Every finding on record at Lutheran Village at Wolfcreek

Based on observation, staff interview, review of a medication expiration list, review of a medication package insert, and review of a facility policy, the facility failed to ensure medications and biologicals were properly dated and discarded after expiration. This had the potential to affect all 57 residents in the facility. The facility census was 57.Findings include:Observation on [DATE] at 9:08 A.M. of the medication storage room with Registered Nurse (RN) #682 revealed a bottle of Geri-Lanta (an oral medication to relieve symptoms of excess stomach acid and gas) on the shelf. The bottle was opened with an expiration date of [DATE]. Further observation of the medication refrigerator revealed a bottle of Tuberculin purified protein derivative (PPD), a Tuberculosis testing solution, that was opened and undated.Interview on [DATE] at 9:10 A.M. with RN #682 verified the Geri-Lanta was opened and expired and further verified the Tuberculin PPD was opened and undated. Additional interview with RN #682 stated the Tuberculin PPD should be dated and initialed when opened.Review of an undated document titled, Medications with Shortened Expiration Dates, revealed Tuberculin PPD should be discarded 30 days after being opened.Review of a package insert for Tuberculin PPD revealed the medication must be discarded 30 days after opened. Review of facility policy titled, Medication Administration, with a revision date of [DATE], revealed staff must date all date sensitive medications upon opening.

Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure oxygen tubing was changed and labeled as required, and failed to ensure oxygen was administered at the appropriate rate as ordered. This affected four (#20, #12, #21, and #39) of six residents reviewed for oxygen therapy. The facility census was 57. Findings Include: 1. Review of Resident #20's medical record revealed an admission date of 03/21/24. Diagnoses included pulmonary embolism, chronic obstructive pulmonary disease (COPD), osteoarthritis, anxiety disorder, morbid obesity, depression, and polyneuropathy. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #20 was cognitively intact. Resident #20 was dependent on staff for toilet use and required maximal assistance with bathing and parts of dressing. Resident #20 displayed no behaviors during the review period. Resident #20 had oxygen therapy at the time of the review. Review of Resident #20's care plan revised 08/21/25 revealed supports and interventions for self-care deficits, risk for falls, psychosocial wellbeing problem, chronic pain, and COPD. Resident #20's COPD supports included oxygen settings via nasal cannula at four liters. Review of Resident #20's physician orders revealed an order dated 03/22/25 for oxygen tubing and humidifier change the first Wednesday of the month every night shift every four weeks. Interview on 09/02/25 at 10:56 A.M. with Resident #20 found her to alert and aware. Resident #20 reported she was able to put on and take off her oxygen nasal cannula by herself, but she required staff assistance with changing the tubing. Resident #20 reported her tubing was to be changed at least monthly and she was long overdue for her tubing change. Resident #20 pointed out how stiff and discolored her tubing was. Resident #20 stated new tubing was soft and pliable and the tubing she had was so stiff and hard it made it hard to keep the piece in her nose. Coinciding observation found the tubing was stiff, had yellowing discoloration, and there was no date or label on the tubing indicating when it was last changed. Interview on 09/02/25 at 11:29 A.M. with Licensed Practical Nurse (LPN) #616 verified the tubing was not dated or labeled and she was not able to be determined when it had last been changed. Observation on 09/02/25 at 11:32 A.M. of LPN #616 found she applied a piece of tape to the oxygen tubing with the date 09/02/25. The oxygen tubing was not observed being changed. Interview on 09/03/25 at 3:09 P.M. with Resident #20 found she was alert and aware. Resident #20 reported her oxygen tubing had not been changed. Resident #20 reported the sticker the nurse put on yesterday was still on the tubing and no one had actually changed the tubing as far as she was aware. Coinciding observation of Resident #20's oxygen tubing found it continued to have a piece of tape dated 09/02/25. 2. Review of Resident #12's medical record revealed an admission date of 06/06/24 diagnoses included COPD, peripheral vascular disease, type II diabetes, major depressive disorder, bipolar disorder, anxiety disorder, stroke, chronic pain, and hallucinations. Review of Resident #12's MDS assessment dated [DATE] revealed a BIMS score of seven indicating Resident #12 was severely cognitively impaired. Resident #12 was dependent on staff for toilet use, bathing, dressing and transfer. Resident #12 had hallucinations at the time of the review. Resident #12 received oxygen therapy at the time of the review. Review of Resident #12's care plan revised 07/15/25 revealed supports and interventions for self-care deficits, impaired cognitive function, chronic pain, high risk for falls, and COPD. COPD interventions included oxygen via nasal cannula at two to four liters as ordered. Review of Resident #12's physician orders revealed an order dated 05/27/25 for oxygen at two to four liters per nasal cannula every shift. No order was found regarding changing Resident #12's oxygen tubing. Observation on 09/02/25 at 11:42 A.M. of Resident #12 found he had oxygen running connected to a nasal cannula. The oxygen tubing was partially touching the floor, wrapped around the side rail of his bed, no label was found on the oxygen tubing indicating when it was last changed, and his nasal cannula was lying on his chest and not connected to his nose. Interview on 09/02/25 at 11:43 A.M. with Resident #12 revealed he was not able to apply his nasal cannula and needed assistance with untangling it and putting it on. Interview on 09/02/25 at 11:44 A.M. with LPN #616 verified Resident #12's oxygen tubing had not been labeled and she was not able to determine when it was last changed. LPN #616 assisted Resident #12 with untangling, picking the tubbing up off the floor, and reapplying his nasal cannula. LPN #616 then took a piece of tape and labeled the tubing with the date 09/02/25. 3. Review of the medical record for Resident #21 revealed she was admitted on [DATE] with diagnoses of congestive heart failure (CHF). Review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed she was cognitively impaired and required the use of oxygen therapy. Review of the current physician orders for September 2025 for Resident #21 revealed she was ordered oxygen therapy with the oxygen tubing and humidifier (water for less drying affect of oxygen) change to be completed the first Wednesday of every month. Observation on 09/02/25 at 11:10 A.M. of Resident #21's oxygen tubing revealed no date on the oxygen tubing. Interview on 09/02/25 at 12:33 P.M. with LPN #610 verified the oxygen tubing for Resident #21 not dated. 4. Review of the medical record for Resident #39 revealed an admission date of 06/09/14 with diagnoses of asthma and chronic respiratory failure. Review of the quarterly MDS assessment dated [DATE] for Resident #39 revealed she was cognitively intact and required the use of oxygen therapy. Review of the current physician orders from September 2025 for Resident #39 revealed she had orders in place for oxygen at two liters per minute and the oxygen tubing and humidifier to be changed the first Wednesday of the month, must date and initial on tape on the oxygen tubing. Observation on 09/02/25 at 9:51 A.M. of Resident #39 revealed the oxygen rate was at 2.5 liters per minute and the oxygen tubing was not dated. Observation and interview on 09/02/25 at 12:38 P.M. with LPN #610 verified oxygen order for Resident #39 was for oxygen to run at two liters per minute. Further interview with LPN #610 verified oxygen rate for Resident #39 was running at 2.5 liters per minute and verified oxygen tubing was not dated. Review of the facility policy titled, Oxygen Administration, dated 07/22, revealed the facility will facilitate breathing by providing supplemental oxygen to residents. Procedure includes turn the oxygen on to the prescribed amount and change and label the oxygen tubing monthly and as needed.

