Every finding on record at Legend Healthcare and Rehabilitation - Paris

Based on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. 1. The facility did not update the facility assessment to include Resident #38 gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). 2. The facility failed to include on the facility assessment the care of bariatric residents. These failures could affect residents by not having the necessary resources to ensure appropriate care is provided. Findings included: Record review of the facility's assessment reviewed on 06/17/25 reflected zero enteral feeding and did not address bariatric residents. 1. Record review of Resident #38's face sheet, dated 02/04/26, reflected Resident #38 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included gastrostomy. Record review of Resident #38's quarterly MDS assessment, dated 01/22/26, reflected Resident #38 rarely/never made herself understood, and rarely/never understood others. The assessment did not address Resident #38's BIMS score but reflected she had long term and short-term memory problems. The assessment reflected eating was not attempted due to medical condition or safety concerns. Resident #38 had a feeding while a resident of the facility and within the last 7 days. Record review of Resident #38's undated comprehensive care plan reflected Resident #38 required a feeding tube related to dysphagia (difficulty swallowing). The care plan interventions included: provide local care to feeding tube site as ordered and monitor for s/sx of infection. Record review of Resident #38's physician order summary report dated 02/04/26, reflected an active physician order for enteral feed order; Jevity (nutrition formula) 1.5- 1 carton (237 ml) five times a day with a start date 10/23/25. 2. Record review of Resident #44's face sheet, dated 02/04/26, reflected Resident #44 was a [AGE] year-old female, readmitted to the facility 01/14/26 with a diagnosis which included morbid (severe) obesity due to excess calories. Record review of Resident #44's quarterly MDS assessment, dated 12/17/25, reflected Resident #44 made herself understood, and understood others. Resident #44's BIMS score was a 15, which reflected her cognition was intact. The assessment reflected Resident #44 was dependent with toileting, shower/bathe, upper/lower and putting on/taking off footwear. Resident #44 required setup or clean-up assistance with oral/personally hygiene and independent with eating. Record review of Resident #44's updated comprehensive care plan reflected Resident #44 had ADL self-care performance deficit related to self-care deficit and morbid obesity. The care plan interventions included: Resident #44 required total assistance with Hoyer lift times two person assist for transfers at times depending on fatigue level and encouraged to discuss feelings about self-care deficit. Record review of Resident #44's physician order summary report dated 02/04/26 reflected an active order to use mobility bars to aide in east turning and repositioning while in bed every shift related morbid (severe) obesity due to excess calories with a start date 06/18/25. Record review of an undated/untitled sheet given by the Administrator on 02/04/26 at 10:15 a.m., reflected the facility had 4 bariatric residents. During an interview on 02/05/26 at 4:19 p.m., the Administrator stated she was responsible for completing and updating the facility assessment annually or anytime there was a major change in the facility such as the memory care closed or a new department head employee. The Administrator stated those things mentioned above would be updated in the facility assessment annually. The Administrator stated it was important the facility assessment was updated to have a plan of action in care of an emergency. Record review of the facility's policy titled, Facility Assessment revised 04/2025 reflected. the facility will conduct and document a facility-wide assessment, which includes both the resident population and the resources the facility needs to care competently for its residents during both day-to-day operations and emergencies. The facility will review and update the assessment at least annually and as necessary whenever there is, or the facility plans for any change that would require a substantial modification to any part of the assessment. 2. The facility assessment will include the following: a. resident population profile including numbers, diseases/conditions.4. The facility will be review and update the assessment annually or whenever the facility plans for any change that would require a modification to any part of the assessment.

1.The facility failed to ensure RN P wore PPE (gown) while performing wound care on 02/04/26.2.The facility failed to ensure CNA S wore PPE (gown) while performing care on 02/03/26.3. The facility failed to have Personal Protective Equipment, also known as PPE, (is specialized clothing or equipment worn to protect individuals from hazards in various settings, such as the workplace, and includes items like gloves, safety helmets, masks, and eye protection) outside Resident #64's and Resident #5's rooms, who required enhanced barrier precautions also known as EBP (an infection control strategy that uses gowns and gloves during high-contact care activities to reduce the transmission of multidrug-resistant organisms (MDROs).These failures could place any resident at the facility at risk for cross-contamination and the spread of infection. Finding included: 1.Record review of Resident #78's face sheet, dated 02/06/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include left femur fracture (a serious, high-energy injury (e.g., car crashes, severe falls) resulting in a break in the thighbone), muscle weakness (often temporary, reduction in strength causing muscles to feel uncooperative, soft, or incapable of normal movement, distinct from fatigue), and vitamin D deficiency (occurs when the body does not get enough essential nutrients, leading to systemic malfunction and potential long-term health issues). Record review of Resident #78's admission MDS assessment, dated 12/15/25, indicated Resident #78 understood and was understood by others. Resident #78's BIMS score was 13, which indicated her cognition was intact. The MDS indicated Resident #78 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she had an unhealed pressure ulcer. Record review of Resident #78's comprehensive care plan, revised on 01/12/26, indicated that Resident #78 had a stage 3 pressure ulcer to her left lower lateral leg related to her disease process of immobility. The interventions were for staff to do the wound treatment as ordered. Record review of Resident #78's Physician order dated 01/26/25 indicated, Cleanse wound to the left lateral lower leg with normal saline, then pat dry, then apply pharmacy compounded ointment (3%acetlycysteine and 10% urea and 125u/g collagenase in white petrolatum) over the wound bed then apply calcium alginate then apply a silicone dressing daily. Record review of Resident #78's Physician order dated 12/12/25 indicated, enhance barrier precautions for left hip surgical incision with wound vacuum every shift. During an observation on 02/04/26 at 2:58 p.m., RN P performed wound care for Resident #78. RN P did not wear PPE (gown) while providing wound care. 2.Record review of Resident #64's face sheet, dated 02/05/26, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes (a chronic condition characterized by high blood sugar also known as hyperglycemia) and high blood pressure. Record review of Resident 64's admission MDS assessment, dated 12/28/25, indicated Resident #64 understood and was understood by others. Resident #64's BIMS score was 14, indicating his cognition was intact. The MDS indicated Resident #64 required assistance with his ADLs, including transfers, dressing, personal hygiene, bed mobility and set up for eating. The MDS indicated application of dressing to his feet. Record review of Resident #64's comprehensive care plan revised 01/12/26 indicated, Resident #64 had a deep tissue pressure injury to his right heel. The intervention was for staff to do treatment as ordered and monitor wound healing. Record review of Resident #64's Physician order dated 12/30/25 indicated, Apply povidone-iodine to the right heel daily. The physician order did not address the use of enhanced barrier precautions. During an interview on 02/03/2026 9:30 a.m., Resident #64 was in his room sitting in his wheelchair. Resident #64 said he had a wound on his buttock and his left leg. During an observation and interview on 02/03/2026 at 5:13 p.m., CNA S went into Resident #64's room to allow the state surveyor to see his buttock. During the process, the state surveyor noted something on his left heel and CNA S said he had a wound to his heel. The surveyor asked if she was supposed to wear anything with residents if they had wounds and she said, Yes. She said she was supposed to wear a gown and gloves when providing care. CNA S said Resident #64 did not have an EBP sign or cart outside his door, so she had not thought about wearing PPE (gown and gloves). She said she did not know why Resident #64 did not have a sign or cart outside his room. She said she knew if they were on EBP she needed to wear gowns and gloves when providing care to prevent the spread of infection. During an interview on 02/04/2026 at 5:08 p.m., RN P said Resident #78 and Resident #64 had wounds. He said his understanding about when to wear EBP was intended for a surgical wound or chronic wound. He said staff should wear gloves and gowns for residents who require EPB. He said LVN Q determined when EBP was required. He said he had been trained on EBP and PPE use. He said the risks of not wearing the correct PPE (gown and gloves) could cause the transmission of Multidrug-resistant organisms also known as MRDO's (a germ that is resistant to many antibiotics). 3.Record review of Resident #5 face sheet dated 02/04/26 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (irregular, often rapid heart rate). Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected Resident #5 usually made herself understood and usually understood others. Resident #5's BIMS score was a 7, which reflected her cognition was severely impaired. Record review of Resident #5's undated comprehensive care plan reflected Resident #5 had actual impairment to skin integrity related to ruptured abscess (pus-filled pocket in the body)/venous leg ulcer (chronic, painful open sire that typically form near the ankle due to poor circulation). The care plan interventions included: encourage good nutrition and hydration to promote healthier skin. The care plan did not address the use of enhanced barrier precautions. Record review of Resident #5's order summary report dated 02/04/26 reflected an active physician order to cleanse wound to the left lower leg with normal saline then pat dry, apply a silicone dressing (wound supplies) daily with a start date 01/30/26. The order summary did not address the use of enhanced barrier precautions. During an observation on 02/02/26 at 4:43 p.m., Resident #5 was sitting in her wheelchair, and the surveyor noted a dressing to her lower left leg. Resident #5 had no EBP posting or cart outside her door. During an interview on 02/05/26 at 10:31 a.m., CNA D said she was Resident #5 aide. She said she had provided incontinent care for Resident #5 but had not worn PPE (gown) when she provided care. She said she had not been told to wear PPE (gown) for Resident #5. She said she knew if Resident #5 had a sign on her door, then she was supposed to wear PPE (gown and gloves) when providing care for Resident #5 to prevent infection. During an observation and interview on 02/05/26 at 3:01 p.m., LVN E said she was Resident #5 and Resident #78's nurse. She said she was not aware If they had wounds, she looked down the hall and said there was no sign or cart by their room. She said RN P usually did wound care. She said they had to do wound care over the weekend but could not remember who had wounds or who did not. She said since they had wounds, they should have signage posted and a cart outside of their room. She said staff should wear PPE (gown and gloves) when providing care for the protection of the residents and staff for the transmission of infection. During a phone interview on 02/05/26 at 2:42 p.m., LVN Q said she was the infection preventionist. She said she was responsible for ensuring EBP signage and cart were in place if needed. She said she had read on the Centers for Medicare and Medicaid Services (CMS) website that only residents with chronic or surgical wounds needed to have EBP signage and for staff to wear PPE (gown and gloves). She said she was not aware of what the facility's policy said. She said the reason for EBP was to protect the residents against our germs. She said staff needed to wear a gown and gloves when providing care for residents who required EBP. During an interview on 02/05/26 at 3:44 p.m., the DON said she expected staff to wash their hands and wear proper PPE (gown and gloves) when caring for residents on EBP to prevent infection. She said the ADON oversaw the infection control process. She said if residents had wounds, then they were supposed to have signage on the door and a cart outside of their doors. During an interview on 02/05/26 at 4:53 p.m., the Administrator said she expected any resident who had a wound for staff to wear PPE (gown and gloves) when providing care. She said they should have a sign and a cart outside of the door. She said LVN Q was responsible for ensuring signage and carts were in place. She said failure to wear proper PPE could cause the resident an infection. Record review of the facilities policy titled, IPCP Standard and Transmission-Based Precautions, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In Long Term Care (LTC). the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least restrictive approach possible that adequately protects the residents and others. #3 Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gowns and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., 'residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs}. PPE: infection. gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: Wounds-and/or-indwelling -medical-devices known as MDRO infection. Wounds include, but are not limited to chronic Wounds, pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.

