could go to his appointment. The Nurse #1 unlocked the door from the nurse's station using the remote-control keypad. Resident #5 pushed the handicap button to open the door. Nurse #1 saw the resident walk out but did not watch the door close. Nurse #1 went back down 200 Hall. Resident #3 then went out the door. The wander guard activated the door alarm sound, but none of the staff members heard it. Certified Medication Aide CMA #1 notified the Director of Nursing (DON) of the event on 4/10/2021 at approximately 11:45 AM. Address how corrective action will be accomplished for resident(s) found to have been affected. The Certified Medication Aide CMA #1, Nurse #1, Maintenance Director, Social Worker, Minimum Data Set (MDS) Nurse, Staff Development Coordinator (SDC), Director of Nursing (DON), and Administrator responded immediately on 4/10/2021. The Nurse #1 completed a head-to-toe assessment on Resident #3 with no injury noted. An updated wandering assessment was completed by the Director of Nursing (DON). The care plan for Resident #3 was reviewed and updated by the Director of Nursing (DON) to include reviewing the current interventions and the use of a wander guard. The Nurse #1 and Certified Medication Aide CMA #1 initiated increased supervision for Resident #3 to include constant knowledge of whereabouts through hall monitoring as well as every 15-minute checks. This was documented on safety check sheets which are located in the resident's medical record. Post event at approximately 11:45 AM, a head count of all residents in the facility was conducted by Certified Medication Aide CMA #1. All residents were present and accounted for. Administrator notified Resident #3's family on 4/10/2021 at 2:00 PM regarding Resident #3 exiting the facility, physical assessment following the event, and plan for increased monitoring. No new physician orders were received. Resident #3 wears a wander guard bracelet on right ankle. Maintenance Director checked the wander guard and exit doors, and both were working properly. At 4:00 PM Administrator and Director of Nursing (DON) completed an additional head-to-toe assessment finding no signs of injury. When asked why he exited the facility, Resident #3 said he was going to his car to get some money for the vending machine. He exhibited no signs of distress. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed. On 4/10/2021 Maintenance Director checked all exit doors and wander guards. All were working properly. On 4/10/2021, Director of Nursing (DON) and Minimum Data Set (MDS) Nurse completed a review of all residents in the entire facility to identify residents that have exit-seeking behaviors, ensure they have an updated wandering risk assessment (Gates Wandering Assessment), and care plan is reflective of interventions. Wandering Risk books containing face sheets with photographs of each resident at risk were updated and placed at the nurse's station and front desk. Address what measures will be put in place and systematic changes made to ensure that the identified issue does not occur in the future. On 4/10/2021, current staff were educated by the Administrator, Director of Nursing (DON), Staff Development Coordinator (SDC) or Minimum Data Set (MDS) Nurse. Education included the facility policy on elopements and wandering residents. It also included recognition of exit seeking behaviors in residents and what intervention strategies could be put into place along with the supervision required. This education was done in person and via phone. Staff were not permitted to work until they were educated. Therefore, 100% of current staff were educated by 4/10/2021. Hired a weekend receptionist to monitor the front lobby and enter/exit screening process on 4/10/2021. If the receptionist needs a break the nurse or Certified Nurse Assistant will cover. Indicate how the facility plan to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. Maintenance Director checked the wander guard system and door alarms for proper functionality on 4/10/21 and will continue it on a daily basis. If the wander guard system or door alarms are not working properly, the Maintenance Director will notify the Administrator and correct the problem. This is documented daily on a log and kept by the Administrator. Director of Nursing (DON) updated the Wandering Assessment in Point Click Care to populate quarterly for the nurses to assess all residents exhibiting new behaviors of wandering or exit-seeking on 4/10/21 and will continue it. Director of Nursing (DON) placed wander guard checks on the Medication Administration Record for the nurses to check placement and functionality each shift on 4/10/21 and will continue it. The