Based on observation, staff interview, medical record review, review of manufacture instructions, review of a facility medication guide, and review of facility policies, the facility failed to ensure staff wore appropriate personal protective equipment when providing care for residents on enhanced barrier precautions, failed to ensure medical equipment was properly sanitized between resident use, failed to ensure hand hygiene was performed during resident care, and failed to an insulin pen was sanitized prior to applying a needle for administration. This affected four (#41, #19, #23, and #1) of four residents reviewed for infection control measured during resident care. The census was 57. Findings include: 1. Review of medical record revealed Resident #1 was admitted on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus with diabetic neuropathy. Review of current physician orders from September 2025 for Resident #1 revealed order for insulin aspart before meals per sliding scale. Observation on 09/03/25 at 11:30 A.M. of medication administration for Resident #1 from Registered Nurse (RN) #682 revealed RN #682 checked Resident #1's blood sugar. RN #682 then checked the order and determined the correct dosage of insulin apart to be given. RN #682 removed the insulin pen for Resident #1 from the drawer on the medication cart, removed the cap, and placed the needle onto insulin pen. Continued observation of RN #682 revealed the nurse did not clean the end of the insulin pen prior to putting the needle on it. Further observation of RN #682 revealed she administered the insulin to Resident #1. Interview with RN #682 on 09/03/25 at 11:32 A.M. verified she did not clean the end of the insulin pen prior to applying the needle and administration of the insulin. Further interview revealed RN #682 stated she should have cleaned the end of the insulin pen prior to attaching the needle and administration of the insulin. Review of manufacturer instructions for insulin aspart pen delivery system revealed the first step when preparing an insulin pen for administration was to disinfect the rubber stopper of the pen tip with alcohol prior to attaching the needle to the pen. Review of the undated facility document titled, Insulin and Non-Insulin Pen Quick Reference Guide, revealed important points with pen injections included disinfecting the tip of the pen with an alcohol preparation pad before each use. 2. Review of the medical record for Resident #41 revealed he was admitted on [DATE] with diagnoses of malignant neoplasm of the rectum, malignant neoplasm of prostate, and obstructive reflux uropathy. Review of the care plan for Resident #41 dated 04/02/25 revealed the resident required enhanced barrier precautions (EBP) related to and indwelling medical device, a urinary catheter. Further review revealed Resident #41 had an indwelling urinary catheter due to obstructive and reflux uropathy. Review of medical record for Resident #19 revealed the resident was admitted on [DATE] with a diagnoses of quadriplegia, a carrier of carbapenem resistant enterobacter, and neuromuscular dysfunction of the bladder. Review of current physician orders from September 2025 for Resident #19 revealed an order for a urinary catheter with instructions to change the urinary catheter every 28 days and as needed. Review of the care plan for Resident #19 dated 06/11/25 revealed Resident #19 has a potential for reinfection related to chronic urinary tract infections. Further review revealed Resident #19 required EBP related to chronic wounds and an indwelling urinary catheter. Observation during medication administration on 09/03/25 at 9:34 A.M. revealed Licensed Practical Nurse (LPN) #672 went into Resident #41's room and took the resident's blood pressure with a wrist blood pressure cuff. Observation of Resident #41's door revealed the resident was identified to require staff to practice EBP. Continued observation during medication administration on 09/03/25 at 9:44 A.M. revealed LPN #672 entered into Resident #19's room and obtained a blood pressure with the same wrist blood pressure cuff used on Resident #41. Resident #19 was identified to require staff to practice EBP. Continued observation of LPN #672 revealed the nurse did not clean and disinfect the wrist blood pressure cuff between using the device on Resident #41 and Resident #19. Interview with LPN #672 on 09/03/25 at 9:55 A.M. verified he did not clean the blood pressure cuff between using it on Resident #41 and Resident #19. Further interview with LPN #672 verified he did not know it should be cleaned or how to clean it. Interview on 09/03/25 at 10:02 A.M. with LPN #672 stated he asked the Director of Nursing (DON) how to clean the blood pressure cuff, and stated the DON was unable to explain how to clean it to him. Interview on 09/03/25 at 4:03 P.M. with the DON revealed blood pressure cuffs should be cleaned between residents on EBP. Additional interview revealed manufacturer's instructions for cleaning wrist blood cuffs are to clean all surfaces with alcohol and for it to remain wet for several minutes. The DON confirmed that was not done. Review of facility policy titled, Cleaning and Disinfection of Resident-Care items and Equipment, revised May 2020, revealed if disposable devices are not available, disinfect patient care devices after usage on a patient who is in contact/universal precautions. Further review revealed patient care devices include but are not limited to blood pressure cuffs. 3. Review of Resident #19's medical record revealed the resident had an order for a urinary catheter and a current care plan which included the resident's need to be on EBP related to chronic wounds and use of an indwelling urinary catheter. Interventions for the care plan included staff to use personal protective equipment (PPE) when completing high contact activities including changing briefs or assisting with toileting, changing linens, dressing, and providing hygiene. Observation on 09/04/25 at 9:23 A.M. of Certified Nurse Aide (CNA) #709 revealed she was in the room with Resident #19 completing morning care without wearing PPE. Observation of Resident #19's room revealed the resident was identified as requiring EBP. Interview with CNA #709 on 09/04/25 at 9:28 A.M. revealed she completed all morning care for Resident #19. Further interview with CNA #709 stated she changed Resident #19's incontinence brief and provided peri-care, assisted with hygiene and brushing teeth, and dressed the resident. Further interview confirmed CNA #709 was not wearing PPE during any of these activities. CNA #709 stated for EBP, PPE was to be used for high contact activities. Further interview with CNA #709 stated she completed high-contact care with the Resident #19 and should have used PPE. 4. Review of the medical record for Resident #23 revealed she was admitted on [DATE] with diagnoses that included Parkinson's disease, cerebral infarction, dysphagia following unspecified cerebrovascular disease, intracranial hemorrhage, and gastrostomy complication. Review of an active order dated 03/27/25 indicated Resident #23 would be in EBP related to her gastrostomy tube (g-tube), until criteria were no longer met. Observation on 09/04/25 at 8:20 A.M. of Resident #23's room revealed PPE was placed adjacent to the doorway, signs were on the door, and the door frame indicated the resident was in EBP. Observation on 09/04/25 at 8:20 A.M. of RN #708 providing gastrostomy tube care for Resident #23 revealed RN #708 donned (put on) gloves without performing hand hygiene, did not don an isolation gown, then disconnected the nocturnal tube feeding and flushed the g-tube with water. RN #708 changed her gloves, did not perform hand hygiene, then returned to Resident #23 to remove the existing drain sponge. RN #708 changed her gloves again, did not perform hand hygiene, then returned to Resident #23 to apply a new drain sponge to the g-tube site. RN #708 removed her gloves and did not perform hand hygiene prior to exiting the room. Interview on 09/04/25 at 8:28 A.M. with RN #708 confirmed the above observation. RN #708 indicated she should have donned an isolation gown, and washed hands before resident care, between glove changes, and after resident care. Review of facility policy dated 04/01/25 titled, Enhanced Barrier Precautions, revealed staff would utilize EBP when providing high-contact care to residents with indwelling medical devices and residents with multidrug-resistant organisms. Gowns and gloves would be utilized in conjunction with standard precautions when care was provided to residents under EBP precautions. Review of facility policy with a reviewed date of May 2020 titled, Handwashing/Hand Hygiene, revealed staff would perform hand hygiene before and after direct contact with residents, after removing gloves, and as a final step after removing and disposing of personal protective equipment.

Based on medical record review, staff interview, facility policy review, the facility failed to ensure a resident code statue was documented across all medical records. This affected two (#10 and #36) of 28 residents sampled for record review. The facility census was 57.Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's disease, noninfective gastroenteritis and colitis, type II diabetes mellitus, chronic obstructive pulmonary disease, peptic ulcer disease, diverticulosis, iron deficiency anemia, and history of multiple hospitalizations for gastrointestinal (GI) bleed. Review of Resident #10's paper medical record on 09/02/25 at 8:28 A.M. revealed a Do Not Resuscitate Comfort Care (DNR-CC; cardiopulmonary resuscitation will not be initiated with cardiac and/or respiratory arrest) paper signed. Review of current physician orders as of 09/02/25 in the electronic health record (EHR) for Resident #10 revealed no code status order. Review of current physician orders in Resident #10's EHR as of 09/08/25 revealed an order for DNR-CC. Interview on 09/08/25 at 12:01 P.M. with the Director of Nursing (DON) verified the order for Resident #10's DNR-CC code status was not placed in the EHR until 09/03/25 at 12:20 P.M. 2. Review of the medical record for Resident #36 revealed she was admitted on [DATE] with diagnoses that included dementia, hypertension, hyperlipidemia, atherosclerotic heart disease, and heart valve replacement. Review of Resident #36's EHR revealed no orders for the resident's code status. Interview on 09/03/25 at 12:17 P.M. with Unit Manager Licensed Practical Nurse (LPN) #656 confirmed a code status was not present in the EHR for Resident #36 and should have been. Interview on 09/03/25 at 2:00 P.M. with the DON revealed the facility changed their EHR software on 04/03/25, and on 07/11/25 was alerted that code status information did not migrate correctly. Continued interview confirmed resident code status should have been documented for each resident in two places in the EHR - on the landing page banner and in orders. Interview on 09/08/25 at 12:00 P.M. with the DON confirmed the code status for Resident #36 was entered on 09/03/25. Review of facility policy dated April 2021 titled, Advance Directives, revealed physician orders for preferred code status would be documented in the medical record.

