Every finding on record at Laurels Peak Health Care, LLC

Based on observation, interview, and document review the facility failed to provide appropriate services to ensure 1 of 1 resident (R10) reviewed for abuse maintained his highest practicable psychosocial well-being, specifically dignity.Findings include:R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, no behaviors or rejection of care, lower extremity impairment on both sides, use of wheelchair, partial assistance for toileting, dressing, and personal hygiene, and diagnoses high blood pressure, obstructive uropathy (blockage in urinary tract), and dementia.R10's care plan reviewed 5/2026, indicated resident may have an alteration in mood and behavior related to diagnoses of urinary tract infection, malnutrition, and sepsis. Resident has a history of attempting to masturbate in common areas with the potential of exposing himself to others. Resident has demonstrated unsafe wandering behaviors characterized by entering other resident rooms, creating potential safety and privacy concerns. Due to cognitive impairment, resident has difficulty recognizing boundaries and has entered other resident rooms without awareness of privacy. Interventions: ensure private room, identify triggers, provide clear privacy cues, modify seating in common areas, placing resident in staff view, seat resident in staff-visible areas during communal events, provide structured daily activities, maintain clothing that is harder to remove, provide calm redirection, use consistent staff, reassure, offer alternatives, document all occurrences, implement toileting schedule, increase staff observation.During interview on 8/3/26 at 1:17 p.m., R10's family member (FM)-A stated R10 exposed himself to a female resident in the dining room a few days ago. FM-A stated R10 had not done something like that for quite some time, but the facility had told her they might have to look for a memory care facility for him if the behavior continued.During observation on 8/3/26 at 5:03 p.m., R10 was seated in the dining room with other residents, no staff were present.During observation on 8/4/26 at 8:25 a.m., R10 was seated in the dining room with other residents, no staff were present.During observations on 8/4/26 at 9:17 a.m. and 9:48 a.m., R10 was seated in the facility common area/day room with other residents, no staff were present.During observation on 8/4/26 at 1:36 p.m., R10 was by the main entrance and then propelled himself in his wheelchair toward the 100 hall. No staff were present. R10 then went outside into a courtyard independently with no staff present to observe him.During observation on 8/5/26 at 9:48 a.m., R10 was seated in the dining room with other residents, no staff were present.During observation on 8/5/26 at 1:20 p.m., R10 was seated outside in the courtyard with another resident, no staff were present.During interview on 8/4/26 at 8:27 a.m., activities director (AD)-A stated she had heard about R10 exposing himself to a female resident. AD-A stated she was not aware of any special instructions for R10's care or any new interventions since the exposure incident. AD-A stated R10 liked to be in the facility day room. AD-A stated she was not aware of any extra supervision R10 needed while in the day room or during group activities.During interview on 8/4/26 at 8:31 a.m., registered nurse (RN)-B stated she worked with R10 often. RN-B stated she was not aware of any specific interventions for R10's behaviors and nothing had changed since the recent exposure incident. RN-B stated they were supposed to keep an eye on him and chart any behaviors, but he was not always in sight of a staff member. RN-B stated she did not have the ability to provide one-on-one supervision to R10. RN-B stated she had to check off behavior monitoring on R10's treatment administration record (TAR) but was not able to actively see him or monitor him at all times. RN-B stated she would expect nursing assistants to monitor him and report any behavior.During interview on 8/4/26 at 8:44 a.m., nursing assistant (NA)-C stated she had heard about R10 exposing himself to a female resident a long time ago but was not aware of a recent incident. NA-C stated she was not given any education to do anything different with R10 and was not sure if R10 had any increased supervision or monitoring needs.During interview on 8/4/26 at 8:50 a.m., NA-D stated she had heard about R10 exposing himself to a female resident. NA-D stated she had been told to do hourly checks for a couple of days after the incident but wasn't currently doing anything different. NA-D was not sure if R10 needed increased supervision and monitoring due to his behavior.R10's facility progress note dated 11/21/25, authored by social services director (SSD), indicated she followed up with R10's daughter regarding R10 entering other resident rooms and exposing himself. SSD recommended memory care, daughter in agreement.R10's facility progress note dated 7/28/26, authored by SSD, indicated R10 propelled his wheelchair up to a female resident in the dining room, exposed himself, and asked the female resident if she wanted to touch him. Female resident said no and reported to facility staff. No staff observed the incident.R10's facility progress note dated 7/28/26, authored by SSD, indicated SSD notified R10's daughter of the exposure incident and requested different clothing and a move to memory care. R10's daughter declined those interventions.Facility provide document titled (R10's name, 7/28/26), indicated the facility completed the following investigation after the exposure incident on 7/28/26:-Trauma assessment completed with female resident-R10's Brief Interview for Mental Status (BIMS) was completed and indicated a score of four, meaning severe cognitive impairment.-Hourly checks were completed on R10 for 48 hours.-No patterns were identified by staff that could have led to this event.No other documentation was provided.During interview on 8/5/26 at 1:30 p.m., licensed practical nurse (LPN)-A also known as nurse manager, stated she was aware of R10's exposure incident. LPN-A stated she did not think a new assessment was completed and was not aware of any new interventions other than hourly checks for 48 hours after the incident. LPN-A stated she had not investigated the root cause of R10's behavior and was unsure why it happened. LPN-A was unsure of a new intervention to maintain R10's dignity.During interview on 8/4/26 at 1:11 p.m., RN-C stated she was R10's hospice case manager. RN-C state R10 admitted to hospice 1/2026, and had not had any behaviors since admission. RN-C stated the facility informed her of his exposure incident on 7/28/26. RN-C stated she was not aware of any new assessments, care plan changes, or interventions for R10. RN-C stated she had not discussed R10's behavior with his hospice medical director and had not made any changes to his hospice plan of care.During interview on 8/4/26 at 10:16 a.m., SSD stated she was not sure if a new assessment of R10 was completed after he exposed himself to a female resident. SSD stated she thought new things were added to his TAR and his care plan but viewed both of those things and confirmed no new monitoring or interventions had been added since the exposure incident. All interventions and monitoring were from the 11/2025 incident. SSD stated she thought they monitored R10 for 48 hours but did not know of anything they were doing now as an intervention to ensure his dignity was maintained. SSD stated she did not know if any new education was provided to staff.During interview on 8/4/26 at 11:15 a.m., administrator stated she did not do a comprehensive investigation of R10's exposure incident because it was not reportable. Administrator stated she spoke to a few staff and no trend or cause of the incident was discovered. Administrator stated she put hourly checks in place for 48 hours and that meant staff would keep extra watch over him. Administrator stated she was not sure of anything new they were currently doing to ensure R10's dignity, other than what was previously on the care plan. Administrator stated she was unsure if a new intervention had been added to the care plan or if his Kardex was updated regarding this exposure incident. Administrator stated staff would know what to do for R10 based on his Kardex and care plan. Administrator stated no other residents had been interviewed, and no staff education had been completed. Administrator stated she was unaware how often R10 was unsupervised in the facility and expected staff to be monitoring him based on his care plan interventions. Administrator stated she was unsure how the facility was going to maintain R10's dignity, and R10's daughter had declined to have him moved to a memory care unit.A facility email provided on 8/5/26 at 2:06 p.m., indicated new all staff education was completed regarding R10's exposure behavior, hourly checks were reimplemented and added to R10's care plan, all female residents were interviewed with no concerns.Facility Care Planning policy revised 11/2024, indicated the following:In accordance with state and federal regulation, each resident will have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on observation, interview, and document review, the facility failed to provide the necessary assistance with activities of daily living (ADL) to maintain oral hygiene for 1 of 1 resident (R36) reviewed for ADL assistance. Findings include:R36's face sheet provided on 8/5/26, included diagnoses of malignant neoplasm (cancerous tumor) of right bronchus or lung, and palliative care (specialized medical care during serious illness).R36's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R36 had no rejection of care and required partial-moderate assistance with oral hygiene.R36's care plan dated 6/25/26, indicated a self-care deficit related to multiple diagnoses, including neoplasm of lung and required staff assistance of one with personal hygiene in the morning, evening and as needed. The care plan did not specify what personal hygiene entailed and if it included oral care.Review of the TASK tab in POC (point of care - the part of the electronic medical record [EMR] where NAs documented completion of resident cares) indicated a task titled personal hygiene which further identified oral hygiene. The document indicated from 7/6/26 to 8/4/26, oral hygiene had been provided 38 times. On 7/15/26, 7/23/26, 8/1/26, and 8/2/26, documentation indicated no oral care had been provided. The document did not indicate how often oral hygiene was to be provided.R36's Kardex (quick reference summarizing a resident's care needs) dated 8/4/26, indicated a category titled grooming, which included: personal hygiene -A-1, meaning R36 required assistance of one staff for personal hygiene. The Kardex didn't specifically identify oral care or brushing teeth as being part of personal hygiene, or the frequency of providing personal hygiene.During an observation and interview on 8/3/26 at 11:35 a.m., R36 was lying in bed and stated staff did not help her clean her teeth; adding she had her own teeth, top and bottom. R36 stated she couldn't recall the last time her teeth had been cleaned by staff. R36 stated two friends had cleaned her teeth twice since she had been here. R36's top teeth looked dull. During an interview on 8/4/26 at 10:30 a.m., R36 was lying in bed and stated no one had brushed her teeth that morning.During an interview on 8/4/26 at 1:42 p.m., nursing assistant (NA)-A described morning cares that were provided to R36, however the description did not include oral care or brushing teeth. NA-A stated when he was going to brush R36 teeth, hospice came in so he left but admitted he didn't go back and offer/provide oral care. NA-A stated oral care should be offered to residents twice a day and stated clean teeth would make a resident feel better.During an interview on 8/5/26 at 12:03 p.m., R36 had been lying in bed with her eyes closed. R36 stated she could not remember if anyone had brushed her teeth that morning. During an interview on 8/5/26 at 1:19 p.m., NA-B stated she performed morning cares on R36 but did not do oral care. NA-B stated the visitor in her room had asked her too, but she didn't and stated she would do it now. NA-B did not offer a reason why she had not provided oral care. During an interview on 8/5/26 at 1:27 p.m., registered nurse (RN)-A, who was also a nurse manager, stated oral care/brushing teeth or dentures should be offered in the morning and at bedtime and any other time a resident requested, but at least twice a day. Looking in the EMR, RN-A verified according to the documentation, R36's teeth had not been cleaned twice a day and on some days, not at all. During an interview on 8/5/26 at 2:29 p.m., the director of nursing (DON) stated she would expect residents to be offered/provided oral care twice a day, either setting up supplies for a resident who could perform the task independently, or to provide total oral care for a resident if needed. The DON acknowledged R36 was not able to perform oral care without assistance of staff.Interviews with RN-A and the DON, indicated R36 should have been offered/assisted with oral care twice a day. Out of 60 opportunities, oral care had been documented as being performed 38 times. Facility Activity of Daily Living/Maintain Abilities policy dated 3/31/23, indicated the facility would provide care and services for oral care. A resident who was not able to carry out ADLs would receive the services to maintain oral hygiene

Based on interview, and record review the facility failed to ensure all staff were competent with transferring and walking residents that required transfer assistance for 1 of 3 residents (R1). This deficient practice resulted in R1 falling and fracturing the facial bone. The facility had put corrective measure in place, prior to the start of the survey and therefore, this was issued at past non-compliance.Findings include:R1's face sheet dated 1/6/26, identified diagnoses of respiratory failure, atrial fibrillation (irregular heart rhythm), osteoporosis, and other variants of Turners Syndrome (condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. [NAME] syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects.), and disorientation.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no issues with hearing or speech, no cognition issues, no behaviors or rejection of care, used a walker, partial assist with toileting hygiene, lower body dressing, supervision with upper body dressing, supervision with sit to stand, chair/bed transfer, and walk 50 feet with two turns. R1 had a fall in the month prior to admission but no falls since admission. R1's care plan dated 12/2/25, identified interventions to follow physical therapy (PT) and occupational therapy (OT) for mobility function. Toileting with stand by assistance and R1 was to ambulate to the bathroom with front wheeled walker (FWW) and toilet self with staff present but providing only encouragement; transfer with stand by assist and use FWW- staff to provide encouragement training in hallway without assistive device. R1 demonstrated mild loss of balance but able to recover independently. R1 demonstrated an inconsistent gait path and had a tendency to wander throughout hallway. Ambulated with FWW in hallway with noted improvement in stability. Educated on current continued use of FWW recommendation. R1 remained appropriate for use of FWW.Nursing Home Incident Report (NHIR) submitted to the State Agency on 12/12/25 at 10:23 a.m., identified R1 requested to walk for walking program. Nursing assistant (NA)-A was walking with resident, when resident fell and hit her head. R1 was transported to the emergency department (ED) for evaluation with physical injuries noted of bruising above right eye, nosebleed, and hematoma (collection of blood outside of a blood vessel) to right side of head.R1's progress note dated 12/13/25 at 7:38 a.m., identified on 12/12/25, R1 was lying on her back on the floor. Right eyelid bruised and swollen shut. Hematoma to right side of forehead and bloody nose. R1 stated she was walking without her walker and fell forward hitting her face. R1 had an ice pack applied to her face and was sent to ED for evaluation as she took blood thinning medication.R1's hospital Discharge summary dated [DATE], identified R1 had a closed facial bone fracture, spent the night at the hospital, and returned to facility on 12/13/25, follow-up visits scheduled with neurosurgery and head computed tomography (CT).R1's progress note dated 12/15/25 at 11:19 a.m., identified R1 had been downgraded to assist of one staff using FWW and gait belt due to recent fall, care plan and Kardex updated.R1's progress note dated 12/19/25 at 10:51 a.m., identified R1 had new therapy orders to walk to all meals with FWW and gait belt, assist of one to follow with wheelchair, care plan and Kardex updated.R1's care plan was updated on 12/16/25, and identified education provided to staff to utilize appropriate devices during mobility; on 12/19/25 walk to all meals with FWW and gait belt, wheelchair to follow, with assist of one staff member.During an observation and interview on 1/6/26 at 10:13 a.m., R1 was in a wheelchair with visible bruising under both eyes, had a visitor in the room; the visitor was leaving and R1 stood up from the wheelchair and hugged the visitor and sat back down in the wheelchair. R1 stated on 12/12/25, NA-A came into the room and put a gait belt on her. R1 stated she watched NA-A struggle to put the gait belt on. R1 did not recall taking her walker with when they went on the walk. she should have made sure I had my walker. R1 stated NA-A was not holding the gait belt during the walk and R1 was turning a corner and just went down, it was a very traumatic fall. R1 ended up in the hospital with blood behind her brain, a brain bleed, but was unsure if she had a fracture. R1 stated she did not get dizzy or lose her balance prior to the fall. All the other staff have used the gait belt and walker properly. R1 was updated by facility that all staff would have training on using proper equipment with residents. R1 stated she had just had her follow-up neurology appointment, and the CT scan showed no more bleeding in the brain.During a phone interview on 1/6/26 at 1:17 p.m., NA-A stated she is a per diem (as needed) employee and worked at the facility when shifts were available. The facility had encouraged staff to come in and read care plans, but sometimes care plans were read when there was time. On 12/12/25 she was working on R1's wing and that was the second shift she had worked with her. NA-A indicated R1 was self-directed and she had been told by other staff to let R1 do what she wanted to do and to stand-by and watch. R1 put on her bathroom call light around 10:10 a.m. or 10:15 a.m. NA-A responded to the light and found R1 in the bathroom with no walker and no gait belt on. R1 told NA-A she had walked to the bathroom by herself. NA-A assisted R1 to clean up in the bathroom, and R1 walked out of the bathroom without assistance and her walker then sat in her wheelchair. R1 stated she wanted to take a walk (in the hallway). NA-A asked if R1 wanted to use her front wheeled walker and NA-A would push the wheelchair behind her, R1 declined. NA-A stated she applied the gait belt around R1's waist. When R1 stood up and NA-A attempted to hold the gait belt, R1 told NA-A NO I can do it!. NA-A followed R1 as she walked from her room to the entrance of therapy, that is where they turned. NA-A stated there was a dip in the floor, R1 mis-stepped which caused R1 to fall forward very fast. NA-A reiterated that she had taken her time and even read R1's care plan but given R1's refusal of all the crutches she offered, she respected R1's wishes. R1 wanted to do everything herself.During an interview on 1/6/26 at 1:47 p.m., nurse manager (NM)-A stated on 12/12/25, she came from a meeting to assist R1 off the floor. The nurse practitioner was onsite and examined R1 and gave an order to send her to the ED. R1 was able to move all extremities and verbalized what happened. NM-A applied ice to R1's face while they waited for the ambulance to arrive. NM-A is part of the IDT and is involved with fall prevention and interventions after a fall occurs. The root cause of R1's fall was R1 refused to use her FWW and NA-A let R1 inappropriately walk without assistive devices.During an interview on 1/6/26 at 10:21 a.m., director of rehabilitation services (DOR)-A stated R1's level of function prior to admitting at the facility was not using assistive devices and therapy was working to get R1 independent with the FWW. By 12/12/25, therapy had been working with R1 to walk without her walker, going short distances to build up endurance. R1 was not safe to walk 100 feet without her walker, she would fatigue and lose her balance. The week of 12/12/25, therapy had talked with R1 about being independent in her room and not needing to use her walker, but not that she could walk in the hallways unassisted. DOR-A stated on 12/12/25, she was called out of a meeting around 10:30 a.m., due to R1 falling on the ground. DOR-A assisted the NM-A and a NA to use a mechanical lift to move R1 from the floor to the wheelchair. When R1 returned on 12/13/25, she was assist of one with all activities and had a fear using less assistance from staff. By 12/30/25, R1 was a stand-by assist in her room with FWW, and on 1/5/26, she was able to be independent in her room with FWW. After falls, the Interdisciplinary Team (IDT) works together to come up with appropriate interventions.During a phone interview on 1/6/26 at 1:59 p.m., medical doctor (MD)-A stated one of the biggest risk factors of a fall would be a fracture and brain bleed but there could be lots of minor injuries also that would set back therapy as well. Anyone that has a brain bleed the doctor needs to be cognizant about anticoagulation and repeated falls, where the brain bleed is at, how much of the brain is bleeding, and what it will affect. Orbital fractures, such as what R1 was diagnosed with, staff should watch for more pain and headaches, and that could reduce therapy time and take longer to reach her goals. MD-A reviewed R1's hospital chart and stated R1 had a telephone visit with neurology on 1/6/26, to discuss the CT that was completed 1/5/26 and It did not look like they thought much of the injuries. Falls are discussed at the facility Quality Assurance Performance Improvement (QAPI) meetings. MD-A is notified of any falls with injuries, or that require hospital or ED visits. During an interview on 1/6/26 at 2:51 p.m., Administrator stated for audits the nurse management staff would observe staff and residents completing the tasks of walking and transfers to make sure it was done correctly; after the observation they would review with staff what to do if a resident would refuse to use an assistive device, and where they would locate the information on each resident to know what devices they utilized. The facility investigation revealed it was a one-time occurrence, and that staff member is no longer employed at the facility. An audit on all resident Kardex's was also completed to make sure all residents information was current and up to date. Staff should always follow the care plans and Kardex. Reviewed with Administrator the corrective actions taken by the facility to correct the deficient practice and the dates they were completed.The deficient practice was issued at past non-compliance after the following corrective actions were implemented, and verified the facility took the following actions, prior to the start of the survey:-NA-A was suspended on 12/12/25, and resigned from her position on 12/12/25.-updated R1's care plan on 12/16/25, and ongoing as needed.-reviewed and updated as needed all residents care plans on 12/16/25.-education on ambulation began on 12/16/25 and will be ongoing-education on following care plans/Kardex began on 12/16/25 and will be ongoing.-audits to ensure staff are aware of following care plans and what to do if a resident refuses to utilize appropriate devices began 12/16/25 and will be ongoing.-PHQ-9 and trauma assessments completed 12/16/25.-R1 continues to work with therapy on ambulation and independence to return to community setting.The facility Fall Prevention and Management policy updated 11/2025, identified nursing staff will begin to try to identify possible or likely causes of the incident and evaluate the chain of events or circumstances preceding a recent fall. The IDT will review falls daily at morning meeting and care plans will be updated to reflect fall interventions.The facility Safe Resident Handling Program policy updated 11/2025, identified the policy was to protect the health and comfort of residents and staff when residents require assistance in moving through the consistent use of mechanical aides/devices. Gait belts must be used for ambulatory residents when indicated in the care plan to allow employees to hold onto the belt to provide support and stabilize the resident when walking. Training of nurses and other direct care employees will be provided to demonstrate proper application and use of available safe patient handling equipment.