Director of Nursing (DON) will review residents at risk for wandering or exit-seeking weekly for 12 weeks to ensure interventions remain in place. Residents exhibiting new behaviors of wandering or exit seeking will be reviewed to ensure the wandering assessment is accurate and interventions are in place. The Director of Nursing (DON) will report findings monthly to the QAPI Team for review times 3 months. Documentation of the review will be kept by the Administrator in the QAPI Book. The Administrator will review the wander guard system and door alarms daily check log, weekly for 12 weeks to ensure the wander guards and door alarms are functioning properly. The Administrator will report findings monthly to the QAPI Team for review times 3 months. Documentation of the review will be kept by the Administrator in the QAPI Book. The facility alleges compliance as of 4/11/2021. The corrective action plan was validated on 5/6/2021 and concluded the facility implemented an acceptable correction action plan on 4/11/2021. Record review of wandering residents revealed care plans with interventions were updated and in place along with elopement/wander alarm checks on the medication administration records. Record review revealed a skin assessment was completed for Resident #3 on 4/10/2021. An interview with the maintenance supervisor revealed wander/elopement alarm checks were implemented. An interview was conducted with the weekend front desk receptionist confirming wandering residents were monitored for elopement risks. Interviews were conducted with staff members confirming training was conducted on 4/10/2021 regarding monitoring of wandering residents and elopement procedures. Observations were made of Wandering Risk books located at the front desk and the nursing station.

Based on record review, staff interview, physician interview, nurse practitioner interview, and family interview the facility failed to provide necessary services and medical equipment for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to obtain replacement parts for a wound vac, provide an air mattress, provide wound treatments as ordered, and notify the physician of a decline in the wound for Resident #13, resulting in a deterioration of a stage 4 pressure wound with an increase in size and infection. Findings included: Resident #13 was admitted to the facility from the hospital on 3/3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge summary from the hospital dated 3/3/2021 revealed Resident #13 was discharged to the facility with a wound vac to a Stage 4 pressure ulcer on the sacrum. A wound VAC is a vacuum-assisted closure of a wound as a type of therapy to help wounds heal. The discharge summary also indicated Resident #13 required a low-pressure mattress. The admission minimum data set assessment dated [DATE] coded Resident #13 as having moderately impaired cognition with no behaviors or rejection of care. Resident #13 required extensive assistance of one person with bed mobility and did not walk or perform locomotion during the assessment period. The assessment coded Resident #13 as having a Stage 4 pressure sore and one unstageable pressure sore present on admission. The assessment additionally coded the resident as utilizing a pressure reducing device for the bed. Review of the care plan for Resident #13 revealed a focus area initiated on 3/25/2021 for a pressure ulcer to the sacrum and unstageable to heel. The care plan indicated Resident #13 was at risk for further impaired skin integrity and/or worsening of current wounds relative to a urinary catheter, diabetes, [CONDITION(S)], [CONDITION(S)], and activity of daily living self-care deficit. Some of the interventions were to administer treatments as ordered and monitor for effectiveness as well as the requirement of a pressure relieving (air mattress) on bed. Documentation in the medical record revealed Resident #13 was admitted to the facility with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician admission progress note dated 3/8/2021, written by MD #1, noted Resident #13 was to be followed and treated at a wound clinic. Documentation on a follow-up progress note dated 4/6/2021, written by the wound care nurse practitioner (NP #1), revealed the recommendations for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The recommendations clarified the cleaning, packing, and sealing of the wound in addition to the wound VAC settings. Documentation in physician follow-up note dated 4/7/2021, written by MD #1, revealed the family of Resident #13 had requested the facility wound provider (NP #1) follow the patient. MD #1 documented he agreed because Resident #13 was making progress. Documentation in