Based on observation, resident and family interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure residents who were not able to speak English had a consistent means of communication for their care needs. This affected one (#1) of two residents reviewed for communication. The facility census was 57. Findings include: Review of Resident #1's medical record revealed an admission date of 07/03/25. Diagnoses included end stage renal disease, dependence on renal dialysis, colostomy status, muscle weakness, and type II diabetes. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating Resident #1 was moderately cognitively impaired. Resident #1's preferred language was Chinese. Resident #1 required moderate assistance with toilet use and personal hygiene. Resident #1 required maximal assistance with bathing, parts of dressing, and transfers. Resident #1 displayed no behaviors during the review period. Review of Resident #1's care plan revised 08/27/25 revealed supports and interventions to address risks for alteration in skin integrity, self-care deficit, and communication as Resident #1's primary language was Chinese. Interventions for communication included a picture board for basic needs, and translation needs which noted the resident's husband was available for translation. Attempted interview on 09/02/25 at 1:34 P.M. with Resident #1 found when Resident #1 was asked questions she shook her head and pointed to her husband. Interview on 09/02/25 at 1:35 P.M. with Resident #1's husband verified Resident #1 was not able to speak any English and he was only able to speak a little. Resident #1's husband reported he was there to help translate during the day and helped with her care, but he was not sure how staff communicated with her when he was not there. He stated he could not be there all the time. Interview on 09/03/25 at 10:44 A.M. with Certified Nurse Aide (CNA) #705 verified the staff were not able to communicate with Resident #1 when her husband was not there. CNA #705 reported there were no translation devices or communication tools she was aware of. CNA #705 reported Resident #1 had put her call light on that morning, but she was unable to determine what Resident #1 needed when she responded to the light. She was able to determine it had something to do with the telephone, but she could not determine what Resident #1 needed. CNA #705 reported she asked Resident #1 to write it down, but Resident #1 shook her head, No, when she was handed paper and a pen. CNA #705 reported Resident #1's husband came in later in the morning and she found out Resident #1 had been trying to communicate she needed help with using the telephone to call her husband and had not been able to get the call to go through. Review of the facility policy titled, Translation/Interpretation, revised June 2020, revealed the residents at their care communities had the right to communicate in a dignified manner when unable to communicate either related to language, hearing, or sight barrier.

Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents who were dependent on staff for care received adequate and timely care to maintain oral hygiene. This affected one (#6) of four residents reviewed for activities of daily living. The facility census was 57. Findings Include:Review of Resident #6's medical record revealed an admission date of 08/05/25. Diagnoses included fusion of the cervical spine, fracture of cervical vertebrae subsequent encounter, fracture of tibia subsequent encounter, pulmonary embolism, muscle wasting, and morbid obesity. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #6 was cognitively intact. Resident #6 was dependent on staff for all activities of daily living (ADLs) including oral hygiene. Resident #6 displayed no behaviors. Review of Resident #6's care plan revised 08/20/25 revealed supports and interventions for self-care deficits. Interventions for self-care deficits included a touch pad call light to the right side of the resident's body at all times when in bed, total dependence on one staff for bathing, bedfast most of the time, dependent on one staff for eating, and Resident #6 had his own teeth and required assistance with oral care every shift. Review of Resident #6's certified nurse aide (CNA) care task documentation for oral hygiene over the last 30 days revealed Resident #6 was assisted with oral care one time each day on 08/13/25, 08/17/25, 08/19/25, 08/21/25, 08/22/25, 08/26/25, 09/01/25, 09/03/25, and 09/04/25. Resident #6 was not provided any oral care on 08/31/25 and refused care on 09/05/25. Interview on 09/02/25 at 11:17 A.M. with Resident #6 found him to be alert and aware. Resident #6 reported he was not getting his teeth brushed as often as he would want. Resident #6 reported he was not physically able to brush his teeth himself and the nurse aides were supposed to brush his teeth for him daily. Resident #6 reported there were days his teeth were not getting brushed at all. Interview on 09/03/25 at 10:54 A.M. with CNA #705 revealed it was her first time working on her assigned hall for the shift and she was not aware yet of Resident #6's care needs. Interview on 09/03/25 at 3:16 P.M. with CNA #657 revealed Resident #6 required total assistance with all ADLs including eating and brushing his teeth. CNA #657 reported all care provided was documented in the electronic medical record when it was completed. If it was not in there, it was not completed, and confirmed documentation revealed Resident #6's teeth were not brushed daily. Interview on 09/08/25 at 9:40 A.M. with CNA #606 revealed it was her first time working her assigned hall for the shift in a long time. CNA #606 verified she was providing Resident #6's care that day and stated the resident required assistance of one staff for his care and she was not aware of how often Resident #6 got his teeth brushed. Interview on 09/08/25 at 9:40 A.M. with CNA #711 revealed she had been working at the facility for about three months and verified she was working on Resident #6's hallway that day. CNA #711 stated she did not know how often Resident #6 got his teeth brushed and stated she did not work with him. Review of the facility policy titled, ADL Nursing Care and Therapy Cares, revised April 2021, revealed residents care plan was to be followed daily for residents who required such services.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure interventions for prevention of pressure ulcers were applied as ordered. This affected one (#7) of four residents reviewed for pressure ulcers. The facility census was 57. Findings Include:Review of Resident #7's medical record revealed an admission date of 02/10/25. Diagnoses included dementia, chronic obstructive pulmonary disease, Alzheimer's disease, major depressive disorder, left heel stage four pressure ulcer, unstageable pressure ulcer of her right heel, and anxiety disorder. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 required maximal assistance with eating, and was dependent on staff for toilet use, bathing, dressing, bed mobility, and transfers. Resident #7 had one stage four pressure ulcer (full-thickness skin and tissue loss), and one unstageable pressure ulcer (obscured full-thickness skin and tissue loss) at the time of the review. Resident #7 displayed no behaviors and received hospice services at the time of the review. Review of Resident #7's care plan revised 08/21/25 revealed supports and interventions for self-care deficits, limited physical mobility, received hospice services, impaired cognitive function, required enhanced barrier precautions related to chronic wounds, stage three pressure ulcer (full-thickness skin loss) to the right heel, right lateral stage two (partial thickness skin loss with exposed dermis) and stage four to the left heel. Pressure ulcer interventions included to administer medications and provide treatments as ordered, follow up with wound care, assistance with turning and repositioning at least every two hours, low air loss mattress, and weekly treatment documentation to include measurement of each skin breakdown's width, length, depth, and type of tissue and exudate. and terminal prognosis with hospice services. Review of Resident #7's physician orders revealed an order dated 04/24/25 for heel protector boots to be worn while in bed as resident tolerated and allowed every day and night shift. Further review of Resident #7's physician orders revealed an order dated 07/10/25 for heel boots to bilateral lower extremities at all times as resident tolerated and allowed. Staff were to monitor Resident #7's skin integrity every shift. Further review of Resident #7's current physician orders revealed treatment orders in place to address a right lateral heel wound, a right medial heel wound, and left heel wound. Review of Resident #7's wound clinic evaluations found Resident #7 had three wounds that were being followed. The wounds included a stage four pressure wound to the left heel, a stage three pressure wound to the medial heel, and a stage two pressure wound of the right lateral heel. All three wounds were noted to be improving. Observation on 09/02/25 at 3:39 P.M. of Resident #7 found her in bed with her heels flat on the mattress. No pressure relieving boots were in place. Coinciding interview with Licensed Practical Nurse (LPN) #710 revealed Resident #7's dressing had been changed on the prior shift. LPN #710 stated Resident #7 had no boots she was aware of and verified there were treatment orders in place for Resident #7's right and left heels. Observation on 09/03/25 at 10:49 A.M. of Resident #7 found her up in the common area seated in her wheelchair. Resident #7's feet were in the footrests of the wheelchair and she was wearing a plain white sock on her right foot and purple boot was in place on the left. There was no pressure relieving device on her right foot. Observation on 09/03/25 at 1:15 P.M. of Resident #7 found her in bed with one purple boot on her left foot. Resident #7's right foot was unable to be observed as it was covered by a blanket. Interview on 09/03/25 at 3:12 P.M. with Certified Nurse Aide (CNA) #657 revealed Resident #7 required total care with dressing and personal care. Resident #7 was not always cooperative with care but if they spoke nicely to her and gave her some time it would help. CNA #657 reported they would put Resident #7's heel protector boots on her sometimes and Resident #6 was supposed to have two, but she had not seen two in a while. Observation on 09/03/25 at 3:14 P.M. of Resident #7 found she continued to be in bed with a purple boot on her left foot and a plain white sock on her right. Coinciding interview with CNA #657 verified Resident #7's did not have both her boots on and her heels were flat on the bed with her right foot only having a white sock. Observation on 09/04/25 at 8:33 A.M. of Resident #7 found she had white gauze wrapping her left foot and a purple foam boot on the right. Coinciding interview with LPN #672 verified Resident #7's dressing was changed last night and Resident #7 had white gauze wrapping her left foot which was lying flat on the bed and had a purple foam boot on her right foot. There was a current order for to have dressing changes completed on night shift and boots. Review of the facility policy titled, Skin Management Protocol, revised March 2021, revealed residents at high risk for pressure ulcers should have interventions implemented including protective skin devices such as heel protectors.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one (#21) of five residents reviewed for fall interventions. The facility census was 57.Findings include: Review of the medical record for Resident #21 revealed she was admitted on [DATE] with a diagnosis of congestive heart failure (CHF).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed she was cognitively impaired and was at risk for falls.Review of the current physician orders from September 2025 for Resident #21 revealed she had an order for shorter oxygen tubing as a fall intervention.Review of the care plan, revised 08/27/25, for Resident #21 revealed she was care planned for a fall risk with an intervention in place for shorter oxygen tubing.Observation on 09/02/25 at 11:42 A.M. of Resident #21 revealed she had green oxygen tubing extension along with the nasal cannula tubing. Further observation of the oxygen tubing revealed the oxygen concentrator was located in the farthest corner of the room from the bathroom and the oxygen tubing stretched into the bathroom, a shared bathroom, and beyond. Interview on 09/02/25 at 12:33 P.M. with Licensed Practical Nurse (LPN) # 610 verified Resident #21 had an order for shorter oxygen tubing as a fall intervention and verified Resident #21 had green extension tubing in place that was approximately 25 feet long.Interview on 09/04/25 at 9:02 A.M. with the Director of Nursing (DON) stated Resident #21 tripped over 25 feet extension oxygen tubing and the intervention put into place was a shorter extension oxygen tubing. The DON further stated the length of the tubing at the time of the fall for Resident #21 was 25 feet long and green tubing from hospice. The DON stated the facility tubing was clear and was seven feet long, and that along with the nasal cannula resulted in a ten foot tubing that allowed Resident #21 to reach the bathroom while utilizing the oxygen.Review of the facilities policy titled, Fall Policy, revised 06/20, revealed the facility strives to reduce the occurrence of fall and to minimize complications from falling. The resident will be observed to ensure the new interventions are in place.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered per physician's order. This affected one (#41) of four reviewed for medication administration. The facility census was 57.Findings include:Review of the medical record for Resident #41 revealed the resident was admitted on [DATE] with diagnoses of malignant neoplasm of the rectum, malignant neoplasm of the prostate, chronic kidney disease, and hypertension.Review of the medical record for Resident #41 revealed the resident developed a new diagnosis of hypotension on 03/12/25 and other hypotension on 07/01/25. Review of a progress note dated 03/27/25 for Resident #41 revealed the resident had a diagnosis of hypotension with a plan to continue midodrine (a medication to increase blood pressure) for low blood pressure management.Review of the care plan for Resident #41 dated 05/07/25 revealed focus of for hypotension related to multiple co-morbidities and an intervention to give medications as ordered. Review of a physician order dated 05/25/25 revealed Resident #41 was ordered midodrine 10 milligrams (mg) by mouth three times daily with no ordered blood pressure parameters.Review of Resident #41's medication administration record for August 2025 revealed the resident's midodrine was held for administrations on 08/01/25, 08/04/25, 08/19/25, 08/20/25, 08/21/25, and 08/22/25.Review of current physician's order on 09/02/25 at 2:30 P.M. for Resident #41 revealed he was prescribed midodrine five (5) mg with directions to give two tablets by mouth three times a day. Further review of the physician's orders revealed no hold parameters for the midodrine. Observation of medication administration on 09/03/25 at 10:50 A.M. revealed Licensed Practical Nurse (LPN) #672 obtained the blood pressure for Resident #41 with a reading of 120/51 millimeters of mercury (mmhg) obtained. Further observation of LPN #672 revealed the midodrine was not administered to Resident #41.Interview on 09/03/25 at 4:01 P.M. with LPN #672 verified there were no parameters for the administration of Resident #41's midodrine and further verified the medication was not given because the resident's blood pressure was 120/51 mmhg. LPN #672 further stated he was calling the physician immediately to have hold parameters added to the order.Interview on 09/03/25 at 4:04 P.M. with the Director of Nursing (DON) stated there was an understanding that the standard of practice was to hold the midodrine if the blood pressure was above 110 or 120 mmhg. Interview with LPN #672 on 09/03/25 at 4:45 P.M. confirmed that order parameters were added to Resident #41's midodrine order on 09/03/25 at about 4:05 P.M., shortly after confirmation that the order did not have parameters. Review of the ordered parameters revealed midodrine was to be held for a systolic blood pressure (the top number; the pressure in the arteries when the heart contracts) of greater than 120 mmhg or a diastolic blood pressure (the bottom number; the pressure in the arteries when the heart is at rest) of greater than 80 mmhg. Interview with the DON on 09/08/25 at 2:45 P.M. revealed the facility was unable to produce documentation of the standard blood pressure parameters for midodrine. Further interview with the DON stated that parameters for midodrine can vary based on the resident.Review of policy titled, Medication Administration, last revised in May 2019, revealed prescribed medications are ordered and delivered in a timely fashion to residents taking into account, when possible and appropriate, the resident's wishes for medication delivery times. Further review revealed the physician shall be notified if a medication is withheld.