Based on observation and interview, the facility failed to ensure basic infection control practices were followed when 1 of 1 resident (R38's) urinary drainage bag was observed resting on the floor, failed to ensure enhanced barrier precautions (EBP) were implemented for 1 of 1 resident (R68) when staff failed to wear personnel protective equipment (PPE) to empty urinary drainage bag, and failed to ensure proper glove use and hand hygiene was performed during wound care for 1 of 2 residents (R5) reviewed for pressure ulcers. Furthermore, the facility failed to ensure proper infection control practices were followed for 1 of 1 resident (R66) whose nebulizer machine and tubing were left on the floor.Findings include: R38: R38's facesheet received on 9/11/25, included a diagnosis neuromuscular dysfunction of the bladder (a condition where the nerves and muscles that control the bladder are impaired). R38's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R38 was dependent upon staff for most ADLs. R38 had an indwelling urinary catheter. R38's physician orders dated 6/27/25, indicated change foley catheter monthly and PRN (as needed), 16 French with 10 cc (cubic centimeter) balloon in the evening starting on the 27th and ending on the 27th every month. Orders dated 6/27/25, directed staff to follow EBP every shift for suprapubic catheter. R38's care plan dated 8/28/24, indicated R38 was on EBP related to suprapubic catheter. Staff to follow EBP and don/doff PPE per EBP when providing high contact cares. Care plan dated 2/12/25, indicated R38 had a suprapubic catheter related to neuromuscular dysfunction of bladder. During observations on 9/9/25 at 7:46 p.m., and on 9/10/25, at 8:52 a.m., observed R38's foley catheter bag hooked to the side pocket of his recliner with the entire bottom of the drainage bag resting on the floor. During an observation and interview on 9/10/25 at 11:42 a.m., together with trained medication aide (TMA)-B, observed the location of R38's urinary drainage bag resting on the floor next to the recliner. TMA-B stated, Thats where he wants it. TMA-B did not initially recognize the potential infection control concern until it was pointed out. During an observation and interview on 9/10/25 at 12:01 p.m., together with the assistant director of nursing (ADON) who was also the infection preventionist and LPN-C, observed the location of R38's urinary drainage bag resting on the floor next to the recliner. The ADON stated, it needed to be up off the floor, but below the level of R38's bladder and advised LPN-C to put a hook on the wall for staff to hang the drainage bag. The ADON stated it was an infection control concern resting on the floor. R68: R68's facesheet received on 9/11/25, included a diagnosis of benign prostatic hyperplasia (causes urination difficulties). R68's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R68 was independent or required supervision with activities of daily living (ADLs). R68 had an indwelling urinary catheter. R68 did not walk and used an electric wheelchair for mobility. R68's physician orders dated 9/8/25, indicated change foley/suprapubic catheter bag on shower day in the morning every Friday. Staff to follow EBP every shift for foley catheter. R68's care plan dated 6/22/23, indicated R68 had an alteration in elimination. Care plan dated 4/18/25, indicated monitor foley catheter output, change foley catheter per policy and foley catheter care per policy. During an observation on 9/9/25 at 7:41 p.m., nursing assistant (NA)-E entered R68's room to empty his urinary leg bag. A sign on the door to R68's room indicated R68 was on EBP and staff must wear gloves and gown for device care, including urinary catheter. Outside R68's room was a three-drawer plastic PPE cart with disposable gowns in it. NA-E entered the room without donning a gown. NA-E donned gloves and obtained a plastic graduate, then emptied the urine from the leg collection bag into the graduate. When complete and outside of the room, NA-E admitted she did not wear a gown to empty R68's leg bag. NA-A stated she knew she should have worn a gown as well as gloves because R68 was in EPB but was in a hurry because she was told to go into his room and empty the collection bag. During an interview on 9/10/25 at 3:30 p.m., licensed practical nurse (LPN)-C who was also a care coordinator confirmed R68 was in EBP due to urinary catheter. LPN-C stated she would expect staff do wear a PPE gown when emptying R68's leg bag. When informed of observation, LPN-C stated staff had received training on EBP. Facility policy on managing urinary drainage bag was requested. An Indwelling Catheter Tubing Safety skills checklist was received dated 2018, which indicated: keep tubing and drainage bag from touching the floor. Facility Enhanced Barrier Precautions policy with revised date of 4/1/24, indicated it was the practice of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Staff received training on enhanced barrier precautions upon hire and at least annually and were expected to comply with all designated precautions. Clear signage would be posted on the door or wall outside of the resident room indicating the type of precautions. Enhanced barrier precautions would be implemented for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers); indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident was not known to be infected or colonized with a MDRO. High-contact resident care activities including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use including central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Wound care: any skin opening requiring a dressing. R5 R5's quarterly [NAME] Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, required substantial/maximal assistance with transfers, and diagnosis included one stage three pressure ulcer. R5's care plan dated 7/1/25, indicated enhanced barrier precautions r/t (related to) wound care, staff to don/doff PPE per enhanced barrier precautions when providing high contact cares. R5's wound care orders with start date 1/21/25, included: wound care left first MTP (metatarsophalangeal joints, knuckle of the toe) 1. Wash hands 2. Remove old dressings 3. Cleanse left foot with VASHE (wound cleanser) and dab dry 4. Paint the incisional area and any calluses with Betadine (antiseptic) 5. Cover with 4x4s 6. Secure with Kerlix (bandage) roll 7. Further secure with loose Coban (self-adherent wrap) wrap in the morning. On 9/9/25 at 10:40 a.m., licensed practical nurse (LPN)-C was observed entering R5's room wearing a gown and gloves while carrying wound care supplies. R5 was seated in a recliner in his room. LPN-C removed R5's left shoe, and dressing from R5's left foot. LPN-C discarded her gloves, without performing hand hygiene, LPN-C reached into her right scrub pocket under her gown and retrieved clean gloves, which she applied. LPN-C then reached into her left scrub pocket and removed a bandage scissors, which she used to cut the new dressing. LPN-C then discarded her gloves, returned the used scissors to her left scrub pocket without disinfecting it, retrieved another pair of clean gloves from her right scrub pocket, and completed the dressing change, without performing hand hygiene between glove changes. LPN-C was only observed performing hand hygiene upon exiting R5's room. On 9/9/25 at 10:52 a.m., LPN-C confirmed she did not disinfect her hands between glove changes during the dressing change. LPN-C stated it was her normal practice not to perform hand hygiene between glove removal and re-gloving during dressing changes. LPN-C also stated she did not disinfect the scissors before placing them back in her pocket but typically would disinfect them prior to the next use. LPN-C acknowledged that hand hygiene was expected between glove changes, but this was not a standard part of her dressing change procedure. On 9/10/25 at 2:12 p.m., the director of nursing (DON) stated during a dressing change staff were expected to remove gloves, complete hand hygiene, and get new gloves prior to the clean dressing applied to prevent contamination. Facility Policy titled Wound Care Treatment procedure dated 2/24, indicated:Steps to complete addressing change:Prior to starting, wash your hands and prepare the dressing supplies in an established clean field. Apply clean gloves Remove the previous dressing. Dispose of previous dressing and designated container Remove your gloves and complete hand hygiene Evaluate the woundClean the wound Remove gloves dispose of them in the designated container and complete hand hygiene Apply clean gloves and complete dressing change while following the provider's order When the treatment is completed remove your gloves dispose of any additional items and complete hand hygiene R66: R66's Facesheet, received 9/11/25 included diagnosis of bronchiolitis obliterans (constrictive, chronic inflammation and scarring of the small airways), acute respiratory failure, and chronic obstructive pulmonary disease (COPD). R66's 5 days MDS assessment dated [DATE] (admission MDS in progress) included R66 understands and is understood with intact cognition. R66 required supervision or touching assistance to partial to moderate assistance with activities of daily living and received continuous oxygen. R66's plan of care included alternation in oxygen/gas exchange, respiratory status with diagnosis of congestive heart failure, acute respiratory failure, and COPD. Interventions included continuous oxygen at 2-3 liters via nasal cannula, monitor oxygen saturations as ordered, monitor for cyanosis (bluish coloration of the skin), accessory muscle use, shortness of breath, increased respirations and difficulty coughing up sputum. Keep physician informed of changes. R66's provider orders included ipratropium-albuterol inhalation solution 0.5-2.5 3milligrams/milliliters. Inhaled orally as needed for wheezing and shortness of breath four times a day. On interview and observation 9/8/25 at 11:23 a.m., R66 sat in his wheelchair. A nebulizer machine and tubing sat on the floor next to the bed. R66 states that is where they put it because the only outlet is behind the bed. R66's bedside table sat next to him but full of personal items. R66 stated he has been doing a nebulizer treatment generally four times a day since he was admitted to the facility. On observation 9/9/25 at 7:04 p.m., the nebulizer machine with tubing was sitting on the floor next to R66's bed. Again, R66 stated that is the only place they have to plug it in. On observation 9/10/25 at 7:44 a.m., R66 sat on the edge of his bed receiving a nebulizer treatment. Nebulizer machine sat on the floor and tubing was ran from nebulizer machine to the nebulizer cup which R66 was inhaling medication from. Date on tubing indicated 9/4/25. On observation and interview 9/10/25 at 11:36 a.m., registered nurse (RN)-E was observed in R66's room completing dressing change on lower leg. The nebulizer machine sat on the floor, but tubing was wrapped around the window handle and not on the floor. RN-E stated she wrapped the tubing it around the window handle as there is no other place to put it but the floor which it shouldn't be on. On interview 9/10/25 at 10:57 a.m., registered nurse, also identified as infection preventionist and assistant director of nursing (ADON)-C stated a nebulizer machine, and tubing should not be housed on the floor as the floor is not clean. On interview 9/11/25 at 9:45 a.m., licensed practical nurse (LPN)-A stated a nebulizer machine and tubing should never be on the floor of a resident's room as the floor is not clean. On 9/11/25 at 12:20 p.m., LPN-B, also identified as care coordinator, stated a nebulizer machine and the tubing should not be on the floor. Stated there are portable stands they could put it on if his bedside table is full. On 9/11/25 at 12:41 p.m., the director of nursing stated she would not expect a nebulizer machine nor the tubing to be on the floor and that it is an infection issue.

Based on observation, interview, and document review, the facility failed to maintain the physical environment in good repair to ensure a safe and homelike setting for resident's when baseboard heating register covers were detached or not repaired for 6 of 23 resident rooms (R29, R34, R5, R14, R25, and R49) reviewed for environment. Findings include: R29: R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, no rejection of care, extensive assistance with bed mobility, dependent for transfers, and diagnoses of bed bound, urinary incontinence, edema, and morbid obesity. During observation and interview on 9/9/25 at 1:45 p.m., R29's heat register cover was observed on the floor next to her heat register. R29 stated it had been like that for a long time and no attempt had been made to fix it or replace it. R29 stated maintenance would sometimes put it back on, but it would be back on the floor the next day. R29 further stated the staff sometimes stepped on the cover when they came around that side of her bed. During observation and interview on 9/102/25 at 1:20 p.m., R29's heat register cover was again on the floor next to her vent. R29 stated it looked awful and she wished someone would have fixed it. R34: R34's facesheet received on 9/3/25, included a diagnosis of multiple sclerosis (a disease that affects the protective covering of nerves). R34's significant change MDS dated [DATE], indicated intact cognition, clear speech, could understand and be understood. During an observation and interview on 9/9/25 at 3:03 p.m., R34 was seated in her recliner. On the base-board heat register below the window, the outer panel which was about a foot in height and extended along the lower wall had a number of horizontal dark scratches along the surface, was pulled away from the heat coils and buckled. R34 stated it had been that way for a long time and yesterday someone from maintenance stopped in her room to look at it and stated it would be fixed. R34 stated it didn't bother her but it should be fixed. During an interview and observation on 9/09/25 at 4:48 p.m., together with maintenance director (MD)-A, looked at the heat register in R34's room. Although there was no bed in the room (R34 slept in a recliner), MD-A stated the register was likely struck by a bed at one time, causing the heat register cover to buckle. MD-A stated he was unaware of this and stated he would expect housekeeping staff to inform him when they see things that needed repair by either telling him directly or contacting him via walk-talkie. R5 R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, required substantial/maximal assistance with transfers, and diagnoses included Parkinsons, diabetes, and aftercare following surgical amputation. R5's progress note dated 6/7/25 at 2:15 p.m., scratches noted to right hand were not actively bleeding on day shift. Only light scratches noted, no open areas. Updated wife, who was in the facility visiting regarding right hand. Informed wife that the night nurse had put in a TELS (workorder) to maintenance to fix the cover to the vents next to bed. Also updated CNAs (certified nursing assistance) to keep bed pulled away from vents some. Document titled work order dated 6/7/25, indicated room [ROOM NUMBER] (R5) wall heater needed to be replaced, the metal cover came off, and further indicated completed by MD-A on 6/9/25. R5's weekly skin inspection dated 6/10/25, indicated old scab on the right wrist area, area clean, and dry. Lotion applied to resident skin. R5's progress note dated 6/12/25 at 1:32 p.m., indicated monitor R5's wrist for bleeding, clean with saline, apply bacitracin and cover if needed, ensure resident's bed is not too close to the wall, every shift for skin cares for 5 Days, no open areas or bleeding noted. Washed/dried scratches, applied bacitracin, and left open to air R5's progress note dated 9/10/25 at 8:54 a.m., licensed practical nurse (LPN)- C, the care coordinator, indicated contacted resident's wife and explained about the heater and about the body pillows being taken away due to the heater getting fixed, wife was happy with this result. R14 R14's admission MDS dated [DATE], indicated severe cognitive impairment, and R14 required substantial/maximal assistance with transfers. Diagnoses included diabetes and Parkinson's. R25 R25's quarterly MDS dated [DATE], indicated cognitively intact, dependent on staff with personal hygiene, toileting, required set up with eating, oral hygiene, utilized a wheelchair. Diagnoses included depression, peripheral vascular disease, and diabetes. R49 R49's quarterly MDS dated [DATE], indicated severe cognitive impairment, and R49 required partial/moderate assistance with transfers. Diagnoses included diabetes and hemiplegia following cerebral infarct affecting right side (paralysis of the right side of the body after stroke) Resident Council Departmental Response form dated 6/16/25, heater covers broken. Maintenance director (MD)-A written response undated, indicated repaired heater covers. Resident Council Departmental Response form dated 8/18/25, indicated residents would like furnaces in room fixed. MD-A written response on the form dated 9/8/25, indicated no they are not going to replace furnaces but covers replaced. Record review did not reflect any other documentation on work orders for R5, R14, R25, R29, R34, R49, and R77. On 9/8/25 at 9:33 a.m., R5 was seated in a recliner speaking on the telephone with family member (FM)-A. FM-A reported the heat register cover in R5's room frequently falls off. FM-A stated R5's arm often hangs over the bed and has sustained scratches from the exposed metal edges of the heat register. Both FM-A and R5 stated the facility was aware of the problem, but the current solution was to place a pillow over the heat register to prevent further injury. On 9/8/25 at 5:04 p.m., MD-A acknowledged missing or loose heat register covers were a known, ongoing issue at the facility, though the cause of the covers falling off was unknown. MD-A inspected R5's heat register, confirmed it was unsecured, and identified it as a safety hazard due to exposed sharp metal edges. MD-A stated routine walk-throughs were not performed and was unsure if he had previously repaired R5's heat register cover, although R5 stated MD-A had attempted repairs multiple times. On 9/8/25 at 5:12 p.m., the director of nursing (DON) observed R5's room and confirmed the heat register cover should not be missing. DON stated staff should report such issues and initiate a work order promptly. DON also confirmed placing a pillow over the heat register was an inappropriate and unsafe temporary solution. The DON stated she was not aware of the scratches that occurred on R5's arm and would expect staff to make her aware and ensure R5 heater was fixed to not get scratched. On 9/8/25 at 5:15 p.m., RN-C stated that it was common for heat register covers to fall off, staff were expected to submit a TELS order (computerized work order) when this occurred. On 9/9/25 at 8:15 a.m., R5 was observed seated upright in bed eating breakfast. The heat register cover remained hanging off the register with exposed metal slats. The pillow was still positioned over the exposed area between the bed and wall. On 9/9/25 at 10:20 a.m., nursing assistant (NA)-B stated that staff had repeatedly requested nursing and management to fix the heat registers. NA-B indicated it was an ongoing issue. NA-A reported MD-A was aware but often only placed the covers loosely without securely attaching them. On 9/9/2025 at 10:25 a.m., LPN-C, care coordinator, stated she first became aware of R5's unattached heat register cover the previous day (9/8/25) and was educated pillows should not be placed over the registers. On 9/9/25 at 10:58 a.m., RN-D stated she was aware of R5's broken heat register vent for several months but was unaware staff had been placing pillows over it. RN-D became aware of R5's scratches caused by the heat register on 9/8/25 and stated she would expect staff to submit work orders for such repairs. RN-D described the heat registers as being in poor condition and noted that beds leaning against them contributed to covers falling off of the rooms throughout the facility. On 9/9/25 at 1:50 p.m., the regional director of operations (RDO) stated he reviewed the concerns from the resident council meeting from 8/1/25, that indicated the furnaces in the rooms needed fixing. The RDO stated MD-A stated all the furnace covers were fixed, and stated he had not checked himself, but expected the furnace covers were fixed and securely attached in all resident rooms. On 9/9/25 at 1:53 p.m., during observation with RDO in rooms for in rooms R5, R14, R25, R29, R34, R49, and R77, RDO observed the baseboard heater covers were either detached, loose, or missing, exposing heating elements and/or sharp metal edges. On 9/9/25 at 1:59 p.m., housekeeper (HK)-A stated the baseboard heater covers falling off was a known issue and stated the covers are not securely attached. HK-A stated when MD-A is made aware of the issue he verbalizes he will “put it on the list”. On 9/6/25 at 2:05 p.m., RDO stated the heat register covers were expected securely attached and would expect maintenance to have fixed the concerns prior to today. On 9/10/25 at 7:11 a.m., MD-A stated he could not fully remember the details, but the TELS order submitted 6/25, indicated he completed the work order, that the metal cover came off R5's heater. MD-A stated though he did not recall the details he assumed the issue had been resolved if the work order had been closed. MD-A acknowledged concerns about the missing covers were brought up again during the 8/2025 resident council meeting, and became aware of those concerns on 9/8/25. Following this, MD-A stated he conducted a walkthrough of all resident rooms and personally observed multiple rooms with furnace covers that were either missing or in disrepair. MD-A recognized these posed a safety hazard. Residents or staff, could get cut, on the exposed areas. Despite identifying the issue, MD-A admitted he did not repair or replace the covers at that time. MD-A explained, staff can report maintenance concerns either by entering a request in the TELS (work order) system or by informing MD-A verbally. MD-A also stated he does not keep a written list of reported concerns, as he relies on his, great memory, and did not find it necessary to track issues in writing. On 9/10/25 at 9:51 a.m., an email received by the DON indicated, the facility did not have a policy or procedure for requesting maintenance, we don't have a policy or procedure, all staff are able to put in a TELS which goes directly to the maintenance team for any repairs needed, no policy on clean building and indicated the facility adhered to the resident bill of rights for home like environment, and further indicated no environmental policy.