a follow-up progress note dated 4/12/2021, written by NP #1, revealed under treatment recommendations instructions for the sacral pressure ulcer stated, Wound VAC on hold due to malfunctioning, clean with dwc (wound cleanser), pack with calcium alginate, cover the abd (abdominal) pad, secure with tape. Change daily. Documentation in a skin/wound progress note dated 4/12/2021 by treatment nurse #1 (TN #1), revealed NP #1 did an assessment of Resident #13. The progress note revealed the NP #1 recommended continuing the current treatment at that time. The progress notes also revealed the wound VAC for Resident #13 was on hold. TN #1 was not available for interview due to a medical leave of absence. Review of the April treatment administration record (TAR) for Resident #13 revealed an order initiated on 4/13/2021 and discontinued on 4/15/2021, Cleanse sacral wound with NS (normal saline). Apply NS moistened calcium alginate packing to wound bed. Cover with ABD pad. Secure with tape. Every day shift for wound healing for 8 days. This order was documented as administered on 4/13/2021 and 4/15/2021. The TAR was blank on for this treatment order on 4/14/2021. Nurse #2, who was assigned to provide care for Resident #13 on the day shift on 4/14/2021, was interviewed on 5/7/2021 at 11:54 AM. Nurse #2 stated she did not recall if she did the sacral wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 stated she routinely did her treatments and routinely documented the treatments she completed. Review of a nursing progress note dated 4/18/2021 at 8:24 AM revealed, Resident alert and oriented able to voice needs during morning care resident rolled out of bed. CNA (certified nursing assistant) was at bedside holding onto resident. Resident was sitting on the floor left arm on the side rail left pinky toe open area cleansed dry dressing applied. [Responsible party] was made aware. The Director of Nursing (DON) was interviewed on 5/7/2021 at 12:15 PM. The DON revealed she was made aware Resident #13 rolled out of bed on Saturday, 4/18/2021. The DON stated she decided Resident #13 was to be placed on a bariatric (larger) bed on Monday, 4/20/2021. The DON stated prior to the fall out of the bed, Resident #13 was on an air mattress. The DON indicated a company that made an air mattress for the bariatric bed had to be found. The DON recalled treatment nurse (TN #2) came to her and asked her if an air mattress for Resident #13 was ordered and she told her yes it was. Documentation in a follow-up progress note dated 4/20/2021, written by NP #1, revealed under treatment recommendations, Wound VAC on hold due to malfunctioning, clean with dwc, pack with [MEDICATION(S)] blue, cover with abd pad, secure with tape, change daily or as needed depending on if the foam turns white or if dressing becomes dirty from stool. Documentation in a skin/wound progress note dated 4/20/2021, written by TN #2, revealed the sacral pressure ulcer was continuing to improve. The wound was described as measuring 3.5cm length x 3.8cm width x 0.9 cm depth with a small amount of serosanguinous drainage with no redness or warmth to surrounding tissue. Review of the April TAR for Resident #13 revealed an order initiated on 4/16/2021 and discontinued on 4/26/2021 for Sacrum cleanse with sterile water, apply sterile water moistened [MEDICATION(S)] blue to wound bed, cover with dry dressing every day shift. This order was documented as completed from 4/16/2021 to 4/25/2021. The TAR was blank for this treatment order on 4/26/2021. Nurse #12, who was assigned to provide care for Resident #13 on the day shift on 4/26/2021, was interviewed on 5/7/2021 at 2:21 PM. Nurse #12 stated maybe she forgot to click on the TAR indicating the treatment was completed on 4/26/2021 because there was a lot of orders to click on the TAR of Resident #13. Review of a follow-up wound care progress note dated 4/26/2021 written by NP #1 stated in part, Patient (Resident #13) with a Stage 4 wound to her sacrum with slight decline since changed to bariatric bed. The wound was assessed as 5 cm in length, 6 cm in width, and 4 cm in depth. It was noted, dark appearing wound bed, no dressing on wound when assessed. The treatment recommendations were for Dakin's solution 0.125% on an abd pad, skin prep around perimeter of the wound, cover with a dry sterile dressing twice daily. Review of the April TAR for Resident #13 revealed an order initiated on the evening shift on 4/26/2021 for the sacrum to be cleansed with sterile water, apply Dakins soaked gauze, cover with dry dressing every day and evening shift. Documentation on the TAR revealed this order was documented as completed on as ordered except for the evening shift