Based on observation, interview and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice for 3 of 13 residents (Residents #5, 6, and 15) in that: Residents #5, Resident #6 and Resident #15 had pacemakers/defibrillator and had no specific guidelines for maintenance, precautions and care. The practice guidelines related to the maintenance, precautions and care were not clearly communicated in the EMR. These 3 residents had no specific care plan for pacemaker and defibrillator care or documentation of coordination of care with a cardiologist. These failures could result in residents experiencing cardiovascular problems, improper cardiac monitoring/transmission and follow up care.The findings include: Record review of Resident #5's face sheet dated 02/05/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included presence of an automatic (implantable) cardiac defibrillator (a battery powered device surgically placed under the skin to monitor heart rhythms and prevent sudden cardiac death), Atrial Fibrillation (chronic, rapid and irregular heartbeat), Chronic kidney disease (a long-term condition characterized by gradual loss of kidney function), hypertension (high blood pressure), cardiomyopathy (a heart muscle disease that reduces the hearts ability to pump blood) and congestive heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs). Record review of Resident #5's comprehensive MDS dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment with fluctuating inattention and disorganized thinking. Further review of the comprehensive MDS revealed Resident #5 had upper extremity range of motion impairment, required the use of a walker for mobility, moderate assistance in toileting bathing, dressing and transfers and was independent in bed mobility and gait. Record review of Resident #5's care plan with target date of 04/22/2026 revealed a focus area that indicated Resident #5 has a pacemaker related to Atrial Fibrillation with goal to remain free from signs and symptoms of pacemaker malfunction or failure. and interventions to include, monitor apical pulse daily, monitor for signs and symptoms of pacemaker malfunction, and report resident complaints of dizziness, pair or fatigue to the nurse. Record review of Resident #5's physicians orders revealed orders dated 10/21/2025 to monitor the apical pulse daily for pacemaker use and to monitor for signs and symptoms of pacemaker malfunction. Record review of Resident #5's EMR revealed no specific information regarding the defibrillator to include at a minimum, the make, the model, the last date the defibrillator was checked or the name of cardiologist. Record review of Resident #6's face sheet dated 02/05/2026 revealed a [AGE] year-old female originally admitted [DATE] and readmitted [DATE] with diagnoses that included the presence of a cardiac pacemaker (an implantable device placed under the skin to treat irregular heartbeats by sending painless electrical signals to normalize heart rhythm), atrial fibrillation (chronic, rapid and irregular heartbeat), cerebral infarction (a type of stroke caused by a blockage in a brain artery) and hypertension (high blood pressure), Record review of Resident #6's comprehensive MDS dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Further review of the comprehensive MDS revealed Resident #6 required the use of a wheelchair for mobility, was independent in toileting, bathing, dressing, bed mobility, transfers and wheelchair mobility. Record review of Resident #6's care plan with target date of 05/06/2026 revealed a focus area that indicated Resident #6 has a pacemaker related to Atrial Fibrillation with goal to .remain free from signs and symptoms of pacemaker malfunction or failure. and interventions to include, monitor /document/report to MD PRN any signs or symptoms of altered cardiac output or pacemaker malfunction, dizziness, syncope, difficulty breathing, pulse rate lower than programmed rate, lower than baseline B/P and monitor vital signs as ordered/per facility protocol and record. Record review of Resident #5's physicians orders revealed orders dated 11/06/2025 to monitor pulse daily for pacemaker use. Record review of Resident #5's EMR revealed no specific information regarding the pacemaker to include at a minimum, the make, the model, the last date of pacemaker check or the name of the cardiologist. Record review of Resident #15's face sheet dated 02/05/2026 revealed an [AGE] year-old male admitted [DATE] with diagnoses that included presence of a cardiac pacemaker (an implantable device placed under the skin to treat irregular heartbeats by sending painless electrical signals to normalize heart rhythm), atherosclerotic heart disease (plaque buildup in the coronary arteries that restricts blood flow to the heart), heart failure (a chronic condition where the heart cannot pump enough blood and oxygen to meet the body's needs), peripheral vascular disease (narrowing blood vessels due to plaque buildup), and hypertension (high blood pressure). Record review of Resident #15's comprehensive MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment with fluctuating inattention. Further review of the comprehensive MDS revealed Resident #15 required the use of a walker or wheelchair for mobility, supervision with toileting, bathing, dressing, transfers and gait, and was independent in bed mobility. Record review of Resident #15's care plan with target date of 04/30/2026 revealed a focus area that indicated Resident #15 has a pacemaker related to atrial fibrillation with goal to .remain free from signs and symptoms of pacemaker malfunction or failure. and interventions to include, monitor apical pulse daily, monitor for signs and symptoms of pacemaker malfunction, monitor vital signs as ordered and record, report resident complaints of dizziness, pain or fatigue to the nurse. Record review of Resident #15's physicians orders revealed orders dated 01/23/2026 to monitor apical pulse daily for pacemaker use. Record review of Resident #15's EMR revealed no specific information regarding the pacemaker to include at a minimum, the make, the model, the last date of pacemaker check or the name of the cardiologist. During an interview and observation on 02/04/2026 at 11:00 a.m., Resident #5 stated that the staff do check her pulse. There was no equipment to monitor or check the pacemaker present in Resident #5's room. During an interview and observation on 02/04/2026 at 11:15 a.m., Resident #6 stated that the staff do check her pulse. There was no equipment to monitor or check the pacemaker present in Resident #6's room. During an observation on 02/05/2026 at 11:25 a.m., no equipment to monitor or check the pacemaker was present in Resident #15's room. During an interview on 02/05/2026 at 1:20 p.m., LVN O stated she was aware that some residents had a pacemaker because they would have order to monitor the apical pulse daily for pacemaker use. LVN O stated she did not know the specific make, model or cardiologist for Resident #5, Resident #6 or Resident #15 and she would look in the chart to see if she could find it. During an interview on 02/05/2026 at 1:38 p.m., the ADON stated he would look in the EMR to obtain the information and specifics related to the pacemaker by looking at the physicians order, a copy of the pacemaker card that may be uploaded under the miscellaneous files or indicated in the Care Plan. The ADON stated that different manufactures have different guidelines for monitoring of the pacemakers / defibrillators to include when the device should be interrogated (checked). The ADON stated he would look for the manufacturer to obtain the pacemaker specifications and ensure they were accessible in the EMR. The ADON stated that it would be important to know who the cardiologist was and when the last time the pacemaker/defibrillator was checked and risks of not knowing this information could mean the information would not be available in an emergency situation. The ADON stated to his knowledge, the facility does not have a specific policy for pacemakers. During an interview on 02/05/2026 at 1:51 p.m., the DON stated she would reach out to the family member to obtain the specific information regarding the pacemaker to include the make, model and cardiologist for Resident #15 and review for all resident's with a pacemaker / defibrillator. During an interview on 02/05/2026 at 3:10 p.m., the MDS Nurse stated that if a resident was identified as having a pacemaker or defibrillator, the Care Plan would reflect the presence of the device and orders would include monitoring the apical pulse and monitoring for malfunction. The MDS Nurse stated it would be important to know when the pacemaker was last checked but that this information is not always available from the resident, responsible party or identified in the medical record when a resident is admitted . The DON stated she was able to obtain and document in Resident #15's EMR the make and model of Resident #15's pacemaker as well as the name of his cardiologist. During an interview on 02/05/2026 at 3:41 p.m., the DON stated she did not feel that knowing the make and model of the pacemaker or defibrillator was important and that she expected the nursing staff to monitor the pulse and pacemaker checks. The DON stated the ADON would be responsible for ensuring the information is present in the orders and the MDS Nurse would be responsible for ensuring the device is annotated in the Care Plan. The DON stated she is ultimately responsible for accuracy of the record. During an interview on 02/05/2026 at 4:20 p.m., the Administrator stated it was important to gather the necessary information regarding a resident's pacemaker and to her knowledge they did have the cardiologist information on all the resident's with a pacemaker. The Administrator stated, it is always important to know about any internal device a resident may have to include the name and contact information for the cardiologist. The Administrator stated that the nursing staff are responsible for obtaining the pacemaker date and ensuring a cardiology follow up appointment is completed. Requested a policy for monitoring pacemakers / defibrillators on 02/05/2026 at 1:38 p.m. and was informed by the DON that the facility did not have a specific policy for pacemakers.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was an open can of soda, an uncovered Styrofoam cup, an energy drink and a plastic drink container from unapproved sources observed on a food prep counter in the kitchen. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 02/02/2026 at 9;40 a.m. revealed an open can of soda and an uncovered Styrofoam cup with approximately 4 ounces of dark liquid assumed to be coffee in the kitchen on the food prep counter. Observation on 02/03/2026 at 7:15 a.m. revealed an open 16-ounce energy drink and an open 16-ounce plastic container with tan liquid that appeared to be iced coffee. During an interview on 02/02/2026 at 9:50 a.m., [NAME] M stated she had not noticed the personal drink items on the food prep area and that she would have them removed right away. [NAME] M stated that personal food items are not allowed to be in the kitchen area and should be kept either in the office or the break room. During an interview on 02/03/26 at 7:28 a.m., Dietary Aide N stated that the drink items did not belong to him and that all personal food items should be consumed in the breakroom. During an interview on 02/05/2026 at 1:10 p.m., the Dietary Supervisor stated that she was not aware of the personal drink items in the kitchen and that she had informed all staff that personal food items are not allowed in the kitchen area and must be kept either in the breakroom or the dietary office. The Dietary Supervisor stated she is ultimately responsible to ensure personal food items are not in the kitchen area to prevent risk for food borne illness. During an interview on 02/05/2026 at 3:41 p.m., the DON stated that personal food items are not allowed on the nursing carts or kitchen areas to prevent cross-contamination. The DON stated that it is the responsibility of the Dietary Supervisor to ensure dietary staff do not have personal food and drink items in the kitchen area. During an interview on 02/05/2026 at 4:20 p.m., the Administrator stated that she expects the dietary staff to follow the instructions provided to them regarding not having personal drink items in the kitchen food prep area and that she expects personal food and drink items to be kept in the staff breakroom. The Administrator stated she would have concerns for cross contamination and that while the Dietary Supervisor is responsible for ensuring compliance in the kitchen, the Administrator is ultimately responsible to ensure all policies and procedures are followed. The Administrator stated she would monitor the effectiveness of policy adherence by completing spot checks in the kitchen and daily communication with the Dietary Supervisor. Requested a facility policy for personal food items on 02/05/2026 at 1:45 p.m. and was provided a policy titled Resident Personal Food storage. The facility did not have a policy for personal food storage for staff members food or drink items. Review of the Food Code, U.S. Public Health Service, U.S. FDA (Food & Drug Administration), 2022, U.S. Department of H&HS (Health & Human Services), 2-401.11, revealed, Eating, Drinking or Using Tobacco Products. (A) Except as specified in (B) of this section, an employee shall eat, drink, or use any form of tobacco products only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result.

Based on observation, interviews, and record review the facility failed to ensure that residents were free of significant medication errors for 3 of 7 residents review for pharmacy services (Resident #74, Resident #46, and Resident #40. ) 1.The facility failed to ensure LVN E administered Resident #74 Humalog KwikPen (insulin medication) according to the manufacturer's instructions.2.The facility failed to ensure LVN F administered Resident #46 Novolog KwikPen (insulin medication) according to the manufacturer's instructions.3.The facility failed to ensure LVN E administered Resident #V Vancomycin (infection medication) according to the manufacturer's instructions. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.1.Record review of Resident #74 face sheet indicated she was a [AGE] year-old female admitted to the facility originally 07/07/23 with the primary diagnosis of TYPE 1 DIABETES MELLITUS WITH HYPERGLYCEMIA (a chronic pancreatic condition that affects the blood sugar).Record review of Resident #74 Comprehensive MDS dated [DATE] indicated she had a BIMS of 14 with no cognitive impairment. Resident #74 was being treated with antidiabetic medications including insulin to control daily blood sugar level.Record review of Resident #74 care plan undated indicated she was care planned for type 1 diabetes mellites with interventions of Diabetes medication as ordered by doctor, monitor and document for side effects and effectiveness, and finger stick blood sugar as ordered.Record review of Resident #74 order summary dated 02/05/26 indicated she had an order for HumaLOG KwikPen Subcutaneous Solution Peninjector100 UNIT/ML (Insulin Lispro) Inject as per 10 units before meals and HumaLOG KwikPen Subcutaneous Solution Peninjector100 UNIT/ML (Insulin Lispro) Inject as per sliding scale orders.if 0 - 150 = 0 units;151 - 200 = 2 units;201 - 250 = 4 units;251 - 300 = 6 units;301 - 350 = 8 units;351 - 400 = 10 units;401+ = 12 units call physician, subcutaneously before meals and at bedtime for DM.Record review of Resident #74 administration report dated 02/05/26 indicated she had received 12 units of HumaLog KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML for a blood sugar of 497 at 11:30 AM.During an observation on 02/05/26 at 10:48 AM, LVN E dialed unites 22 of HumaLog, administered in the left arm, and failed to prime the insulin pen prior to administration. Resident #74 received 10 united routine and 12 units for blood sugar level per sliding scale.During an interview on 02/05/26 at 10:48 AM, LVN E stated that she was not taught to prime the insulin pen prior to injection with the needle on. LVN E stated that priming the pen is to get the air out.2.Record review of Resident #46 face sheet indicated he was a [AGE] year-old male originally admitted to the facility on [DATE] with the primary diagnosis of ALZHEIMER'S DISEASE WITH LATE ONSET (chronic deterioration of cognitive functioning).Record Review of resident #46 Comprehensive MDS dated [DATE] indicated a BIMS of 14 revealing little to no impairment. Resident #46 was being treated with insulin injections 7 of the last 7 days with hypoglycemia (including insulin) medication class.Record review of Resident #46 care plan 02/05/26 indicated he was care planned for diabetes mellitus with interventions as diabetes medication as order by doctor, monitor and document for side effects and effectiveness, and fasting serum blood sugar as order by doctor.Record review of Resident #46 order summary dated 02/05/26 indicated he has an order for Novolin R FlexPen inject 4 units subcutaneously before meals with a start date of 09/24/25.During an observation on 02/05/26 at 10:38AM, LVN F dialed 6 units of Novolin R FlexPen administering the whole dose without priming the pen with 2 units to remove air from the needle. LVN F should have dialed up 2 units with a new needle pushing it through needle and then dialed up 4 units to administer.During an interview on 02/05/26 at 10:38 AM, LVN F stated although she could not see the 2 units come through the needle to expel air that her intentions were to remove air and that is how her DON taught her.3.Record review of Resident #40's face sheet indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] with the primary diagnosis of endocarditis, valve unspecified (inflammation of the heart caused by infection).Record review of Resident #40's comprehensive MDS dated [DATE] indicated a BIMS of 12 revealing only minimal cognitive impairment. Resident #40 was being treated with IV medication antibiotics (to treat infection).Record Review of Resident #40's care plan indicated she was care planned for IV therapy required related to endocarditis potential for infection with intervention listed as infuse the fluids and medications as ordered.Record review of Resident #40's order summary indicated she had an order for Vancomycin HCl Intravenous Solution 500 MG/100ML intravenously two times a day for endocarditis. Infuse at 100mL/hr.Record review of Resident #40 administration report dated 02/5/26 indicated she received vancomycin 500mg/100mL started on 01/30/26 without missing a dose.During an observation and interview on 02/03/26 at 8:56AM, LVN E administered 500mg of Vancomycin in a 100mL bag at 400mL/hr. The order stated for LVN E to administer the IV infusion over 100mL/hr for a total of 60 minutes of infusion time. The IV vancomycin infused in 15 minutes. After surveyor intervention LVN E disconnected the IV after the medication had infused from the PICC line, flushed with 10mL of normal saline and 5mL of heparin. LVN E then documented the medication error, called the doctor, family representative, pharmacist, and notified the DON. LVN E stated she thought the medication was in a 400mL bag. LVN E stated that this was the first dose of the new order, and she misread the order.During an interview on 02/03/26 at 9:30AM, DON stated that was conducting a medication error evaluation form. During an interview on 02/05/26 at 3:48PM, DON stated that she expects all residents to be free from significant medication errors including IV medications and insulin. DON stated that Resident #40, Resident #74, Resident #46, and Resident #14 was at risk for adverse reactions to the medication and possibly harm. DON stated that she performs medication pass audits and insulin administration audits randomly. DON stated that she was not aware of incorrect administration of insulin and an in services was to be done. DON stated that she expects insulin to be administered according to manufacturing requirements and medications to be administered according to physician orders. DON stated the last annual all in-services checkoff for LVN E, LVN F was in November completed by the DON. During an interview on 02/05/26 at 4:36PM, the Administrator stated that she expected the DON to oversee and ensure safe administration of high risk medications. The Administrator stated that she expected all nursing staff to report medication errors to the nurse, DON, doctor, and herself the administrator. The administrator stated that when a medication error occurs, she expected nursing to monitor for sign and symptoms of adverse reactions and she stated that Resident#74, Resident #46, and Resident #14 is at risk of negative impacts of the medication error. Record review of Nursing Clinical policy dated 02/2022, revealed the definition of significant medication error one which causes the resident discomfort or jeopardizes his or her health and safety. Significant may be subjective or relative depending on the individual situation and duration. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately.*Record review of the manufacture's guidelines titled Humalog KwikPen, revised 05/2025 reflected. Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.Record review of the manufacture's guidelines titled Novolog KwikPen, revised 05/2025 reflected. Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.

Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 10%, based on 4 errors out of 40 opportunities, which involved 4 of 7 residents (Resident #74, Resident #46, Resident #40 and Resident #3) reviewed for medication administration. The facility failed to ensure LVN E administered Resident #74 Humalog KwikPen (insulin medication) according to the manufacturer's instructions.The facility failed to ensure LVN F primed Resident #46 Novolog KwikPen (insulin medication) according to the manufacturer's instructions. The facility failed to ensure LVN F administer 4 units of Novolog KwikPen to Resident #46 on 02/05/26 according to physician orders.The facility failed to ensure LVN E administered Resident #40 IV Vancomycin (infection medication) according to the manufacturer's instructions.The facility failed to ensure CMA G administration Resident #3 Allopurinol (gout medication) according to the physician orders. These failures could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs. Finding Including: Record review of Resident #74 face sheet indicated she was a [AGE] year-old female admitted to the facility originally 07/07/23 with the primary diagnosis of TYPE 1 DIABETES MELLITUS WITH HYPERGLYCEMIA (a chronic pancreatic condition that affects the blood sugar).Record review of Resident #74 Comprehensive MDS dated [DATE] indicated she had a BIMS of 14 with no cognitive impairment. Resident #74 was being treated with antidiabetic medications including insulin to control daily blood sugar level. Record review of Resident #74 care plan undated indicated she was care planned for type 1 diabetes mellitus with interventions of Diabetes medication as ordered by doctor, monitor and document for side effects and effectiveness, and finger stick blood sugar as ordered. Record review of Resident #74 order summary dated 02/05/26 indicated she had an order start date of 07/30/24 for HumaLOG KwikPen (prefilled insulin device) Subcutaneous Solution Peninjector100 UNIT/ML (Insulin Lispro) HumaLOG KwikPen Subcutaneous Solution Peninjector100 UNIT/ML (Insulin Lispro) Inject as per sliding scale orders. if 0 - 150 = 0 units;151 - 200 = 2 units;201 - 250 = 4 units;251 - 300 = 6 units;301 - 350 = 8 units;351 - 400 = 10 units;401+ = 12 units call physician, subcutaneously before meals and at bedtime for DM. Record review of Resident #74 order summary dated 02/05/26 indicated she had an order start date of 12/05/25 for HumaLOG KwikPen Subcutaneous Solution Peninjector100 UNIT/ML (Insulin Lispro) Inject as per 10 units before meals Record review of Resident #74 administration report dated 02/05/26 indicated she had received 12 units of HumaLog KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML for a blood sugar of 497 at 11:30 AM. During an observation on 02/05/26 at 10:48 AM, LVN E dialed 22 units of HumaLog and administered in the left arm of Resident #74. LVN E failed to prime the insulin pen prior to administration. During an interview on 02/05/26 at 10:48 AM, LVN E stated that she was not taught to prime the insulin pen prior to injection with the needle on. LVN E stated that priming the pen was to get the air out. LVN E stated that Resident #74 was at risk for not receiving the correct dose of insulin. LVN E contacted the physician with orders to recheck blood sugar. LVN E follow-up phone call reported to the physician a 380 blood sugar. Record review of Resident #46 face sheet indicated he was an [AGE] year-old male originally admitted to the facility on [DATE] with the diagnosis of TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (chronic pancreatic condition that causes inability to regulate blood sugar).Record Review of Resident #46 Comprehensive MDS dated [DATE] indicated a BIMS of 14 revealing little to no impairment. Resident #46 was being treated with insulin injections 7 of the last 7 days with hypoglycemia (including insulin) medication class. Record review of Resident #46 care plan 02/05/26 indicated he was care planned for diabetes mellitus with interventions as diabetes medication as order by doctor, monitor and document for side effects and effectiveness, and fasting serum blood sugar as order by doctor. Record review of Resident #46 order summary dated 02/05/26 indicated he has an order for Novolin R FlexPen inject 4 units subcutaneously before meals with a start date of 09/24/25. During an observation on 02/05/26 at 10:38AM, LVN F dialed 6 units of Novolin R FlexPen administering the whole dose to Resident #46 without priming the pen with 2 units to remove air from the needle. During an interview on 02/05/26 at 10:38 AM, LVN F stated although she could not see the 2 units come through the needle to expel air that her intentions were to remove air and that was how her DON taught her.Record review of Resident #40's face sheet indicated she was an [AGE] year-old female originally admitted to the facility on [DATE] with the primary diagnosis of endocarditis, valve unspecified (inflammation of the heart caused by infection).Record review of Resident #40's comprehensive MDS dated [DATE] indicated a BIMS of 12 revealing only minimal cognitive impairment. Resident #40 was being treated with IV medication antibiotics (to treat infection). Record Review of Resident #40's care plan indicated she was care planned for IV therapy required related to endocarditis potential for infection with intervention listed as infuse the fluids and medications as ordered. Record review of Resident #40's order summary indicated she had an order for Vancomycin HCl Intravenous Solution 500 MG/100ML intravenously two times a day for endocarditis. Infuse at 100mL/hr start date 02/03/26. Record review of Resident #40 administration report dated 02/5/26 indicated she received vancomycin 500mg/100mL started on 01/30/26 without missing a dose. During an observation and interview on 02/03/26 at 8:56AM, LVN E administered 500mg of Vancomycin in a 100mL bag at 400mL/hr. The IV vancomycin infused in 15 minutes. After surveyor intervention LVN E disconnected the IV after the medication had infused from the PICC line, flushed with 10mL of normal saline and 5mL of heparin. LVN E then documented the medication error, called the doctor, family representative, pharmacist, and notified the DON. LVN E stated she thought the medication was in a 400mL bag. LVN E stated that this was the first dose of the new order, and she misread the order. LVN E stated that she had recently had an IV check off during her annual competency check off in November. LVN E stated that Resident #40 was at risk of pain to the site and alteration in vital signs. During an interview on 02/03/26 at 9:30AM, DON stated she was conducting a medication error evaluation form and the last training was in November for all skills annual check off for LVN E.Record review of Resident #3's face sheet indicated she was an [AGE] year-old female originally admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia without behavioral disturbance, psychotropic disturbance, mood disturbance, and anxiety.Record review of Resident #3's quarterly MDS dated [DATE] indicated she a BIMS of 09 revealing moderate cognitive impairment. MDS indicated she received scheduled pain medication. MDS indicated she had a diagnosis of low back pain. Record review of Resident #3's care plan indicated she was being care planned for risk for pain related to diabetic neuropathy and gout with interventions to monitor and document side effects of pain medications. Record review of Resident #3's order summary indicated an order for allopurinol oral tablet 100mg; give 2 tablet by mouth one time a day for gout started on 01/16/26. During an observation on 02/03/26 at 9:00AM, CMA G administered 1 100mg tablet of Allopurinol (gout medication) when the order indicated to administer 2 tablets. During an interview on 02/04/26 at 9:13AM, CMA G stated she made a mistake and did not give 2 tablets. CMA stated the resident was at risk of not being fully treated for her gout pain. During an interview on 02/04/26 at 11:32AM, CMA G stated she reported the medication error to her nurse, DON, and doctor with orders to monitor vital signs and symptoms with no changes in the medication order. Record review of progress note dated 02/04/26 at 11:27AM, LVN K documented that she was notified that the resident received 100mg of Allopurinol on 02/03/26 and the order read to give 2 tablets once a day for gout pain. LVN K documented resident representative made aware. Record review of medication administration skills checklist undated completed by ADON revealed medication administration skills checklist requirements met for CMA G. Record review of medication administration skills checklist undated completed by ADON revealed medication administration skills checklist requirements met for LVN E. Record review of orientation and annual skills checklist dated 11/20/25 completed by ADON revealed LVN E revealed her annual skills checked off for medications and treatment passes including IV medication administration. Record review of orientation and annual skills checklist dated 11/20/25 completed by ADON revealed LVN F revealed her annual skills checked off for medications and treatment passes. Record review of Nursing Clinical policy dated 02/2022 revealed this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments. Record review of the manufacture's guidelines titled Humalog KwikPen, revised 05/2025 reflected. Priming your Pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of vancomycin hydrochloride, USP VIAL Dosage and Administration | Pfizer Medical - US accessed on 2/10/2026 indicated:DOSAGE AND ADMINISTRATIONInfusion-related events are related to both the concentration and the rate of administration of vancomycin. Concentrations of no more than 5 mg/mL and rates of no more than 10 mg/min are recommended in adults (see also age-specific recommendations). In selected patients in need of fluid restriction, a concentration up to 10 mg/mL may be used; use of such higher concentrations may increase the risk of infusion-related events. An infusion rate of 10 mg/min or less is associated with fewer infusion-related events (see ADVERSE REACTIONS). Infusion-related events may occur, however, at any rate or concentration.Patients with Normal Renal FunctionAdultsThe usual daily intravenous dose is 2 g divided either as 500 mg every 6 hours or 1 g every 12 hours. Each dose should be administered at no more than 10 mg/min or over a period of at least 60 minutes, whichever is longer. Other patient factors, such as age or obesity, may call for modification of the usual intravenous daily dose.Patients with Impaired Renal Function and Elderly PatientsDosage adjustment must be made in patients with impaired renal function. In premature infants and the elderly, greater dosage reductions than expected may be necessary because of decreased renal function. Measurement of vancomycin serum concentrations can be helpful in optimizing therapy, especially in seriously ill patients with changing renal function. Vancomycin serum concentrations can be determined by use of microbiologic assay, radioimmunoassay, fluorescence polarization immunoassay, fluorescence immunoassay, or high-pressure liquid chromatography. If creatinine clearance can be measured or estimated accurately, the dosage for most patients with renal impairment can be calculated using the following table. The dosage of vancomycin hydrochloride for injection per day in mg is about 15 times the glomerular filtration rate in mL/min (see following table).

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 6 residents (Resident # 4 and Resident #30) reviewed for notification of changes. 1.The facility failed to notify the physician for Resident #4's blood sugars above 401 on 01/08/26, 01/16/26, 01/18/26, 01/22/26, and 01/31/26 2.The facility failed to notify the physician for Resident #30's blood sugars above 401 on 01/09/26, 01/17/26, 01/16/26, and 01/22/26. These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions.Findings included:1.Record review of Resident #4's face sheet dated 02/04/26 indicated he was a [AGE] year-old male admitted on [DATE] with diagnoses which included diabetes (a condition that happens when your blood sugar (glucose) is too high), stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and kidney failure (occurs when kidneys lose the ability to filter waste from the blood).Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated he understood and was understood by others. The MDS indicated Resident #4 had a BIMS score of 14 which indicated he was cognitively intact. The MDS indicated Resident #4 required assistance with personal hygiene, dressing bed mobility, transfers, toileting, and set up for eating and oral care. The MDS indicated he took insulin medication during the 7-day look-back period. Record review of Resident #4's comprehensive care plan dated 09/03/25 indicated he had a diagnosis of diabetes. The interventions were to give medication as ordered and to monitor, document, and report to the doctor as needed for signs and symptoms of hyperglycemia (high blood sugars).Record review of Resident #4's physician order dated 01/03/26, indicated give Novolin R Injection Solution 100 UNIT/ milliliter (Insulin Regular (Human)) Inject as per sliding scale: if 0 - 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 399 = 10 units; 400+ = 12 units and call the doctor, subcutaneously before meals and at bedtime for diabetes.Record review of Resident #4's medication administration record dated January 2026 revealed a high blood sugar over 400 on the following days and times: documented by LVN R, 406 on 01/08/26 at 4:30 pm, 425 on 01/08/26 at 8:00 pm and 408 on 01/16/26 at 8:00 pm, documented by RN P, 422 on 01/18/26 at 11:30 am, and 449 on 01/22/26 at 4:30pm, and documented by LVN Q 420 on 01/31/26 at 4:30 pm. The medication administration record indicated they received the 12 units of insulin ordered but did not indicate if any extra insulin was given on the above dates. Record review of Resident #4's nurses notes did not indicate the doctor was notified when Resident #4's blood sugar was above 401 for the following dates 01/08/26 at 4:30 pm, 01/08/26 at 8:00 pm, 01/16/26 at 8:00 pm, 01/18/26 at 11:30 am, 01/22/26 at 4:30 pm, and 01/31/26 at 4:40 pm. The nurse's notes did not indicate any new orders related to his blood sugar being elevated, any signs or symptoms of hyperglycemia, or hospitalization during the above dates.During an attempted phone interview on 02/05/26 at 1:01 p.m., called LVN R with a message left.During an observation and interview on 02/05/26 at 3:08 p.m., RN P said he was Resident #4's charge nurse at times. He looked at Resident #4's medication administration records and indicated he worked 01/18/26, and 01/22/26. He saw where Resident #4's blood sugar was above 401. He said he did not know if he notified the doctor about Resident #4's elevated blood sugar but knew he should have for the safety of the resident to prevent hyperglycemia (high blood sugar). He said Resident #4 was not showing any signs and symptoms of hyperglycemia.During a phone interview on 02/05/26 at 3:11 p.m., LVN Q said she was Resident #4's charge nurse on 01/31/26. She said she recalled him having high blood sugar but does not remember if she called the doctor or not. She said if it was not documented then she did not call him. She said she should document to prove she followed the doctor's order. She said it was important to notify the doctor for blood sugars over 401 because it was his order and in case the doctor wanted to change the resident's medication.2.Record review of Resident #30's face sheet, dated 02/05/26, indicated he was an [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included diabetes (a condition that happens when your blood sugar (glucose) is too high),dementia (loss of memory), and high blood pressure.Record review of Resident #30's comprehensive care plan, dated 05/17/22, indicated Resident #30 had a diagnosis of diabetes. The intervention was for staff members to give medication as ordered by the doctor, monitor and document for side effects and effectiveness, and report to the doctor as needed for signs and symptoms of hyperglycemia (high blood sugars).Record review of Resident #30's physician order dated 10/31/25, indicated give Novolin R Injection Solution 100 UNIT/ milliliter (Insulin Regular (Human)) Inject as per sliding scale: if 0 - 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300 = 6 units, 301 - 350 = 8 units, 351 - 399 = 10 units; 400+ = 12 units and call the doctor, subcutaneously before meals and at bedtime for diabetes.Record review of Resident #30's quarterly MDS assessment, dated 12/02/25, indicated Resident #30 understood and was understood by others. Resident #30's BIMS score was 12, indicating his cognition was moderately impaired. The MDS indicated Resident #30 required assistance with his ADLs, including transfers, dressing, personal hygiene, and bed mobility. The MDS indicated he received insulin during his 7-day look back period. Record review of Resident #30's medication administration record dated January 2026 revealed a high blood sugar over 400 on the following days and times: documented by RN P revealed a high blood sugar over 401 on the following days and times 01/09/26 at 4:30 pm blood sugar was 412,and 01/22/26 at 4:30 am blood sugar was 506, and documented by LVN Q on 01/16/26 at 8:00 pm blood sugar was 405,and 01/17/26 at 4:30 pm blood sugar was 475. The medication administration record indicated they received the 12 units of insulin ordered but did not indicate if any extra insulin was given on the above dates. Record review of Resident #30's nurses notes did not indicate the doctor was notified when Resident #30's blood sugar was above 401 for the following dates 01/09/26 at 4:30 pm, 01/08/26 at 4:30 pm, 01/08/26 at 8:00 pm, 01/16/26 at 8:00 pm, and 01/22/26 at 4:30 pm. The nurse's notes did not indicate any signs or symptoms of hyperglycemia, no new orders related to his blood sugar being elevated, or hospitalization during the above dates.During an observation and interview on 02/05/26 at 1:39 p.m., RN P said he was Resident #30's charge nurse at times. He looked at Resident #30's medication administration records and indicated he worked 01/09/26 and 1/22/26. He said he could not see where he notified the doctor. He said it was important to notify the doctor of any changes, and blood sugar was important because the resident could have a change. He said it should be documented so others would know of his changes.During a phone interview on 02/05/26 at 3:13 p.m., the facility doctor said he expected staff to notify him of blood sugar readings below 60 and above 400. He said usually the staff communicated with him about the resident's blood sugar, but he could not say if he was or was not notified on Resident #4's or Resident #30's blood sugars on the dates mentioned above. He said if he had been notified, he would not have changed their orders. He said untreated hyperglycemia over a period could lead to organ damage.During an interview on 02/05/26 at 3:41 p.m., the DON said the charge nurse should notify the doctor of any blood sugars over 401. She said she and the ADONs were randomly monitoring vital signs. She said the nurses should document in the nurse's notes that they notified the doctor and if they received any new orders. The DON said if blood sugar remains uncontrolled a resident could have adverse effects such as high blood sugars. During an interview on 02/05/26 at 4:53 p.m., the Administrator said she expected the charge nurses to notify the doctor of any blood sugar over the parameters. She said nurse managers and the DON should be monitoring blood sugars readings. The Administrator said if the nurses were not notifying the doctor they could be giving the wrong care. The Administrator said they did not have a policy on notification, they followed the nursing clinical policy and procedure.During an attempted phone interview on 02/05/2026 at 5:34 p.m., called LVN R with a message left.Record review of the facility policy for Policy/ Procedure - Nursing Clinical revised 05/2007, indicated, Policy: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #60) reviewed for accident hazards and supervision. The facility did not ensure Resident #60 wore a smoking apron on 02/03/26 at 9:30 a.m. smoke break. This failure could place residents who smoke at risk of physical harm. Findings included: Record review of Resident #60's face sheet dated, 02/04/26, reflected Resident #60 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included Tourette's disorder (nervous system disorder characterized by involuntary, repetitive movements and sounds known as tics). Record review of Resident #60's quarterly MDS assessment, dated 12/19/25, reflected #60 rarely/never understood others, and rarely/never made herself understood. Resident #60 had a BIMS score of 00, which reflected her cognition was severely impaired. Record review of Resident #60's undated care plan reflected Resident #60 had potential for injury related to smoking. The care plan interventions included: complete smoking assessment, provide 1:1 observation while smoking and utilize smoking apron during smoking activities. Record review of Resident #60's smoking evaluation dated 02/03/26 reflected Resident #60 required a smoking apron. During an attempted interview on 02/02/26 at 1:17 p.m., with Resident #60, she was non-interview able. During an observation on 02/03/26 at 9:30 a.m., Resident #60 was being supervised by Maintenance B while smoking 2 cigarettes without wearing a smoking apron. Resident #60 hands were shaking and not steady while holding the cigarettes. Resident #60 did not have any burn marks on her clothing. During an interview on 02/04/26 at 4:40 p.m., Maintenance B stated Resident #60 required a smoking apron while smoking. Maintenance B stated normally he placed an apron on her, but he forgot. Maintenance B stated this failure put her at risk of burning herself. During an interview on 02/05/26 at 3:30 p.m., the DON stated a clothing protector should be worn for Resident #60 while smoking. The DON stated the staff that took her out there was responsible for ensuring she wore an apron. The DON stated she monitored by random checks and has not seen any issues with staff not ensuring Resident #60 wore a clothing protector. The DON stated Resident #60 has not had any burns in the past. The DON stated this failure put Resident #60 at risk for burns. During an interview on 02/05/26 at 4:19 p.m., the Administrator stated she expected Resident #60 to wear an apron while smoking. The Administrator stated the staff that was scheduled for that break was responsible for ensuring Resident #60 had one on. The Administrator stated this failure put Resident #60 at risk for burns. Record review of a facility's policy titled Smoking and Safety Measures, revised 10/2022, reflected . It is the policy of this facility to provide a smoke-free environment for residents and staff. While our policy is to accommodate smoking opportunities.safety is our utmost concern.2. Residents who desire to smoke will be assessed for safety with smoking materials. (b) the need for protective smoking gear.