Based on observation, interview, and document review, the facility failed to assess and determine safety for self-administration of medications (SAM) for 5 of 5 residents (R68, R25, R28, R11 and R66) who were observed to have medications at bedside. Findings include: R68's facesheet received on 9/11/25, included diagnosis of gastroesophageal reflux (when stomach acid flows back into the esophagus causing heartburn). R68's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R68 was independent or required supervision with activities of daily living. R68's physician orders did not include an order for antacid, or self-administration of an antacid. R68's care plan did not include self-administration of antacid. During an observation and interview on 9/9/25 at 2:30 p.m., observed a bottle of TUMS (over-the counter medication that neutralizes excess stomach acid) located on an open shelving unit below R68's TV. There were two tablets left in a 72-tablet bottle. R68 stated he brought them from home and took them on his own. During an interview on 9/10/25 at 9:49 a.m., licensed practical nurse (LPN)-C, who was also the care coordinator for the wing R68 resided on, was not aware R68 had TUMS in his room. LPN-C stated R68 would sometimes get things he was not supposed to have. LPN-C verified via electronic medical record (EMR), R68 did not have an order for TUMS, was not assessed for self-administration of TUMS, nor was self-administration of TUMS on his care plan. LPN-C stated she would remove them from his room and explain reason to R68. Durning an interview on 9/11/25 at 7:58 a.m., the director of nursing (DON) stated she had been informed R68 had TUMS in his room and acknowledged he should not have without an order and an assessment for safe administration. R25 R25's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R25 was cognitively intact, dependent on staff with personal hygiene, toileting, required set up with eating, oral hygiene, and utilized a wheelchair. MDS indicated diagnoses included depression, peripheral vascular disease, and diabetic. R25's care plan dated 6/26/25, indicated alteration in comfort related to lower back pain, spinal stenosis, gout, pain in right hip, generalized arthritis, osteomyelitis to right ankle/foot, and osteoporosis to the ankle/foot. Care plan directed staff to monitor for potential medication side effects related to pain medication usage including constipation, nausea and vomiting, sedation, lethargy, anorexia and increased confusion. On 9/8/25 at 9:16 a.m., R25 was observed lying in bed. On R25's bedside table was a bottle labeled Equate Calcium Carbonate Chewable Tablets (antacid) 1000 mg (milligrams). The bottle was approximately half full. R25 stated she takes the tablets for acid reflux and did not believe staff were aware she was taking them. R25 reported taking a couple of tablets at a time, but not on a daily basis. On 9/8/25 at 4:55 p.m., R25 was in her room seated in her wheelchair with the bedside table in front of her. The bottle of antacid tablets remained on the bedside table. On 9/9/25 at 9:52 a.m., R25 bottle of antacids continued to be present on the bedside table. On 9/9/25 at 1:07 p.m., trained medication aide (TMA)-A confirmed R25 did not have a provider order for medications to be kept at bedside or for self-administration. TMA-A acknowledged the antacid tablets were not supposed to be in the resident's room as there was not an order on the electronic medical record (EMR) and stated they would remove the medication and inform the nurse manager. On 9/9/25 at 1:09 p.m., registered nurse (RN)-A stated a provider order was required for residents to have medications at the bedside. On 9/9/2025 at 1:12 p.m., TMA-A removed the antacid tablets from R25's room. On 9/10/25 at 11:39 a.m., nurse practitioner (NP)-A stated R25 did not have an order to have medications at the beside and would expect the facility to contact her if R25 wanted an order to take the antacids. On 9/10/25 at 2:17 p.m., the director of nursing (DON) confirmed R25 did not have a self-administration of medication order and stated the medication was not supposed to be in R25's room. The DON confirmed R25 did not have a self-administration medication assessment. R28: R28's facesheet received on 9/10/25, included diagnoses type 2 diabetes mellitus, pneumonia, obsessive-compulsive disorder, seborrheic dermatitis (itchy, flaky and scaly patches on skin) and pancreatic insufficiency (pancreas fails to produce enough digestive enzymes). R28's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, understood others and was understood. R28 required supervision to partial/moderate assist with activities of daily living. R28's physician orders initially dated 7/17/25 included: 1. Ciclopirax Olamine external cream 0.77%, apply to face/chest topically two times a day every other day for prevention. 2. Clobetsaol Proplonate external gel 0.05% apply to scalp topically at bedtime every Wednesday or Friday for rash. 3. Hydrocortisone external cream 2.5%, apply to armpit topically two times a day for 14 days on and 14 days off for rash. 4. Pimecrollmus external cream 1%, apply to face topically every morning and at bedtime related to seborrheic dermatitis. On observation 9/8/25 at 12:18 p.m., R28 had creams in his bathroom including Triamcinolone acetonide external cream 0.1%, ciclopirox olamine external cream 077%, and hydrocortisone external cream 2.5%. On record review, no self-administration assessment, care plan or provider order was present on 9/8/25. On record review 9/9/25, an order was placed that R28 may keep at bedside and self-administer for all four creams ordered above. A self-administration assessment was completed 9/9/25 by licensed practical nurse (LPN)-B, also identified as care coordinator deeming R28 capable of self-administrating topical medication and treatment. On interview 9/10/25 at 10:31 a.m., R28 stated he was using those creams in his bathroom at home for years for a skin condition. R28 stated they have been in his room since he was admitted and he has been self-administering them since that time. A care plan dated 9/9/25, included resident chooses to self-administer topical and external creams. R11: R11's facesheet received 9/11/25, included diagnoses malignant neoplasm (tumor) of esophagus, respiratory failure and morbid (severe) obesity. R11's admission MDS dated [DATE], indicated R11 understood others and was understood with intact cognition. R11 required partial to moderate assist with activities of daily living. Physician orders included nystatin external powder 100000 units/gm (Gram) topical, apply to affected areas topically three times a day for rash irritation dated 8/25/25. On observation and interview 9/8/25 at 2:23 p.m., R11 had a bottle of nystatin powder 100000 units/gm, instructions on bottle included to apply to affected areas topically three times a day for rash/irritation, on his dresser next to his bed. R11 stated he doesn't apply it but staff are supposed to apply it a few times a day but that doesn't always happen. Review of R11's medical record on 9/8/25, did not include a plan of care, orders or assessments for medications to be kept at bedside. On observation 9/9/25 at 7:19 p.m., nystatin powder remains on the dresser next to R11's bed. On observation and interview 9/11/25 at 9:01 a.m., R11 continued to have nystatin powder on the bedside table. R11 stated he isn't sure why staff have been keeping it on his dresser. Review of R11's medical record on 9/11/25, did not include a plan of care, orders or assessments for medications to be kept at bedside. R66: R66's facesheet, received 9/11/25, include diagnoses bronchiolitis obliterans (constrictive, chronic inflammation and scarring of the small airways), acute respiratory failure, chronic obstructive pulmonary disease (COPD) and anxiety disorder. R66's 5-day MDS assessment completed and dated 9/4/25, (admission MDS still in progress) indicated R66 understood others and was understood with intact cognition. R66 required supervision or touching assistance to partial to moderate assistance with activities of daily living. Physician's orders dated 8/29/25, included orders for fluticasone-salmeterol 250-50 mcg (micrograms) per activation of aerosol powder, breath activated one puff inhaled orally two times a day for COPD and rinse mouth after use and Spiriva Respimat 2.5 mcg/act (activation) aerosol, solution two puffs inhale orally in the morning for COPD. On observation and interview 9/8/25 at 12:12 p.m., R66 was seated in his wheelchair in his room. On his bedside table were two inhalers: Fluticasone-Salmeterol 250-50 mcg/activation aerosol powder and Spiriva Respimat 2.5 mcg/activation aerosol. R66 stated the inhalers have been there since shortly after he was admitted a few weeks ago and he administered them himself. Review of medical record on 9/8/25, R66's record did not include physician orders, plan of care or self-administration assessments for inhalers. On observation 9/9/25 at 7:04 p.m., R66's above inhalers remained on his bedside table. On record review, R66's record included a physician order for self-administration of medicated dated 9/9/25, and medication administration assessment indicating resident is capable of self-administration of inhalation medication (including nebulizer). On interview 9/11/25 at 8:14 a.m., trained medication assistant (TMA)-A stated medications including creams, powders and inhalers can only be kept in the resident's room if a physician order is present and the resident has been assessed to be capable of self-administration. TMA indicated she was not aware R66 had medications in his room without a provider order. On interview 9/11/25 at 9:45 a.m., licensed practical nurse (LPN)-A stated medications cannot be kept at bedside or in a resident room without a physician order and completed assessment. LPN-A indicated she wasn't aware R66 had medications present in his room without a provider order. On interview at 12:11 p.m., LPN-B, also identified as care coordinator, stated she was not aware multiple residents had medications at the bedside or in their room until 9/9/25, at which time she completed assessments and obtained provider orders. She would expect staff to notify her if a resident requested medications at the bedside so an order could be requested from the provider and an assessment could be completed. LPN-B stated she wasn't aware R11 had nystatin powder at the bedside and she would ensure it was removed from the room or a provider order was received. On interview 9/11/25 at 12:41 p.m., the director of nursing (DON) stated medications could only be self-administered and kept at bedside if a provider order and assessment was completed. The DON added it needed to be communicated to the care manager on the floor for those items to be completed. A Self-Administration of Medications policy, undated included: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration; b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re[1]assessed periodically based on changes in the resident's medical and/or decision-making status. 4. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. 5. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. 6. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on interview, observation, and document review, the facility failed to serve menu items as listed and planned for 1 of 3 residents (R37) reviewed for nutrition services.Findings include:R37's facesheet printed 9/10/25, indicated diagnoses of chronic pain syndrome, edema, liver transplant, and pain.R37's care plan dated 8/1/25, indicated potential for alteration in nutrition with interventions of low sodium diet, soft and bite sized textures, take orders at meals and offer alternatives.R37's physician's order dated 1/6/25, indicated low sodium diet, thin liquids, sit upright for all meals.R37's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, independent with eating after setup assistance, and no weight loss.During observation and interview on 9/8/25 at 11:57 a.m., R37 stated she did not get the correct meal for supper on 9/7/25. R37 further stated she frequently got food other than what she requested on her facility provided meal selection ticket. R37 displayed a picture on her phone showing her plate on her meal tray from 9/7/25, which included only macaroni and cheese and cocoa. R37's picture showed her meal ticket on which she had selected milk, hamburger on bun, ketchup, macaroni and cheese, ranch dressing, cocoa, and oranges. R37 stated she turned on her light and requested her missing food items and was brought a dry hamburger on a bun with no condiments. R37 further stated she added her hamburger to her macaroni and cheese to make her own hotdish and gave up on requesting her additional items.During interview and observation on 9/9/25 at 12:34 p.m., R37 stated she had requested mashed potatoes as a substitute for rice for the noon meal on 9/9/25 but instead received cilantro rice. R37 showed her facility provided meal selection ticket which had a specific typed note on it indicating she should not be served rice.During interview and observation on 9/9/35 at 6:06 p.m., R37 was observed eating in her room. Her facility provided meal selection ticket was on her tray with her provided meal. The meal ticket order was for grilled chicken breast, pasta salad, and a peanut butter bar. Her tray included chicken nuggets, pasta salad, mandarin oranges, beets, cocoa, and chocolate ice cream. R37 stated the texture of the large chicken nuggets was too hard for her and that is why she requested the grilled chicken breast instead.During interview on 9/9/25 at 6:27 p.m., cook (C)-A stated she was unaware R37 had been served the wrong menu items for any of her meals. C-A stated usually she followed what the meal tickets had circled or written on them, put the food on the tray, and then it was delivered to R37. She did not give alternatives or add extra food without first discussing with the resident. C-A stated she had not talked to R37 recently.During interview on 9/10/25 at 9:47 a.m., culinary services director (CSD)-D stated she was unaware R37 was not getting her selected meals. CSD-D further stated she had just started her job one week ago and was going to work on improving things. CSD-D stated she would have expected R37 to get served her chosen meals unless they did not have something available. CSD-D stated she would talk to R37 to figure out a solution.During interview on 9/11/25 at 11:15 a.m., regional director of operations stated he was aware there had been some problems in the culinary department and they were working on fixing areas of concern and had hired a new culinary services director. Regional director of operations further stated he would expect residents to get their selected menu items or be offered a different choice if not available.A facility policy titled Resident Food Preferences dated 7/17, included the following:If the resident refuses or is unhappy with his or her meal, the staff will create a care plan that the resident is satisfied with. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snack.

Based on observation, interview, and document review, the facility failed to ensure proper cleaning and storage of respiratory equipment (nebulizer and CPAP/BiPAP) resulting in improperly maintained respiratory devices, potential for cross-contamination, and increased risk for respiratory infection for 3 of 4 residents (R12, R44, R68) reviewed for respiratory equipment use. Findings include: R12 R12's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, independent with dressing, eating, and required partial to moderate assistance with personal hygiene, utilized a wheelchair, and used a non-invasive mechanical ventilator, (CPAP/BiPAP). Diagnoses included respiratory failure, and chronic lung disease. R12's care plan dated 5/20/25, indicated alteration in respiratory status related to diagnosis of hyper carbic respiratory failure (occurs when the lungs cannot effectively remove carbon dioxide from the blood) BiPAP: on at bedtime, off when up, history of non-compliance with BiPAP usage, resident chooses to self-administer nebulizer treatments after nurse sets up. Resident is found to be competent to do so and interventions included: monitor usage of bedside medications, nursing to administer all other medications and monitor response and side effects as needed. R12's Treatment administration record dated 9/1/25-9/30/25, start date 9/9/25, indicated BiPAP: Cleanse BiPAP water chamber, mask and tubing with soap and water after use every day shift for sleep apnea and Ipratropium-Albuterol Inhalation Solution 3 ml (milliliters) 1 vial inhale orally three times a day related to acute respiratory failure ok for nursing to set up and then can self-administer. On 9/9/25 at 11:10 a.m., R12 had a BiPAP device located on the bedside table and with water visible in the chamber, also on the bedside table was a nebulizer device, which was fully assembled with: the tubing, nebulizer canister, and nebulizer mask. The nebulizer canister contained visible condensation. On 9/9/25 at 11:51 a.m., R12's BiPAP machine continued to be at the bedside table with the water chamber partially full, and an oxygen type face mask was attached to the tubing. A nebulizer machine was also located on the bedside table that was fully assembled with the tubing, nebulizer mask and canister were still hooked up and lying on the bedside table. There was no evidence the equipment had been rinsed, cleaned, or set out to dry after use. On 9/9/25 at 2:42 p.m., R12 stated the staff filled the water chamber on the BiPAP machine for him and stated was not sure if staffed rinsed or cleaned in the morning or daily, R12 also stated he was not sure if staff rinsed the nebulizer cannister after use. R12 confirmed so far no one had come and rinsed out the water chamber of his BiPAP machine today or the nebulizer cannister. On 9/9/25 at 2:47 p.m., trained medication aide (TMA)-A confirmed R12 used the nebulizer independently after set-up by staff. TMA-A stated the medication was put in the nebulizer cannister and she would set a timer and then rinsed the nebulizer cannister after use. TMA-A confirmed the facility had an ongoing issue with staff not rinsing and allowing the nebulizer cannisters to air dry after use. TMA-A stated there were instances when she went to administer nebulizer treatments, and the previous staff have not cleaned the nebulizer canister and would obtain new equipment or rinsed the cannister prior to the nebulizer treatment. TMA-A acknowledged staff had been educated on the importance of rinsing and drying the equipment. TMA-A stated the nurse was responsible for cleaning the BiPAP device. On 9/10/25 at 6:44 a.m., In R12's room, the nebulizer tubing and canister remained attached to the machine with condensation noted in the cannister. The BiPAP mask and tubing were found lying on the floor next to the bed, with the mask facing downwards touching the floor and the tubing attached to the BiPAP device. On 9/10/25 at 10:25 a.m., assistant director of nursing (ADON) observed the BiPAP mask on the R12's floor and stated this was not acceptable, the floor was contaminated and could contribute to infection. The ADON confirmed the nebulizer remained hooked up and was expected to have been rinsed and air-dried immediately after use. On 9/10/25 at 10:28 a.m., licensed practical nurse (LPN)-A confirmed R12's nebulizer should not remain connected after use and should be rinsed and left to air dry after use. On 9/10/25 at 10:25 a.m., assistant director of nursing (ADON) observed the CPAP mask on the R12's floor and stated this was not acceptable, the ADON stated the floor was contaminated and could contribute to infection. The ADON confirmed the nebulizer remained hooked up and was expected rinsed and air-dried immediately after use. On 9/10/25 at 12:01 p.m., LPN-A confirmed R12's BiPAP reservoir had not been cleaned or emptied today. LPN-A stated the evening nurse was responsible for emptying and replacing with clean water prior to R12's use at bedtime. LPN-A stated she had not been trained to do anything with the BiPAP reservoir and was not facility practice for her to empty or clean the reservoir in the morning or during the day shift. On 9/10/25 at 12:09 p.m., ADON stated she expected the day nurse to empty and clean the CPAP reservoir daily after use. ADON stated she was also the infection prevention nurse, and if not emptied, the reservoir could harbor bacteria and potentially cause respiratory infections. The ADON stated she had not been overseeing or auditing the cleaning of respiratory equipment. R44 R44's MDS dated [DATE], indicated R44 was cognitively intact and independent with personal hygiene and transfers. Diagnoses included chronic obstructive pulmonary disease (COPD). asthma, respiratory failure, and pneumonia. R44's care plan dated 9/5/25, indicated alteration in oxygen/gas exchange, respiratory status COPD. Interventions included to keep MD (medical doctor) informed of changes. R44's medication treatment record dated 9/1/25-9/30/25, indicated sodium chloride one vial inhaled orally via nebulizer two times a day related to COPD, Ipratropium-Albuterol Inhalation Solution 3 ml inhaled orally via nebulizer every four hours as needed for wheezing or SOB (shortness of breath) related to COPD. On 9/8/25 at 4:53 p.m., R44 was seated in a recliner in his room with a nebulizer device on the bedside table next to R44's bed, this included the nebulizer machine, tubing and a cannister connected to the tubing. R44 stated he had finished his nebulizer treatment. R44 further stated some of the staff would unhook the cannister from the tubing and rinse out the nebulizer cannister and other staff did not rinse the cannister out prior to the next nebulizer treatment administered. On 9/9/25 at 8:19 a.m., R44 was observed lying in bed and nebulizer was on bedside table, the nebulizer was fully assembled with tubing, cannister and T-mouthpiece attached. Condensation was present in the nebulizer canister. R44 stated the cannister usually remained attached to the tubing on the nebulizer machine after use. On 9/9/25 11:01 a.m., registered nurse (RN)-D, also known as nurse manger, stated nebulizer canisters were expected rinsed out after every use and would not expect the nebulizer cannister to remain attached to the tubing. RN-D stated residents had an increased risk for infection if the nebulizer cannister was not rinsed and left to air dry after use On 9/10/25 at 9:01 a.m., nurse practitioner (NP)-A stated they would expect the nebulizer cannister rinsed out after each use and stated BiPAP devices were expected emptied and cleaned after each use, to prevent infections. On 9/10/25 at 2:12 p.m., the director of nursing (DON) stated nebulizers were expected rinsed after use and set to air dry. DON expected the BiPAP water chamber emptied and cleaned daily after use. This was important to help prevent possible infections. Facility Policy titled Oral Inhalation Administration dated 5/22, indicated When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup.Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations, or:1) Wash pieces (except tubing) with warm, water daily. Rinse with hot water. Allow to air dry completely on paper towel.2) Replace tubing weekly and as needed R68 R68's facesheet received on 9/11/25, included diagnoses of pneumonia, obstructive sleep apnea (intermittent airflow blockage during sleep), COPD (chronic obstructive pulmonary disease; a lung disease that blocks airflow making it difficult to breathe), and benign prostatic hyperplasia (causes urination difficulties). R68's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R68 was independent or required supervision with activities of daily living. R68 did not walk and used an electric wheelchair for mobility. R68's physician orders dated 9/8/25, included nebulizer order: Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg [milligram] / 3 ml [milliliter], 0.083%, 2.5 mg inhale orally via nebulizer three times a day for COPD. At time of survey, R68's orders did not include CPAP use. An order dated 12/17/24 and discontinued when R68 went to the hospital on 9/3/25, indicated: Assist resident with putting his CPAP on at HS (bedtime). There were no orders related to the maintenance, care and cleaning of the CPAP machine or mask. R68's care plan dated 6/21/23, indicated nursing care plan for sleep apnea was directed at supporting the infant's cardiopulmonary status, improvement in gas exchange and breathing pattern, attainment of an optimal level of parental coping, knowledge on the treatment program and home care, and absence of complications. Resident does refuse to wear CPAP and allow staff to assist with cleaning and setting up. In addition to some of the language not being for an adult in a nursing home, it did not include if or how staff were to maintain and clean the CPAP machine and mask to prevent bacterial growth. Further, the care plan indicated safe self-administration of nebulized medication but did not include rinsing and drying the nebulizer set up after use to prevent bacterial growth. R68's TAR (treatment administration record) indicated out of 31 days in August, R68 used the CPAP 24 times: in September, twice before being hospitalized on [DATE]. R68's MAR (medication administration record) indicated R68 received a nebulization treatment on 9/8/25, (the day he returned from the hospital) in the PM (evening), on 9/9/25, in the AM (morning), noon, and PM, and on 9/10/25, in the AM. During interview and observation on 9/8/25 at 1:15 p.m., in his room, R68 stated he had just returned from a four-day hospitalization for pneumonia. Observed R68's CPAP unit and nebulizer unit on the dresser next to his bed. A SoClean brand CPAP mask cleaner was also on the dresser. Water and condensation were visible in the reservoir window on the CPAP machine. An opened and undated jug of distilled water was on the floor. R68 stated he filled the CPAP reservoir himself with the distilled water and that the water had been in the CPAP machine since before he left for the hospital on 9/3/25. R68 stated the water reservoir was never emptied, rinsed or cleaned that he was aware of. During an observation on 9/9/25 at 11:35 a.m., observed nebulizer mask with chamber and tubing attached to nebulizer machine. The chamber had condensation in it, indicative of not being rinsed out and dried after last use. The MAR indicated R68 had a nebulizer treatment that morning. During an observation on 9/9/25 at 2:30 p.m., observed nebulizer mask with chamber and tubing chamber attached to nebulizer machine. The chamber had condensation in it. The MAR indicated R68 had a nebulizer treatment at noon. R68 stated some staff rinsed the nebulizer set up; he had seen it in his bathroom sometimes, taken apart, but not very often. R68 stated he had never seen his CPAP mask in the SoClean machine. During an interview on 9/9/25 at 4:39 p.m., nursing assistant (NA)-D stated NAs did not have anything to do with a resident's CPAP machine - only the nurses did - this included applying, removing and cleaning. During an interview on 9/9/25 at 7:34 p.m., in R68's room, trained medication aide (TMA)-A stated nurses or NAs filled R68's CPAP machine with distilled water and cleaned the mask but wasn't sure how often the mask was cleaned or if cleaning was documented in the electronic medical record (EMR). TMA-A did not know how often R68 used the CPAP as she did not work the night shift. TMA-A stated when R68's nebulization was complete, she took the equipment to the bathroom, disassembled it, rinsed it and set it on paper towel to dry, adding she was aware not all nurses did that. TMA-A stated the nebulizer set-up should be dried to prevent bacteria. During an interview on 9/10/25 at 8:57 a.m., nurse practitioner (NP)-A was informed of finding with R68's nebulizer not being rinsed after use, his CPAP machine water reservoir not being emptied and rinsed, and his CPAP mask not being cleaned. NP-A stated those factors could have contributed to R68's recent pneumonia. During an interview on 9/10/25 at 9:49 a.m., licensed practical nurse (LPN)-C who was also the care coordinator for the wing on which R68 resided admitted there was nothing in R68's orders or care plan to guide staff how to clean and maintain the CPAP machine and mask. LPN-C stated nurses knew to rinse nebulizer set-ups after use -- that is something all nurses were trained on but could not say if nurses knew how to clean and maintain CPAP equipment. When informed, LPN-C was not aware all nurses were not rinsing and drying the nebulizer set-up after use. During an interview on 9/10/25, at 10:57 a.m., assistant director of nursing (ADON), who was also the infection preventionist, stated if nebulizers and CPAP machines were not cleaned properly, that could lead to pneumonia or other infections. When informed of findings, ADON stated failure to properly clean this equipment could be a contributing factor to several residents acquiring pneumonia. ADON stated staff should clean a nebulizer after every use, wash out the mask and allow it to air dry it to prevent bacterial growth. The ADON would expect the CPAP masks to be cleaned daily with soap and water and air dried, and the CPAP water reservoir emptied daily and air dried to prevent bacterial growth. During an interview on 9/11/25, at 7:58 a.m., the director of nursing (DON) stated she had been made aware of the concern of improper cleaning and maintenance of nebulizers, CPAP machines and masks, and stated the ADON had gone to resident rooms to audit the equipment and to educate staff on expectations. The DON stated nursing care coordinators were responsible for ensuring orders were entered into the EMR and onto care plans to prompt and guide nursing staff to clean and maintain nebulizers, CPAP machines and masks. In an email exchanged dated 9/10/25, the DON stated the facility did not have a CPAP policy and would follow manufactures guidelines. Page 8 of an untitled and undated document was provided. The guidelines indicated to regularly clean the tubing assembly, water tub and mask to prevent the grown of germs that could adversely affect health. The document included step by step instructions with illustrations including discarding remaining water. The device should be cleaned weekly as described. Refer to the mask user guide for detailed instructions (this was not provided). Wash the water tub and air tubing in warm water using mild detergent. Rinse the tub and air tubing thoroughly and allow to dry. Wipe exterior with a dry cloth. Facility Oral Inhalation Administration policy dated May 2022, indicated to rinse and disinfect the nebulizer equipment according to manufacturer's recommendations, or: 1) Wash pieces (except tubing) with warm water daily. Rinse with hot water. Allow to air dry completely on paper towel. 2) Replace tubing weekly and as needed. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days and as needed.