on 4/27/2021, which was left blank and the evening shift on 4/29/2021 when treatment was documented as refused. Nurse #12, who was assigned to care for Resident #13 on 4/27/2021 on the evening shift, was interviewed on 5/7/2021 at 2:21 PM. Nurse #12 reiterated she might have performed the dressing change for Resident #13 on her sacrum but forgot to document she did so. The facility Administrator was interviewed on 5/7/2021 at 10:35 AM and revealed the air mattress to fit the bariatric bed of Resident #13 was ordered on 4/27/2021. Nurse #11, who was assigned to care for Resident #13 on 4/29/2021 on the evening shift, was interviewed on 5/7/2021 at 1:30 PM. Nurse #11 stated Resident #13 declined having the treatment performed on her sacrum on 4/29/2021 because she was in pain. Nurse #11 stated she gave Resident #13 pain medication and after she refused three times, documented the treatment was refused. Nurse #11 did not notify the physician of the resident's refusal of the treatment on 4/29/2021. Nurse #1, who administered sacral dressing changes for Resident #13 on 4/29/2021 and 4/30/2021, was interviewed on 4/7/2021 at 1:40 PM. Nurse #1 stated the sacral wound looked, horrible, huge and just awful on 4/29/2021 and 4/30/2021. Nurse #1 indicated she had not performed wound care on Resident #13 on a regular basis and that was only the third dressing change she had ever performed for this resident. Nurse #1 stated she knew Resident #13 was being followed by a wound nurse practitioner every Monday so the resident would be assessed again within a couple of days. Documentation in the nursing progress notes on 5/1/2021 at 11:40 AM stated, During dressing change foul odor noted to wound no drainage noted. The nursing progress note further revealed MD #1 was called, orders for antibiotics, orders for laboratory tests, and orders for a follow up at the wound clinic received. Documentation in the nursing progress notes on 5/1/2021 at 10:18 PM revealed Resident #13 had an altered mental status along with decreased oxygen saturation level of 88% on room air. MD #1 was called, and the resident was sent to the emergency room . An interview was conducted with the responsible party (RP) for Resident #13 on 5/6/2021 at 2:50 PM. The RP revealed stated she called Resident #13 on 4/29/2021 and 4/30/2021 and she was not answering her phone, which was highly unusual. The RP stated she went to the facility on the morning of 5/1/2021 and discovered Resident #13 was not herself. The RP indicted the whole room just smelled rotten. The RP stated she gave Resident #13 a bath and saw the wound care performed by the nurse (Nurse #2). The RP revealed the wound looked awful to her and smelled horrible. Nurse #2, who performed the dressing change and sent Resident #13 to the emergency roiagnom on [DATE], was interviewed on 5/7/2021 at 2:31 PM. Nurse #2 stated Resident #13 was not as alert and talkative on 5/1/2021. Nurse #2 revealed she noted the wound was bigger with a foul odor during wound care that day but had no drainage. Nurse #2 confirmed she called MD #1 and the family of Resident #13 were already at her bedside during the dressing change. Nurse #2 revealed Resident #13 later that evening had a temperature and MD #1 wanted her sent to the emergency room . Documentation in the hospital emergency room described the pressure ulcer of Resident #13 as, extraordinarily large cantaloupe sized [unstageable] sacral decubitus with very foul smelling [odor] obvious necrosis of tissue around the exterior edges of this ulcer and internally. Old records reviewed patient has had an ulcer like this before but unsure if is being followed by wound care or would need further evaluation [when] took down the dressing there was two small 4 X 4's inside the wound. Resident #13 was admitted to the hospital for further treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation in the nursing progress notes on 5/2/2021 at 1:47 PM revealed Resident #13 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse aide (NA #2) was interviewed on 5/7/2021 at 1:05 PM. NA #2 confirmed she provided care for Resident #13 on the 7:00 AM to 3:00 PM shift when she was on the bariatric bed. NA #2 stated she was a cooperative resident who was turned and repositioned every two hours to three hours. NA #11 was interviewed on 5/7/2021 at 1:12 PM. NA #11 confirmed she provided care for Resident #13 on the 3:00 PM to 11:00 PM shift when she was on the bariatric bed. NA #11 stated Resident #13 never refused care and was repositioned every three hours. TN#2 was interviewed on 5/7/2021 at 10:20 AM. TN #2 revealed that the previous treatment nurse (TN #1) was working in the facility when the wound VAC was