Based on observations, staff interview, review of sanitizer log and policy review, the facility failed to ensure foods were stored in a safe and sanitary manner. In addition, the facility failed to ensure the chemical dish washing machine had the proper chemical sanitizer level for effective disinfection of dishes and utensils. This had the potential to affect 52 residents who receive food from the kitchen. Three residents (#37, #43 and #53) received no food by mouth and thus no food from the kitchen. The facility census was 55. Findings include: Observation on 04/10/23 at 8:43 A.M., of main kitchen's walk-in cooler found a ten inch by twelve inches by six-inch-deep steam table tray full of meatballs in a red sauce on a wheeled cart in line for use. The date marked was 03/30/23, eleven days prior. Interview on 04/10/23 at 8:46 A.M., with Dietary Staff (DS) #662 verified the date on the meatballs was the use by date and they should have been thrown away and not in line for use. Observation on 04/10/23 at 8:50 A.M., of the dry storage area found a one-gallon jug of soy sauce open and partially used on the dry storage shelf. The label on the soy sauce read Refrigerate After Opening. Interview on 04/10/23 at 8:51 A.M., with DS #655 verified the gallon jug of soy sauce was open, approximately 1/4 of it was used and it was stored in the dry storage area and was not refrigerated as it should have been. DS #655 said it would be thrown out. Observation on 04/10/23 at 8:55 A.M., of the dishwashing machine found it was a low temperature chemical machine. Observations of the chemicals connected to the machine found two dishwashing detergents and a rinse solution. No sanitizer was found. Observation on 04/10/23 at 9:02 A.M., of DS #655 completing a chemical test strip found the sanitizer level was zero. Coinciding interview with DS #655 verified the white five-gallon jug contained dish soap, the one-gallon pink jug contained dish soap, the blue one-gallon jug contained a rinsing agent and there was no sanitizer connected to the dishwasher. DS #655 reported he was not sure how long there was no sanitizer connected to the machine but there should have been. Interview on 04/10/23 at 9:06 A.M., with Dietary Manager (DM) #606 verified there was a mix up with the chemicals and there should have been a dish soap and a sanitizer not two dish soaps connected to the machine. DM #606 stated they would have the dishwashing machine repair person come out today and correct the machine. While they waited, they would wash in the three-sink system and provide disposable items. Observation on 04/11/23 at 7:28 A.M., of the dishwasher in the main kitchen found a yellow one-gallon jug of sanitizer, a pink one-gallon jug of dish soap, and a blue one gallon of jug of rinse agent connected to the dishwashing machine. Coinciding interview with DS #655 verified the machine maintenance company came out yesterday and corrected the issue. DS #655 verified the issue was the white five-gallon bucket was dish soap and was supposed to be yellow sanitizer. They had been running two dish soaps and no sanitizer. Review of the Facility's Dish Machine Chlorine Sanitizer Log revealed in March 2023 only one A.M. chlorine level was taken, and the last P.M. level taken was on 03/24/23. There were no sanitizer level tests logged from 03/25/23 to 04/10/23. Review of the policy titled, Food Storage revised March 2022 revealed left over food was to be used within seven days or discarded.