Based on observation, interview, and document review, the facility failed to follow up on a resident's request for vision care and failed to ensure timely scheduling of an eye appointment, resulting in a delay in care for 1 of 1 resident (R44) reviewed for vision services.Findings include:R44's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R44 was cognitively intact, vision was impaired sees large print but not regular print in newspaper/books, no corrective lenses, diagnoses included diabetes and coronary artery disease.R44's care plan dated 9/5/25, did not address R44's vision impairment.R44's care conference form dated 7/21/25, licensed practical nurse (LPN)-C indicated R44 would like to set-up eye care appointment. NM (nurse manager) will work of scheduling an eye exam.R44's document titled hearing/vision form dated 7/24/25, registered nurse (RN)-D, nurse manager indicated R44 had impaired vision and does not use corrective lenses, R44 requested to have appointment scheduled for ophthalmology and audiology. NM will work of scheduling appointments and update resident regarding appointment.R44's progress note dated 9/8/25 at 3:46 p.m., assistant director of nursing (ADON) indicated R44 stated that his vision has gotten worse, and he is unable to read the words on his TV which is a large screen. He has readers in his room, but he is requesting a vision appointment be made, writer updated his nurse manager regarding vision appointment needed.R44's progress note dated 9/8/25 at 3:47 p.m., RN-D indicated appointment scheduled 9/16/25 1:35 p.m., [name of eye clinic] for eye exam and to establish cares. Appointment added to calendar. Resident updated at this timeOn 9/8/25 at 8:46 a.m., R44 was observed seated in a recliner watching television. R44 reported that the television image was blurry and hard to see. He stated he had expressed concerns about his vision and requested an appointment with an eye doctor a few months ago, but had not yet been scheduled to see one.On 9/9/25 a.m., LPN-C stated she would attend R44's care conference if his nurse manager (RN-D) was not available. LPN-C stated she did not recall specifics about R44's care conference held on 7/21/25, and but believed she had relayed the request for an eye appointment to RN-C. LPN-C stated an eye appointment would have been expected scheduled prior to yesterday (9/8/25)On 9/9/25 at 11:01 a.m., RN-D, the assigned nurse manager for R44, stated she had not made any attempt to schedule an eye appointment for R44 prior to yesterday (9/8/25). RN-D acknowledged she was aware of R44's request and confirmed that an appointment should have been scheduled earlier.ON 9/10/25 at 9:05 a.m., nurse practitioner (NP)-A stated the facility to have made an eye appointment for R44 when requested in July 2025.On 9/10/25 at 12:45 p.m., the director of nursing (DON) indicated in an email the facility does not have a policy on making eye appointments, we would just follow up as needed or upon request from the residentOn 9/10/25 at 2:23 p.m., the director of nursing stated would have expected an appointment scheduled when R44 brought up concerns at the 7/25, care conference.

Based on interview, observation and record review the facility failed to complete a comprehensive skin assessment and monitoring of impaired skin integrity for 1 of 2 residents (R65) reviewed for skin care. Findings include:R65's face sheet provided on 9/10/25, included diagnoses of diabetes mellitus type II, protein-calorie malnutrition, cellulitis (infection) of left lower leg, Pilonidal cyst (fluid filled sac that forms typically near the tailbone often due to infection of a hair follicle) without abscess and pressure ulcer of unknown site, stage II (partial-thickness tissue loss, shallow open wound caused by pressure) . Resident also had malignant neoplasm (cancerous tumor) of colon. R65's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R65 had intact cognition, clear speech, could understand and be understood. R65 required assistance with transfers. R65 had an open lesion other than ulcers, rashes, cuts and had a stage II pressure ulcer (PU) present on admission. R65's care plan dated 8/26/25, indicated R65 had a self-care deficit related to multiple health care issues. R65's care plan interventions included: bathing assist of 1, dressing assist of 1, and personal hygiene assist of 1. R65 also had an alternation in skin integrity related to open area to coccyx and bilateral wounds to lower extremities upon admission. Interventions included monitor skin integrity daily during cares and weekly skin inspection by the nurse; treatment to open areas per order; pressure redistribution mattress to bed, wheelchair and chair; weekly measurements and assessment of wounds; monitor for skin breakdown for signs/symptoms of infection; document on skin condition and keep physician informed of changes; followed by wound care provided by the facility. A Care Area Assessment (CAA) dated 8/28/25 included pressure ulcer/injury. R65 had alteration in skin integrity related to cellulitis (skin infection), complicated by immunodeficiency, diabetes, metastatic colon cancer, biventricular heart failure and history of malnutrition. R65 had a Pilonidal cyst with daily treatment and skin shear/excoriation (injury that occurs when tissue layers shift laterally to each other causing damage to the skin). Staff routinely assist with skin care, toileting and repositioning, encourage optimum activity levels within limits of safety. Staff provide treatments as ordered, diabetic cares per protocol, observe for adequate intake of fluid and nutrients. Skin audit and documentation per protocol. Update provider if evidence of infection or non-healing. Wound assessment from hospitalization dated 8/19/25 included: Perianal/Posterior thigh: Thigh wound was on right posterior identified as ulcers of unclear etiology with length of 20 centimeters (cm) , width of 1cm and depth of 0.2 cm. Pink yellow and granulation tissue was 100%. Perianal (area that contains the external genitalia and anus) ulcers, length 5 cm x 1 cm with depth of 0.2 cm. Wound # 3 was identified as cyst to the coccyx area with length of 1 cm, width 0.1 cm and depth 0.2cm. 100% granulation tissue present with skin around wound clean, dry and intact. R65's Discharge summary dated [DATE] did not include a skin assessment or wound care treatments or orders. Wound care orders dated 8/21/25, included: Pilondal Cysts - cleanse wounds with acetic acid 0.25% or wound cleanser and pat dry. Put hydrogel (treatment to maintain hydrated environment for proper wound healing) into a med cup and cut strip of 1/4 plain packing gauze strip. Put the gauze strip into the hydrogel. Gently pack the packing gauze infused with hydrogel into the cyst opening. Cover with a 4x4 gauze and cover with border foam dressing. Change daily and as needed in the morning for wound care. For perianal wound and posterior thigh, cleanse with 0.25% acetic acid wound cleanser (antimicrobial and antioxidant properties for treatment of wounds), pat skin dry and apply a nickel thick layer of zinc barrier cream directly to wound area. A Skin assessment dated [DATE] by registered nurse (RN)-C included [resident] received a shower this morning, skin is fragile and generalized bruising. Excoriated skin (caused by act of scratching or rubbing skin) to buttocks with small open area to intergluteal cleft. Ongoing open area/cyst to right thigh inner. No further wound measurements or wound assessments present. A Skin assessment dated [DATE] included Braden score (tool used to predict pressure ulcers) of 15-18 which is mild risk. Coccyx wound (cyst) had tunneling and one open spot. Serosanguineous (combination of clear thin watery fluid and blood) was present. No new wounds. Resident had turning and repositioning schedule, pressure redistributing ultra-foam mattress, and wheelchair cushion. No wound measurements or wound bed assessment present.A Wound Examination dated 9/4/25, completed by certified nurse practitioner, also wound, ostomy and continence certified nurse (CNP, WOCN) included ulcer of perianal area measuring 1.91 cm x 0.75 cm x 0.1cm. Pilonidal cyst area improving. Orders and plan for Pilonidal cyst included cleanse wounds with acetic acid 0.25% or wound cleanser, pat dry, place collagen powder into wound bed and apply a thin layer of Triad paste (zinc-oxide based hydrophilic paste used for wound care with light to moderate levels of wound drainage) over wound and powder. Repeat twice daily as needed. Wound care for perianal ulcer included cleanse wound and surrounding skin with acetic acid 0.25% , pat dry. Apply collagen powder to wound bed. Apply a thin layer of Triad paste over the wound and powder. Repeat twice daily as needed. On observation and interview 9/10/25 at 8:20 a.m., nursing assistant (NA)-A provided perianal care for R6. NA-A exposed the wounds on coccyx, perianal area and thigh which were open and covered with a white paste. NA-A stated the thigh wound has had some bleeding on occasion and R65 stated the area hurts when touched. On interview and observation on 9/10/25 at 12:17 p.m., registered nurse (RN)-E completed wound care treatment to R65's wounds. When asked to measure, RN-E stated they do not measure the wounds, the wound care staff do that. Their next scheduled visit was 9/11/25. RN-E wiped the wound on coccyx with acetic acid 0.25% on a sterile 4x4. RN-E repeated the process on perianal area that had 2 open wounds next to each other. RN-E repeated the process on the thigh wound. RN-E allowed all areas to dry and applied collagen powder (used to promote wound healing and tissue regeneration) to all the wound beds, then wound protector (Triad paste) to keep collagen in place. On interview and observation 9/10/25 at 2:36 p.m., licensed practical nurse (LPN)-B, also identified as care coordinator was requested to view R65's thigh wound. After examination of R65's wounds, LPN-B stated I wasn't aware that was there when referring to thigh wound. LPN-B stated she didn't see documentation of this wound on the skin/wound assessment forms. LPN-B placed a Mepilex (absorbent foam dressing) on top of the thigh wound to protect it and stated she would reach out to the provider and get an order and have them review the wound tomorrow. On interview 9/10/2025 at 3:51 p.m., RN-E stated R65 did not have a thigh wound on his initial admission but returned from the hospital 8/21/25 with it. RN-E stated he came back with orders to treat the Pilonidal cyst. RN-E identified the perianal area as the thigh area with all three areas related to the pilonidal cyst. RN-E identified the coccyx area as a pressure area. RN-E stated she has been treating the wounds per orders. On interview 9/11/25 at 8:50 a.m., certified nurse practitioner (CNP)-E, also identified as certified wound care specialist stated she was not aware of a thigh wound for R65 but has assessed and treated Pilonidal cyst areas and pressure ulcer identified on coccyx and perianal area. CNP-E stated she relied on staff to inform her of new wounds and no one at the facility had told her about a thigh wound. On interview and observation 9/11/25 at 11:32 a.m., CNP-E and LPN-B evaluated R65's wounds. CNP-E cleaned the pilonidal cyst area and measure 0.5 depth and now only 0.1 length. CNP-E stated this has showed good improvement. Coccyx ulcer measured 0.3 depth and was pinpoint which also has shown improvement. CNP-E visualized thigh wound and measured 0.5 cm x 2.6 cm with depth of 0.4cm with undermining (erosion beneath the visible edges of a wound) from 10 o'clock to 3 o'clock on the wound. CNP-E stated the wound appeared to be a skin tear of some kind and requested Xeroform ( sterile non-adherent wound dressing) for the wound bed and covered with Mepilex. CNP-E stated she would not recommend collagen powder and Triad paste for this type of wound as it could dry it out which is not what the wound needed to heal. CNP-E confirmed she was not aware of this thigh wound until today and stated this was not part of the Pilonidal cyst or pressure ulcer area. On interview 9/11/25 at 12:23 p.m., LPN-B stated she asked RN-E yesterday what she called the thigh area and she stated perianal to her. LPN-B confirmed the thigh wound is not located in the perianal area. LPN-B stated she was not aware of R65's thigh wound as staff never communicated it to her until yesterday when requested to view it. LPN-B confirmed the wound has not been measured or documented and assessments completed on the thigh wound. On interview 9/11/25 at 12:45 p.m., the director of nursing (DON) stated she is not sure where the mix up of R65's wound came from. The DON stated the wound care specialist was made aware of the wound today. The DON stated the thigh wound was being assessed and treated per the orders. When asked to see the wound assessments and measurements, the DON did not provide them. A Skin Assessment and Wound Management policy, dated 2/25 included: Provide guidelines for assessing and managing wounds.1. A pressure ulcer risk assessment (Braden Scale) will be completed per facility Assessment Schedule/Grid.2. Implement appropriate preventative skin measures. Examples include, but are not limited to-nutritional interventions, mobility and repositioning plan, pressure redistribution plan.3. Skin Evaluation and Skin Risk Factors Form is completed before initial MDS, annually, and upon significant change.4. Staff will perform routine skin inspections (with daily care).5. Nurses are to be notified if skin changes are identified.6. A weekly skin inspection will be completed by licensed staff.New Skin Problem:When a significant alteration in skin integrity is noted; (i.e., large, or multiple bruising, large skin tear, or other non-pressure related wounds such as diabetic, venous, or arterial ulcers), the following actions will be taken:7. Notify Provider/Treatment Ordered8. Notify resident representative.9. Complete education with resident/resident representative includingrisks & benefits.10. Initiate Skin and Wound Evaluation11. Notify Nurse Manager/WoundNurse12. Referral to dietary, if appropriate13. Referral to therapies, if appropriate14. Review and update care plan including interventions.15. Update resident care lists16. Update Care Plan to identify risks for skin breakdown

Based on observation, interview, and record review, the facility failed to assist with oral care as directed by the plan of care for 1 of 4 resident (R65) reviewed for activities of daily living (ADLs).Findings include:R65's face sheet provided on 9/10/25, included diagnoses of diabetes mellitus type II, protein-calorie malnutrition, cellulitis (common bacterial infection that affects skin and tissue beneath) of left lower leg and sepsis (blood infection). R65's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R65 had intact cognition, clear speech, could understand and be understood. R65 required assistance with transfers. For oral care, the MDS indicated: supervision or touching assistance. R65's care plan dated 8/22/25, indicated R65 had a self-care deficit related to multiple health care issues. R65's care plan interventions included: bathing assist of one, dressing assist of one, and personal hygiene assist of one. R65's electronic medical record (EMR), under the TASK tab, included a personal hygiene tab but did not include a specific category for oral care. The hygiene tab was documented on seven of 14 opportunities and required limited to extensive assistance from staff. During interview and observation on 9/9/25 at 6:32 p.m., R65 stated, he has his own teeth yet and since his admission, no one has offered to assist him with brushing his teeth. R65 stated he can brush them himself, but staff need to bring the supplies to him including a basin to spit into when done. Present on the TV stand was a toothbrush and toothpaste that is unopened and in the original packaging. No basin was visualized in his room or bathroom. During interview and observation on 9/10/25 at 8:20 a.m., nursing assistant (NA)-A assisted R65 with a bed bath. R65 was transferred to wheelchair and taken to the scale for his weight and then returned to the room and sat in his chair. Oral care was not set up or offered to the R65. R65 stated he generally brushes his teeth in the morning, but no one has offered to set him up to do it since he has been at the facility, about three weeks. During interview on 9/11/25 at 9:50 a.m., NA-A stated she generally sets residents up to complete oral care but was distracted yesterday so maybe she didn't. NA-A stated R65 was assisted with dressing this morning, but she didn't offer oral care yet and will take care of that right away. During interview on 9/11/25 at 9:45 a.m., licensed practical nurse (LPN)-A stated oral care should be offered at least daily to all residents who require assistance with set up. During interview on 9/11/25 at 12:23 p.m., LPN-B, also identified as care coordinator, stated R65 is supposed to be encouraged to be more independent with his own cares, but should have a basin, toothbrush and toothpaste available for him to use to brush his teeth. During interview on, 9/11/25 at 12:37 p.m., director of nursing (DON) stated she would expect staff to assist with set up for oral care if that is what the MDS states.

Based on observation, interview and document review, the facility failed to address urinary catheter/drainage bag/leg bag, and CPAP (continuous positive airway pressure) machine in the care plan for 1 of 3 residents (R68) reviewed for care plans. Findings include: R68's facesheet received on 9/11/25, included diagnoses of pneumonia, obstructive sleep apnea (intermittent airflow blockage during sleep), chronic obstructive pulmonary disease (lung disease that blocks airflow making it difficult to breathe), and diagnosis added 6/23/25: hydronephrosis with ureteral stricture (narrowing in the ureter, a tube carrying urine from kidney to bladder, obstructs urine flow, causing affected kidney to swell with urine). R68's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R68 was independent or required supervision with activities of daily living (ADLs). R68 had an indwelling urinary catheter. R68 did not walk and used an electric wheelchair for mobility. R68's physician orders dated 9/8/25, indicated change foley/suprapubic catheter bag on shower day in the morning every Friday. Staff to follow EBP (enhanced barrier precautions) every shift for foley catheter. R68's care plan dated 6/22/23, indicated R68 had an alteration in elimination. Care plan dated 4/18/25, indicated monitor foley catheter output, change foley catheter per policy and foley catheter care per policy. R68's physician orders at time of survey did not include leg bag or urinary drainage bag monitoring/care, or CPAP use or maintenance. R68's care plan dated 6/21/23, indicated nursing care plan for sleep apnea was directed at supporting the infant's cardiopulmonary status, improvement in gas exchange and breathing pattern, attainment of an optimal level of parental coping, knowledge on the treatment program and home care, and absence of complications. Resident does refuse to wear CPAP and allow staff to assist with cleaning and setting up. In addition to some of the language not being for an adult in a nursing home, it did not include if or how staff were to assist R68 to apply the CPAP at night, how to maintain and clean the CPAP and what to do if R68 declined to wear the CPAP. Further, the care plan did not indicate R68 used a urinary leg bag and did not include frequency of emptying, cleaning and maintenance of the leg bag, nor of the overnight urinary drainage bag. R68's Kardex (a quick reference tool usually used by nursing assistants that summarized key resident information) printed 9/9/25, did not include cares for urinary catheter or urinary leg bag, other than foley catheter output. R68's TAR (treatment administration record) dated 12/17/24, indicated: CPAP on at HS (bedtime) per provider. For the month of August 2025, out of 31 days, documentation indicated R68 used CPAP 24 times. For September 2025, documentation indicated R68 used CPAP two nights before being hospitalized on [DATE].During an interview and observation on 9/8/25 at 1:15 p.m., in his room, R68 stated he had just returned from a four-day hospitalization for pneumonia. Observed R68's CPAP unit on the dresser next to his bed. A SoClean brand CPAP mask cleaner was also on the dresser. Water and condensation were visible in the reservoir window on the CPAP unit. An undated jug of distilled water was on the floor. R68 stated he filled the CPAP reservoir himself with the distilled water. R68 stated the water reservoir was never cleaned or rinsed out that he was aware of and had never seen his CPAP mask in the SoClean machine. During an interview and observation on 9/9/25 at 2:30 p.m., R68 stated he did not use the CPAP every night but felt better when he did. R68 stated he would like to use it every night but had trouble adjusting the mask himself.During an interview on 9/9/25 at 4:39 p.m., nursing assistant (NA)-D stated NAs did not have anything to do with a resident's CPAP machine - only the nurses did - this included applying, removing and cleaning. During an interview on 9/9/25 at 7:20 p.m., R68 stated his urinary leg bag was full of urine, adding no one had emptied it, not even after he got out of bed this morning. R68 pulled up his pant leg to reveal a leg bag completely full of urine. During an interview and observation on 9/9/25 at 7:34 p.m., in R68's room, trained medication aide (TMA)-A stated nurses or NAs filled R68's CPAP machine with distilled water and cleaned the mask but wasn't sure how often the mask was cleaned or if cleaning was documented in the EMR. R68 informed TMA-A his leg bag had not been emptied. TMA-A stated his leg bag should be emptied regularly and he should not have to ask. TMA-A stated she would inform the NA. During an interview and observation on 9/9/25 at 7:41 p.m., NA-E arrived to empty R68's leg bag of 750 milliliters of urine. NA-E stated she had not been aware R68 had a leg bag, as she did not usually work on the wing R68 resided on.During an interview on 9/10/25 at 9:49 a.m., licensed practice nurse (LPN)-C who was also the care coordinator for the wing on which R68 resided, stated as care coordinator, it was her responsibility to add areas of focus to a residents care plan and should have added both R68's CPAP and urinary leg bag use with instructions for care and maintenance to guide the staff. During an interview on 9/11/25 at 7:58 a.m., the director of nursing (DON) was informed of the absence of CPAP and urinary leg bag on R68's care plan. The DON stated she expected care coordinators to monitor and update a resident's comprehensive care plan to include all pertinent focus areas.Facility Care Planning policy, with revised dated of 11/2024, indicated the interdisciplinary team (IDT), in conjunction with the resident and the resident representative, would develop and implement a comprehensive individualized care plan. Care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care plan would be used in developing the resident's daily care routines and would be utilized by staff personnel for the purposes of providing care or services to the resident. The plan of care would be utilized to provide care to the resident. The care plan would be modified and updated as the condition and care needs of the resident changed.