malfunctioning, and TN #2 indicated she was unsure of what happened. TN #2 thought parts were ordered for the wound VAC, but they never seem to arrive. TN #2 stated NP #1 changed the treatment orders and the sacral wound on Resident #13 started to look a lot better, so NP #1 agreed to discontinue the wound VAC. TN #2 stated the air mattress was switched out for a bariatric bed at some point. TN #2 stated she was told by the Administrator the bariatric air mattress had been ordered. TN #2 attested to the fact she pushed and pushed for the resident to be put on an air mattress but was told by the DON the air mattress was on order. TN #2 reiterated she stressed the point to the DON an air mattress was necessary for this resident. TN #2 stated Resident #13 was doing so well with the new treatments without the wound VAC but as soon as the bariatric bed in placed the sacral wound started to decline. TN #2 felt like the nurse aides were doing the turning a repositioning that was necessary but the firm mattress with the weight and pressure caused the sacral wound to decline quickly. NP #1 was interviewed on 5/6/2021 at 4:02 PM. NP #1 indicated the last time she did a wound care assessment on Resident #13 was 4/26/2021. NP #1 explained Resident #13 was on a wound VAC, but it malfunctioned and for some reason another wound VAC was not obtainable. NP #1 explained she changed the treatment to a daily treatment to accommodate the loss of the wound VAC. NP #1 further explained that one day a nurse aide was turning Resident #13 and she fell out of bed. NP #1 stated the resident was taken off the air mattress and put on a bariatric bed. NP #1 stated the resident needed an air mattress for her wound and no body could clarify why a bariatric air mattress was not available. NP #1 revealed at the same time the treatment nurse went on leave and a new treatment nurse took her place. NP #1 stated on her assessment on 4/26/2021 she noticed the wound was increasing in size and was very dark, while prior to that the wound was healthy pink. NP #1 indicated it was her impression the wound was not getting enough circulation on the bariatric bed causing a very quick decline in the wound status. NP #1 emphasized she went to the Administrator and the DON to let them know the urgent priority of having Resident #13 not go another day without an air mattress on her bed. NP #1 stated there was no way the wound changed to the degree it did and nobody noticed. MD #1 was interviewed on 5/5/2021 at 3:37 PM. MD #1 provided the following information regarding his professional opinion on the wound care and status of Resident #13. Resident #13 arrived at the facility with [CONDITION(S)] of a sacral wound. At that time the resident was going to the wound clinic and had a wound VAC. The wound continued to improve so in April 2021 the family wanted the resident to see the facility wound care provider instead of going to the wound clinic. The nurse practitioner at the facility discontinued the wound VAC for the resident and changed the treatment orders to daily wound care. Resident #13 was admitted to the hospital on 5/1/2021 and the wound was observed at the hospital. MD #1 did not think the treatments were done at the facility and he did not know the treatment nurse (TN #1) at the facility had taken a 6 week leave of absence. MD #1 knew the facility took Resident #13 off the low air loss mattress and never got her a new one. MD #1 spoke with the DON who told him she usually looked at the wounds but did not look at the wounds in the facility the week prior to the hospitalization of Resident #13. MD #1 felt the care provided to Resident #13 was particularly distressing because he was a wound care specialist himself and he was the medical director at the facility. The facility nurse consultant was interviewed on 5/7/2021 at 2:53 PM. The nurse consultant stated she felt several factors led the decline in the wound status of Resident #13. The nurse consultant stated the wound VAC was malfunctioning on 4/12/2021 and the wound care treatments were changed several times to compensate for the lack of a wound VAC. The nurse consultant indicated a wound VAC could have been obtained from a sister facility to optimize the wound care provided to Resident #13. The nurse consultant believed the wound VAC would have been the optimal treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse consultant admitted the resident rolled out of bed on 4/18/2021 and was subsequently removed from the air mattress and put on a bariatric mattress. The nurse consultant did not think NP #1 or TN #2 effectively communicated the concerns they had about the bariatric air mattress to the DON and the Administrator.