Based on interviews, observation, and record review, the facility failed to ensure the resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 26 (Resident #44) residents reviewed for psychoactive medications. The facility did not ensure Resident #44 had signed a psychotropic consent for Prozac (antidepressant) 40 mg. This failure could place residents at risk for receiving unnecessary psychotropic medications without informed consent.Findings included: Record review of Resident #44's face sheet, dated 02/04/26, reflected Resident #44 was a [AGE] year-old female, readmitted to the facility 01/14/26 with a diagnosis which included depression (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #44's order summary report dated 02/04/26 reflected Resident #44 had an order for Prozac 40 mg, 1 tablet by mouth every day for depression with a start date 01/29/26. Record review of Resident #44's quarterly MDS assessment, dated 12/17/25, reflected Resident #44 made herself understood, and understood others. Resident #44's BIMS score was a 15, which reflected her cognition was intact. Resident #44 had little interest or pleasure in doing things 2-6 days and feeling down, depressed or hopeless 12-14 days during the 14-day look-back period. Resident #44 received an antidepressant medication during the look-back period. Record review of Resident #44's undated comprehensive care plan reflected Resident #44 was on antidepressant medication related to depression. The care plan interventions included: give antidepressant medications ordered by the physician, monitor/documents side effects and effectiveness. Record review of the MAR dated 01/01/26-01/31/26 reflected Resident #44 received Prozac 40mg orally daily on 01/29/26, 01/30/26, and 01/31/26. Record review of the MAR dated 02/01/26-02/28/26 reflected Resident #44 received Prozac 40mg orally daily on 02/01/26, 02/02/26, 02/03/26, and 02/04/26. Record review of the facility's electronic charting system on 02/04/26 revealed a consent formfor Prozac 30 mg signed by the resident. During an interview, observation and record review on 02/04/26 at 9:15 a.m., the DON was asked by the state surveyor for Resident #44's most recent consent for Prozac. The DON brought the consent for the 30 mg to the state surveyor. During an interview on 02/04/26 at 2:38 p.m., RN A stated she was the nurse that received the new order for Prozac 40 mg. RN A stated she did complete a consent for the 40 mg and placed it in a folder at the nurse's station. RN A stated it was important to ensure consent forms were obtained to make sure the resident was aware of the dosage change and side effects. During an interview, observation and record review on 02/04/26 at 2:50 p.m., RN A brought a signed consent for Prozac 40 mg to the state surveyor back dated 01/29/26. During an interview on 02/04/26 at 3:00 p.m., the state surveyor went to the dining room and asked Resident #44 if she had signed the consent for Prozac 40 mg on 01/29/26. Resident #44 stated RN A had just brought the paperwork for her to sign today (02/04/26) while she was playing bingo. Resident #44 stated she did not sign a consent on 01/29/26 for the Prozac 40 mg. During an interview on 02/05/26 at 3:30 p.m., the DON stated the nurse that received the change dosage order was responsible for ensuring a consent form was signed prior to administration. The DON stated she was responsible for monitoring and overseeing by reviewing the order listing report on psychotropic medications weekly. The DON stated her last audit was done before 01/29/26. The DON stated it was important to ensure consent forms were obtained to make sure the resident was aware of the medication, side effects and ensure she wanted to take the medication. During an interview on 02/05/26 at 4:19 p.m., the Administrator stated she expected consents to be signed prior to administration. The Administrator stated ultimately the DON was responsible for monitoring and overseeing psychoactive medications. The Administrator stated it was important to ensure consent forms were obtained to make sure the residents were aware of the medication, dosage, and side effects. Record review of the facility's policy titled Psychotropic Drug Use last reviewed on 08/2017, reflected. It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnoses and documented in the clinical record.6 (f). informed consent was obtained prior to medication use.7. Upon change of condition or initiation of a new order for psychoactive medications, the licensed nurses shall complete the verification of informed consent form prior to the initiation of the new medication.

Based on interviews and record reviews, the facility failed to treat each resident with respect and dignity and provided care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 26 residents (Resident #44) reviewed for resident rights. The facility did not ensure Resident #44 had the correct size briefs to go to dialysis. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.Findings included: 1. Record review of Resident #44's face sheet, dated 02/04/26, reflected Resident #44 was a [AGE] year-old female, readmitted to the facility 01/14/26 with a diagnosis which included morbid (severe) obesity due to excess calories. Record review of Resident #44's quarterly MDS assessment, dated 12/17/25, reflected Resident #44 made herself understood, and understood others. Resident #44's BIMS score was a 15, which reflected her cognition was intact. The assessment reflected Resident #44 was dependent with toileting, shower/bathe, upper/lower body dressing and putting on/taking off footwear. Resident #44 required setup or clean-up assistance with personal hygiene and independent with eating. Record review of Resident #44's updated comprehensive care plan reflected Resident #44 had ADL self-care performance deficit related to self-care deficit and morbid obesity. The care plan interventions included: Resident #44 required total assistance with Hoyer lift times two person assist for transfers at times depending on fatigue level and encouraged to discuss feelings about self-care deficit. Record review of an untitled and undated sheet given by Medical Records reflected there were no 3XL briefs in the supply room on 12/09/25, 12/16/25, and 12/23/25. During an interview on 02/02/26 at 11:05 a.m., Resident #44 stated she often missed dialysis due to personal reasons but there was a time she missed because the facility did not have briefs that fit her. Resident #44 stated she wanted to go that day but was told by CNA D that the facility was out of the briefs that would fit her. Resident #44 stated that it made her feel depressed. Resident #44 could not recall the exact date but knew it was sometime in December 2025. During an interview on 02/02/26 at 11:35 a.m., CNA D stated she could not recall the exact day, but the incident happened sometime in December 2025. CNA D recalled that Resident #44 missed dialysis because the facility did not have the correct size briefs. CNA D stated there were other sizes available, but it would not go all around her to fasten. CNA D stated she went and asked the other aides if they had any 3XL briefs on their hall and they stated no. CNA D stated she told the charge nurse (unable to recall name) that there were no briefs to fit Resident #44. CNA D remembered the nurse getting up and going to see if she could find some. CNA D stated the nurse came back and told her there was not any. CNA D stated she went and told Resident #44 the facility was out of the briefs she wore. During an interview on 02/03/26 at 5:43 p.m., Medical Records stated on 12/09/25, 12/16/25, and 12/23/25 there were no 3XL briefs in the supply room. Medical Records stated she did not go and count what was on the linen cart or in the resident's room. Medical Records stated she was unaware there were 4 bariatric residents in the facility. Medical Records stated it was never told to her that Resident #44 had to miss dialysis due to not having the correct size briefs. Medical Records stated not having the correct size briefs in the facility could cause residents to have to wear smaller size briefs which could be uncomfortable. During a telephone interview on 02/04/26 at 8:59 a.m., the Social Worker from the dialysis stated she could not recall the exact day, but she did remember the conversation between her and Resident #44 about her not coming to dialysis because the facility did not have the correct size briefs for her. During an interview on 02/05/26 at 3:30 p.m., the DON stated she was never told by staff nor Resident #44 that Resident #44 missed dialysis because the facility did not have the correct size briefs. The DON stated she was responsible for monitoring and overseeing supplies by asking Medical Records if there were not enough supplies and if she stated yes and she trusted her to do her job. The DON stated wearing smaller size briefs would not contain urine or feces. During an interview on 02/05/26 at 4:19 p.m., the Administrator stated she was not aware of Resident #44 missing dialysis due to her not having the correct size briefs. The Administrator stated she expected staff to notify her immediately if that issue occurred. The Administrator stated the DON/designee was responsible for monitoring and overseeing supplies. The Administrator stated this failure was a dignity issue. Record review of the facility's undated policy titled Resident Rights, reflected . It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 6 residents (Resident #59 and Resident #54) reviewed for pharmacy services. The facility failed to ensure Resident #59's discontinued wrapped in the back of the narcotic box Diazepam (controlled medication used to treat anxiety) was being accurately reconciled on 02/04/26. The facility failed to ensure Resident #54's discontinued wrapped in the back of the narcotic box Lyrica (controlled medication used for pain) was being accurately reconciled on 02/04/26. These failures could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.Findings included:1.Record review of Resident #59's face sheet, dated 02/05/26, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a neurological condition that can present as issues with muscle tone, posture and/or a movement disorder), impulsive disorder (a group of psychiatric conditions characterized by the inability to resist intense urges or temptations that may harm oneself or others), and high blood pressure. Record review of Resident #59's quarterly MDS assessment, dated 01/10/25, indicated Resident #59 understood and was understood by others. Resident #59's BIMS score was 15, which meant he was cognitively intact. The MDS indicated Resident #59 required help with toileting bed mobility, dressing, transfers, personal hygiene, and set up for eating. The MDS indicated he took antianxiety medication during the 7-day look back period. Record review of Resident #59's comprehensive care plan, undated, indicated he had a diagnosis of anxiety. The interventions were to administer medication as ordered by the physician and monitor/document side effects and effectiveness. Record review of Resident #59's active physician orders dated 02/05/26 indicated: diazepam Oral Tablet 5 MG (Diazepam) Give 2.5 mg by mouth at bedtime for anxiety with a start date of (01/13/26).Physician order summary did not address Diazepam 5mg tablet take one tablet by mouth at bedside dispensed on 12/27/25 which was in the narcotic lock box on observation. Record review of Resident #59's administration record February 2026 indicated Diazepam Oral Tablet 5 MG (Diazepam) Give 2.5 mg by mouth at bedtime for Anxiety administered daily at 2000(8:00PM) without missing a dose. The administration record did not address Diazepam 5mg tablet take one by mouth at bedtime which was in the narcotic lock box on observation which was last signed out with an illegible signature 0.5 tab and given on 1/14/26 at 2000 (8:00PM). 2. Record review of Resident #54's face sheet, dated 02/05/26 indicated Resident #54 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included low back pain. Record review of Resident #54's quarterly MDS assessment, dated 01/17/26, indicated Resident #54 was understood and was understood by others. Resident #54's BIMs score was 15, which indicated she was cognitively intact. Resident #54 required assistance with bathing, eating, toileting, transfer, personal hygiene, bed mobility and independent with dressing. The MDS indicated Resident #54 received pain medication during the 7-day look back period. Record review of Resident #54's comprehensive care plan, undated, indicated Resident #54 had potential for pain related to diagnosis of neuropathy. The intervention was to assess pain every shift and follow pain scale as ordered. Record review of Resident #54's physician's orders dated 01/09/26 indicated, Lyrica Oral Capsule 150 MG (Pregabalin) Give 1 capsule by mouth at bedtime for pain. Physician orders did not address Pregabalin 75mg take one capsule by mouth twice daily which was in the narcotic lock box on observation. Record review of Resident #54's of MAR indicated Lyrica Oral Capsule 150 MG (Pregabalin) Give 1 capsule by mouth at bedtime for pain given daily for the month of February 2026 at 2000 (8:00PM). MAR did not reflect an order for Pregabalin 75mg take one capsule by mouth twice daily last administered 1/9/26 at 12:00PM which was in the narcotic lock box on observation. During an observation and interview on 02/04/26 at 2:55PM, MA H said Resident #59's Diazepam was last administered on 01/14/26. Resident #59's diazepam card was noted at the back of the narcotic lock box, in the medication cart, wrapped in the narcotic count sheet order noted to take one tablet by mouth at bedtime. MA H revealed Resident #54's Pregabalin was last administered 01/09/26 signed out with an illegible signature. Resident #54's pregabalin card was noted at the back of the narcotic lock box wrapped in the narcotic count sheet order to take one capsule by mouth twice daily. MA H stated that she had no idea those were there and that the medications should have been given to the DON when discontinued. MA H stated that Resident #59 was at risk of theft of medication. Observation revealed Resident #54 pregabalin 75mg 38 tablets with no signs of tamper and Resident #59 diazepam 5mg 9 tablets with no signs of tamper. During an interview on 02/05/26 at 11:05 AM, the Pharmacist stated she expected all narcotics to be reconciled each shift every 8 hours, a log kept when administered, and the narcotics pulled from the cart and refrigerator and immediately given to the DON for destruction when no longer being prescribed by the physician. Pharmacist stated residents are at risk of theft of the medication and harm to the resident. During an interview on 02/05/26 at 3:48 PM, the DON said she performed random chart audits and the pharmacist did audits as well. The DON said the last audit conducted was on Hall 500 by the pharmacist and was dated 01/09/26. The DON stated she expected the Nurse to pull the discounted medication when order changes and immediately brought to the DON for destruction. The DON stated she expects all narcotics that are in the cart to be reconciled. DON stated that the facility was at risk of theft of medications. During an interview on 02/05/26 at 4:36 PM, the Administrator said the DON was responsible for ensuring all medications were locked, stored, distributed according to professional standards and pharmacist recommendations. The Administrator stated that she expected the DON to be responsible for drug destruction and in services regarding medication and medication storage. The administrator stated that she expected the discounted medications to be taken to the DON immediately because the facility was at risk of theft of narcotic medications. Record review of Legend Hall 500 medication cart audit, dated 01/09/26 done by the pharmacist, stated there was no evidence of out of date or discontinued medications on the cart. Record review of the facility policy titled, Nursing Services Drug Storage, dated 01/2022 indicated it is the policy of this facility to ensure the proper and safe storage of drugs and biologicals.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 4 medication storage areas (300 hall Medication Cart and medication refrigerator) observed for storage and security. 1. The facility failed to ensure MA H secured the 300 hall Medication Cart, when it was not in use and unattended on 02/02/2026. 2. The facility did not ensure Resident #14's medication named Lorazepam (used for anxiety) was secure in the unlocked refrigerator on 02/04/26. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. During an observation and interview starting on 02/02/2026 at 10:31 AM, there was an unlocked, unattended medication cart at the beginning of hall 400. Multiple staff and residents passed by the unlocked, unattended medication cart. At 10:46 AM, the DON observed the surveyor standing by the 300 hall Medication Cart, approached it, and locked it. The DON said the medication carts should not be left unlocked when unattended. The DON said all nursing staff should be conducting rounds to ensure the medication carts were locked. The DON said when a medication cart was left unlocked anybody could get into the medications carts and the residents could take the medications. During an interview on 02/03/2026 at 11:18 AM, MA H said she thought she locked the 300 hall Medication Cart, when she walked away from it on 02/02/2026. MA H said she had gone down the hall, then went outside to take a call, and when she returned, she was told she had left the 300 hall Medication Cart unlocked. MA H said the medication cart should be locked when she walked away from it. MA H said if the medications carts were left unlocked any of the medications could come up missing from the medication cart and the residents could have gotten into the medications. During an interview on 02/03/2026 at 6:19 PM, the Administrator said she expected the medication carts to be locked when unattended. The Administrator said the staff should be making sure the medication carts were locked. The Administrator said the residents could open an unlocked medication cart and take something out of it that was not for them. 2. During an observation and interview on 02/04/26 at 3:56 PM, LVN L revealed that the narcotic refrigerator was unlocked with Resident #14 Lorazepam drops stored inside. LVN L stated he thought he had locked the refrigerator when he counted at shift change 02/04/26 at 2:00PM. LVN L revealed the refrigerator should be locked for the safety of the staff and residents from theft. LVN L stated that he was responsible for ensuring the refrigerator was locked. During an interview on 02/05/26 at 11:05 AM, the pharmacist stated controlled medications should be locked with 2 locks. The medication fridge was required to be locked. During an interview on 02/05/26 at 3:48 PM, the DON stated she expected the nurses during count to ensure the refrigerator was locked and she expected the refrigerator to be locked at all times. DON stated she was responsible for ensuring the nursing staff are securing the medications and locking the refrigerator and each nurse who counts each shift. During an interview on 02/05/26 at 4:36 PM, the Administrator said the DON was responsible for ensuring all medications are locked, stored, distributed according to professional standards and pharmacist recommendations. The Administration stated that she expects the DON to be responsible for drug destruction and in-services regarding medication and medication storage. Record review of the facility policy titled, Nursing Services Drug Storage, dated 01/2022 indicated it is the policy of this facility to ensure the proper and safe storage of drugs and biologicals. Record review of the facility's policy titled, Pharmacy Services Drug Storage, revised 05/2021, indicated, It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals. Medication and treatment carts will be kept locked when unattended.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 2 of 2 residents (Resident #43, Resident #62) and 1 of 1 lunch meal reviewed for palatability. The facility did not provide palatable food served at an appetizing temperature or taste to Resident #43 and #62 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: During an observation and interview on 02/02/2026 at 11:30 a.m., [NAME] M completed temperature checks for all food textures and meal items prior to the start of the tray line and annotated temperatures in the temperature logbook. All temperatures were within acceptable temperature parameters. [NAME] M stated she checked the temperature at the start of the meal and about halfway through the meal service. [NAME] M stated if a resident complained that the meal items were cold, she would retake the temperature and provide a new tray or item for the resident. During an observation and interview on 02/02/2026 at 12:28 p.m., lunch tray was sampled by the Dietary Manager and 3 surveyors. The sample tray was served on a plate warmer, had a cover and consisted of chicken parmesan, barbecue sausage, and white beans. The Dietary Manager stated the chicken parmesan, sausage and beans were warm and could have been hotter. The surveyors agreed that all the sampled food temperatures could have been hotter. During an interview on 02/02/2026 at 1:06 p.m., Resident #43 stated the food was terrible. When asked to elaborate, he stated it was cold and bland. During an interview on 02/02/2026 at 1:09 p.m., Resident #62 stated the food was not seasoned enough. During an interview on 02/03/2026 at 1:10 p.m., the Dietary Supervisor stated that she had not received any complaints regarding food being cold. The Dietary Supervisor stated that the cook monitors food temperatures throughout the meal service and that she (the Dietary Supervisor) completes spot checks of the temperature logs and spot checks of actual temperature weekly. The Dietary Supervisor stated she monitored the meals by daily rounds in the dining room and random walks on the halls to communicate directly with the residents and asked questions about the food. The Dietary Supervisor stated it was important to ensure food temperatures are monitored when serving food to ensure temperature is acceptable for the residents to prevent poor intake, weight loss or malnutrition. During an interview on 02/05/2026 at 3:41 p.m., the DON stated that no residents have voiced concerns to her regarding food temperature and/or taste. The DON stated the facility used plate warmers on all trays to ensure food is kept as warm as possible. The DON stated that the potential risk is weight loss and unhappy residents. During an interview on 02/05/2026 at 4:20 p.m., the Administrator stated that to her knowledge, no residents have complained of cold food temperatures and that she expects staff to notify the kitchen and obtain a new food item if the resident complained of cold food. The Administrator stated that complaints of cold food could result in residents not eating their meals and weight loss. The Administrator stated the Dietary Supervisor is responsible for ensuring appropriate food temperatures for all tray items prior to serving to the residents and that the Administrator is ultimately responsible for ensuring the Dietary Supervisor monitors the temperatures appropriately. The Administrator stated that she would monitor the food temperatures by randomly requesting a meal tray on a monthly basis. The Administrator stated she expects the meals to be served at an acceptable temperature level and that it was important for the temperatures to be at acceptable levels to prevent potential weight loss and grievances. Record review of the facility policy titled Food Temperatures, undated, indicated, Policy: The temperatures of all food items will be taken and properly recorded prior to service of each meal.Procedure: 3. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit.during the holding and plating process and until food leaves the service area.

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 facility. 1. The facility failed to provide a metal container with a self-closing cover device. 2. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. These failures could place residents and staff at risk of unsafe smoking and injury.Findings included: During an observation on 02/03/26 at 9:30 a.m., there was a 31-gallon galvanized removable lid outdoor trash can with numerous cigarettes butts observed in it. There were numerous cigarette butts laying on the ground. There was no metal ash tray observed in the smoking area. During an interview on 02/04/26 at 4:40 p.m., Maintenance B stated it was ok to dispose of the cigarette butts in the outdoor trash with removable lid because it was a metal container. Maintenance B stated he did not notice the cigarette butts on the ground. Maintenance B stated they should be disposed of in the metal container. Maintenance B stated these failures could potentially cause a fire. During an interview on 02/05/26 at 8:06 a.m., Maintenance C stated cigarette butts should be disposed of in the metal ash tray. Maintenance C stated that it was the correct metal receptacle to dispose of the cigarette butts. Maintenance C stated he was responsible for monitoring the smoking area by rounding every morning. Maintenance C stated these failures could potentially cause a fire. During an interview on 02/05/26 at 4:19 p.m., the Administrator stated the metal container that was out there last month had a self-closing lid, but it had broken, and Maintenance was supposed to replace it. The Administrator stated she expected cigarette butts should be disposed of in the ash tray not on the ground. The Administrator stated the Maintenance Supervisor was responsible for monitoring and overseeing the smoking area, but she did make random rounds monthly. The Administrator stated these failures could potentially cause a fire. Record review of a facility's policy titled Smoking and Safety Measures, revised 10/2022, reflected . It is the policy of this facility to provide a smoke-free environment for residents and staff. While our policy is to accommodate smoking opportunities.safety is our utmost concern.10. Safety code approved ashtrays are provided and are the only approved receptable for disposing of smoking materials.

Based on interview, and record review, the facility failed to ensure in accordance with professional standards and practices, the medical records on each resident were accurately documented for 1 of 7 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure LVN A accurately documented on Resident #1's medical record the time of physician notification in the progress note dated 7/15/25. This failure could place residents at risk of emergency situations not being accurately documented, leading to confusion on what occurred when.Findings included:Record review of the face sheet dated 7/24/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including syncope and collapse (fainting, or sudden temporary loss of consciousness), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (elevated blood pressure), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and heart). Record review of the admission MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 used a walker for mobility. The MDS indicated Resident #1 required partial assistance with indoor mobility and transfers. Record review of the care plan last revised 6/30/25 indicated Resident #1 was at risk for falls related to muscle weakness, unsteady gait, and syncope (fainting). Record review of the incident report dated 7/15/25 written by LVN A indicated Resident #1 was found lying in the floor. The incident report indicated Resident #1 had ambulated to her personal bathroom without her assistive device and fallen to the floor. The incident report indicated Resident #1 was non-responsive to verbal or physical stimulation. The incident report indicated Resident #1's physician was contacted by the facility at 11:00 p.m. and gave an order to send her to the emergency room. Record review of the progress note dated 7/15/25 written by LVN A indicated Resident #1 was found on the floor. The progress note indicated Resident #1 had a decreased blood pressure and decreased pulse. The progress note indicated Resident #1's physician was notified at 10:30 p.m. Record review of the Call for Service Report dated 7/22/25 from EMS indicated on 7/15/25 EMS received a call from the facility at 11:02 p.m. The Call for Service report indicated EMS was on the scene at the facility at 11:07 p.m. on 7/15/25. During an interview on 7/23/25 at 4:40 p.m. CNA B said she was working the night shift on 7/15/25 and was the staff member who found Resident #1 lying in the floor. CNA B said she found Resident #1 in the floor just a little before 11:00 p.m. CNA B said she made sure Resident #1 was breathing and then ran to get the nurse. CNA B said she had come on shift at 10:00 p.m., got report from the previous CNA, gathered her supplies, and started making rounds. CNA B said while making her first round was when she found Resident #1. During an interview on 7/23/25 at 4:43 p.m. LVN A said she was working on 7/15/25 when Resident #1 was found in the floor. LVN A said it was a few minutes before 11:00 p.m. when she was notified of Resident #1 being in the floor. LVN A said she ensured Resident #1 was breathing, obtained her vitals, notified the physician, called EMS, and then notified the family. LVN A said the time documentation discrepancy for physician notification between the incident report and progress note was her fault. LVN A said she completed her incident report with the correct times and then when she completed her progress noted she clicked 10:30 p.m. for physician notification time. LVN A said she did not realize her mistake until the following day, and it was too late to change the documentation. LVN A said she had 2 issues going at the same time 1 with Resident #1 and another resident in the memory care unit which resulted in the time discrepancies. During an interview on 7/24/25 at 11:17 a.m. the Physician said he was unsure of what time he was contacted by the facility regarding Resident #1 on 7/15/25. The Physician said he knew the facility had woken him up when they called on 7/15/25 to report Resident #1 had fallen. During an interview on 7/24/25 at 11:23 a.m. the DON said the facility did not have a policy regarding accuracy of documentation. During an interview on 7/24/25 at 12:25 p.m. the DON said she expected nursing documentation to reflect a description of what was going on (incident, change of condition, etc.) and the action taken. The DON said time of notifications should be the same on an incident report and progress note. The DON said the importance of accuracy of documentation was to paint an accurate picture of what was going on and the actions taken at the time.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents and injury from hot liquid spills for 1 of 6 resident's (Resident #173) reviewed for accident and supervision. Resident #173 sustained a thermal burn from spilling hot coffee on her leg, served by CNA A without obtaining the temperature of the liquid on 11/12/2024. The noncompliance was identified as past non-compliance (PNC). The Immediate Jeopardy (IJ) began on 11/12/2024 and ended on 11/14/2024. The facility had corrected the non-compliance before the survey began. This failure could place residents served hot liquids at risk for thermal burns if spilled. The findings included: Record review of Resident #173's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of diabetes mellitus type II (condition that happens when the body cannot regulate the way sugar is used as fuel), COPD (a group of lung diseases that cause breathing problems over time), and stage III pressure ulcer to the sacrum (deep wound that involves several layers of skin extending to subcutaneous (fatty) tissue located at the where the spine and pelvis connect). Record review of Resident #173's quarterly MDS assessment dated [DATE] revealed a BIMS of 10 which indicated moderate cognitive impairment. Resident #173 required supervision for eating and maximal assistance for personal hygiene, bathing, and toileting. Resident #173 was coded to have (1) Stage III pressure ulcer and (2) unstageable pressure ulcers. Record review of Resident #173's care plan revealed a care plan dated 11/12/2024 titled Actual Impairment. Resident #173 had actual impairment to skin integrity of right medial thigh and right upper thigh related to a 2nd degree burn. Record review of Resident #173's hot liquid assessment dated [DATE] revealed she was able to manage hot liquids independently with no oversight. Record review of Resident #173's incident accident report dated 11/12/2024 at 2:24 p.m., revealed RN ADON B found burns to Resident #173's right upper thigh and medial thigh and around the back of the thigh down to the upper inner knee and upper calf. Open areas were noted to right medial thigh measuring 2cm X 2cm and right upper thigh 0.5 cm X 0.5 cm. Redness to top of thigh to the medial thigh down to the knee and upper calf area. The resident stated I spilled a cup of coffee on my leg this morning. It did not hurt, and it still does not hurt. During an interview on 11/19/2024 at 12:50 p.m., RN ADON B stated Resident #173 had (2) 2nd degree burns being treated daily since 11/12/2024 when she sustained the burns from a hot liquid spill. RN ADON B stated