Based on observation, interview and document review, the facility failed to follow their grievance process for 1 of 1 resident (R28) who reported missing property. Findings include: R28's facesheet received 9/10/25, included diagnoses Type 2 diabetes mellitus, obsessive-compulsive disorder, generalized anxiety and mood disorder. R28's admission Minimum Data Set (MDS) assessment dated [DATE], identified R28 had intact cognition, understands and is understood and has no behaviors.On interview 9/8/25 at 10:54 a.m., R28 stated he lost a couple shirts that meant a lot to him when he was first admitted . R28 states it isn't uncommon for the laundry not to return. R28 stated no one has followed up with him after he reported them missing even when he periodically asks again about them. R28 stated he has told many different staff about his missing clothes but was not able to identify any by name. Review of grievance logs did not include a grievance form for R28's missing clothing. Review of R28's progress notes did not include a note on his missing clothing. During interview on 9/9/25 at 2:01 p.m., R28 stated licensed practical nurse (LPN)-B, also identified as care coordinator, gave him some extra clothes to wear but does not believe it was in response to his lost shirts. R28 stated no one has offered to replace his missing shirts nor could they replace them as they were from vacation places he visited and held sentimental value. R28 stated he had the shirt on when he came and they took it off when he showered the next day and he hasn't seen it since. R28 stated they won't mark your clothes until they are clean so he believes many things get lost initially due to that. R28 reported he is also missing a couple pairs of socks that were labeled and it has been over a week and they haven't come back from laundry. R28 stated he has told staff right away when his clothes/socks go missing and he never gets a response back even when asking about them multiple times. During interview on 9/9/25 at 6:14 p.m., trained medication assistant (TMA)-A and nursing assistant (NA)-C stated when residents inform them of missing belongings including clothing, there is a form that gets filled out. TMA-A stated the forms were at the nurses' station. NA-C stated if they report it to her she generally goes to the laundry room and takes a look around for it. NA-C stated if not found will tell the nurse who will complete the missing belongings report. On 9/9/25 at 3:07 p.m., LPN-B stated if residents are missing clothes, staff should inform the nurse or report it to her. LPN-B stated they do have a form for missing belongings but aren't consistently using it. LPN-B stated they do not know why they have so many missing belongs at the facility. During interview on 9/10/25 at 8:17 a.m., laundry staff (LS)-A, also identified as supervisor, stated this morning she found R28's hoodie in the laundry room but is unsure of the rest of his missing clothes. LS-A stated generally she gets an electronic mail (E-mail) from staff when things are missing but prefers it on paper to communicate with the other laundry staff. LS-A stated they do laundry for three other facilities besides this one so things can get lost. LS-A stated many times they find out belongings are missing when they deliver clothes to the resident's room from the residents, or sometimes from social services or the manager. LS-A confirmed clothes have to be clean before the front desk staff will label the clothing with a name but they generally will put them in a separate bag with the name in the bag. During interview on 9/11/25 at 12:38 p.m., the director of nursing (DON) stated she would expect staff to look for any missing belongings first and if can't find them should fill out a grievance form and turn into social services who will follow-up with the housekeeping supervisor. Facility Lost, Missing or Damaged Items policy dated 2/23, included: 1. A Grievance Form will be completed for all missing valuables of residents, visitors, employees and facility, regardless of item value. 2. The facility employee who received the original missing valuables communication is responsible for initiating the Grievance form. 3. Forms are available at the nurse's station or Social Services office. 4. The written form should be signed and dated by the person making the missing item. 5. The form should be completed and returned to the Administrator's or Social Services office. 6. The grievance process will be followed to determine appropriate next steps. Conducting an Investigation 1. The Administrator or designee shall conduct an investigation to determine the details involved with the missing/damaged item. 2. The Administrator shall respond to the owner/resident representative of the missing/damaged item regarding the investigation outcome and the suggested resolution within 5 business days of receiving the reports

The facility failed to develop and revise a person centered behavior care plan, document the risk verse benefit associated with refusing care, identify root cause analysis, and determine what triggered her anxiety and agitation, and provide ordered psychiatric follow up care for 1 of 3 residents (R2) reviewed, when she was found to have maggots on her body because she refused to accept help to change soiled clothing and bed linen, and let housekeeping clean her room. Findings include: R2's initial admission care plan dated 2/10/23, indicated cognition deficit, unable to communicate her thoughts and needs, history of refusing care and becoming agitated when approached. She required the assistance from one person to dress, bath, incontinent care and brush her hair. Mood and behavior interventions included being alert to any changes in her mood, monitor and document her behaviors, and give medication as ordered by the doctor. The interventions were renewed during quarterly and annual assessments and no other interventions were developed. R2's care plan dated 9/8/23, indicated her inability to express her needs and her impaired cognition affected her behaviors. Interventions remained unchanged and no other interventions were developed. R2's psychiatric appointment dated 2/19/25, indicated her daughter reported in the fall of 2024 she was started on a low anti-anxiety medication to help with her frustration. She was started on sertraline for her irritability and anxiety. Staff instructed to monitor her response to the new medication over the next month. Schedule a follow up appointment in one month to assess the effectiveness of the medication and make any necessary adjustments. R2's care plan dated 2/26/25, developed after her appointment with the psychologist on 2/19/25, indicated interventions included monitoring for adverse drug reactions and update the medical provider as needed. The ordered one month follow up appointment to assess medication changes was not listed. R2's medical doctor (MD) dated 3/27/25, indicated her continued refusals to change urine soaked linen and clothing, refusing daily hygiene and showers is becoming a health hazard. Continue to work with psychologist to develop strategies and ideas to improve behavior and communication. R2's nurse practitioner (NP)-A dated 4/24/25, indicated her last virtual visit with the psychiatrist was 4/24/25 when Sertraline was started. Requested the psychiatrist's note but facility was unable to provide. NP-A documented there was a strong odor of urine during her visit. NP's plan of care included staff to provide incontinent care and keep her room clean. R2's NP note dated 5/29/25, indicated she was seen by a psychiatrist in February and started on sertraline because the resident refused bathing and incontinent care. She was supposed to have a follow up appointment in one month, but staff held off scheduling it hoping to find a different placement for the resident. Alternative placement had been difficult and instructed staff to make an appointment to see the psychologist. R2's MD note dated 5/29/25, indicated she had an appointment on 2/19/25, and sertraline was started. She was supposed to have a follow up appointment in one month, but staff held off scheduling the appointment hoping to find alternative placement. Nurse manager will make a follow up appointment. R2's MD note dated 6/2/25, indicated she refused bathing and during wound care they found maggots in her folds. Staff questioned if they could premedicate her with anxiety medication to decrease anxiety levels. MD gave a new order for Ativan to be given 30 to 60 minutes before showering. R2's interdisciplinary team (IDT) note dated 6/9/25, indicated she continued to be incontinent of urine and refused staff assistance. Staff offered incontinent care and supplies every two hours without improvement in behaviors. During a medical record review on 6/10/25 at 2:35 p.m., requested risk verse benefit assessments but no records were provided. During an interview on 6/10/25 at 12:44 p.m., the receptionist at the Department of Psychiatric and Psychology confirmed R2 had appointment scheduled for next week. The appointment was initiated on 6/3/25. During an interview on 6/10/25 at 1:40 p.m., family member (FM)-A stated the facility was unable to provide the neurological care her mother needed after her stroke. She stated a few months ago the facility started to look for a new placement to deal with her neurological conditions and behaviors. The facility would call her and her brother when R2 refused care. She said the facility had tried alternative approaches to resolve her behaviors including alternative communication devices. Their efforts have only escalated the behaviors and the reason they wanted her transfer to a different facility better suited for stroke patients. She denied telling the facility not to schedule the one month follow up psychologist and wanted her mother's medication reviewed. Her mother never wants the lights on in the room. During an interview on 6/11/25 at 1:04 p.m., director of nursing (DON) stated R2 had resided at the facility for a while and had a history of refusing cares, brushing her hair, and bathing. Some staff has better luck getting her to agree to cares. They try to have consistent staffing for her. In the last few weeks if she refused to let the NA help her, the nurse would reapproach. She felt that they are moving in the right direction and the floor manager checks on her often. She stated they did not set up the initial follow up appointment with the psychologist because the family indicated they wanted to hold off until they found alternative placement. Care Planning Policy dated 11/24, indicated each resident had a person-centered care plan developed by all team members to identify medical, physical, psychosocial, and functional needs. Nursing staff we will review patient rights, identify problem areas, and develop interventions specific and meaningful to the patient. Dementia Training not dated involved care for dementia patients, abuse and neglect topics associated with dementia. Interventions include identifying environmental factors and analyze the behaviors. Challenging behaviors involve identifying common triggers, develop strategies to minimize the behaviors associated with dementia including communication techniques, and recognize caregiver stress.

Based on interviews and document review the facility failed to accurately document a resident's verbal and physical abuse towards staff, and rejection of cares for 1 of 3 residents (R2) reviewed when the Minimum Data Set (MDS) indicated the resident did not have any behaviors or rejection of cares during an evaluation period over seven days. The nursing progress notes for the same period documented daily rejections of care and yelling at staff when they tried to provide hygiene and incontinent care. Findings include: R2's nursing progress notes during the evaluation period dated from 2/27/25 through 3/6/25, indicated she refused the following: medication, walk, brush her hair, change soiled clothing, and bed linen, shower, and housekeeping services. R2's annual MDS dated [DATE], indicated she had moderate impaired cognition and dementia. She was unable to move the right side of her body or communicate her thoughts and feelings after a stroke leading to worsening anxiety and depression. She required staff assistance to dress, shower, brush her hair, and provide incontinent care. There were no incidents of verbal or physical abuse towards staff or refusing care during the seven-day evaluation period. Her evaluation identified care areas of concern for cognitive impairment, communication, activities of daily living, psychosocial wellbeing, falls, nutrition, and psychotropic medication use. During an interview on 6/10/25 at 2:13 p.m., social worker (SW)-A stated anytime a patient shows behaviors such as rejecting care, verbally and physically abusive towards staff should be documented in the MDS to receive full reimbursement for the services provided. Requested policy how to complete an MDS, it was not provided.

Based on interview and document review, the facility failed to clarify medication orders for 1 of 3 residents (R3) reviewed for medication errors. Findings include: R3's undated Face Sheet indicated diagnoses of malignant neoplasm of prostate (prostate cancer), permanent atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the heart), and diabetes. R3's Medicare Part A Discharge Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, and had diagnoses of cancer, end stage renal disease (ESRD), and diabetes. R1 received anticoagulants (blood thinners). R3's progress note dated 3/29/25 at 2:11 a.m., indicated R3 was sent to the emergency department (ED) via ambulance for gross hematuria. R3's progress note dated 3/29/25 at 11:36 a.m., indicated R3 returned to facility around 9:40 a.m. R3 was tired and if there was blood in his urine, to give it a few hours and push water to try to flush his bladder. If urine was to remain significantly bloody or if he developed large clots or had difficulty urinating, R3 was to return to the ED. There were no changes in his medication. R3's hospital After Visit Summary (AVS) dated 3/29/25, directed R3 to follow up with his primary care provider (PCP) and urologist. R3 was to stop taking his blood thinner as instructed, and if he developed further blood in his urine, to wait a few hours and drink lots of water to try to flush his bladder on his own. If his urine remained significantly bloody or he develop large clots or difficulty urinating, he was to return to the ED. R3's medication administration records (MAR) dated March and April 2025 indicated from March 29 through April 8, R1 received rivaroxaban (Xarelto, a blood thinner), daily for 11 days after it was instructed to be held. R3's ED Visit Record dated 3/29/25, indicated R3 was seen in the ED for blood in urine. R3 had history of bladder cancer. R3 was in the hospital for gross hematuria from 3/23/35 through 3/28/25, was treated with continuouss bladder irrigation (CBI) and received a blood transfusion. R3 returned to the ED for gross hematuria once again, and was passing clots. R3 was discontinued off of his anticoagulation upon discharge yesterday. R3's Physician Visit dated 4/2/25, indicated R3 was seen for post-hospital follow up. R3 occasionally had some blood in his urine, but it was not consistent. Per R3's physician's assessment and plan for atrial fibrillation, R3 was on Xarelto 15 milligrams (mg) daily by mouth. R3 was to follow with urology for his hematuria. Medications reviewed at this visit listed rivaroxaban 15 mg by mouth for atrial fibrillation as active. R3's AVS dated 4/9/25, indicated for R3 to hold/pause his rivaroxaban 15 mg until 4/11/25. R3's Provider Visit dated 4/23/25, indicated medications reviewed at this visit were rivaroxaban 15 mg daily, but not taking reported 4/22/25: however, the order remained active. Per physician's assessment and plan for hematuria, continue to follow urology related to metastatic prostate cancer. R3's treatment administration record (TAR) dated March and April 2025 indicated a treatment was entered to monitor R2's urine each shift for blood and clots. R3's March 2025 TAR reviewed from March 29 evening shift through March 31, 2025, indicated 2 out of 8 shifts with blood in his urine. April 2025 TAR indicated from April 1, 2025 to April 9, 2025, R3 had 11 shift out of 25 shifts with blood in his urine. During an interview on 5/16/25 at 12:26 p.m., registered nurse (RN)-A stated she was the nurse working when R3 returned from the ED on 3/29/25. RN-A received a nurse-to-nurse call stating R3 was returning to facility with no medication changes. R3 returned to the facility with AVS indicating to not take blood thinners as he was instructed. RN-A stated because it was still listed as an active medication and she was told no medication changes, that meant no medication changes. She did not clarify the order because the hospital nurse said he had no medication changes and the blood thinner still listed as an active medication. During an interview on 5/16/25 at 10:19 a.m., the director of nursing (DON) stated as the AVS still contained an active order for rivaroxaban and RN-A received a nurse-to-nurse call indicating no medication changes, RN-A had put in an order to monitor R3's urine for blood and large blood clots, and to return to the ED if continued. During an interview on 5/16/25 at 1:54 p.m., medical doctor (MD)-A verified RN-A should have called back to ED to verify the rivaroxaban order. MD-A also stated the section for instructions had to be written in by the physician, and the medications are not always changed as then they are removed from the list and easily forgotten. Nursing staff are to put them on hold or pause. RN-A should have called for clarification of order, as the continued use of this medication could have led to R3's continued hematuria. The facility policy Medication and Treatment Orders dated 2/2024, directed medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on observations, interview and documents review the facility failed to ensure enhanced barrier precautions (EBP-where gown and gloves used for high contact resident care activities) was used for 2 of 2 resident (R3 and R5). Findings include: R3's Admission Minimum Data Set (MDS) dated [DATE], identified diagnoses of malignant neoplasm (cancer) of the brain with intact cognition. R3 had an unstageable area covered with slough and/or eschar (dead tissue/cells, usually black in color). During an observation and interview on 3/5/25 at 1:10 p.m., R3 was in bed and nursing assistants (NA)-R and NA-N were performing peri care for urine incontinence. Neither NA had put on a gown, but did have gloves on. NA-R and NA-H both assisted R3 by lowering her pants and then unsecured the brief. NA-R performed peri care and removed soiled brief and placed in trash can and removed her gloves. NA-R did not perform hand hygiene before putting on clean gloves and placed new brief and applied barrier cream to the buttocks. NA-R and NA-N repositioned R3 on to her left side. Both NA uniforms touched the bed and R3. NAs removed their gloves and used hand sanitizer once outside of R3's room. NA-R stated R3 was on EBP's for her wound on left upper buttock and since there were not doing a dressing change to this area, staff did not need to wear a gown. R5's Quarterly MDS dated [DATE], identified diagnoses of diabetes, osteomyelitis (infection and inflammation of the bone). R5 had a stage 4 pressure ulcer and an unstageable pressure ulcer. R5 had moderate impaired cognition. During an observation and interview on 3/6/25 at 9:34 a.m., NA-C entered R5's room without gloves or gown. At 9:37 a.m., NA-C exited R5's room removing his gloves. NA-C stated when he repositioned R5 he should have worn a gown. During an interview on 3/5/24 at 1:55 p.m., director of nursing (DON) stated it was her expectation EBP's were used when there were areas of high contact with the resident. This would include checking/changing briefs and repositioning. The facility policy on enhanced barrier precautions dated 4/1/2024, identified that EBP is required for the following: 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing.

Based on interview and observation, the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime for 19 of 19 residents (R43, R2, R5, R37, R39, R34, R16, R25, R10, R29, R7, R19, R42, R6, R31, R99, R22, R202, R4) who voiced a concern. This had the potential to affect all 51 residents who resided in the facility. Findings include: Record review for R43, R2, R5, R37, R39, R34, R16, R25, R10, R29, R7, R19, R42, R6, R31, R99, R22, R202, R4 Minimum Data Set (MDS) indicated: 1. R43's significant change MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 2. R2's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included chronic obstructive pulmonary disease (COPD). 3. R5's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included epilepsy. 4. R37's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 5. R39's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included hypertension. 6. R34's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 7. R16's admission MDS dated [DATE], indicated intact cognition and diagnosis included epilepsy. 8. R25's quarterly MDS dated [DATE], indicated moderately impaired cognition and diagnosis included COPD. 9. R10's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 10. R29's admission MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 11. R7's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 12. R19's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 13. R42's annual MDS dated [DATE], indicated intact cognition and diagnosis included hypertension. 14. R6's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 15. R31's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 16. R99's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 17. R22's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included congestive heart failure. 18. R202's quarterly MDS dated [DATE], indicated moderately impaired cognition and diagnosis included stroke. 19. R4's admission MDS dated [DATE], indicated intact cognition and diagnosis included hypertension. During an interview on 8/19/24 at 12:45 p.m., R22 stated no snacks were offered after dinner and before bedtime. R22 stated she would like coffee at that time and did not know if she asked for something if she would receive it. R22 stated she would like chips or fruit with her coffee. During an interview on 8/19/24 at 12:46 p.m., R202 stated no snacks were offered at any time, and would like staff to ask if he wanted a snack. During an interview 8/19/24 at 2:20 p.m., R99 indicated she is not offered a snack in the evening and would like to have one before bed. During an interview on 8/19/24 at 2:31 p.m., R4 stated she did not receive snacks at any time and would like to be offered a snack. On 8/20/24 at 10:37 a.m., an interview the dietary manager (DM)-A stated they have a snack bin at each nurses station and when it is empty, the nursing assistants (NA) bring it to the kitchen to be refilled. Everything is prepackaged in the bin and includes things like pretzels, animal crackers, jello and pudding. DM-A added they go through a lot of snacks. During observation and interview 8/20/24 at 10:42 a.m., a snack bin was located at both nurses stations. Each had 4 pudding containers present. NA-A indicated sometimes the kitchen staff come down and restock it and NA's will take it to the kitchen if they have time. NA-A indicated they will pass out snacks if the resident asks for one but many times residents prefer to have something out of the vending machine which the NA's go get for them. During interview on 8/20/24 at 10:48 a.m., NA-B stated if residents ask for a snack they will get it for them at the vending machine which the resident has to pay for. NA-B stated sometimes will offer snacks from the bins but many times there isn't much in the snack bin. NA-B stated sometimes dietary staff will come and fill it. NA-B has never taken the snack bin to the kitchen to be refilled. On 8/20/24 at 11:40 a.m., during interview the dietary director (DD)-B indicated snacks are provided for the residents and diabetics should be offered a snack in the evening. On interview 8/20/24 at 1:29 p.m., DD-B stated after speaking to the NA's, there are inconsistencies with all residents being offered a snack in the evenings. During interview on 8/20/24 at 11:42 a.m., the registered dietician indicated all diabetic residents at a minimum should be offered a snack in the evening. 42073 During an interview on 8/21/24 at 2:30 p.m., 16 residents attending the resident council meeting stated they were not offered a snack after the dinner meal and before bedtime. R99 stated you could get a snack if you asked, and if there were snacks available. -R5 stated they were supposed to get a snack in the afternoon and after dinner but did not. R5 stated most residents did not know there was a snack bucket at the nurse's station, but it usually consisted of only Jello cups. -All residents were individually asked, and all stated they would like a snack after supper. About half of the residents thought they could get something if they asked, and the other half did not know if they could get something if they asked. -Diabetic residents (R43, R37, R34, R10, R29, R7, R19, R6, R31, R99) stated they did not receive a snack after dinner and before bedtime. R7 stated there used to be sandwiches at the nurse's station for anyone who wanted one, but not anymore. -R5 stated the dietary manager told her there was no money in the budget for resident snacks. A facility policy on snacks was not provided by the end of the survey.