Based on observations, staff interviews and review of medical records, the facility failed to follow a physician's order [REDACTED].#1) which resulted in hospitalization with a [DIAGNOSES REDACTED]. Findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Laboratory (lab) results, dated 12/05/14, indicated a Blood Urea Nitrogen (BUN) level of 18 milligrams per deciliter (mg/dl) (BUN is a blood test that may be used to determine dehydration. The normal range is 7-18 mg/dl). Resident #1 ' s creatinine (a high creatinine level in the blood may also indicate dehydration) was 1.2 mg/dl (the normal range for creatinine is 0.6-1.3mg/dl) and his sodium was reported as 145 millimole per liter (mmol/L) (Elevated sodium levels may indicate dehydration. The normal range for sodium is 136-145mmol/L). Review of a 12/9/14 Medical Nutrition Therapy Assessment, completed by the registered dietician (RD), indicated Resident #1's estimated daily fluid needs were 2256 milliliters (mls) per day. On 12/12/14, Resident #1's BUN had increased to 20 mg/dl, his creatinine had remained at 1.2 mg/dl and his sodium had increased to a level of 150 mmol/L. Review of 12/15/14 lab results indicated Resident #1's BUN had risen to 24 mg/dl, his creatinine was recorded as 1.4 mg/dl and his sodium was recorded as 148. The results had been faxed to the physician. The physician had returned the copy of the labs with the results of the creatinine, sodium, potassium and chloride circled. The physician had hand written the words, push fluids with a line drawn from what he had written to the results of the labs. Review of telephone orders for 12/15/14 did not reveal the order to push fluids had been written. Review of the December 2014 Medication Administration Record (MAR) did not reveal the order to push fluids had been transcribed. Lab results for 12/19/14 indicated a BUN of 20 mg/dl, creatinine of 1.2 mg/dl and sodium level of 148 mmol/L. Review of progress notes, written by Nurse # 6 on 12/19/14 at 6:16 PM, indicated the labs were faxed to the physician with no new orders obtained. On 12/26/14, labs were again drawn with the results of BUN 26 mg/dl and sodium 153 mmol/L obtained. The physician had hand written on the lab results to push fluids. There was no indentifying information that noted which staff member had taken the lab results from the printer and filed the lab results. Review of the physician's telephone orders for 12/26/14 and the December 2014 MAR failed to reveal the order to push fluids had been transcribed. Review of physician's telephone orders for 12/30/14 indicated an order had been obtained to push fluids and to recheck Resident #1's lab work in one week. The facility nurse had signed off on the order on 12/30/14 at 6:00 PM. On 12/30/14 at 6:21 PM, Nurse #6 documented the physician had reviewed Resident #1's lab work and had faxed new orders to push fluids and repeat the lab work in a week. Review of the MAR indicated the order had not been transcribed. Resident #1's care plan, with a review date of 12/30/14, indicated he had [MEDICAL CONDITION] with a kidney injury. Goals were identified as Resident #1 would have adequate fluid volume balance as evidenced by good skin turgor, pink and moist mucous membranes and sufficient fluid intake. Interventions to achieve the goal included giving fluids as ordered-restrict or give as ordered. physician progress notes [REDACTED].#1 was doing fair. The physician documented the resident was drowsy and dehydrated. The physician documented the resident had an increased sodium and his plan was to recheck the lab work. Review of the December 2014 Individual Resident Meal Intake Record indicated the resident's fluid intake ranged from a low of 360 mls on 12/20/14 to a high of 1200 mls on 12/31/14. Review of the January 2015 Individual Resident Meal Intake Record indicated on January 1st and January 2nd, Resident #1 had no fluid intake. On January 3rd, his fluid intake totaled 480 mls and prior to his hospitalization on [DATE]th, his fluid intake totaled 360 mls. Nursing progress notes, dated 1/4/15 at 11:30 AM indicated Resident #1 had a pulse that ranged between 112 beats per minute to 120 beats per minute (the average heart rate is considered to be 70 beats per minute). The resident was described as lethargic. The nurse notified the physician. The nurse documented the physician ordered the resident to be sent to the hospital for evaluation and added he was probably dehydrated. The Hospital History and Physical (H & P), dated 1/4/15, indicated the family member reported decreased oral intake over the past week. The hospital physician documented Resident #1's lab work was checked on 12/26/14 and nursing home staff had been advised to increase the resident's fluid intake. The physician also documented Resident #1 had a November 2014 admission with a [DIAGNOSES REDACTED].