LVN ADON C was the person that investigated the incident and had the details of the occurrence. He stated Resident #173 had not reported the spilled coffee to anyone prior to his findings. During an interview on 11/19/2024 at 1:00 p.m., LVN ADON C stated Resident #173 had spilled a cup of hot coffee on herself on 11/12/2024 and sustained 2nd degree burns to her right thigh. She stated the coffee was served to Resident #173 by CNA A. She stated CNA A made the coffee in the employee breakroom and served it to Resident #173 without taking the temperature of the coffee prior to serving it. She stated it was the policy of the facility to not serve any liquids to residents above 140 degrees to prevent injuries like Resident #173's burns from occurring. She stated she immediately informed the MD and Administrator when RN ADON C informed her on 11/12/2024. She stated the MD/NP came to the facility that afternoon and an ad hoc QAPI meeting was held. She stated the MD, both ADONs, the ADM, dietary manager and social worker all attended the meeting. She stated she began to in-service all staff on not providing hot liquids or foods with hot liquids from anywhere other than the kitchen and not to heat items in the microwave for the residents. She stated she completed 100% of the staff by 8:00 p.m. on 11/12/2024. She stated she also began the hot liquid monitoring tool in which she chose 5 residents to interview about hot liquids and temp their liquids and foods with liquids prior to them eating daily for a week and then 2-3 times a week for 3 weeks. She stated she and the other administrative nurses completed hot liquid assessments and updated the care plans of the resident's that had changes to their dependence level. During an interview on 11/19/2024 at 1:45 p.m., CNA A stated she was the one that served Resident #173 coffee from the breakroom coffee pot. She stated she was just trying to make the resident happy. She stated when doing peri care for Resident #173 she mentioned wishing she had a cup of coffee. CNA A stated she went to the breakroom and brewed a fresh pot of coffee for her and brought her a cup. She stated Resident #173 drank and ate all her food in her bed, so she thought nothing of giving her a cup of coffee. She stated she was unaware she spilled the coffee until she was told when she was called and questioned about the incident by LVN ADON C. CNA A stated it never occurred to her that the temperature would be hot enough to burn the resident if she spilled it on herself. She stated she had been in serviced on not providing any hot liquid or food with liquid to the residents from anywhere but the kitchen and not to microwave anything and give it to the residents. During an interview on 11/19/2024 at 1:50 p.m., Resident #173 stated she asked for a cup of coffee during the night shift on 11/12/2024. She stated CNA A was nice enough to go and get her a cup of coffee and bring it back to her. She stated CNA A sat the coffee on her bedside table and left the room. Resident #173 stated she added sugar and creamer to the coffee and when she went to stir the coffee with a spoon the cup fell over and the coffee spilled onto her sheet and soaked through to her legs. She stated she was not aware of the burn because she had not felt it. She stated CNA A was not aware she was not supposed to have the kitchen test the temperature of the coffee before giving it to her. She stated she had asked for coffee in the past and drank it without any problems . The facility corrected the noncompliance on 11/14/2024 by the following: - Inservice 100% of staff about not serving hot liquids or food containing hot liquid that was not provided by the kitchen. Do not microwave food and serve to the resident. And all liquids or food with liquids served to the resident must be 140 degrees or below. -Completed 11/12/2024 8:00 p.m. - Started hot liquid assessment tool 11/12/2024 to interview residents and monitor the temperature of the liquids served to 5 residents daily for week and then 5 residents 2-3 days a week for 3 weeks. - Monitoring remained in progress - QAPI meeting held to discuss hot liquid management for resident safety on 11/12/2024. - Completed 11/12/2024 - MD/NP evaluated Resident #173's burn and wrote treatment orders - Completed 11/12/2024 - Hot liquid assessments completed on all residents- Completed 11/14/2024 - Care plan updated on any resident that had a status change related to the hot liquid assessment- Completed 11/14/2024. Record review of a Quality Assurance (QA) Meeting Sign-in Sheet dated 11/12/2024 indicated the facility had an QA meeting addressing hot liquid management for resident safety. The QA Meeting Sign-in Sheet indicated the RN ADON B, LVN ADON C, ADM, MD/NP, dietary manger, housekeeping supervisor, floor nurses, and CNAs attended the meeting. Record review of the MD progress note dated 11/12/2024 revealed Resident #173 had been seen on 11/12/2024 at 4:00 p.m. and was noted to have spilled hot coffee on her thigh. Resident #173 had a large red patch with a few blistered areas. Most of the redness was now a 1st degree burn. A couple of the area are 2nd degree burns with no evidence of infection. Record review of the hot liquids assessment dated [DATE] completed by LVN ADON C for Resident #173 indicated she was to remain independent with hot liquids with no oversight required. Record review of the care plan titled actual skin impairment updated on 11/12/2024 by RN ADON B revealed Resident #173 had actual impairment to skin integrity of right medial thigh 2 cm x 2 cm and right upper thigh 0.5 cm x 0.5 cm related to a 2nd degree burn. It indicated the treatment for the burns was for each area to be cleansed daily, triple antibiotic ointment applied and covered with a silicone dressing. Record review of the treatment administration record (TAR) for Resident #173 dated 11/12/2024 to 11/19/2024 indicated daily treatments were completed to the right medial thigh and right upper thigh burns. Record review of the hot liquid monitoring tool dated 11/12/2024 revealed monitoring of 5 residents from 11/12/2024 to 11/18/2024. The residents were asked if they were served hot liquids after 8 p.m. when the kitchen was closed, if the temperature of the liquids consumed the prior meal was too hot, and temperatures were recorded for hot liquids and soups. All staff interviewed (RN ADON B, LVN D, LVN E, CNA F, LVN H, CNA I, CNA J, LVN K, Laundry L, Therapist M, and Housekeeper N) on 11/19/2024 verbalized understanding of not providing hot liquids or food with hot liquid to the resident that was not prepared in the kitchen and not to microwave any food and give it to the resident without the kitchen testing the temperature first. They all verbalized 140 degrees as the maximum temperature of food and liquids served to a resident. During an interview on 11/19/2024 at 4:30 p.m., the DON stated the facility did not have a hot liquid policy. They only policy the facility had was a kitchen policy that no liquid be served greater than 140 degrees to the residents. She stated the facility did not have an accidents and hazards policy either. She stated she was on vacation when the incident with Resident #173 occurred, and she was not aware of the incident until she returned on 11/16/2024. She stated it was her expectation for all staff to go through the kitchen for service of food and liquids because the kitchen staff was trained to handle foods at temperatures safe for consumption by the residents. She stated she was unaware night shift was making coffee for Resident #173 in the breakroom, but the coffee pot had been removed from the breakroom. During an interview on 11/20/2024 at 1:00 p.m., the ADM stated he was torn by the incident that occurred with Resident #173. He stated CNA A was making sure the resident's rights were protected by allowing her coffee when the kitchen was closed, but it was an unsafe choice because the resident had a fluke accident with the coffee. He stated he expected all liquids to come from the kitchen and be the appropriate temperature prior to being served to the residents to prevent accidents such as this from occurring. The ADM stated there was no policy on accidents and hazards related to hot liquids spills caused by nursing staff. The ADM stated all liquids served to the residents should be 140 degrees or less to prevent burns. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/12/2024 and ended on 11/14/2024. The facility corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to complete a resident assessment within the required time frame for 4 of 18 residents (Resident #9, Resident #16, Resident #26, and Resident #31) reviewed for quarterly assessments. The facility did not ensure Resident #9, Resident #16, Resident #26, and Resident #31's quarterly MDS assessments were completed within 14 days of the ARD. This failure placed residents at risk of not having their assessments completed timely which could result in not having their individually assessed needs met. Findings included: 1. Record review of Resident #9's face sheet dated 11/20/24 indicated she was [AGE] years old and admitted to the facility initially on 10/12/21 and readmitted on [DATE] with diagnoses which included syncope and collapse (fainting or passing out). Record review of Resident #9's MDS assessment, with an ARD of 10/23/24, indicated in Section A0310 it was a Quarterly assessment (required by day 14). The MDS assessment for Resident #9 indicated in Section A1600 an entry date of 2/27/24. The MDS assessment in Section Z0500 was signed completed on 11/08/24, which indicated the MDS assessment for Resident #9 was completed 3 days late. Record review of the CMS transmittal report dated 11/13/24, indicated Resident #9's quarterly assessment was due to be completed by 10/23/24. The MDS assessment was accepted with the CMS Warning Record, Assessment Completed Late . the assessment completion date was more than 14 days after the assessment reference date. 2. Record review of Resident #16's face sheet dated 11/20/24 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #16's MDS assessment, with an ARD of 10/18/24, indicated in Section A0310 it was a Quarterly assessment (required by day 14). The MDS assessment for Resident #16 indicated in Section A1600 an entry date of 11/23/16. The MDS assessment in Section Z0500 was signed completed on 11/03/24, which indicated the MDS assessment for Resident #16 was completed 3 days late. Record review of the CMS transmittal report dated 11/06/24, indicated Resident #16's quarterly assessment was due to be completed by 10/18/24. The MDS assessment was accepted with the CMS Warning Record, Assessment Completed Late . the assessment completion date was more than 14 days after the assessment reference date. 3. Record review of Resident #26's face sheet dated 11/20/24 indicated he was [AGE] years old and admitted to the facility on initially 9/13/19 and readmitted [DATE] with diagnoses which included hypertension (high blood pressure). Record review of Resident #26's MDS assessment, with an ARD of 10/16/24, indicated in Section A0310 it was a Quarterly assessment (required by day 14). The MDS assessment for Resident #26 indicated in Section A1600 an entry date of 1/06/24. The MDS assessment in Section Z0500 was signed completed on 11/03/24, which indicated the MDS assessment for Resident #26 was completed 5 days late. Record review of the CMS transmittal report dated 11/06/24, indicated Resident #26's quarterly assessment was due to be completed by 10/16/24. The MDS assessment was accepted with the CMS Warning Record, Assessment Completed Late . the assessment completion date was more than 14 days after the assessment reference date. 4. Record review of Resident #31's face sheet dated 11/20/24 indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar). Record review of Resident #31's MDS assessment, with an ARD of 10/17/24, indicated in Section A0310 it was a Quarterly assessment (required by day 14). The MDS assessment for Resident #31 indicated in Section A1600 an entry date of 8/19/19. The MDS assessment in Section Z0500 was signed completed on 11/03/24, which indicated the MDS assessment for Resident #31 was completed 4 days late. Record review of the CMS transmittal report dated 11/06/24, indicated Resident #31's quarterly assessment was due to be completed by 10/17/24. The MDS assessment was accepted with the CMS Warning Record, Assessment Completed Late . the assessment completion date was more than 14 days after the assessment reference date. During an interview on 11/20/24 at 9:26 AM, the MDS Coordinator Resource Nurse said she took over the facility's MDS Coordinator duties on 10/22/24 after the regular MDS nurse left 10/18/24 on maternity leave. The MDS Coordinator Resource Nurse said there was no excuse on the assessments being completed/signed late. The MDS Coordinator Resource Nurse said the assessments were just part of the end of the month assessments that were due or past due when she assumed the building. The MDS Coordinator Resource Nurse said they did not have a policy related to MDS assessments, but they followed the RAI Manual as their guidelines. During an interview on 11/20/24 2:22 PM, the ADM said he would expect MDS assessments to be completed and signed timely per the facility's policies. Review of the RAI guidelines accessed on 11/25/24 at 10:42 AM, Minimum Data Set 3.0 Resident Assessment Instrument User's Manual v1.19.1 dated October 2024 revealed . the Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type . the MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) .

Based on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional for 2 of 4 residents (Resident #13 and Resident #28) reviewed for comprehensive assessments and timing. The facility did not ensure Resident #13's Annual MDS assessment was completed within 14 days of admission. The facility did not ensure Resident #28's Admission MDS assessment was completed within 14 days of admission. This failure could place residents at risk of not having their needs identified and met. Findings included: Record review of Resident #13's face sheet dated 11/18/24 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar). Record review of Resident #13's comprehensive MDS assessment, with an ARD of 10/23/24, indicated in Section A0310 it was an Annual assessment (required by day 14). The MDS assessment for Resident #13 indicated in Section A1600 an entry date of 7/02/22. The MDS assessment in Section Z0500 was signed completed on 11/08/24, which indicated the MDS assessment for Resident #13 was completed 3 days late. Record review of Resident #28's face sheet dated 11/20/24 indicated he was [AGE] years old and admitted to the facility initially on 10/14/24 and readmitted on [DATE] with diagnoses which included vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain). Record review of Resident #28's comprehensive MDS assessment, with an ARD of 10/18/24, indicated in Section A0310 it was an Admission assessment (required by day 14). The MDS assessment for Resident #28 indicated in Section A1600 an entry date of 10/14/24. The MDS assessment in Section Z0500 was signed completed on 11/03/24, which indicated the MDS assessment for Resident #28 was completed 3 days late. During an interview on 11/20/24 at 9:26 AM, the MDS Coordinator Resource Nurse said she took over the facility's MDS Coordinator duties on 10/22/24 after the regular MDS nurse left 10/18/24 on maternity leave. The MDS Coordinator Resource Nurse said there was no excuse on the assessments being completed/signed late. The MDS Coordinator Resource Nurse said the assessments were just part of the end of the month assessments that were due or past due when she assumed the building. The MDS Coordinator Resource Nurse said they did not have a policy related to MDS assessments, but they followed the RAI Manual as their guidelines. During an interview on 11/20/24 at 2:22 PM, the ADM said he would expect MDS assessments to be completed and signed timely per the facility's policies. Review of the RAI guidelines accessed on 11/25/24 at 10:42 AM, Minimum Data Set 3.0 Resident Assessment Instrument User's Manual v1.19.1, dated October 2024 revealed . for OBRA-required Comprehensive assessments, assessment completion is defined as completion of the CAA process in addition to the MDS items, meaning that the RN assessment coordinator has signed and dated both the MDS (item Z0500) and CAA(s) (item V0200B) completion attestations . since a Comprehensive assessment includes completion of both the MDS and the CAA process, the assessment timing requirements for a comprehensive assessment apply to both the completion of the MDS and the CAA process . the MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than .