Based on observation, interview and document review, the facility failed to consistently monitor and assess a resident for potential complications related to dialysis treatment post treatment, failed to monitor fluid restrictions, failed to notify the provider of refusal of dialysis, and failure to complete dialysis treatment and monitor daily weights per order for 1 of 1 resident (R99) reviewed for dialysis. Findings include: R99's facesheet printed on 8/21/24, included diagnoses of diabetes type 2, peripheral vascular disease (slow progressive disorder of blood vessels outside the heart), end stage renal disease (kidneys no longer work to meet the needs of the body), edema (swelling) and cellulitis (bacterial skin infection) of lower limb. R22's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R99 had intact cognition, end stage renal disease (ESRD), had 2 venous/arterial ulcers present and was receiving hemodialysis (a machine filters wastes, salts and fluid from the blood). During observation and interview on 8/19/24 at 2:23 p.m., R99 returned from dialysis and was taken to her room by the transportation driver. R99 was sitting in room in her wheelchair. R99 was crying and stated it didn't go well today at dialysis and they had to stop dialysis early. R99 stated she got short of breath and her legs bothered her so she told them to stop. R99 had an oxygen concentrator in her room but she stated she no longer uses that. R99 stated she feels better now and is no longer short of breath. R99 had a dialysis port in her right upper chest, which was intact with no signs of bleeding present and dressing was intact. R99 stated sometimes the facility staff let her drink all she wants and other times they tell her she can't have any fluids. R99 had a full cup of water sitting on her bedside table. During interview with R99 from 2:23 p.m. until 3:15 p.m., no staff entered R99's room to complete post dialysis assessment. R99's plan of care dated 4/1/24, last updated 7/22/24, included R99 was at risk for complications related to dialysis secondary to diagnosis of chronic kidney disease stage 5. Attends dialysis three times weekly and has right chest port placed. Goal included resident will attend dialysis and have no uncontrolled bleeding from central line. Interventions included if resident is unable to make dialysis appointment secondary to weather, transportation issues etc update the provider, dialysis unit and responsible party for further instruction. Monitor central dialysis catheter port site for signs of bleeding every shift; dialysis per schedule Monday, Wednesday and Friday. Fluid restriction per order, 1400 ml/24 hour (720 ml days, 780 ml nights) last updated 7/3/23. A progress note dated 7/17/24 at 11:46 a.m., by RN-C indicated R99 refused dialysis treatment today and was seen by provider with new order for daily weights. A progress note dated 7/19/24 at 4:19 p.m., by LPN-B indicated R99 was seen for dialysis but terminated treatment early related to left leg falling asleep and feeling uncomfortable. Patient was educated on risks of terminating treatment early. A progress note 7/23/24 at 8:46 a.m., by LPN-C indicated R99 was transferred to the ED for chief concern of resident showing signs of toxin build up due to not finishing dialysis treatments. A progress note dated 7/23/24 at 9:29 a.m., by LPN-B indicated R99 was refusing to go to appointment and had emesis. Provider was notified and order received to send resident to emergency department (ED) for evaluation of toxin overload. R99 initially refused transfer, daughter was notified and agreed R99 should go to the ED and R99 agreed. R99 left via ambulance. A progress note dated 7/23/24 at 12:48 p.m., by LPN-B indicated order received to start 1500 ml fluid restriction. A doctor's order dated 7/23/24, included start 1500 ml fluid restriction and continue other diet orders. An After Visit Summary, dated 8/8/24, indicated R99 was hospitalized [DATE] - 8/8/24, for peripheral vascular disease with BLE wounds and chronic limb-threatening ischemia (lack of blood flow). A progress note dated 8/9/24 at 4:17 p.m., by RN-A included a communication note was sent to physician and certified nurse practitioner (CNP) regarding resident's readmission to the facility on [DATE]. Provider orders dated 8/19/24, included daily weights and call provider with weight gain of 3 lb in one day or 5 lb in 7 days one time a day, dated 8/16/24, and regular diet, regular texture, regular thin consistency dated 8/8/24. Review of progress notes for July and August did not include any further notes regarding stopping dialysis early or refusing to go to dialysis. Review of EMR indicated a weight was completed on 8/18/24 with previous weight documented 7/23/24. Review of fluid intakes for 8/6/24 through 8/21/24 included: 8/6/24 No fluid intake documented 8/7/24: No fluid intake documented 8/8/24: 220 ml fluid intake 8/9/24: No fluid intake documented 8/10/24: 240 ml fluid intake 8/11/24: 240.0 ml fluid intake 8/12/24, 8/13/24, 8/14/24 - No fluid intake documented 8/15/24: 350 ml fluid intake 8/16/24: 250 ml fluid intake 8/17/24: 225 ml fluid intake 8/18/24: 225 ml fluid intake 8/19/24, 8/20/24 no fluid intake documented. During observation and interview 8/20/24 at 8:22 a.m., R99 continued to state some staff enforce a fluid restriction and others say she can have all she wants to drink. R99 got teary eyed and stated the communication here (at facility) isn't good. During interview on 8/20/24 at 11:05 a.m., license practical nurse (LPN)-A indicated R99 used to be on a fluid restriction but doesn't think she is anymore and was unsure about daily weights. LPN-A indicated R99 has been refusing to go to dialysis at times and when she goes she stops treatment about half the way through. LPN-A indicated she would let the care coordinator for R99 know or the physician. During interview on 8/21/24 at 7:41 a.m., nursing assistant (NA)-B stated she does not believe R99 is on a fluid restriction and was unsure about daily weights. NA-B indicated if she refuses anything including dialysis she would let the nurse know. During interview on 8/21/24 at 8:27 a.m., registered nurse (RN)-B indicated R99 is not currently on a fluid restriction but is on daily weights. RN-B stated she would notify the care coordinator if R99 refuses dialysis. RN-B indicated when R99 returns from dialysis, the port should be checked and complete a set of vital signs at a minimum. During interview on 8/21/24 at 1:15 p.m., trained medication aide (TMA)-A indicated R99 is on daily weights and are done right away in the mornings. TMA-A confirmed there was no weight documented for this morning and other dates were missing also. TMA-A stated R99 isn't on a fluid restriction anymore and when asked if there was an order to stop, TMA-A stated she can't see the orders but it isn't on her list of things to document on. TMA-A indicated the nurse would be responsible for any post-dialysis care when R99 returns. During interview 8/21/24 at 10:20 a.m., nurse practitioner (NP)-B stated if weights are ordered they should be completed and expects fluid restrictions to be followed. NP-B stated staff should let her know when R99 refuses dialysis. NP-B indicated she was notified recently (unable to state the date) that she refused to go to dialysis and upon asking questions found out she had refused three times in a row but had not been notified with the other two refusals. NP-B expected staff would follow the facility protocols for assessments upon return from dialysis. During interview 8/21/24 at 1:51 p.m., licensed practical nurse (LPN)-B, also identified as care coordinator, indicated R99 is on a daily weights but sometimes refuses. LPN-B indicated R99 has also been refusing to go to dialysis. LPN-B indicated she would expect vital signs and dialysis port to be assessed at a minimum upon return from dialysis especially if R99 had shortness of breath or any other complication during dialysis. LPN-B indicated staff do let her know when R99 refuses to go to dialysis and she notifies the provider. LPN-B reviewed the EMR and confirmed there was no progress note indicating provider notification for dialysis refusal or stopping dialysis early and was unable to find when dialysis was refused or terminated early in the EMR. LPN-B indicated staff should be documenting weights and if refusing they should document that also. LPN-B confirmed a nurse should have checked on and completed an assessment on R99 upon return from dialysis on 8/19/24 if she had complaints of shortness of breath and leg pain during dialysis. LPN-B stated the initial order for fluid restriction was received the date R99 went to the hospital from the nephrologist (kidney specialty doctor). LPN-B confirmed the care plan did include the fluid restriction but that when hospitalized the order was discontinued and should have been followed up on with the nephrologist. During interview on 8/21/24 at 2:18 p.m., the director of nursing (DON) indicated she would expect vital signs to be completed if R99 complained of shortness of breath during her dialysis upon return. The DON stated she would expect staff to contact the provider if R99 refuses dialysis or stops dialysis during treatment especially because of her full code status. The DON stated when R99 was hospitalized , the fluid restriction was not reordered from the hospital upon discharge but would expect if on care plan, staff to follow-up with a provider who initially ordered it. The DON confirmed daily weights should be completed as ordered also. On 8/21/24 at 3:10 p.m., LPN-B provided progress notes that included weight refusal on 8/16/24 and 8/17/24. The facility Hemodialysis policy dated 11/22/19, included: - The facility will ensure that residents who require dialysis, receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. - Resident will be monitored for complications before and after dialysis treatment. - Ongoing assessment/evaluation of the resident's condition and monitoring for complications should occur before and after dialysis treatments. -The resident's representative, if applicable, primary provider and dialysis coordinator/nephrologist, will be kept informed of any change in the resident's status or observations of potential complications. - Canceling or postponing dialysis: The nephrologist/dialysis team, resident's primary provider and resident representative must be notified of the canceled or postponed dialysis treatment. - The resident's condition will be monitored closely for changes, such as fluid gain, changes in vital signs, respiratory issues, changes in lab results and any other complications that may occur until dialysis can be rescheduled. - The resident's psychosocial status should be evaluated with further services and interventions provided as needed. - Initiate the refusal of care/risk and benefit procedure if applicable. - Residents plan of care will be modified accordingly. - Documentation: Documentation should include but is not limited to pre and post dialysis assessment/observation, daily check of the access site, evaluation for signs and symptoms of infection and fluid intake amounts for each shift with a 24 hour total if a fluid restriction is in place. If dialysis is missed or canceled, documentation should include, but is not limited to, notifications made, response to missing dialysis, medical management required, completion of the risk and benefit procedure if indicated, interventions to manage psychosocial wellbeing, and any other pertinent information that should be included in the resident's medical record.