Based on observation, staff interview, resident interview, record review and review of policy, the facility failed to ensure residents were treated with dignity and respect. This affected two (#20 and #48) of three residents reviewed for dignity. The facility census was 55. Findings include: 1. Review of Resident #20's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, osteoarthritis, atherosclerotic heart disease, essential hypertension, major depressive disorder, and dementia with psychotic disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively impaired. Observation on 04/10/23 at 12:01 P.M., revealed Licensed Practical Nurse (LPN) #659 stood in the middle of the hallway outside the room of Resident #20 and yelled into the resident room for Resident #20 to sit up while eating and stated, you are going to choke. Resident #20 was lying in bed, sat up, leaned over tray table to the right of the bed to take a bit of food and then laid back down in bed. Interview on 04/11/23 at 9:59 A.M., with LPN #659 verified LPN #659 did direct Resident #20 to sit up in bed while eating from the hallway. LPN #659 stated the resident lays down to eat and sometimes when medications are administered, not sure if it is just laziness or what. LPN #659 stated she should have entered the resident's room and provided directions to ensure the resident's safety when eating rather than yelling at Resident #20 from the hallway. 2. Review of Resident #48's medical record revealed an admitted [DATE]. Diagnoses included aftercare following explanation of knee joint prosthesis, presence of cardiac pacemaker, obstructive sleep apnea, chronic pulmonary embolism, presence of right artificial knee joint, morbid obesity, irritable bowel syndrome, asthma, chronic kidney disease, fibromyalgia, right heart failure, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Interview on 04/10/23 at 12:45 P.M., with Resident #48 revealed there was a State tested Nurse Aide (STNA) #615, who was a bully. Resident #48 stated she told Social Worker (SW) #639 during a care conference last week about STNA #615 and how she made her feel like she was bothering her. Resident #48 stated STNA #615 would stand in the hall, speak loudly, and say things like she technically did not have to answer call lights except for once every two hours, spoke about other residents, would tell her she could do things for herself and not want to help, and was just not friendly. Resident #48 stated she initially thought STNA #615 talked to herself but then she realized she wore ear buds and was on her phone. Resident #48 stated her condition had fortunately improved and she was able to do more for herself and did not ask for help unless necessary because she did not want to encounter STNA #615. Interview on 04/11/23 at 12:10 P.M., with STNA #615 revealed Resident #48 required more assistance when she initially admitted but was doing better and was able to do most things for herself. STNA #615 did not provide any additional pertinent information. Interview on 04/12/23 at 8:03 A.M., with Social Worker (SW) #639 revealed Resident #48 expressed concern last week regarding STNAs making her feel like they did not want to help her. SW #639 stated Resident #48 indicated STNAs would tell her she could do things for herself when she requested assistance. SW #639 stated Resident #48 was apprehensive about reporting her concerns and did not provide any specific staff names. SW #639 stated STNA #615 had a history of customer service concerns and had received education in the past related to her approach with residents. SW #639 stated she did report Resident #48's concerns to the former Director of Nursing (DON) #660 and she believed the concerns were addressed. Interview on 04/12/23 at 8:15 A.M., with the Administrator confirmed Resident #48 expressed concerns related to STNA #615 and her approach with residents. The Administrator stated Resident #48 provided information to former Unit Manager (UM) #700, who followed up with STNA #615. While the Administrator was unaware of any specific concerns related to STNA #615's approach with Resident #48, Resident #48 had reported to UM #700 that STNA #615 spoke loudly in the hall, talked about other residents, stated she was only checking on residents every two hours, and used profanity. The Administrator stated UM #700 provided verbal education to STNA #615. In addition, the Administrator stated there was an active investigation with the union related to the concerns expressed by Resident #48. Review of the policy titled Resident Rights Guidelines, dated July 2022, revealed residents had the right to be treated with dignity and respect and to be treated fairly, courteously, and with respect by all staff.

Based on medical record review, observation, and resident and staff interview, the facility failed to ensure a resident was evaluated for safe use of a motorized wheelchair and provided a foot pedal for the manual wheelchair. This affected one (#5) of one resident reviewed for accommodation of needs. The facility census was 55. Findings include: Review of Resident #5's medical record revealed an admitted [DATE]. Diagnoses included urinary retention, edema, hypothyroidism, muscle weakness, insomnia, idiopathic peripheral autonomic neuropathy, heart failure, osteoarthritis, coronary artery disease, and unsteadiness on feet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, was dependent on two staff for bed mobility and transfers and utilized a wheelchair for mobility. In addition, Resident #5 received Occupational Therapy (OT) from 08/03/22 to 10/06/22. Review of the plan of care initiated 05/13/22 revealed Resident #5 had impaired mobility related to history of right femur fracture, weakness, and right foot drop and needed assistance with transfers and mobility. Interventions included OT, Physical Therapy (PT) and Speech Therapy (ST) as needed. In addition, Resident #5 was at risk for falls related to pain, right foot drop, weakness, and use of assistive device. Interventions included encouraging the use of wheelchairs and PT and OT to evaluate and treat as ordered. Lastly, Resident #5 had basic care needs and preferences for daily routine. Interventions included wheelchair for mobility. Observation and interview on 04/10/23 at 12:05 P.M., with Resident #5 revealed the resident sitting in the doorway of her room. Resident #5 was in a manual wheelchair. Resident #5 stopped the surveyor and inquired if the surveyor could find the foot pedal for her wheelchair. Resident #5's right foot was noted to be hanging, not touching the floor, and no foot pedal was attached to the wheelchair. State tested Nurse Aide (STNA) #725 approached Resident #5 and assisted the Resident to the dining room for lunch. STNA #725 was observed not to attach a right foot pedal to the wheelchair. Interview on 04/10/23 at 3:15 P.M., with Resident #5 revealed prior to her admission to the facility, she had a power wheelchair. Resident #5 stated the facility took it from her because something was wrong with it, and she never got it back. Resident #5 stated she preferred her power wheelchair because it was easier for her to navigate and move about independently. Interview on 04/13/23 at 10:02 A.M., with Director of Rehabilitation (DOR) #720 revealed Resident #5 admitted to the facility with a power wheelchair. DOR #720 stated, upon admission, the use of a power wheelchair was not appropriate for use due to Resident #5's limited range of motion of the right knee. DOR #720 stated Resident #5's power wheelchair was stored at the facility and, while it was manual, the wheelchair she was using was appropriate. DOR #720 could not recall if Resident #5 had been reassessed to determine if the use of her power wheelchair would be appropriate at this time. DOR #720 stated he was working based off memory of something that occurred about a year ago and did not recall all the specifics. DOR #720 agreed to review Resident #5's treatment history and follow up with the surveyor. A follow up interview on 04/13/23 at 1:19 P.M., with DOR #720 revealed Resident #5 admitted to the facility in May 2022 for rehabilitation following a fall and right leg fracture. DOR #720 stated it was not safe for Resident #5 to utilize her power wheelchair due to a lack of range of motion of her right knee, noting it was a safety issue because the resident's right foot could not rest on the foot plate. DOR #720 explained the power wheelchair's foot plate did not extend to accommodate Resident #5's lack of range of motion of the right knee. DOR #720 stated Resident #5's power wheelchair was placed upstairs at the facility, and she was provided a manual wheelchair. DOR #720 stated Resident #5 was able to propel her manual wheelchair herself, but preferred to have staff push her. DOR #720 confirmed Resident #5 had not been re-evaluated to determine if she could safely use her power wheelchair and the facility had not explored if the resident could get a new power wheelchair if the one stored at the facility was determined to not be safe or could not be modified to accommodate her needs. DOR #720 stated the therapy department would investigate her power wheelchair if Resident #5 asked, but she had not requested that be done.

Based on medical record review, staff interview and policy review, the facility failed to notify the physician when medications were not being administered per physician's orders. This affected one (#43) of five residents reviewed for medications. The facility census was 55. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included cerebral infarct, epilepsy, hypertension, cognitive communication deficit, status post gastrostomy, aphasia, and dysphagia oropharyngeal phase status post cerebral infarct. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively impaired and required the extensive assistance of one staff for activities of daily living and was dependent on staff for eating, had a gastrostomy tube for feeding and medication administration due to dysphagia. Review of the current orders for Resident #43 revealed orders dated 09/15/22 for the gastrostomy tube patency and placement to be verified with 30 milliliters (ml) of air before each medication administration and feeding and for the gastrostomy tube to be flushed with 30 ml of water before and after medication administration. Orders initiated on 09/16/22, for the diagnosis of hypertension called for amlodipine 10 milligrams (mg) to be administered per gastrostomy tube every morning, hydralazine 50 mg administered per gastrostomy tube three times a day and lisinopril 40 mg administered per gastrostomy tube once a day. Review of the medication administration record for February 2023 revealed lisinopril 40 mg was documented as on hold on 02/21/23 at 5:06 A.M., amlodipine 10 mg was on hold on 02/21/23 at 5:06 A.M. and hydralazine 50 mg was on hold on 02/02/23 at 11:35 A.M., 02/21/23 at 5:06 A.M., 02/22/23 at 12:19 P.M. and on 02/26/23 at 12:05 P.M. and documented as not administered on 02/04/23 at 9:39 A.M. and 02/20/23 at 11:44 A.M. Review of the medication administration record for March 2023 revealed hydralazine 50 mg was on hold on 03/01/23 at 12:45 P.M., 03/12/23 at 5:57 P.M., 03/19/23 at 12:32 P.M. and 5:37 P.M., 03/21/23 at 11:21 A.M., 03/31/23 at 11:27 A.M. and not administered on 03/11/23 at 12:23 P.M., 03/12/23 at 12:21 P.M., 03/23/23 at 12:02 P.M., 03/25/23 at 6:51 P.M. and 03/26/23 at 6:15 P.M. Review of the medication administration record for April 2023 revealed hydralazine 50 mg had not been administered as ordered on 04/11/23 at 11:33 A.M. and 4:16 P.M. Review of the medical record and the medication administration records for February, March and April 2023 remained silent for documentation related to medications being held or not administered and further remained silent for the physician notification related to the medications held or not administered. Interview on 04/12/23 at 3:50 P.M., with the Interim Director of Nursing (DON) verified both the medications were held without physician notification and added the facility policy regarding medication administration was not followed. Review of the policy titled Medication Administration, dated May 2019 revealed prescribed medications are ordered and delivered in a timely fashion, if medications are withheld the licensed nurse professional administering the medications shall appropriately mark the electronic medical record and document the reason. The physician shall be notified when the medication is not given, and the physician notification is to be documented in the electronic medical record.