#1's oral mucosa as dry. Lab work revealed a sodium of 159 mmol/L, a BUN of 62 mg/dl and a creatinine of 1.6 mg/dl. Under Assessment and Plan, the hospital physician documented acute [MEDICAL CONDITION] multifactorial, recent dehydration, [MEDICAL CONDITION] and acute urinary tract infection most likely as the causes. He also documented the [MEDICAL CONDITION] was most likely due to the dehydration. The plan was to rehydrate. Review of hospital forms dated 1/6/15 listed dehydration as an active problem for Resident #1. Nurse #7 was interviewed on 1/14/15 at 2:52 PM. She stated the term push fluids meant to give fluids during medication pass and with meals. If a physician had ordered push fluids for a resident, the nurse stated it would have been entered on the MAR and all fluids given would be documented. The nurse was unaware the resident had received an order to push fluid. On 1/14/15 at 4:04 PM, Nurse #1 was interviewed. She stated an order to push fluids meant she was supposed to encourage as much fluid as possible and then to document on the intake and output sheet the amount of fluid taken. Nurse #1 stated she would also include the intake amount in her nurse's notes and on the MAR. The nurse added she was unaware Resident #1 had an order to push fluids. The Director of Nursing (DON) was interviewed on 1/14/15 at 5:11 PM. She stated fluids documented on the meal intake form only represented the fluids received at meals. She stated if a nurse received an order to push fluids, the nurse was expected to transcribe that order to the MAR, divide the entry by shifts and initial fluids were encouraged. The RD was interviewed on 1/14/15 at 5:50 PM. She stated fluids documented on the meal intake record only represented fluids received on the meal tray. She added there was no system in place to document supplements or extra fluids given throughout the day. Nurse #3 was interviewed via telephone on 1/15/15 at 8:20 AM. She stated any order to push fluids was placed on the MAR. The nurse could not remember if Resident #1 had an order to push fluids. On 1/15/15 at 8:52 AM, Nursing Assistant (NA) #3 was interviewed. She stated fluids documented on the meal intake record only represented fluids received during meals. She was not sure where other fluids received would be documented. She stated prior to Resident #1's hospitalization on [DATE], he would typically drink the water, juice and hot tea that was provided on his meal trays. NA #4 was interviewed on 1/15/15 at 9:19 AM. She stated initially Resident #1 drank pretty well. On his breakfast tray he received water, juice and milk and for lunch usually tea and water. She stated she recorded only the fluids received on the meal tray. The NA stated she had worked with Resident #1 on 1/2/15 and 1/3/15. The NA stated she had reported the resident was not eating and drinking to the nurse. Nurse #4 was interviewed on 1/15/15 at 9:43 AM. She stated orders to push fluids were to be placed on the MAR. Nurse #4 stated she had been unaware Resident #1 had an order to push fluids until 1/4/15 when she reviewed the chart prior to sending him to the hospital. She stated the facility had the ability to give intravenous fluids, but was unsure this would have made a difference in the outcome for Resident #1. On 1/15/15 at 10:42 PM, Nurse #5 was interviewed. She stated after the NA reported the resident ' s poor intake of fluids and food on 1/3/15, she assessed Resident #1. The nurse stated she found Resident #1's mucous membranes to be dry. She added his lips were also dry. Nurse #5 could not remember if the resident's skin tented (tenting is a term used to describe dehydration. Tenting appears when the skin is pinched and the skin remains in a tented position after the skin is released). She stated she did not notify the physician of the resident's lack of oral intake or the signs of dehydration because it was late and near the end of her shift. Nurse #5 stated an order to push fluids was expected to be written on the MAR. The nurse added she had been unaware Resident #1 had an order to push fluids. Nurse #6 was interviewed on 1/15/15 at 12:04 PM. She stated when an order is received to push fluids; it was placed on the MAR. The nurse acknowledged she was the nurse that received the 12/30/14 physician's orders [REDACTED].#1. She stated the order should have been placed on the MAR and had no explanation why she had not placed the order on the MAR. Nurse #6 stated she had relayed the information regarding the order to push fluids verbally to the other nurses.