Based on observation, interview, and document review the facility failed to label insulin pens with opened and expiration dates for 3 of 3 residents (R10, R253, and R24). Further, the facility failed to label an insulin pen with clear, concise, and viewable resident identification for 1 of 1 resident (R10). Finally, the facility failed to dispose of expired eye drop medication for 1 of 1 resident (R4). Findings include: On 8/20/24 at 1:14 p.m., observation of medication storage with licensed practical nurse (LPN)-A, identified insulin pens for (R10, R253, and R24) were not labeled with the opened and expiration dates. Each insulin pen included the label to document the opened and expiration dates, however, it was left blank. During the same observation, a Novolog insulin pen for R10 was not labeled with clear, concise, and viewable resident information. The only resident identifier noted on the R10's Novolog insulin pen was a handwritten resident room number in permanent marker. Prednisolone-Bromfenac Ophthalmic Suspension 1-0.0075% eye drops for R4 was observed to not be discarded on the expiration date of 8/18/24 . The medication administration record (MAR) printed on 8/20/24 at 2:04 p.m. indicated R4 received the medication after it expired. On 8/20/24 at 1:14 p.m., an interview with LPN-A stated the insulin pens are typically used before it's expired but should have been labeled with the opened and expiration dates. LPN- A stated that medications also need to be labeled with resident information, not just a room number. LPN-A acknowledged the potential for a medication error and/or compromised resident safety. On 8/20/24 at 3:37 p.m., an interview with the director of nursing (DON) stated that insulin pens need to be labeled with resident information, opened date, and expiration date. DON also stated that anytime eyedrops are opened, it must be dated. If eye drop medications come from the pharmacy, they will be in a separate bag with an expiration date and if the expiration date is missing, the eye drops are to be discarded on day 28 after opening or per facility policy. The facility Medication Storage in the Facility-Pharmacy Services for Nursing Facilities policy revised January 2018, indicated drugs dispensed in the manufacture's original container will carry the manufacturer's expiration date. Once opened, these will be good until the manufacturer's date is reached unless the medication is in a multi-dose injectable vial, an ophthalmic medication, or an item for which the manufacturer has specified a usable life after opening. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Review of the facility policy, Preparation and General Guidelines-Pharmacy Services for Nursing Facilities revised January 2019, indicated five resident rights: right resident, right drug, right dose, right route, and right time are applied for each medication being administered. Triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away. Further, the policy indicated once the medication is selected, check the label, container, and contents for integrity then it's compared against the MAR by reviewing the five rights.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R15) reviewed for behavioral and emotional status was provided supervision and monitoring to ensure safety after making statements of self-harm and being observed to have suicidal intent. R15 left the facility to go into the community unsupervised even after staff had determined she needed to have frequent visual checks. This resulted in an immediate jeopardy (IJ), due to the risk of serious harm and/or death for R15 and for 5 of 47 (R29, R18, R47, R35, R31) current residents who had known history of expressions of self-harm, or active thoughts of being better off dead. The immediate jeopardy began on 1/26/18, when R15 had been observed with an elastic theraband (an elastic band used for therapy) around her neck with intent for self-harm, and was identified on 3/9/18. The administrator and regional administrator were notified of the immediate jeopardy at 11:10 a.m. on 3/9/18. The immediacy was removed on 3/10/18, however, noncompliance remained at the lower scope and severity level of E, no actual harm with potential for serious harm, death or injury for multiple residents. Findings include: R15's current face sheet dated 3/12/18, identified [DIAGNOSES REDACTED]. The face sheet also identified R15 as being her own responsible party. R15's quarterly Minimum Data Set (MDS) assessment, dated 1/30/18 identified R15 had a patient health questionnaire (PHQ)-9 severity score of 16, moderately severe depression. The MDS indicated R15 had thoughts about being dead 2-6 days during the look back period, and reported feeling down and hopeless nearly daily. The MDS identified R15's medical provider had been notified of her thoughts of self-harm. R15's care plan, dated 2/16/18 identified R15 had thoughts of self-harm related to pain, and that R15 had been found by the Ombudsman to have a rubber band (theraband) around her neck and had expressed wanting to harm herself. The care plan further indicated it had been determined R15 was to have every 15 minute safety checks, and should be discouraged from leaving the facility if she was displaying an unhealthy mental state such as making comments of self harm, or appearing to be in manic or depressed state. In addition, the care plan identified R15 as a vulnerable adult due to dependencies. R15's Suicide Prevention Evaluation dated 1/26/18 at 11:59 a.m. identified: Ombudsman reported to writer he'd entered the resident's room to find her with a rubber band (theraband) around her neck. The report further indicated, Resident states she has thought about cutting herself or wrapping something around her neck just like her brother did. Signs of depression included tearfulness, hopelessness, and thoughts of self-harm. A section entitled Do you think of harming or killing yourself?, indicated R15 had stated, Yes, I thought a lot about it yesterday, I think about cutting myself here (pointing to her wrists and thighs) and wrapping that (theraband) around my neck. The evaluation further indicated R15's room had been searched for potential dangers and two rubber bands (therabands), a call light cord, a phone charger, headphones, scissors, two razors and a metal nail file had been removed at that time. A summary section entitled Interventions and Plan Implemented, indicated a message was left by facility staff for R15's medical provider, and that every 15 minute checks would be initiated for R15's safety. R15 had also agreed to leave her room door open. The evaluation note further indicated R15 had a Bible at her bedside and had reported her faith was important to her. A nursing progress note from 12:45 p.m. on 1/26/18, indicated a suicide prevention evaluation had been conducted. The note further indicated R15 had reported her mother may have passed away recently, and had requested staff assistance to verify this information. The note also indicated R15 would be monitored with every 15 minute checks to ensure her safety, that R15 had agreed to leave the door to her room open, and that her room had been searched for dangerous objects. A nursing progress note from 2:10 p.m. on 1/26/18, included: Resident was noted to be leaving facility with hat and coat on. Writer checked in with resident to see how she was feeling after suicide statements/actions made earlier in day. Resident was smiling and states 'I'm feeling much better, I'm headed to the mall to see my friend at (name of local business).' Writer responded to resident's question then informed resident to check back in with the nurse when she returns and 15 minute checks will continue through the weekend until her follow-up with psychiatry on Monday. Resident states, 'I am doing everything you want me to, I am fine, I better go or I will miss my bus' and left the facility in a happy demeanor. A nursing progress note from 2:20 p.m. on 1/26/18 indicated a call from R15's physician's assistant (PA)-A had been received, and that PA-A was okay with the facility's current suicide prevention plan noted per the suicide prevention form. The note indicated a message had been left for R15's psychiatric provider, that PA-A would let the facility know of any changes to the plan of care, and that R15 was to follow up with psychiatry the following Monday. There were no further nursing progress notes documented for 1/26/18. Review of an untitled form used to track when residents signed themselves out of the facility, indicated R15 had signed herself out on 1/26/18 at 2:10 p.m. and had not returned until 7:30 p.m. that same day. Review of R15's 15-minute safety check flowsheets confirmed she was out of the building from 2:00 to 7:30 p.m., and was noted to be sleeping during the overnight shift. A Deer Oaks Clinician Note (behavioral health organization that offered the facility on-site psychological services), dated 1/26/18 at 5:27 p.m., included: I had checked at (R15's) room several times in the afternoon and evening, but she was out so coule (sic) not meet for therapy. I consulted with social services at the home. The clinician's note further listed [DIAGNOSES REDACTED]. The documentation did not indicate any notification of the behavioral health clinician regarding R15's attempt at suicide from earlier in the day. A Mankato Clinic Extended Care Non-Visit Note, dated 1/26/18 at 3:13 p.m., indicated PA-A had been notified of R15's suicide attempt and staff reported that they found R15 in her room with an exercise band (theraband) around her neck. The PA's note indicated staff had reported the resident appeared calm and stated she did not now have intent to harm herself, and that R15 had an appointment with psychiatry on Monday. The note further indicated PA-A had reviewed R15's suicide attempt with licensed psychiatrist (LP)-A. Further instructions included: R15 may remain at the nursing home with current 15 minute safety checks and precautions as staff have begun, and to refer R15 to the emergency department if she made further expressions of self-harm. The note did not indicate whether PA-A was aware R15 had left the facility later in the afternoon, nor if this information had been reported to psychiatry. The report was noted as being received at the facility on 1/27/18, a day later. Further review of R15's progress notes, medical provider notes, facility sign-out sheets and safety check flowsheets indicated: 1/27/18, at 2:44 p.m. - R15 stated she was upset with a staff member as she had been accused of doing cocaine while at the facility. R15 stated the staff member had seen dry wall powder from the blinds on her windowsill. In addition, the note indicated R15 was going to catch a 2:00 p.m. bus from the facility. On 1/28/18, at 12:37 a.m., an overnight shift nursing staff member documented R15 had not returned to the facility until 11:50 p.m., and went directly to her room to watch a movie. Review of the 15-minute safety check documentation, dated 1/27/18, confirmed R15 left the facility at 2:00 p.m. and did not return until almost midnight. 1/28/18 - at 5:38 a.m. - Staff continued 15 minute checks throughout the overnight shift, R15 had watched a movie and was sleeping at 12:45 a.m. No other notes were documented for 1/28/18. Review of the 15 minute safety checks for 1/28/18 indicated R15 was watching television or out of her room between 7:45 a.m. and 3:00 p.m., however, review of the facility sign-out sheet revealed she was out of the building with a friend from 7:45 a.m. until 2:45 p.m. 1/29/18 - at 10:45 a.m., - R15 returned from appointment at psychiatry. No changes in orders. Continue 15 minute checks until crisis situation is over. A subsequent nursing note, documented at 3:39 p.m. identified, Writer called the resident assigned telephone number because the resident frequently travels outside of the facility, but is supposed to be on 15 minute checks for suicide watch. Writer also asked if the resident was coming back for supper. Resident stated she thought she would, but if not the kitchen is to save her a grilled cheese sandwich and ham soup. No other notes were documented for 1/29/18. Review of the facility sign out sheet, dated 1/29/18 did not reveal R15 left the facility, however, the 15 minute safety check flowsheets indicated R15 was out of the facility from 8:30 a.m. to 10:15 a.m. for an appointment, as well as out of the facility from 2:45 p.m. until 4:15 p.m. A Laurels Peak Referral Sheet, dated 1/29/18 from her Mankato Clinic - Psychiatry appointment did not include any report to psychiatry in the section to be completed by the facility. The section to be completed by the physician indicated, Worked on Safety Plan. Continue 15 minute checks until crisis situation is over; Check with pt. (patient) about safety every shift; if expressing suicidal plan/intent, call 911 or send to ER. The referral was signed by licensed psychologist (LP)-A. 1/30/18 - at 11:50 a.m. - A social services note documented they met with R15 to complete an MDS assessment. R15 reported, I am unhappy all the time, and stated My mom is dying and I want her to forgive me for what I have done. R15 stated she had thoughts of hurting herself, and the note indicated she had been on suicide watch. The note indicated social services asked R15 if they could assist with calling a local housing development for an application for housing for R15, however, did not further address her thoughts of self-harm, nor whether or not support had been provided for R15 to contact her mother or a clergy member. At 3:54 p.m., a note documented R15 had visited with activities and was asking how long she should stay in the facility. No further progress notes were documented for 1/30/18. Review of the facility sign out sheet, dated 1/30/18 indicated she was out of the facility from 1:35 p.m. to 6:25 p.m., which was also reflected on R15's 15 minute check flowsheets. A Mankato Clinic Extended Care Non-visit Note, authored by PA-A, dated 1/30/18 at 9:11 a.m., indicated R15 had a recent suicide attempt and was found wrapping exercise band around her neck. Nursing home staff had continued to take safety precautions as R15 allowed. The note indicated PA-A had been informed R15 had not made any further statements of self harm, however, R15 was continuing to leave the building for extended periods of time, telling staff she had appointments to go to which turned out to be invalid when staff checked up on them. A Mankato Clinic Extended Care Non-Visit Note, dated 1/31/18, at 6:18 a.m. from PA-A indicated that after reviewing R15's status with LP-A, nursing home staff were to monitor R15 closely, R15 was to be discouraged from leaving the facility due to recent statements and actions indicating suicidal intent. Staff were to monitor R15 closely and contact emergency services if she appeared to plan to leave with unstable mental status. 1/31/18 - at 9:37 a.m. - Progress note indicated a fax was received from PA-A to discourage R15 from leaving the facility due to recent statements and actions including suicidal intent, to monitor R15 closely and contact emergency services if she appears to leave in unstable medical status, and indicated, Resident did leave facility at 9:00 this morning. The note indicated R15 had stated the provider was silly and, should have thought about that a long time ago. R15's provider was to be updated on R15's status. At 2:09 p.m., a nursing progress note indicated R15 had been out of the building from 8:45 a.m. to 11:15 a.m., and at 6:35 p.m., another note indicated R15 was out of the facility at 2:00 p.m. when evening shift came on duty, R15 came back briefly but left again at 3:00 p.m. Review of the facility sign out sheet indicated R15 signed out of the facility at 2:25 p.m., and returned at 11:00 p.m. Review of the 15 minute safety check form, dated 1/31/18 identified R15 was out of the facility from 8:45 a.m. until 11:15 a.m., left again at 2:45 p.m. and did not return until after 11:00 p.m. 2/1/18 - at 8:44 a.m. - R15 left the facility to go to(NAME)restaurant. No further notes were documented, until 7:16 p.m. indicating R15 had returned to facility and was walking independently with her cane, and had not voiced any concerns. Review of the facility sign-out sheet for 2/1/18 revealed R15 had not signed herself out. R15's 15 minute safety check forms confirmed she was out from 9:00 a.m. until 7:15 p.m. No other documentation related to R15's status or mood was recorded. 2/2/18 - at 5:54 p.m. - A note was entered indicating R15 returned to the facility at 4:55 p.m. No other nursing notes were documented, the 15 minute safety check sheets indicated R15 was out from 9:00 a.m. until 4:55 p.m. Facility sign out sheets for 2/2/18 revealed R15 signed out at 9:00 a.m. and returned at 5:00 p.m. 2/3/18 - at 4:59 p.m. - Nursing notes indicated R15 returned from an outing smelling heavily of marijuana, the current administrator was notified, who stated they would come to the facility. At 5:25 p.m., a nursing note authored by the administrator in charge at the time, (RA)-A indicated, This writer was notified that resident was under the influence and had illegal substance upon returning from outing. This writer and LPN (licensed practical nurse, name) asked resident to enter room. Resident agreed. This writer and LPN informed resident of report and asked for permission to perform room search. Resident agreed and present during room search. Resident denies being under the influence. Resident denies having any illegal substance. 2 items removed from resident room: 1 oil pill bottle with needle in cap and purple medication box with various white pills (vitamins according to resident). Informed resident of removing two items and placing in medication cart. (MONTH) take with resident upon return. No illegal substance items found during room search. Writer and LPN left resident room and locked items in medication cart. The facility sign out sheets, dated 2/3/18 indicated R15 signed herself out from 10:00 a.m. to 5:00 p.m., no 15 minute safety check documentation for the dates of 2/3/18 were present in the medical record. A nursing note entry at 6:00 p.m. on 2/3/18 indicated R15 again left the facility, but did not indicate when she returned or where she was going. 2/4/18 - No nursing progress notes were on file. The facility sign out sheet indicated R15 was out between 12:30 p.m. and 6:30 p.m. No 15 minute safety checks were completed. 2/5/18 - Nursing progress notes indicated resident returned to the facility at 5:20 p.m., left the facility at 7:18 p.m., then returned at 11:55 p.m. No other notes documented. Review of the facility sign out sheet for 2/5/18 indicated R15 signed out from 7:35 a.m. to 5:00 p.m. No 15 minute safety checks were documented. 2/6/18 - Nursing progress notes at 5:55 a.m. indicated R15 had been given a sleeping pill and rested an average of 7-8 hours per night. No further notes were documented. Facility sign out sheets for 2/6/18 indicated R15 was out of the facility from 11:35 a.m. to 11:29 p.m. No 15 minute safety checks were documented. A Mankato Clinic Extended Care Note, dated 2/6/18 at 8:30 a.m. by PA-A indicated R15 was being seen for a referral due to history of substance abuse. The note further indicated R15 had a history of [REDACTED]. The note indicated that R15 had been noted returning to the facility smelling heavily of marijuana with another nursing home resident, law enforcement was contacted and took the other resident into custody, however, by the time they got there R15 was already out of the facility. R15 was noted to have several unidentified pills which she reported were vitamins. The note further indicated the R15 had a failed suicide attempt and now reports no intent of self harm, but mood, very labile and she continues to arrange transportation or takes the bus on outings from the facility. R15 reported she was upset someone could be arrested for smoking marijuana at the nursing home, and asked to be discharged from the facility. Review of the nursing progress notes indicated R15 subsequently discharged from the facility on 2/9/18 to a friend's home. Review of the facility's Suicide Prevention Assessments revealed five other residents currently in the facility, with history of suicidal statements or expressions of being better off dead: R35 had a Suicide Prevention Evaluation dated 8/29/17, which indicated he had thoughts of self-charm, indicating a plan of I could go next door and start the place of fire and not care if anyone got hurt. R31 had a Suicide Prevention Evaluation dated 6/2/17, which indicated, If someone would give me a gun I'd shoot myself, I could get to the street and get hit by truck but that would be hard because I can't wheel myself. R47 had a Suicide Prevention Evaluation dated 12/27/17, indicated he had thoughts of killing himself if he ever returned to home. R29 had a Suicide Prevention Evaluation dated 2/23/17, which indicated she had thoughts of hurting herself every night, while lying in bed. R18 had a Suicide Prevention Evaluation dated 5/22/17, which indicated she felt she'd be better off dead, however, did not have current plans to harm herself. During interview on 3/8/18, at 2:50 p.m., R15's registered nurse manager (NM)-A stated she had completed R15's Suicide Prevention Evaluation on 1/26/18, after the Ombudsman had reported he had seen R15 with an exercise band around her neck. NM-A stated she called PA-A to report the suicide attempt and searched R15's room, removing several belongings deemed to be dangerous to her at the time. NM-A stated she did not have any other residents currently on suicide watch, however R35 did have suicidal tendencies a month or so ago. NM-A stated R15 was her own decision maker, so she had not notified law enforcement or called 911 when she left the faciity on [DATE], as she felt it was the resident's right to leave the building. The interim director of nursing (DON) was present during the interview and did not indicate anyone else was on suicide precautions currently. During interview about R15's suicide attempt on 1/26/18 and the follow-up care provided by facility staff the regional administrator (RA)-A verified she was the administrator of record at the time of the incident, and had limited experience with R15. RA-A had thought R15 was on 15 minute checks after the suicide attempt, but stated social worker (SW)-A would know the most about her care. RA-A recalled searching R15's room for illegal drugs at one time, finding a bottle of oil capsules with a needle in it and some other pills in R15's room which were thought to be vitamins. RA-A encouraged staff to get an order for [REDACTED]. recently been employed by the facility. During interview on 3/8/18, at 3:08 p.m. SW-A stated she was aware of R15's suicide attempt on 1/26/18, and had R15 being followed by Deer Oaks psychological services in house. SW-A stated she didn't interact much with R15 unless R15 brought a concern to her attention, and thought R15 was on every 15 minute checks for safety after the suicide attempt however, was noncompliant with them. SW-A stated R15 had since discharged to a friend's home and that she had tried setting up follow up psychiatry care for her after discharge, but had not been able to get her an appointment due to a long waiting list. SW-A also did not recall the facility providing any further intervention for R15's suicidal statements. During interview on 3/9/18, at 9:04 a.m. LP-A stated she was unaware R15 had left the facility several hours after she had attempted suicide on 1/26/18, and stated it was especially concerning, that would be a pretty big concern, and would have recommended facility staff call 911 or ask for inpatient psychiatric admission at that time. LP-A could not recall being notified by PA-A that R15 was leaving the building on 1/26/18, and further stated if R15 was abusing chemical substances it would increase her risk of self-harm. During further interview with SW-A on 3/9/18, at 10:25 a.m., SW-A stated she was out of the building for lunch at the time R15 had attempted suicide. Staff told her about it after she got back, however, she could not recall ever communicating with Deer Oaks psychological services about the incident. A call was placed to R15's Deer Oaks provider at this time, however, a phone call was not returned during the survey. During interview on 3/9/18, at 10:40 a.m. the interim DON stated she was unsure who had been in charge of the nursing department on 1/26/18. The interim DON further stated, We cannot stop people from leaving (the building), we called the physician (has actually contacted the PA). During interview on 3/9/18, at 1:00 p.m., PA-A stated she did not consider inpatient psychiatric hospital admission for R15 on 1/26/18 when she was notified of R15's suicide attempt, as she thought the situation had been diffused, the resident was no longer suicidal and was her own decision maker. She stated she would expect the facility to follow their internal procedures for caring for a suicidal resident, and stated she did not know R15 left the facility shortly after her suicide attempt on 1/26/18, however found out about it at a later date, on nursing home rounds at some point. During interview on 3/12/18 at 10:56 a.m., the Ombudsman stated he had entered R15's room and had seen her with an exercise band (theraband) tied around her neck on 1/26/18, and stated R15 was pulling it tight when he entered the room. The Ombudsman stated R15 had expressed thoughts of self harm so he reported these concerns to nursing. The Ombudsman expressed surprise stating, wow and further verified he was not aware R15 had gone out of the building on an outing just a couple of hours after the suicide attempt. He stated he did not feel the outing was appropriate given R15's recent self harm actions. Attempts to reach R15's physician for interview on 3/9 and 3/12/18, were unsuccessful. No return call was received. The facility policy Suicide Prevention dated 11/2010, indicated resident's at risk after an assessment for suicide were to have their rooms searched for potential dangers, the physician was to be contacted for further medical evaluation, and referral to a counselor or psychiatric practitioner, if necessary, obtain physician's orders [REDACTED]. The IJ that began on 1/26/18 was removed on 3/10/18, when it could be verified the facility had conducted updated depression screens on all residents identified to be at risk, had revised their protocols for suicidal ideation concerns, and had implemented education for all staff. The facility's revised policy indicated that staff were not to allow residents on suicide precautions/monitoring to leave the facility, and indicated staff were to call 911 for crisis intervention if the resident was insistent on leaving.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R15) reviewed for behavioral and emotional status was provided supervision and monitoring to ensure safety after making statements of self-harm and being observed to have suicidal intent. R15 left the facility to go into the community unsupervised even after staff had determined she needed to have frequent visual checks. This resulted in an immediate jeopardy (IJ), due to the risk of serious harm and/or death for R15 and for 5 of 47 (R29, R18, R47, R35, R31) current residents who had known history of expressions of self-harm, or active thoughts of being better off dead. The immediate jeopardy began on 1/26/18, when R15 had been observed with an elastic theraband (an elastic band used for therapy) around her neck with intent for self-harm, and was identified on 3/9/18. The administrator and regional administrator were notified of the immediate jeopardy at 11:10 a.m. on 3/9/18. The immediacy was removed on 3/10/18, however, noncompliance remained at the lower scope and severity level of E, no actual harm with potential for serious harm, death or injury for multiple residents. Findings include: R15's current face sheet dated 3/12/18, identified [DIAGNOSES REDACTED]. The face sheet also identified R15 as being her own responsible party. R15's quarterly Minimum Data Set (MDS) assessment, dated 1/30/18 identified R15 had a patient health questionnaire (PHQ)-9 severity score of 16, moderately severe depression. The MDS indicated R15 had thoughts about being dead 2-6 days during the look back period, and reported feeling down and hopeless nearly daily. The MDS identified R15's medical provider had been notified of her thoughts of self-harm. R15's care plan, dated 2/16/18 identified R15 had thoughts of self-harm related to pain, and that R15 had been found by the Ombudsman to have a rubber band (theraband) around her neck and had expressed wanting to harm herself. The care plan further indicated it had been determined R15 was to have every 15 minute safety checks, and should be discouraged from leaving the facility if she was displaying an unhealthy mental state such as making comments of self harm, or appearing to be in manic or depressed state. In addition, the care plan identified R15 as a vulnerable adult due to dependencies. R15's Suicide Prevention Evaluation dated 1/26/18 at 11:59 a.m. identified: Ombudsman reported to writer he'd entered the resident's room to find her with a rubber band (theraband) around her neck. The report further indicated, Resident states she has thought about cutting herself or wrapping something around her neck just like her brother did. Signs of depression included tearfulness, hopelessness, and thoughts of self-harm. A section entitled Do you think of harming or killing yourself?, indicated R15 had stated, Yes, I thought a lot about it yesterday, I think about cutting myself here (pointing to her wrists and thighs) and wrapping that (theraband) around my neck. The evaluation further indicated R15's room had been searched for potential dangers and two rubber bands (therabands), a call light cord, a phone charger, headphones, scissors, two razors and a metal nail file had been removed at that time. A summary section entitled Interventions and Plan Implemented, indicated a message was left by facility staff for R15's medical provider, and that every 15 minute checks would be initiated for R15's safety. R15 had also agreed to leave her room door open. The evaluation note further indicated R15 had a Bible at her bedside and had reported her faith was important to her. A nursing progress note from 12:45 p.m. on 1/26/18, indicated a suicide prevention evaluation had been conducted. The note further indicated R15 had reported her mother may have passed away recently, and had requested staff assistance to verify this information. The note also indicated R15 would be monitored with every 15 minute checks to ensure her safety, that R15 had agreed to leave the door to her room open, and that her room had been searched for dangerous objects. A nursing progress note from 2:10 p.m. on 1/26/18, included: Resident was noted to be leaving facility with hat and coat on. Writer checked in with resident to see how she was feeling after suicide statements/actions made earlier in day. Resident was smiling and states 'I'm feeling much better, I'm headed to the mall to see my friend at (name of local business).' Writer responded to resident's question then informed resident to check back in with the nurse when she returns and 15 minute checks will continue through the weekend until her follow-up with psychiatry on Monday. Resident states, 'I am doing everything you want me to, I am fine, I better go or I will miss my bus' and left the facility in a happy demeanor. A nursing progress note from 2:20 p.m. on 1/26/18 indicated a call from R15's physician's assistant (PA)-A had been received, and that PA-A was okay with the facility's current suicide prevention plan noted per the suicide prevention form. The note indicated a message had been left for R15's psychiatric provider, that PA-A would let the facility know of any changes to the plan of care, and that R15 was to follow up with psychiatry the following Monday. There were no further nursing progress notes documented for 1/26/18. Review of an untitled form used to track when residents signed themselves out of the facility, indicated R15 had signed herself out on 1/26/18 at 2:10 p.m. and had not returned until 7:30 p.m. that same day. Review of R15's 15-minute safety check flowsheets confirmed she was out of the building from 2:00 to 7:30 p.m., and was noted to be sleeping during the overnight shift. A Deer Oaks Clinician Note (behavioral health organization that offered the facility on-site psychological services), dated 1/26/18 at 5:27 p.m., included: I had checked at (R15's) room several times in the afternoon and evening, but she was out so coule (sic) not meet for therapy. I consulted with social services at the home. The clinician's note further listed [DIAGNOSES REDACTED]. The documentation did not indicate any notification of the behavioral health clinician regarding R15's attempt at suicide from earlier in the day. A Mankato Clinic Extended Care Non-Visit Note, dated 1/26/18 at 3:13 p.m., indicated PA-A had been notified of R15's suicide attempt and staff reported that they found R15 in her room with an exercise band (theraband) around her neck. The PA's note indicated staff had reported the resident appeared calm and stated she did not now have intent to harm herself, and that R15 had an appointment with psychiatry on Monday. The note further indicated PA-A had reviewed R15's suicide attempt with licensed psychiatrist (LP)-[NAME] Further instructions included: R15 may remain at the nursing home with current 15 minute safety checks and precautions as staff have begun, and to refer R15 to the emergency department if she made further expressions of self-harm. The note did not indicate whether PA-A was aware R15 had left the facility later in the afternoon, nor if this information had been reported to psychiatry. The report was noted as being received at the facility on 1/27/18, a day later. Further review of R15's progress notes, medical provider notes, facility sign-out sheets and safety check flowsheets indicated: 1/27/18, at 2:44 p.m. - R15 stated she was upset with a staff member as she had been accused of doing cocaine while at the facility. R15 stated the staff member had seen dry wall powder from the blinds on her windowsill. In addition, the note indicated R15 was going to catch a 2:00 p.m. bus from the facility. On 1/28/18, at 12:37 a.m., an overnight shift nursing staff member documented R15 had not returned to the facility until 11:50 p.m., and went directly to her room to watch a movie. Review of the 15-minute safety check documentation, dated 1/27/18, confirmed R15 left the facility at 2:00 p.m. and did not return until almost midnight. 1/28/18 - at 5:38 a.m. - Staff continued 15 minute checks throughout the overnight shift, R15 had watched a movie and was sleeping at 12:45 a.m. No other notes were documented for 1/28/18. Review of the 15 minute safety checks for 1/28/18 indicated R15 was watching television or out of her room between 7:45 a.m. and 3:00 p.m., however, review of the facility sign-out sheet revealed she was out of the building with a friend from 7:45 a.m. until 2:45 p.m. 1/29/18 - at 10:45 a.m., - R15 returned from appointment at psychiatry. No changes in orders. Continue 15 minute checks until crisis situation is over. A subsequent nursing note, documented at 3:39 p.m. identified, Writer called the resident assigned telephone number because the resident frequently travels outside of the facility, but is supposed to be on 15 minute checks for suicide watch. Writer also asked if the resident was coming back for supper. Resident stated she thought she would, but if not the kitchen is to save her a grilled cheese sandwich and ham soup. No other notes were documented for 1/29/18. Review of the facility sign out sheet, dated 1/29/18 did not reveal R15 left the facility, however, the 15 minute safety check flowsheets indicated R15 was out of the facility from 8:30 a.m. to 10:15 a.m. for an appointment, as well as out of the facility from 2:45 p.m. until 4:15 p.m. A Laurels Peak Referral Sheet, dated 1/29/18 from her Mankato Clinic - Psychiatry appointment did not include any report to psychiatry in the section to be completed by the facility. The section to be completed by the physician indicated, Worked on Safety Plan. Continue 15 minute checks until crisis situation is over; Check with pt. (patient) about safety every shift; if expressing suicidal plan/intent, call 911 or send to ER. The referral was signed by licensed psychologist (LP)-[NAME] 1/30/18 - at 11:50 a.m. - A social services note documented they met with R15 to complete an MDS assessment. R15 reported, I am unhappy all the time, and stated My mom is dying and I want her to forgive me for what I have done. R15 stated she had thoughts of hurting herself, and the note indicated she had been on suicide watch. The note indicated social services asked R15 if they could assist with calling a local housing development for an application for housing for R15, however, did not further address her thoughts of self-harm, nor whether or not support had been provided for R15 to contact her mother or a clergy member. At 3:54 p.m., a note documented R15 had visited with activities and was asking how long she should stay in the facility. No further progress notes were documented for 1/30/18. Review of the facility sign out sheet, dated 1/30/18 indicated she was out of the facility from 1:35 p.m. to 6:25 p.m., which was also reflected on R15's 15 minute check flowsheets. A Mankato Clinic Extended Care Non-visit Note, authored by PA-A, dated 1/30/18 at 9:11 a.m., indicated R15 had a recent suicide attempt and was found wrapping exercise band around her neck. Nursing home staff had continued to take safety precautions as R15 allowed. The note indicated PA-A had been informed R15 had not made any further statements of self harm, however, R15 was continuing to leave the building for extended periods of time, telling staff she had appointments to go to which turned out to be invalid when staff checked up on them. A Mankato Clinic Extended Care Non-Visit Note, dated 1/31/18, at 6:18 a.m. from PA-A indicated that after reviewing R15's status with LP-A, nursing home staff were to monitor R15 closely, R15 was to be discouraged from leaving the facility due to recent statements and actions indicating suicidal intent. Staff were to monitor R15 closely and contact emergency services if she appeared to plan to leave with unstable mental status. 1/31/18 - at 9:37 a.m. - Progress note indicated a fax was received from PA-A to discourage R15 from leaving the facility due to recent statements and actions including suicidal intent, to monitor R15 closely and contact emergency services if she appears to leave in unstable medical status, and indicated, Resident did leave facility at 9:00 this morning. The note indicated R15 had stated the provider was silly and, should have thought about that a long time ago. R15's provider was to be updated on R15's status. At 2:09 p.m., a nursing progress note indicated R15 had been out of the building from 8:45 a.m. to 11:15 a.m., and at 6:35 p.m., another note indicated R15 was out of the facility at 2:00 p.m. when evening shift came on duty, R15 came back briefly but left again at 3:00 p.m. Review of the facility sign out sheet indicated R15 signed out of the facility at 2:25 p.m., and returned at 11:00 p.m. Review of the 15 minute safety check form, dated 1/31/18 identified R15 was out of the facility from 8:45 a.m. until 11:15 a.m., left again at 2:45 p.m. and did not return until after 11:00 p.m. 2/1/18 - at 8:44 a.m. - R15 left the facility to go to[NAME]restaurant. No further notes were documented, until 7:16 p.m. indicating R15 had returned to facility and was walking independently with her cane, and had not voiced any concerns. Review of the facility sign-out sheet for 2/1/18 revealed R15 had not signed herself out. R15's 15 minute safety check forms confirmed she was out from 9:00 a.m. until 7:15 p.m. No other documentation related to R15's status or mood was recorded. 2/2/18 - at 5:54 p.m. - A note was entered indicating R15 returned to the facility at 4:55 p.m. No other nursing notes were documented, the 15 minute safety check sheets indicated R15 was out from 9:00 a.m. until 4:55 p.m. Facility sign out sheets for 2/2/18 revealed R15 signed out at 9:00 a.m. and returned at 5:00 p.m. 2/3/18 - at 4:59 p.m. - Nursing notes indicated R15 returned from an outing smelling heavily of marijuana, the current administrator was notified, who stated they would come to the facility. At 5:25 p.m., a nursing note authored by the administrator in charge at the time, (RA)-A indicated, This writer was notified that resident was under the influence and had illegal substance upon returning from outing. This writer and LPN (licensed practical nurse, name) asked resident to enter room. Resident agreed. This writer and LPN informed resident of report and asked for permission to perform room search. Resident agreed and present during room search. Resident denies being under the influence. Resident denies having any illegal substance. 2 items removed from resident room: 1 oil pill bottle with needle in cap and purple medication box with various white pills (vitamins according to resident). Informed resident of removing two items and placing in medication cart. (MONTH) take with resident upon return. No illegal substance items found during room search. Writer and LPN left resident room and locked items in medication cart. The facility sign out sheets, dated 2/3/18 indicated R15 signed herself out from 10:00 a.m. to 5:00 p.m., no 15 minute safety check documentation for the dates of 2/3/18 were present in the medical record. A nursing note entry at 6:00 p.m. on 2/3/18 indicated R15 again left the facility, but did not indicate when she returned or where she was going. 2/4/18 - No nursing progress notes were on file. The facility sign out sheet indicated R15 was out between 12:30 p.m. and 6:30 p.m. No 15 minute safety checks were completed. 2/5/18 - Nursing progress notes indicated resident returned to the facility at 5:20 p.m., left the facility at 7:18 p.m., then returned at 11:55 p.m. No other notes documented. Review of the facility sign out sheet for 2/5/18 indicated R15 signed out from 7:35 a.m. to 5:00 p.m. No 15 minute safety checks were documented. 2/6/18 - Nursing progress notes at 5:55 a.m. indicated R15 had been given a sleeping pill and rested an average of 7-8 hours per night. No further notes were documented. Facility sign out sheets for 2/6/18 indicated R15 was out of the facility from 11:35 a.m. to 11:29 p.m. No 15 minute safety checks were documented. A Mankato Clinic Extended Care Note, dated 2/6/18 at 8:30 a.m. by PA-A indicated R15 was being seen for a referral due to history of substance abuse. The note further indicated R15 had a history of [REDACTED]. The note indicated that R15 had been noted returning to the facility smelling heavily of marijuana with another nursing home resident, law enforcement was contacted and took the other resident into custody, however, by the time they got there R15 was already out of the facility. R15 was noted to have several unidentified pills which she reported were vitamins. The note further indicated the R15 had a failed suicide attempt and now reports no intent of self harm, but mood, very labile and she continues to arrange transportation or takes the bus on outings from the facility. R15 reported she was upset someone could be arrested for smoking marijuana at the nursing home, and asked to be discharged from the facility. Review of the nursing progress notes indicated R15 subsequently discharged from the facility on 2/9/18 to a friend's home. Review of the facility's Suicide Prevention Assessments revealed five other residents currently in the facility, with history of suicidal statements or expressions of being better off dead: R35 had a Suicide Prevention Evaluation dated 8/29/17, which indicated he had thoughts of self-charm, indicating a plan of I could go next door and start the place of fire and not care if anyone got hurt. R31 had a Suicide Prevention Evaluation dated 6/2/17, which indicated, If someone would give me a gun I'd shoot myself, I could get to the street and get hit by truck but that would be hard because I can't wheel myself. R47 had a Suicide Prevention Evaluation dated 12/27/17, indicated he had thoughts of killing himself if he ever returned to home. R29 had a Suicide Prevention Evaluation dated 2/23/17, which indicated she had thoughts of hurting herself every night, while lying in bed. R18 had a Suicide Prevention Evaluation dated 5/22/17, which indicated she felt she'd be better off dead, however, did not have current plans to harm herself. During interview on 3/8/18, at 2:50 p.m., R15's registered nurse manager (NM)-A stated she had completed R15's Suicide Prevention Evaluation on 1/26/18, after the Ombudsman had reported he had seen R15 with an exercise band around her neck. NM-A stated she called PA-A to report the suicide attempt and searched R15's room, removing several belongings deemed to be dangerous to her at the time. NM-A stated she did not have any other residents currently on suicide watch, however R35 did have suicidal tendencies a month or so ago. NM-A stated R15 was her own decision maker, so she had not notified law enforcement or called 911 when she left the faciity on [DATE], as she felt it was the resident's right to leave the building. The interim director of nursing (DON) was present during the interview and did not indicate anyone else was on suicide precautions currently. During interview about R15's suicide attempt on 1/26/18 and the follow-up care provided by facility staff the regional administrator (RA)-A verified she was the administrator of record at the time of the incident, and had limited experience with R15. RA-A had thought R15 was on 15 minute checks after the suicide attempt, but stated social worker (SW)-A would know the most about her care. RA-A recalled searching R15's room for illegal drugs at one time, finding a bottle of oil capsules with a needle in it and some other pills in R15's room which were thought to be vitamins. RA-A encouraged staff to get an order for [REDACTED]. recently been employed by the facility. During interview on 3/8/18, at 3:08 p.m. SW-A stated she was aware of R15's suicide attempt on 1/26/18, and had R15 being followed by Deer Oaks psychological services in house. SW-A stated she didn't interact much with R15 unless R15 brought a concern to her attention, and thought R15 was on every 15 minute checks for safety after the suicide attempt however, was noncompliant with them. SW-A stated R15 had since discharged to a friend's home and that she had tried setting up follow up psychiatry care for her after discharge, but had not been able to get her an appointment due to a long waiting list. SW-A also did not recall the facility providing any further intervention for R15's suicidal statements. During interview on 3/9/18, at 9:04 a.m. LP-A stated she was unaware R15 had left the facility several hours after she had attempted suicide on 1/26/18, and stated it was especially concerning, that would be a pretty big concern, and would have recommended facility staff call 911 or ask for inpatient psychiatric admission at that time. LP-A could not recall being notified by PA-A that R15 was leaving the building on 1/26/18, and further stated if R15 was abusing chemical substances it would increase her risk of self-harm. During further interview with SW-A on 3/9/18, at 10:25 a.m., SW-A stated she was out of the building for lunch at the time R15 had attempted suicide. Staff told her about it after she got back, however, she could not recall ever communicating with Deer Oaks psychological services about the incident. A call was placed to R15's Deer Oaks provider at this time, however, a phone call was not returned during the survey. During interview on 3/9/18, at 10:40 a.m. the interim DON stated she was unsure who had been in charge of the nursing department on 1/26/18. The interim DON further stated, We cannot stop people from leaving (the building), we called the physician (has actually contacted the PA). During interview on 3/9/18, at 1:00 p.m., PA-A stated she did not consider inpatient psychiatric hospital admission for R15 on 1/26/18 when she was notified of R15's suicide attempt, as she thought the situation had been diffused, the resident was no longer suicidal and was her own decision maker. She stated she would expect the facility to follow their internal procedures for caring for a suicidal resident, and stated she did not know R15 left the facility shortly after her suicide attempt on 1/26/18, however found out about it at a later date, on nursing home rounds at some point. During interview on 3/12/18 at 10:56 a.m., the Ombudsman stated he had entered R15's room and had seen her with an exercise band (theraband) tied around her neck on 1/26/18, and stated R15 was pulling it tight when he entered the room. The Ombudsman stated R15 had expressed thoughts of self harm so he reported these concerns to nursing. The Ombudsman expressed surprise stating, wow and further verified he was not aware R15 had gone out of the building on an outing just a couple of hours after the suicide attempt. He stated he did not feel the outing was appropriate given R15's recent self harm actions. Attempts to reach R15's physician for interview on 3/9 and 3/12/18, were unsuccessful. No return call was received. The facility policy Suicide Prevention dated 11/2010, indicated resident's at risk after an assessment for suicide were to have their rooms searched for potential dangers, the physician was to be contacted for further medical evaluation, and referral to a counselor or psychiatric practitioner, if necessary, obtain physician's orders [REDACTED]. The IJ that began on 1/26/18 was removed on 3/10/18, when it could be verified the facility had conducted updated depression screens on all residents identified to be at risk, had revised their protocols for suicidal ideation concerns, and had implemented education for all staff. The facility's revised policy indicated that staff were not to allow residents on suicide precautions/monitoring to leave the facility, and indicated staff were to call 911 for crisis intervention if the resident was insistent on leaving.