Based on medical record reviews, observations, resident and staff interviews, the facility failed to ensure residents dependent on staff to provide assistance with captivities of daily living (ADLs) was provided the required assistance. This affected two (#36 and #38) of six residents reviewed for ADLs. The facility census was 55. Findings include: 1. Review of Resident #36's medical record revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure (CHF), pulmonary hypertension, atrial fibrillation, chronic obstructive heart disease (COPD), rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two-person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. Review of a plan of care focus area initiated 05/03/22 revealed Resident #36 needed assistance with bathing and hygiene related to restricted mobility, weakness, heart failure, shortness of breath, COPD, and dementia. Interventions included assisting with bathing body parts resident is unable to do, encouraging and assisting in maintenance of good grooming and hygiene, and verbal reminders and verbal cues while bathing, dressing, and grooming. Observation on 04/11/23 at 4:41 P.M., revealed Resident #36 was in bed. Resident #36's meal tray was sitting on the bedside table, out of reach of the resident. The dinner plate had a cover over it. Observation on 04/11/23 at 5:00 P.M., revealed Resident #36's meal tray remained on the bedside table, to the left of the resident, with the plate still covered. Resident #36 was observed to reach with her left hand to try to pull the bedside table toward her. Resident #36 was unable to pull the table to her. Observation on 04/11/23 at 5:25 P.M., revealed Resident #36's meal tray was still on the bedside table, with the cover on the plate, and out of reach of the resident. Licensed Practical Nurse (LPN) #659 entered the room to check on the resident and provide water. Interview of LPN #659, at the time of the observation, confirmed Resident #36 was able to feed herself after receiving assistance with meal set up. LPN #659 verified Resident #36 could not reach her dinner meal. LPN #659 removed the cover from the dinner plate and moved the table to Resident #36, who picked up her hamburger and began eating. Observation on 04/12/23 at 7:10 A.M., revealed breakfast meal trays arrived at the B Hall, the hall Resident #36 resided on. Resident #36 was observed to be sleeping in her bed. Observation on 04/12/23 at 11:18 A.M., revealed Resident #36 laying sideways in her bed, with her head resting on the right-side bed rail. Interview of Resident #36, at the time of the observation, revealed she was not comfortable in bed. Resident #36 raised her right arm and oatmeal was noted on the underside of the resident's right arm and on the right side of her gown, sheets, and blankets. Resident #36 stated she dropped her bowl of oatmeal during breakfast this morning. Resident #36 stated her adult brief was wet and she believed the last time staff was in her room was around 9:00 A.M. Resident #36 had her blanket pulled down to her thighs and her gown was pulled up around her waist. Observation of Resident #36's brief revealed the brief was saturated with a yellow discoloration. Interview on 04/12/23 at 11:42 A.M., of State tested Nurse Aide (STNA) #615 revealed she last provided care to Resident #36 around 6:45 A.M. STNA #615 stated personal care was typically provided to Resident #36 after meals because of potential spills. Observation of Resident #36, with STNA #615, at the time of the interview verified Resident #36's brief was saturated with urine and the resident had oatmeal on her right arm and on her gown, sheets, and blanket. STNA #615 stated she had been in to reposition Resident #36 throughout the morning but denied Resident #36 had been soiled and she had not noticed the oatmeal spilled on the resident and her bedding. STNA #615 stated she picked up Resident #36's breakfast meal tray around 8:30 A.M. and verified Resident #36 would have had the oatmeal on her from that time. Observation on 04/13/23 at 9:41 A.M., of Resident #36 revealed the resident in bed. Resident #36's fingernails were observed to be long, with debris under the nails. Interview of Resident #36, at the time of the observation, revealed she preferred to have her fingernails short. Interview on 04/01/23 at 9:44 A.M., of STNA #730 verified Resident #36's fingernails were long and had debris under them. STNA #730 stated she believed only the podiatrist could cut fingernails because of diabetes. Related to the debris under the fingernails, STNA #730 stated she did just eat breakfast. 2. Review of Resident #38's medical record revealed an admitted [DATE]. Diagnoses included dementia, osteoarthritis, cardiomegaly, essential hypertension, heart failure, hypertensive heart disease, mild cognitive impairment, history of falling, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired and required extensive one-person physical assistance with personal hygiene. In addition, Resident #38 did not reject care during the look back period. Review of a plan of care focus area initiated 07/05/22 revealed Resident #38 needed assistance with bathing and hygiene related to congestive heart failure and weakness. Interventions included encouraging and assisting in maintenance of good grooming and dressing. Observation on 04/11/23 at 2:46 P.M., revealed Resident #38's fingernails were long, with debris under the nails. Interview on 04/11/23 at 2:46 P.M., of STNA #671 verified Resident #38's fingernails were long, with debris under the nails. STNA #671 stated she was an agency STNA and did not know Resident #38. Interview on 04/11/23 at 3:17 P.M., of LPN #659 revealed Resident #38 did not like to get out of bed but she would allow care to be provided. LPN #659 stated Resident #38 did not refuse care. LPN #659 verified Resident #38's fingernails were long and dirty and stated she would trim them today. Observation on 04/12/23 at 7:13 A.M. revealed Resident #38's fingernails remained dirty and untrimmed.

Based on medical record review, observation, resident and staff interview, and review of policy, the facility failed to ensure activities of interest were provided to residents who stayed in their room. This affected two (#36 and #43) of three residents reviewed for activities. The facility census was 55. Findings include: 1. Review of Resident #36's medical record revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure (CHF), pulmonary hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. Review of a plan of care focus area initiated 03/24/23 revealed Resident #36 was a long term resident of the facility and able to make her needs and preferences known. The resident stated she had no interest in activities while at the facility. Interventions included place an enlarged monthly activities calendar in the room to promote daily activities, encourage resident to engage in activities of interest daily, assist with activities as needed, and staff will visit 1:1 as tolerated. Further review of a plan of care focus area initiated 04/11/23 revealed Resident #36 presented with impaired cognition. Interventions included daily orientation to facility routines and activity schedule, environmental cues to stimulate memory, provide consistent physical environment and daily routine, and avoid demands for abstract thinking. Observations on 04/10/23 at 1:41 P.M.; 04/11/23 at 2:54 P.M.' 4:27 P.M., and 5:25 P.M.; 04/12/23 at 7:10 A.M., 11:18 A.M., 3:55 P.M., and 4:22 P.M.; and on 04/13/23 at 9:41 A.M. revealed Resident #36 in bed with the television on during each of the observations. Interview on 04/12/23 at 4:22 P.M., with State tested Nurse Aide (STNA) #632 revealed Resident #36 remained in bed all of the time. STNA #632 stated day shift got Resident #36 out of bed once, about one month ago, but the resident screamed the entire time because she was in pain. Resident #36 was put to bed and had not been up again since. STNA #632 stated it was her understanding Resident #36 did not want to get out of bed and participate in activities or go to the dining room, but she herself had not asked Resident #36. STNA #632 stated Resident #36 laid in bed all day, with staff checking on her about every two hours, and had no other involvement in facility activities. Observation on 04/13/23 at 9:41 A.M., of Resident #36's room revealed an activity calendar hanging on a bulletin board on the wall immediately to the left upon entrance to the room. The bulletin board and calendar were located behind the head of Resident #36's bed, which was not visible to Resident #36. Interview of Resident #36 confirmed she did not get out of bed, participate in facility activities, or go to the dining room for any meals. Resident #36 stated All I do is lay here in this bed. Resident #36 stated she would like to get up and do something but was not aware of the facility activities. Resident #36 stated she assumed there was a physician order requiring her to stay in her room. Interview on 04/13/23 at 9:45 A.M. with STNA #645 revealed Resident #36 remained in bed all of the time, with no active engagement or participation in activities or dining. STNA #645 stated she was not sure why Resident #36 never got up to go to activities or the dining room, stating she was told Resident #36 got up one time and yelled because she was in pain and staff never got her up again. STNA #645 confirmed she had never approached Resident #36 about getting up to go to the dining room or participate in any other facility activities and the resident laid in bed all day with the television on. Interview on 04/13/23 at 2:23 P.M., with Activities Assistant (AA) #699 revealed the facility used to have specific programming for residents with dementia, but it was not currently in use. AA #699 confirmed Resident #36 did not attend any activities and stayed in her room all of the time. While she attempted to visit with Resident #36 daily, that was not possible and was more likely to be two to three visits each week. In addition, if Resident #36 was sleeping at the time of the visit, AA #699 did not return so visits were sometimes less frequent. AA #699 stated during their visits, Resident #36 would speak of past interests, liked to get her fingernails done, and do crafts. Additionally, AA #699 stated Resident #36 expressed an interest in going outside, but that activity had not occurred. AA #699 confirmed the activity calendar was hanging behind Resident #36, out of her view, and unless someone told her daily what activities were available, she would be unaware. AA #699 confirmed Resident #36's plan of care was not individualized and did not identify areas of interest to assist in keeping Resident #36 engaged. 2. Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included cerebral infarct, epilepsy, hypertension, cognitive communication deficit, status post gastrostomy, aphasia, and dysphagia oropharyngeal phase status post cerebral infarct. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively impaired and required the extensive assistance of one staff for activities of daily living and was totally dependent on staff for eating, had a gastrostomy tube for feeding and medication administration due to dysphagia. Review of the care plan revised 01/12/23 revealed Resident #43 was a long-term resident and is unable to make needs and preferences known. The goal for Resident #43 revealed the resident will engage in activities of interest as tolerates and the resident will accept one on one visits daily. Interventions included staff will place an enlarged monthly activity calendar in the room to promote daily activities, staff will encourage the resident to engage in activities of interest daily and will offer assistance with activities as needed, staff will visit one on one as tolerated. Review of the preferred activities for Resident #43 revealed music, television and being outdoors. Observations on 04/11/23 at 7:15 A.M. of Resident #43 laid in bed looking out the window. Additional observations on 04/11/23 at 3:53 P.M. and on 04/12/23 at 8:01 A.M. and 11:00 A.M. and 3:30 P.M. and on 04/13/23 at 8:56 A.M. revealed Resident #43 was in bed with the television on during each observation. Interview on 04/13/23 at 11:00 A.M., with the Interim Director of Nursing (DON) verified Resident #43 had not been assisted out of bed in some time and is unsure of why the resident has not been assisted out of bed daily as the resident should be. Interview on 04/13/23 at 2:35 P.M., with AA #699 revealed the facility used to have specific programming for residents with dementia, but it was not currently in use. AA #699 confirmed Resident #43 did not attend any activities and stayed in her room all of the time. While she attempted to visit with Resident #43 daily, that was not possible and was more likely to be two to three visits each week. AA #699 stated during their visits, staff would sit with Resident #43 while watching television. Additionally, AA #699 stated Resident #43 expressed an interest in going outside, but that activity had not occurred. AA #699 confirmed the activity calendar was hanging behind Resident #43, out of her view, and unless someone told her daily what activities were available, she would be unaware. AA #699 confirmed Resident #43's plan of care was not individualized and did not identify areas of interest to assist in keeping Resident #43 engaged. Review of the policy titled Programming for Resident with Cognitive Impairments and Other Special Needs, revised March 2012, revealed activity programs were provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive and emotional health. The facility shall offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques. In addition, the activity department coordinates care planning with nursing and other members of the Interdisciplinary Team to develop and effective approach for meeting special activity needs of residents. Lastly, environmental modifications are implemented, as needed, to provide the least restrictive environment to enable activity participation while maintaining dignity. The focus should be on the resident's abilities, not disabilities.