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 3 of 16 residents (Resident #173, Resident #16, and Resident #61) reviewed for ADLs. The facility failed to provide scheduled showers and/or bed baths to Resident #173, Resident #16, and Resident #61 at least 3 times per week. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings included: 1.Record review of Resident #173's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of diabetes mellitus type II (condition that happens when the body cannot regulate the way sugar is used as fuel), COPD (a group of lung diseases that cause breathing problems over time), and stage III pressure ulcer to the sacrum (deep wound that involves several layers of skin extending to subcutaneous (fatty) tissue located at the where the spine and pelvis connect). Record review of Resident #173's quarterly MDS assessment dated [DATE] revealed a BIMS of 10 which indicated moderate cognitive impairment. Resident #173 required supervision for eating and maximal assistance for personal hygiene, bathing, and toileting. Resident #173 was coded to have (1) Stage III pressure ulcer and (2) unstageable pressure ulcers. Record review of Resident #173's care plan dated 09/26/2024 titled ADL self-care deficit revealed Resident #173 had a self-care deficit related to impaired mobility, generalized weakness, and monopoiesis of the left lower extremity. The intervention was listed as staff will physically assist resident with ADLs. Resident #173 had no care plans related to refusal of bathing. Record review of Resident #173's bathing documentation revealed the following days a scheduled bath was missed beginning 09/15/2024 and ending 11/19/2024. 09/17/2024 09/21/2024 09/24/2024 09/26/2024 09/28/2024 10/05/2024 10/08/2024 10/10/2024 10/15/2024 10/17/2024 10/22/2024 11/05/2024 11/14/2024 During an interview and observation on 11/18/2024 at 11:00 a.m., Resident #173 had a strong smell of body odor, greasy hair that was slicked down to her head, and full thick moustache to her upper lip. Resident #173 stated she had a wash down in the bed the previous week, but the CNA had not shaved her in a couple of weeks. Resident #173 stated she liked to have her facial hair removed with each bath, but she was not getting 3 baths per week like she was supposed to. She stated she was supposed to get a bath on Tuesday, Thursday, and Saturday on the 2-10 shift but they were often too busy to get to all the bathing on the 2-10 shift. Resident #173 stated she could not remember the last time she had her head fully washed. She stated she refused a lot of things but never refused to be bathed because she knew she needed it for her skin to heal and she did not want to smell badly. She stated body odor was embarrassing and having facial hair was for men. During an interview on 11/19/2024 at 2:30 p.m., CNA J stated she gave Resident #173 a bed bath on Saturday 11/14/2024. She stated she had not shaved or washed Resident #173's hair when giving her a bed bath. She stated a bath should include personal hygiene like shaving and hair washing. She stated Resident #173 being bed bound made washing her hair difficult. She stated she had not known Resident #173 to refuse care. CNA J stated there were times it was difficult to give full baths or showers to all residents each shift, but if you had good time management it was not impossible. 2. Record review of Resident #16's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, glaucoma (a group of eye diseases that can damage the optic nerve and lead to blindness), and depression (a common mental health condition that can impact thoughts, feelings, and behaviors). Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed a BIMS of 15 which indicated no cognitive impairment. Resident #16 required maximal assist with bathing, personal hygiene and toileting. Resident #16 was not coded for refusal of care. Record review of Resident #16's care plan dated 09/08/2024 titled ADL self-care deficit revealed Resident #16 had a self-care deficit related to impaired mobility, limited range of motion, and blindness. The intervention was listed as staff will physically assist resident with ADLs. Resident #16 had no care plans related to refusal of bathing. Record review of Resident #16's bathing documentation revealed the following days a scheduled bath was missed beginning 09/01/2024 and ending 11/19/2024. 09/02/2024 09/04/2024 09/06/2024 09/11/2024 09/13/2024 09/16/2024 09/23/2024 10/23/2024 10/25/2024 10/30/2024 11/08/2024 11/11/2024 11/13/2024 11/15/2024 During an interview on 11/16/2024 at 9:15 a.m., Resident #16 stated she was given a cold washcloth to wipe off today. She stated she wanted to have a bath more often than 3 days a week, but she understood everyone needed a turn. She stated her bath days were Monday, Wednesday, Friday, and she normally got a bath once or twice a week. She stated it was important for her to be clean to feel happy. During an interview on 11/19/2024 at 2:30 p.m., CNA J stated she gave Resident #16 her bath on the 2 p.m. to 10 p.m. shift. CNA J stated there were times it was difficult to give full baths or showers to all residents each shift, but if you had good time management it was not impossible . 3.Record review of Resident #61's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of anxiety, Raynaud Syndrome (a condition that causes decreased blood flow to extremities and depression (a common mental health condition that can impact thoughts, feelings, and behaviors). Record review of Resident #61's quarterly MDS assessment dated [DATE] revealed a BIMS of 09 which indicated moderate cognitive impairment. Resident #61 required supervision for bathing, toileting, and personal hygiene. No refusal of care was documented on the MDS. Record review of Resident #61's care plan dated 09/08/2024 titled ADL self-care deficit revealed Resident #61 had a self-care deficit related to impaired mobility. No care plan for refusal of care was documented. Record review of Resident #61's bathing documentation revealed the following days a scheduled bath was missed beginning 09/01/2024 and ending 11/19/2024. 09/02/2024 09/11/2024 09/13/2024 09/16/2024 09/20/2024 09/25/2024 09/27/2024 09/30/2024 10/02/2024 10/04/2024 10/14/2024 10/21/2024 10/25/2024 10/28/2024 11/01/2024 11/06/2024 11/08/2024 11/13/2024 11/15/2024 During an interview and observation at 11/16/2024 at 9:00 a.m., Resident #61 stated she had gotten a bath once a week for the last month. She stated she was unsure why the staff would not assist her with a bath she just required supervision and someone to wash her back. She stated she was incontinent at times, and she felt unclean without bathing at least every other day. She stated she wanted to stay in the room when she fears she smells like urine. She stated she had reported to the DON she was not getting her baths and she changed the days the baths were scheduled. She stated she was a Monday, Wednesday, Friday bath on the 6 a.m. to 2 p.m. shift. During an interview on 11/16/2024 at 11:00 a.m., CNA F stated Resident #61 was a resident that received her bath on Monday, Wednesday, and Friday. She stated she was supervision only and baths were important to Resident #61. She stated she had no problems getting all her baths completed on her assigned hallway. She stated Resident #61 had only refused once in the entire time she had been a resident that she recalled. During an interview on 11/20/2024 at 10:00 a.m., the DON stated she expected all residents to get their baths at least 3 days a week. She expected if a refusal occurred for the CNA to notify the nurse and the nurses to contact the family with each refusal. She stated Resident #173 only liked bed baths, Resident #16 had days when she did not want to be bothered and Resident #61 refused in the past. The DON stated she understood refusals were not documented in the chart and notifying the family was not charted either. The DON stated it was important for everyone to maintain hygiene for the residents over all wellbeing. During an interview on 11/20/2024 at 11:00 a.m., the ADM stated he expected all residents to get their baths as scheduled. He stated he expected all refusals to be documented and an attempt to be made to have the family intervene in their refusal. He stated it was crucial for the resident's psychological wellbeing to have good hygiene. Requested ADL policy on 11/19/2024 at 2:00 p.m. and 11/20/204 at 11:00 a.m. No ADL policy was provided prior to exit.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 6 residents (Resident #66) reviewed for unnecessary medications in that: The facility failed to ensure Resident #66 had documented diagnoses for the use of Humulin R (Regular insulin, also known as neutral insulin and soluble insulin, is a type of short-acting medical insulin. It is used to treat type 1 diabetes, type 2 diabetes, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states). This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines) and receiving unnecessary medications. Findings include: Record review of Resident #66's face sheet dated 11/19/24 indicated Resident #66 was a 76-years-old male admitted on [DATE] with diagnoses including malignant neoplasm of colon(a cancerous growth in the colon or rectum), unspecified, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), and unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Resident #66 face sheet did not reflect diagnoses of diabetes mellitus. Record review of Resident #66's quarterly MDS assessment dated [DATE] indicated Resident #66 was understood and understood others. Resident #66 had clear speech, adequate hearing, and adequate vision. Resident #66 had a BIMS score of 15 which indicated intact cognition. Resident #66''s MDS assessment did not reflect diagnoses of diabetes mellitus. Record review of Resident #66''s care plan dated 10/17/24 indicated Resident #66 had diabetes mellitus. Diabetes medication as ordered by doctor. Monitor and document for side effects and effectives. Monitor and document report to MD PRN signs and symptoms of hypoglycemia: sweating, tremor, increased heartrate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Record review of Resident #66's consolidated physician order active as of 11/12/24 indicated : * Humulin R Injection Solution (Insulin Regular) (Human)) Inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units Call MD, subcutaneously in the morning for diabetes mellitus. Ordered date 11/12/24 . Record review of Resident #66's hospital history and physical dated 10/08/2024 did not reflect diagnoses of diabetes mellitus. During an interview on 11/19/24 at 1:25 P.M., the DON was asked why Resident #66 did not have a diagnosis for diabetes mellitus and he took Humulin R insulin. The DON said Resident #66 came from the hospital with the insulin orders. She said the MD said he did not know why Resident #66 did not have a diagnosis for diabetes mellitus from the hospital. During an interview on 11/19/24 at 2:57 P.M., the MD said he glanced over hospital orders for new residents. He said he reviewed and glanced over hospital records when residents came from the hospital. The MD was asked why a diagnosis for diabetes mellitus was not in Resident #66's medical history. He said the hospital should had sent Resident #66 to the facility with a diagnosis of diabetes mellitus, because they sent him back on Humulin R insulin and Glucerna for tube feeding, which implied he had a diagnosis of diabetes mellitus. He said Resident #66 should have had the diagnosis for diabetes mellitus before he came to the facility. The MD said the records did not show Resident #66 had a diagnosis of diabetes mellitus, but the hospital was treating him as a diabetic. During an interview on 11/20/24 at 8:16 A.M., ADON B said everyone that was a nurse would be responsible for putting in a new resident's diagnosis and new orders, but most of the time the charge nurse or the admission nurse put that information in the system. He said ADON C or himself normally checked orders and diagnosis behind the charge nurse or admission nurse. He said the MDS nurse normally put in the diagnosis code. He said ADON C or himself normally checked the resident's orders to make sure the resident has a diagnosis for a medication. During an interview on 11/20/24 at 8:44 A.M., RN Q said the charge nurse was responsible for putting in the orders for a new or returning residents that came from the hospital. She said the MDS nurse normally put the diagnosis in the system. During an interview on 11/20/24 at 9:05 A.M., LVN S said we as nurses a responsible for putting in orders for a new or returning resident when they return from the hospital during an admission. LVN S said the charge nurses do admissions on the weekend, because the facility has an admission nurse during the week. She said when she put orders in, she put the medication and what it was for, but she did not know how to add a diagnosis. During an interview on 11/20/24 at 10:18 A.M., MDS R nurse said the facility had an admission nurse that put in the new admission orders and knew how to link the diagnosis with the orders. She said typically the admission nurse checks the diagnosis and put in the diagnosis when he put in the orders. She said normally one of the ADON's checked behind the admission nurse. During an interview on 11/20/24 at 10:24 A.M., ADON C said usually the residents has a diagnosis for diabetes mellitus if they have been diagnosed with it when they leave the hospital. She said she guess when looked at the diagnosis he should have had a diagnosis for diabetes mellitus. She said she usually the ADON's checked orders and diagnosis behind the admission nurse or charge nurses to make sure the orders are in the system and the admission was complete. She said the resident not having a diagnosis for diabetes mellitus was a rare incident, because he came from the hospital on insulin and glucerna . During an interview on 11/20/24 at 10:36 A.M., the DON said the MDS put in the resident's diagnosis. She said the admission nurse, charge nurse or any available nurse were responsible for putting the orders in the system. She said the ADON's were responsible for checking the any orders placed in the system. She said the ADON's does not check for the diagnosis; the MDS nurse checked the diagnosis . During an interview on 11/20/24 at 11:24 A.M., ADM said the DON was the overseer of all medications and orders. He said it was not just one person responsibility to check medication orders and diagnosis. He said all resident's diagnosis should be in the system because we need to know what we were treating the resident for. Record review of a facility's Administration of Medications revised date 07/2017 indicated .medications must be given in accordance with the resident's service plan .