Based on observation, interview, and document review, facility staff failed to provide adequate supervision for 1 of 4 residents reviewed (R1) when staff applied a single use disposable instant hot compress on the resident and did not follow up and check on the resident per manufacturers guidelines. This resulted in actual harm to R1 when R1 received a burn that blistered and required medical treatment. Findings include: R1's Quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 was cognitively intact, had frequent pain that limited activity, and a history of falls. R1's Braden Scale (assesses a resident's risk of developing a pressure ulcer) dated 2/8/17, indicated R1 was at potential risk for skin breakdown due to decreased mobility related to a history of falls resulting in fracture of right lower extremity and an injury to the left upper extremity. R1's careplan last revised on 1/2/17, indicated alteration in comfort related to history of fracture to the right lower extremity and complaints of shoulder pain with interventions including non medicinal forms of pain relief. R1's resident care sheet (undated) indicated R1 was to be repositioned every two hours with the assist of one. R1's toileting sheet for the evening shift on 3/23/17, indicated R1 was changed and repositioned at 10:00 a.m. and then at 3:30 p.m. The facility was unable to locate the toileting sheet for the morning shift on 3/23/17. An incident report dated 3/23/17, at 3:30 p.m. indicated nursing assistant (NA)-E informed registered nurse (RN)-C that R1 had a burn to the left scapula (shoulder). RN-C's assessment of R1 revealed the burn measured 3.5 centimeters (cm) x 2.5 cm with an open blister. The report indicated the burn was from a hot compress placed on R1's left shoulder at 9:00 a.m. The hot compress had been wrapped in a pillow case and placed under R1's nightgown. R1 had been in bed all day due to shoulder pain. A nurse practitioner's telephone order dated 3/23/17, at 4:36 p.m. instructed staff to apply Silvadene 1% cream to left rear shoulder burn and cover with gauze twice a day, and to re-evaluate in one week on 3/30/17. R1's skin audit dated 3/29/17, indicated the burn on the left scapula was healing with no signs and symptoms of infection. Continue to apply Silvadene cream treatment and cover with gauze. A nurse practitioner's progress note dated 3/30/17, described the burn as 5 cm x 3 cm area of [DIAGNOSES REDACTED] with yellow slough material in the middle. Yellow-green drainage was on the gauze pad covering the burn. A nurse practitioner's order dated 3/30/17, instructed staff to discontinue the Silvadene cream and start mepilex dressing to the burn site and change every three days and every day as needed. An interview with NA-L was conducted on 4/10/17, at 1:10 p.m. NA-L stated nursing assistants may give residents hot compresses if requested and inform the nurse it was given. NA-L stated they don't record anywhere the hot compress was given, but they record when the resident was toileted or repositioned on the toileting sheet. An interview with R1 was conducted on 4/10/17, at 1:20 p.m. R1 stated after the hot compress was applied at 9:00 a.m. no one returned to check on the compress. R1 could not remember the staff that applied the hot compress. R1 fell asleep and remained in bed until the afternoon. R1 stated initially the burn itched and then it started to sting. R1 stated the burn was no longer painful. Observation of the burn on 4/10/17, at 1:30 p.m. revealed a small pink closed area on the left shoulder. An interview with TMA-F was conducted on 4/10/17, at 2:15 p.m. TMA-F stated use of a hot compress was not documented in the medical record. An interview with RN-J was conducted on 4/10/17, at 2:30 p.m. RN-J stated there was no protocol for using hot compresses, but would expect the hot compresses would be applied for 20 minutes and then removed. RN-J also stated the NA's could give resident's hot compresses under the direction of the RN. An interview with RN-D was conducted on 4/11/17, at 9:10 a.m. RN-D stated the nursing assistants were allowed to give residents a hot compress without nurses permission. The hot compress was to be wrapped in pillowcases and applied on top of the resident's clothing. RN-D stated not all the nursing assistants would tell the nurses if they gave one to a resident. RN-D stated the use of a hot compress did not require a physician's orders [REDACTED].>An interview with RN-C was conducted on 4/12/17, at 5:00 p.m. RN-C stated on 3/23/17, at 3:30 p.m. NA-E informed RN-C that R1 had a burn on the left shoulder. RN-C assessed the burn and R1 told RN-C a hot compress wrapped in a pillowcase had been placed under R1's nightgown on the left shoulder at 9:00 a.m. RN-C stated R1 described the burn as uncomfortable. RN-C notified the nurse practitioner and received a telephone order for treatment of [REDACTED]. A hot compress was wrapped in a pillowcase or towel, and checked twenty minutes after applied on a resident. RN-C stated the nurse was responsible for assessing the effectiveness of the hot compress. An interview with NA-G was conducted on 4/19/17, at 2:40 p.m. NA-G stated nursing assistants would talk to the nurse before giving a hot compress to a resident. A hot compresses was wrapped in a pillowcase or towel and checked on 30 minutes after applied. Nursing assistants did not document the use of a hot compress. An interview with NA-H was conducted on 4/19/17, at 3:00 p.m. NA-H stated nursing assistants were suppose to tell the nurse when a resident requested a hot compress. The nurse made the decision and conducted the follow up when a hot compress was used. An interview with NA- E was conducted on 4/26/17, at 3:05 p.m. NA- E stated nursing assistants need permission from the nurse to give a resident a hot compress. NA-E stated on 3/23/17, at 3:30 p.m. NA-E answered R1's call light, and assisted R1 change clothes. While taking R1's shirt off, R1 complained of pain on the left shoulder. NA-E saw a burn on the shoulder and immediately notified RN-C. An interview with the director of nursing DON was conducted on 5/19/17, at 1:30 p.m. The DON stated she would have expected the staff that gave R1 the hot compress to follow up with R1 20 minutes later to assess the effectiveness of it. The DON also stated she would have expected the staff to inform the nurse of the resident's request for the hot compress. The DON stated she would expect the nurse to document a hot compress was given to a resident, and the resident's response to it. The DON stated she was unable to identify who had given R1 the hot compress on 3/23/17. The DON confirmed there was no protocol or policy in place regarding the use of hot compresses. There was not a facility policy that specified the use of hot compresses. The facility did have a policy that included hot compresses as a non-pharmacological intervention, but this policy did not give direction about application and removal of the compress. Instructions, warnings, and cautions were listed on the back of the single use disposable instant hot compress. Instructions included shaking contents of bag until hot. Wrap in soft cloth or towel and apply. Caution statements included peak temperature may reach 160 degrees Ferenheiht once activated. Avoid contact with skin. Use cloth or towel for protection. Do not use for more than 30 minutes.

Based on interviews and documentation review the facility failed to ensure that the consultant pharmacist identified and reported prolonged use of Coumadin (an anticoagulant medication) without an updated physicians order during a monthly drug regimen review for 2 of 5 residents reviewed (residents #1 and #2). Residents #1 and #2 both had physicians orders to receive Coumadin (an anticoagulant medication) and both had orders for a prothrombin time/international normalization ratio (PT/INR) (a blood test to monitor the effectiveness of Coumadin to prevent blood clots without causing excessive bleeding) to be completed on 12/14/2010. According to their discharge summaries from the hospital, both dated 12/08/2010, their goal INR range was 2 to 3. When the laboratory findings were obtained, they were faxed to the clinic. Although the facility did not verify if the fax was received by the physician and did not receive a response from the physician regarding the Coumadin, the staff continued to administer Coumadin to the two residents without an updated physicians order for nine consecutive days. Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #2 did not experience any apparent adverse effects related to the error. The forms titled "MEDICATION REGIME REVIEW" for residents #1 and #2, completed by individual (K)/consultant pharmacist and dated 12/23/2010, were reviewed. Resident #1's form identified the INR from 12/14/2010 at 4.41, documented in the comment section "(question mark) INR orders," and a box on the form for no irregularities (NI) is checked . Resident #2's form identified the INR from 12/14/2010 at 2.83, did not document anything in the comment section in relation to the INR and/or Coumadin and the no irregularities (NI) box is checked. Individual (K)/pharmacist was interviewed on 01/05/2011 at 1:55 p.m. He verified that he reviewed both resident #1's and #2's medication regime reviews on 12/23/2010 and completed the documentation on the "MEDICATION REGIME REVIEW" forms. He indicated that when completing medication regime reviews, he closely monitors residents receiving Coumadin and checks to ensure laboratory findings and updated orders are addressed. He indicated that with Coumadin he usually talks directly with the nurses. He verified that for both residents #1 and #2 he documented no irregularities (NI) and he could not recall if he discussed either resident with any of the nurses.

Based on interviews and documentation review the facility failed to ensure that 2 of 5 residents reviewed (residents #1 and #2), who received [MEDICATION NAME] (an anticoagulant medication) at the facility, were free of significant medication errors. Findings include: Residents #1 and #2 both had physicians orders to receive [MEDICATION NAME] (an anticoagulant medication) and both had orders for a [MEDICATION NAME] time/international normalization ratio (PT/INR) (a blood test to monitor the effectiveness of [MEDICATION NAME] to prevent blood clots without causing excessive bleeding) to be completed on 12/14/2010. When the laboratory findings were obtained, they were faxed to the clinic. Although the facility did not receive a response from the physician regarding the [MEDICATION NAME], the staff continued to administer [MEDICATION NAME] to the two residents without an updated physicians order for nine consecutive days. Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. According to documentation review, resident #1 had [DIAGNOSES REDACTED]. She was prescribed the medication [MEDICATION NAME]. According to the discharge summary from the hospital, dated 12/08/2010, her goal INR range was 2 to 3. On 12/10/2010, she received a physicians order for [MEDICATION NAME] 2 mg daily and to recheck her PT/INR on the next lab day (12/14/2010). On 12/14/2010, her PT/INR was drawn by the lab and the results were faxed to the clinic. Her PT was at 42.9 and INR was at 4.41. Employee (B)/nurse was interviewed on 01/04/2010 at 1:00 p.m. and indicated that he was assigned to work the day shift on 12/14/2010 from 6:00 a.m. to 2:30 p.m. He indicated that he faxed the laboratory findings for residents #1 to the clinic on 12/14/2010 during the day shift (exact time unknown). He did not receive a response back from the physician and verbally reported the information to employee (E)/nurse, who was working the next shift. Employee (E) was interviewed on 01/05/2011 at 12:54 p.m. and indicated that she was assigned to work the evening shift on 12/14/2010 from 2:00 p.m. to 10:30 p.m. During the verbal report from employee (B) on 12/14/2010 at the beginning of her afternoon shift, she received the information regarding the laboratory findings being faxed to the clinic and that the facility had not yet received a response from the physician. She indicated that after the verbal report, she did not receive a response from the physician, the shift got busy and she forgot about the information with resident #1. She verified that she did not report the information to the on-coming night shift. Residents #1 continued to receive [MEDICATION NAME] 2 mg daily without an updated physicians order for nine consecutive days. Although several nursing staff worked during the nine days, no one identified the significant medication error. Resident #1 had an interdisciplinary care conference on 12/23/2010 and the significant medication error was not identified and resident #1 had a medication regime review completed by individual (K)/pharmacist on 12/23/2010 and the significant medication error was not identified. On 12/24/2010, employee (H)/Nursing Assistant reported to employee (B) that resident #1 had a large bruise to her left abdominal area and a lump above her left breast. Employee (B) assessed the resident, reviewed her medical record and identified that no updated physicians order was received on 12/14/2010 for resident #1's [MEDICATION NAME]. Employee (B) updated an on-call physician and obtained orders to check the resident's PT/INR. Her PT was at 33.9 and INR was at 8. He again called the on-call physician who gave orders to hold the [MEDICATION NAME] for two days and notify individual (I)/resident #1's primary physician on 12/27/2010. On 12/26/2010, the lump in resident #1's breast was noted to be increasing in size. Individual (I) was notified by a nurse and resident #1 was subsequently transferred to the hospital. Resident #1's hospital records, dated 12/26/2010, were reviewed and revealed that resident #1 was admitted to the hospital with [REDACTED]. Upon admission, Her PT was at 97.6 and INR was at 10.75. The hematoma to her chest was noted to be six inches in diameter and the size of a "cantaloupe." While in the hospital, resident #1 was not in any pain, and the hematoma was "only slightly tender to palpitation." According to documentation review, resident #2 had [DIAGNOSES REDACTED]. She was prescribed the medication [MEDICATION NAME]. According to the discharge summary from the hospital, dated 12/08/2010, her goal INR range was 2 to 3. On 12/10/2010, she received a physicians order for [MEDICATION NAME] 4 mg every other day alternating with 5 mg and to recheck her PT/INR on 12/14/2010. On 12/14/2010, her PT/INR was drawn by the lab and the results were faxed to the clinic. Her PT was at 30.1 and INR was at 2.83. Employee (B)/nurse was interviewed on 01/04/2010 at 1:00 p.m. and indicated that on 12/24/2010, after he identified the error with resident #1, he also identified a similar error with resident #2. Residents #2 continued to receive [MEDICATION NAME] 4 mg every other day alternating with 5 mg without an updated physicians order for nine consecutive days. He indicated that an on-call physician was notified regarding the [MEDICATION NAME] medication error with resident #2 and the physician gave new orders. He indicated that resident #2 did not experience any apparent adverse effects related to the medication error. Employees (A), (B), (C), (D), (E), (F), and (G)/all nurses were all interviewed during the course of the investigation. When asked regarding the facility's system for ensuring that a physician has been notified with any new PT/INR laboratory findings and ensuring that an updated order has been received by the physician, they all indicated that if an updated order is not received from the physician on the day the PT/INR laboratory findings are received from the lab, it should be reported to the following shift. However, if it is not verbally reported shift to shift, they were unaware of any system in place to identify if a resident is continuing to receive [MEDICATION NAME] without an updated order. Individual (K) was interviewed on 01/05/2011 at 1:55 p.m. and again on 01/06/011 at 3:06 p.m. He indicated that resident #1's and #2's physicians should have been notified regarding the residents PT/INR laboratory findings and updated orders should have been received for the residents. Although he stated that the medication errors were isolated and resident #2 did not experience a significant error due to no known adverse effects, he validated that a significant medication error occurred with resident #1 secondary to her increased PT/INR laboratory findings and subsequent hospitalization .