Based on record review, observation, staff interview, and resident interview, the facility failed to provide adequate care and treatment for a resident experiencing edema. This affected one (#17) of 16 residents reviewed for quality of care and treatment. The facility census was 55. Findings include: Review of Resident #17's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included chronic kidney disease, heart failure, hypertension (HTN), osteoarthritis, glaucoma, congestive heart failure (CHF), and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, required set up assistance with activities of daily living (ADLs) and was on a therapeutic diet. Review of the plan of care initiated 01/10/23 revealed Resident #17 was on diuretic therapy related to HTN and CHF. Interventions included administering medications per order. Review of current physician orders for April 2023 revealed Resident #17 was prescribed spironolactone (diuretic) 25 milligram (mg) tablet two times daily. Additional review revealed no physician orders for compression stockings. Review of a physician progress note dated 04/06/23 revealed Resident #17 had leg swelling, noted to be a chronic condition, and was no longer on lasix. Resident #17 was encouraged to wear compression stockings every day. Review of an Occupational Therapy (OT) progress note dated 04/12/23 revealed Resident #17 required maximum assistance to apply compression stockings. Interview on 04/10/23 at 12:13 P.M., with Resident #17 revealed compression stockings were to be applied in the morning and removed at night. Observation at the time of the interview revealed Resident #17 was not wearing compression stockings and swelling was noted to bilateral lower extremities. Resident #17 stated staff were to assist with applying compression stocking, but it was not being done. Interview on 04/11/23 at 3:18 P.M., with Licensed Practical Nurse (LPN) #659 revealed Resident #17 had an order for a diuretic but did not have an order for compression stockings. LPN #659 stated she had never known Resident #17 to wear compression stockings. Observation on 04/11/23 at 3:22 P.M., revealed Resident #17 walking down the hall. Swelling was noted to the Resident's bilateral lower extremities. Resident #17 was not observed to be wearing compression stockings and a pair of compression stockings were observed to be folded and laying at the foot of the Resident's bed. A follow up interview on 04/12/23 at 11:13 A.M., with Resident #17 revealed OT assisted her with applying compression stockings this morning. Resident #17 stated her daughter brought the compression stockings in because of the swelling in her legs and her physician told her last week to wear them. Interview on 04/12/23 4:18 P.M., with State tested Nurse Aide (STNA) #632 confirmed Resident #17's daughter had brought in compression stockings for Resident #17. STNA #632 confirmed Resident #17 had not been wearing them and she did not believe there was an order for them. Observation on 04/13/23 at 8:43 A.M., with LPN #631, confirmed Resident #17 had right leg edema rated at +1 (mild pitting, slight indentation) on the left lower extremity and +2 (moderate pitting, 1/4-to-1/2-inch indentation) on the right lower extremity. LPN #631 stated Resident #17 had bilateral swelling since her admission and, to her knowledge, had never worn compression stocking. During the observation, Resident #17 reiterated that the physician told her last week to wear compression stockings every day. LPN #631 stated she would follow up with the physician. A follow up interview on 04/13/23 at 9:48 A.M., with LPN #631 revealed she spoke with the physician regarding compression stockings for Resident #17. LPN #631 confirmed Resident #17 should have had an order for them, however, the physician stated because Resident #17 had compression stockings in her room, the physician thought there was already an order and had not confirmed an order existed. LPN #631 verified a new order would be entered today for Resident #17 to have compression stockings applied in the morning and removed at night.

Based on medical record review, observation, resident's friend interview, resident interview, and staff interview, the facility failed to ensure residents received timely incontinence care. This affected one (#36) of one residents reviewed for incontinence care. The facility census was 55. Findings include: Review of Resident #36's medical record revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure, pulmonary hypertension, atrial fibrillation, chronic obstructive pulmonary disease, rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. Additionally, Resident #36 was always incontinent of bowel and bladder. Review of a plan of care focus area initiated 05/03/22 revealed Resident #36 had urinary incontinence related to restricted mobility, dementia, and weakness. Interventions included provide toileting assistance as needed, provide adult incontinence products, and monitor for incontinence frequently. Interview on 04/11/23 at 2:54 P.M., with Resident #36's friend revealed she had been visiting with the resident for at least 30 minutes and Resident #36 had indicated to her upon her arrival that she had been incontinent and needed changed. Interview of Resident #36 at the time revealed she required assistance with incontinence care and it had likely been two or more hours since she was last checked on by staff. Follow up interview on 04/11/23 at 4:27 P.M., with Resident #36 revealed staff still had not been in her room to check on her and she required incontinence care. Interview on 04/11/23 at 4:28 P.M., with State tested Nurse Aide (STNA) #671 revealed her shift began at 2:00 P.M. STNA #671 verified she had not provided care to Resident #36 since the start of her shift. STNA #671 asked What's wrong with her? The surveyor indicated Resident #36 required incontinence care. STNA #671 stated she needed to pass dinner meal trays and would change Resident #36 when she was finished. Continued observations on 04/11/23 from 4:41 P.M. through 5:25 P.M., revealed STNA #671 continued to pass dinner meal trays and Resident #36 had not received incontinence care. Observation on 04/11/23 at 5:25 P.M., revealed Licensed Practical Nurse (LPN) #659 entered Resident #36's room to check on the Resident and provide water. Interview with LPN #659 revealed briefs usually had a blue line when they were wet. LPN #659 verified the brief did not have a blue line. LPN #659 poked the brief, which was firm to the touch, and verified Resident #36's brief was saturated with urine. LPN #659 covered Resident #36 with a sheet and blanket, moved the over the bed table with the dinner meal tray over to the resident and left the room without providing incontinence care. Observation on 04/12/23 at 11:18 A.M., revealed Resident #36 laying in bed. Resident #36 stated she had been incontinent and needed changed. Resident #36's blankets were pulled down to her thighs and her gown was around her waste. Resident #36's brief was exposed and a yellow discoloration on the brief was noted. Interview on 04/12/23 at 11:42 A.M., with STNA #615 revealed residents should be checked and changed at least every two hours. STNA #615 stated she last provided incontinence care to Resident #36 around 6:45 A.M. STNA #615 verified Resident #36's brief was saturated with urine and confirmed Resident #36 would not utilize her call light to request assistance if needed.