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 1 of 16 residents reviewed for diabetic management. (Resident #1) The facility did not monitor blood sugars for Resident #1 who had a [DIAGNOSES REDACTED]. Resident #1 was sent to the ER per family request on [DATE] and his blood sugar was 764 (normal blood glucose ,[DATE]). The resident was admitted to the hospital with [REDACTED]. The resident was started on an insulin drip and placed on an insulin sliding scale. The resident died . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with abnormal blood sugar levels at risk of harm or death. Findings included: An Admission Record dated [DATE], indicated Resident #1 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. An order summary report dated [DATE], indicated Resident #1 was to receive Alogliptin Benzoate 12.5 milligrams one tab by mouth daily for [MEDICAL CONDITION], [MEDICATION NAME] 4 milligrams one tablet by mouth twice daily for type 2 diabetes, and [MEDICATION NAME] 50 milligrams one tablet by mouth one time a day for diabetes. An MDS dated [DATE] indicated Resident #1 made himself understood and understood others. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and supervision with eating. The MDS indicated Resident #1 had an active [DIAGNOSES REDACTED]. An MAR indicated [REDACTED]. A weight and vitals summary printed [DATE] indicated no blood sugars were documented for Resident #1 from [DATE]-[DATE]. A care plan dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. Daily skilled nursing notes dated [DATE]-[DATE] did not include documentation regarding Resident #1's blood sugar levels. A hospital nursing every shift reassessment education and progress note dated [DATE] at 6:00 p.m., indicated Resident #1 had his blood sugar checked and was covered by sliding scale insulin. A hospital nursing every shift reassessment education and progress note dated [DATE] at 2:00 p.m., indicated Resident #1 had his blood sugar checked and was covered per sliding scale insulin. A surgical note dated [DATE] indicated Resident #1 had a consultation for evaluation of a wound at the left 1st toe. The note indicated Resident #1 had risk factors including diabetes and depression and had a wound on his left 1st toe caused by diabetes. The note indicated Resident #1 had a chronic wound that may or may not heal and may worsen as a result of chronic comorbidities and restricted mobility. A hospital history and physical dated [DATE] indicated Resident #1 was brought to the emergency room due to increased shortness of breath. The note indicated the resident had significant gangrene to his great toe, he appeared to be in the process of dying. The history and physical indicated Resident #1's glucose was 764, he was admitted to the hospital with [REDACTED]. The history and physical indicated the resident was started on an insulin drip and placed on an insulin sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses). A hospital physician's progress note dated [DATE] at 2:45 p.m., indicated Resident #1 passed away. During an interview on [DATE] at 10:35 a.m., Resident #1's daughter said her father was placed in the facility after he was discharged from a behavioral hospital on [DATE]. She said her father had a cut on his left great toe when he admitted , and the wound care physician was taking care of the wound. She said two weeks after being at the facility she received a call from the facility the wound was worsening, and gangrene was in the wound. She said she begged to be allowed in the facility to see her father as his condition was worsening, she said she was allowed in to see him with full PPE on [DATE]. Resident #1's daughter said upon entering his room she noticed a terrible odor and her father looked very ill, she said he was very thirsty, appeared feverish and had a cough. Resident #1's daughter said she demanded her father be sent to the emergency room , she said at the ER his blood sugar was over 700, he was placed in the intensive care unit with pneumonia, gangrene, multiple pressure ulcers, [MEDICAL CONDITION]. She said he was placed on hospice care after several days due to no improvement and expired on [DATE]. During an interview on [DATE] at 11:25 a.m., LVN A said if a resident was admitted with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:05 p.m., LVN D said she would call the attending physician to obtain blood sugar monitoring orders for any resident being admitted to the facility with diabetes and no current orders for blood sugar monitoring. During an interview on [DATE] at 12:50 p.m., LVN B said she would verify admission orders [REDACTED]. During an interview on [DATE] at 3:10 p.m., Resident #1's physician said he would order blood sugar monitoring on all diabetic residents unless the resident was on hospice or palliative care. He said he would expect all other residents with the [DIAGNOSES REDACTED]. During an interview on [DATE] at 3:34 p.m., LVN C said Resident #1 had a 1x1 cm wound to his great toe on admit, she said the wound started draining around [DATE] and the wound specialist debrided the wound. LVN C said the family was notified and she was unaware the residents blood sugars were not being monitored. She said not all residents with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 4:10 p.m., the DON said she had communicated with the wound physician, Resident #1's family, and the attending physician when the wound was not improving. The DON said the resident's overall status was declining and the family was insistent about visitation. She said she allowed the daughter to enter facility wearing full PPE and during her visit agreed to send the resident to the hospital. The DON said she was notified by Resident #1's family by phone the resident's blood sugar was in the 700s while at the ER, she said she immediately reviewed his chart and noticed blood sugars had not been taken while he was at the facility. She said she overlooked Resident #1 was receiving blood sugar monitoring and sliding scale insulin while at the previous psychiatric facility and did not call to get clarification regarding his diabetes management. She said if a resident was being admitted to the facility and had a [DIAGNOSES REDACTED]. During an interview on [DATE] at 4:40 p.m., the administrator said he would expect all admission orders [REDACTED]. The website https://www.cdc.gov/diabetes/managing/managing-blood-sugar/bloodglucosemonitoring.html indicated regular blood sugar monitoring is the most important thing you can do to manage type 1 or type 2 diabetes. You'll be able to see what makes your numbers go up or down, such as eating different foods, taking your medicine, or being physically active. With this information, you can work with your health care team to make decisions about your best diabetes care plan. These decisions can help delay or prevent diabetes complications such as [MEDICAL CONDITION], stroke, kidney disease, [MEDICAL CONDITION], and amputation. Your doctor will tell you when and how often to check your blood sugar levels. The Website https://www.drugs.com/[MEDICATION NAME].html indicated while taking [MEDICATION NAME] your blood sugar may need to be checked often, and you may need other blood tests at your doctor's office. The administrator and DON were notified on [DATE] at 1:30 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on [DATE] at 6:00 p.m. and included the following: Administrator notified Medical Director and governing body. Medical Director states blood glucose checks are not routinely required with these oral anti-hyperglycemic medications. It is to be determined by the physician. Notification of Physician. DON with assistance of RN Resource began in-service on Immediate Jeopardy Plan of Removal. Prior to IJ being called, all residents with the [DIAGNOSES REDACTED]. All current orders were appropriate. All care plans and MDS's for these residents are being reviewed as well and will be for all residents going forward according to MDS/Care Plans subsequent schedules. In-service initiated on [DATE] with completion date of [DATE] and to include: Verify admitting orders for new and readmitted residents and specifically if resident is on oral anti-hyperglycemic medications to verify if physician requests to have blood glucose checks. Monitoring to Ensure Ongoing Compliance Activity and findings will be summarized and shared with QA and A committee for review and further recommendations monthly to identify any trends, revise plan of correction as needed, and verify compliance. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: An in-service training report titled Verification of orders for diabetic patients dated [DATE], indicated 19 nurses had been in-serviced regarding the need to review the medication reconciliation for each resident upon admission, confirm orders with the admitting physician, and all residents on oral hypoglycemic medications must have orders reviewed by the admitting physician to determine the need for blood glucose monitoring. Eight nurses (7 LVNs and 1 RN) from the ,[DATE] shift, 4 LVN's from the ,[DATE] shift and 3 LVN's from the ,[DATE] shift verbalized the need for medication reconciliation upon admission, the need to confirm orders with the admitting physician upon admission and all resident on oral hypoglycemic medications must have orders reviewed by the admitting physician to determine the need for blood glucose monitoring. The administrator was notified the IJ was lifted on [DATE] at 3:00 p.m., however the facility remained out of compliance at a severity level of actual harm at a scope of isolated, due to the facility's need to complete in-service training and evaluate the effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent pressure sore development and deterioration for 2 of 12 residents sampled for pressure sores (Resident #4 and #18). Resident #4 was readmitted [DATE] without pressure sores. A Stage II pressure sore was identified on his left buttock on 8/11/10. On 8/13/10 the pressure ulcer report indicated he had an unstageable 3.0 centimeter (cm.) by 4.2 cm. coccyx pressure sore, covered with 100% eschar. Resident #4 was not provided pressure reduction devices for his bed or wheelchair and did not receive protein snacks as ordered. Resident #18 had a history of [REDACTED]. by 1.5 cm., Stage II pressure sore was identified on Resident #18's coccyx. On 9/1/10 the pressure sore had deteriorated, measuring 5.0 cm. by 3.5 cm., with slough in the entire wound bed. She was not provided a pressure reduction mattress per her care plan. The facility identified fifteen residents with pressure sores. Seventy-one residents were identified as "at risk" for pressure sore development. These failures contributed to the development and the deterioration of Resident #4 and #18's pressure sores. These failures could place 15 residents with pressure sores and 71 residents at risk for pressure sore development at increased risk of pressure sore development, delayed wound healing, pain, and infection. Findings included: 1) A) Resident #4's physician orders [REDACTED]. Resident #4's most recent Minimum Data Set ((MDS) dated [DATE] revealed he: * had short term memory problems with modified independence in daily decision making. * required limited assistance of one person with bed mobility and transfers. * was continent of bowel and bladder, * had a Stage IV pressure sore. In an interview on 8/30/10 at 10:46 a.m. licensed vocational nurse (LVN) A said Resident #4 was interviewable and healing from a spontaneous spinal fracture. Resident #4's pressure sore risk assessment tool dated 7/30/10 indicated he was at "mild" risk for pressure sore development. During interview with LVN B on 8/31/10 at 10:21 a.m., she said Resident #4 did not have pressure sores until he developed a red excoriation on his left buttock following a day surgery on 8/9/10. Nurses' notes: * dated 7/23/10 at 7:30 p.m. said Resident #4's inner buttocks appeared red and excoriated. * three entries, dated 8/10/10, all untimed, indicated Resident #4 had a, "rash on bottom." * dated 8/11/10 at 7:30 a.m. said a Stage II pressure sore had been identified on Resident #4's left upper buttock. Resident #4's pressure ulcer care plan updated 8/13/10 identified "an unstageable pressure ulcer," Treatment approaches included "1. treat pressure ulcer per physician order," "4. notify physician for any signs and symptoms of infection to the site," "5. following nutritional protocol," "6. re-evaluate site every two weeks," and "9. continue preventative measures." Resident #4's pressure ulcer reports revealed: 8/11/10 - Stage II pressure sore 1 cm. by 1 cm. pink wound bed. 8/13/10 - Unstageable, 1 cm. by 1 cm. pressure sore with slough in wound bed. 8/20/10 - Unstageable, 2.3 cm. by 2.3 cm. pressure sore with slough in wound bed. 8/27/10 - Unstageable, 3.0 cm. by 3.5 cm. pressure sore with purulent drainage and slough in wound bed. On 8/31/10 at 10:25 a.m. Resident #4 was observed as Registered Nurse (RN) B provided treatment to a pressure sore on his upper left buttock which was unstageable, 100 percent (%) covered in dry eschar (20% yellow and 80% blackish/purple in color.) The pressure sore measured 3.0 cm. by 4.2 cm. The skin surrounding the wound bed was red and inflamed, and extended 1 cm. around the outer edge of the wound. In an interview on 8/31/10 at 10:29 a.m. RN B said Resident #4's left buttock "abrasion" quickly turned into a pressure sore. She said Resident #4's physician was going to "look at Resident #4's pressure sore later today." She said residents were sent for "outside" wound care services if there was no improvement in the wound. Records indicated on 8/29/10 Resident #4's physician ordered a culture of the pressure sore drainage, and [MEDICATION NAME] ointment applied to the pressure sore daily. On 8/31/10 Resident #4's physician ordered a 14-day regimen of the oral antibiotic [MEDICATION NAME] DS when the culture returned positive for [MEDICAL CONDITION] (MRSA). A physician progress notes [REDACTED]." In an interview on 9/1/10 at 1:00 p.m., Resident #4's physician said when he saw Resident #4 on 8/31/10 he did not look at the pressure sore on his buttock. B) On 8/30/10 at 2:57 p.m. Resident #4 was observed in bed on a blue standard foam mattress. On 8/31/10 at 10:20 a.m., Resident #4 was observed lying in bed on a blue standard foam mattress. In an observation on 8/31/10 at 2:36 p.m. with LVN A the tag on the blue mattress read "[MEDICATION NAME]." She said the mattress would be considered a standard foam mattress. On 9/1/10 at 1:30 p.m., the DON and the administrator were interviewed regarding mattresses used by the facility. Manufacturer recommendations on standard blue foam mattresses and air mattresses used by the facility were provided. The administrator and the DON said manufacturer's clinical recommendations are followed when determining the type of mattress a resident should be provided. * Standard blue foam mattress: "Gold Care Foam Mattress, Effective for the prevention and treatment of [REDACTED]. * Air mattress: "Patriot Loss Air Loss Mattress, Clinical considerations-multiple Stage II, III or IV pressure ulcers". According to <http://www.tsswoundcare.com> (accessed 2/17/10) a low air loss mattress prevents friction and shear, reduces moisture on the skin, redistributes pressure, prevents pressure sore development and helps heal Stages I through IV pressure sores. C) On 8/30/10 at 10:45 a.m., Resident #4 was observed sitting in his wheelchair without a cushion/pressure relieving device. On 8/31/10 at 2:35 p.m., Resident #4 was observed sitting in a wheelchair without a cushion/pressure relieving device. In an interview on 8/31/10 at 2:36 p.m. charge nurse, LVN A said Resident #4 did not presently have a pressure reduction device in his wheelchair. Information accessed at http://www.spinalcord.uab.edu/show.asp?durki= 8, Spinal Cord Injury Information Network, on 9/14/10 said, "A pressure ulcer is an area of the skin or underlying tissue that is dead or dying as a result of the loss of blood flow to the area. It can begin in a number of ways. The most common is when you rest on a bony area for a prolonged period of time. The extended pressure leads to a pressure ulcer." D) Review of the registered dietitian (RD) progress notes dated 8/11/10 recommended Resident #4 have a [MEDICATION NAME] blood level. Resident #4's laboratory report dated 8/16/10 indicated his [MEDICATION NAME] (measure of healing protein in the blood) level was 17 (reference range 18-39.) A physician order [REDACTED]. Review of Resident #4's entire clinical record revealed no indication he had received high protein snacks twice daily since 8/17/10. The diet roster dated 8/30/10 revealed no indication Resident #4 had been provided high protein snacks twice daily since 8/17/10. In an interview on 8/31/10 at 2:25 p.m., the food service supervisor (FSS) said snacks were passed in the evenings, and Resident #4 received sugar free shakes. She said Resident #4 had not been receiving high protein snacks twice a day since 8/17/10. On 8/30/10 a dietary communication form dated 8/30/10 for Resident #4 read, "Make high protein snack peanut butter sandwich Bid (twice daily), mid a.m. and mid afternoon." In an interview on 9/1/10 at 11:30 a.m., Resident #4 he sat in a wheelchair with a pressure reduction pad he said he received earlier that day. He said prior to getting the pressure cushion, his bottom hurt when he sat in his wheelchair for even a short period of time. However, the pressure pad made his bottom feel a lot better. Resident #4 said staff sometimes offered a snack in the evenings, but snacks were not offered every night. He said he did not think he had been receiving extra snacks twice a day in recent weeks. In an interview on 9/1/10 at 12:00 noon, the RD said she did not have knowledge of Resident #4's low [MEDICATION NAME] level or deterioration of his pressure sore. She said since Resident #4 had renal concerns, she would probably recommend a low dose of Promod like 30 ml to boost his protein stores. 2) Resident #18's physician orders [REDACTED]. Resident #18's MDS dated [DATE] revealed: * she did not have pressure sores, * her skin was desensitized to pain or pressure, * she required "extensive" assistance to move in bed or transfer, * she was incontinent of bowel and bladder, and * she was severely impaired mentally, with short and long term memory problems. The pressure ulcer prevention care plan dated 8/15/10 indicated to use a pressure reducing mattress and utilize a draw sheet. Resident #18's pressure sore risk assessment dated [DATE] indicated she was at moderate risk for pressure sores. Review of a [MEDICATION NAME] laboratory report dated 8/19/10 indicated Resident #18's level was 11 mg/dl (Reference Range 18 to 39 mg/dl). Resident #18's pressure ulcer report dated 8/30/10 identified a Stage II pressure sore to her coccyx, measuring 3 cm. by 1.5 cm., with no depth, exudate, or odor. Resident #18's pressure ulcer report on 9/1/10 described an unstageable pressure sore on the coccyx, measuring 5.0 cm. by 3.5 cm., with slough in the entire wound bed, and two sheared areas measuring 1.5 cm. by 0.5 cm. and 1.0 cm. by 0.6 cm. In an observation with LVN M on 9/1/10 at 1:39 p.m., Resident #18's pressure sore on the coccyx appeared as described in the 9/1/10 pressure ulcer report. During an interview on 9/1/10 at 1:39 p.m., LVN M said the pressure sore had deteriorated since the 8/30/10 assessment. Resident #18 was observed on 9/1/10 at 1:39 p.m. lying on a standard blue foam mattress, manufacturer recommended for Stage I pressure sores. On 9/1/10 at 1:30 p.m., the DON and the administrator were interviewed regarding mattresses used by the facility. Manufacturer recommendations on standard blue foam mattresses and air mattresses used by the facility were provided. The administrator and the DON said manufacturer's clinical recommendations are followed when determining the type of mattress a resident should be provided. * Standard blue foam mattress: "Gold Care Foam Mattress, Effective for the prevention and treatment of [REDACTED]. * Air mattress: "Patriot Loss Air Loss Mattress, Clinical considerations-multiple Stage II, III or IV pressure ulcers". According to <http://www.tsswoundcare.com> (accessed 2/17/10) a low air loss mattress prevents friction and shear, reduces moisture on the skin, redistributes pressure, prevents pressure sore development and helps heal Stages I through IV pressure sores. According to the CMS form 672 the facility had 15 residents with pressure sores. The DON provided a list of 71 residents identified by the facility as "at risk" for pressure sore development. During the exit conference on 9/1/10 the facility was given the opportunity to provide additional information and none was provided.