Based on medical record review, observation, resident and staff interviews, review of resident's meal ticket and review of policy, the facility failed to ensure a resident's physician ordered therapeutic diet was provided as ordered. This affected one (#17) of two residents reviewed for nutrition. The facility census was 55. Findings include: Review of Resident #17's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included chronic kidney disease, heart failure, hypertension (HTN), osteoarthritis, glaucoma, congestive heart failure (CHF), and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, required set up assistance with activities of daily living (ADLs) and was on a therapeutic diet. Review of the plan of care dated 01/23/23 revealed Resident #17 was at risk for altered nutrition and hydration related to advanced age, CHF, and diuretic treatment. Avoid hot dogs, sausage, bacon and ham. Interventions included diet as ordered. Additional review of the plan of care revealed Resident #17 had potential for fluid imbalance and activity tolerance related to CHF. Interventions included diet per order. Review of a Nutrition assessment dated [DATE] revealed Resident #17 was on a no added salt, regular diet with thin liquids and no bacon, ham, hot dogs, and sausage. Review of current physician orders for April 2023 revealed Resident #17 was ordered a no added salt, regular diet with thin liquids, no ham, bacon, sausage, or hot dogs. Interview on 04/10/23 at 11:25 A.M., with Resident #17 revealed the facility did not honor her low salt diet when serving meals. Interview on 04/12/23 at 4:18 P.M., with State tested Nurse Aide (STNA) #632 revealed Resident #17 preferred to not eat salty foods. STNA #632 stated she was unaware of Resident #17's diet orders but stated Resident #17 would become upset when she was served things like ham sandwiches because the resident stated she was not supposed to have salty foods. Observation on 04/13/23 at 8:10 A.M., with Resident #17's breakfast meal tray revealed the resident was served ham, eggs, toast, and cream of wheat. Interview with STNA #730 at the time of the observation verified Resident #17 was served ham for breakfast. STNA #730 stated she was an agency staff and was unaware of Resident #17's diet order. Review of Resident #17's breakfast meal ticket, dated 04/13/23, revealed the resident was on a regular, no added salt diet. The meal ticket did not indicate no ham, bacon, sausage, or hot dogs. Interview on 04/13/23 at 8:19 A.M., with Dietary Aide (DA) #641 revealed nursing staff were to complete a diet communication form indicating a resident's diet orders and send to the kitchen for the dietary meal ticket to be generated. DA #641 verified Resident #17's meal ticket did not indicate she was not to have ham, bacon, sausage, or hot dogs. DA #641 stated she was unaware Resident #17 was not supposed to have those food items since it was not on the meal ticket. Telephone interview on 04/13/23 at 9:25 A.M., with Registered Dietitian (RD) #710 verified Resident #17's diet order was a no added salt, regular diet with thin liquids and no ham, bacon, sausage, or hot dogs. While salt was not added to foods prepared by the kitchen, RD #710 confirmed ham, bacon, sausage and hot dogs were specifically identified due to their high salt content. RD #710 stated nursing staff should be communicating diet orders to the kitchen. Review of the policy titled Diet Orders/Meal Preferences, revised July 2018, revealed nursing would complete a Dietary Communication form and send to dietary in order to generate a tray ticket. Dietary staff would print tray tickets for each meal to reflect the ordered diet.

Based on medical record review, staff interview and policy review, the facility failed to administer medications per physician's orders. This affected one (#43) of five residents reviewed for medications. The facility census was 55. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included cerebral infarct, epilepsy, hypertension, cognitive communication deficit, status post gastrostomy, aphasia, and dysphagia oropharyngeal phase status post cerebral infarct. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively impaired and required the extensive assistance of one staff for activities of daily living and was dependent on staff for eating, had a gastrostomy tube for feeding and medication administration due to dysphagia. Review of the current orders for Resident #43 revealed orders dated 09/15/22 for the gastrostomy tube patency and placement to be verified with 30 milliliters (ml) of air before each medication administration and feeding and for the gastrostomy tube to be flushed with 30 ml of water before and after medication administration. Orders initiated on 09/16/22, for the diagnosis of hypertension called for amlodipine 10 milligrams (mg) to be administered per gastrostomy tube every morning, hydralazine 50 mg administered per gastrostomy tube three times a day and lisinopril 40 mg administered per gastrostomy tube once a day. Review of the medication administration record for February 2023 revealed lisinopril 40 mg was documented as on hold on 02/21/23 at 5:06 A.M., amlodipine 10 mg was on hold on 02/21/23 at 5:06 A.M. and hydralazine 50 mg was on hold on 02/02/23 at 11:35 A.M., 02/21/23 at 5:06 A.M., 02/22/23 at 12:19 P.M. and on 02/26/23 at 12:05 P.M. and documented as not administered on 02/04/23 at 9:39 A.M. and 02/20/23 at 11:44 A.M. Review of the medication administration record for March 2023 revealed hydralazine 50 mg was on hold on 03/01/23 at 12:45 P.M., 03/12/23 at 5:57 P.M., 03/19/23 at 12:32 P.M. and 5:37 P.M., 03/21/23 at 11:21 A.M., 03/31/23 at 11:27 A.M. and not administered on 03/11/23 at 12:23 P.M., 03/12/23 at 12:21 P.M., 03/23/23 at 12:02 P.M., 03/25/23 at 6:51 P.M. and 03/26/23 at 6:15 P.M. Review of the medication administration record for April 2023 revealed hydralazine 50 mg had not been administered as ordered on 04/11/23 at 11:33 A.M. and 4:16 P.M. Review of the medical record and the medication administration records for February, March and April 2023 remained silent for documentation related to medications being held or not administered and further remained silent for the physician notification related to the medications held or not administered. Interview on 04/12/23 at 3:50 P.M., with the Interim Director of Nursing (DON) verified hydralazine and lisinopril were ordered and there are no parameters in place to hold the medications. Interim DON further verified both the hydralazine and lisinopril were held without physician notification and added the facility policy regarding medication administration was not followed. Review of the policy titled Medication Administration, dated May 2019 revealed prescribed medications are ordered and delivered in a timely fashion, if medications are withheld the licensed nurse professional administering the medications shall appropriately mark the electronic medical record and document the reason. The physician shall be notified when the medication is not given, and the physician notification is to be documented in the electronic medical record.

Based on medical record review, resident and staff interview, review of Medscape medication prescribing information, and review of policy, the facility failed to ensure two (#36 and #49) residents did not receive antipsychotic medications without an appropriate diagnosis or treatment of a specific condition. In addition, the facility failed to ensure one resident's (#48) as needed (PRN) use of anxiety medications were not utilized beyond 14 days without physician review and failed to update the physician order with an end date once reviewed by the physician. This affected three (#36, #48, and #49) of five residents reviewed for unnecessary medications. The facility census was 55. Findings include: 1. Review of Resident #36's medical record revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure (CHF), pulmonary hypertension, atrial fibrillation, chronic obstructive heart disease (COPD), rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two-person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. In addition, Resident #36 received antipsychotic medication seven days of the look back period, with active diagnoses including CHF, heart failure, Alzheimer's disease, COPD, atrial fibrillation, rheumatoid arthritis, primary biliary cirrhosis, and gastroesophageal reflux disease (GERD). Review of a plan of care focus area initiated 04/26/22 revealed Resident #36 had potential for drug related complications associated with use of psychotropic medications related to antidepressant, anxiety, insomnia, antipsychotic use, and dementia. Interventions included observe, document, and report to the physician as needed signs and symptoms of drug related complications, maintain behavior monitoring program to monitor behaviors twice daily and as needed, monitor for target behaviors, and document per facility protocol, and consult with the pharmacy and physician to consider dosage reduction when clinically appropriate. Review of current physician orders revealed Resident #36 was ordered Seroquel (antipsychotic medication) 50 milligrams (mg) twice daily for dementia without behavioral disturbance. In addition, behavior monitoring each shift. Review of the Medication Administration Record (MAR) from 01/01/23 through 04/12/23 confirmed Resident #36 received Seroquel twice daily as ordered. Additionally, behavior monitoring was completed twice daily with no behaviors documented behaviors during the reviewed period. Review of nursing progress notes from 01/01/23 through 04/12/23 revealed no behaviors were documented for Resident #36. Review of nurse practitioner progress notes dated 01/09/23 and 03/17/23 revealed no specific behavioral concerns and no nursing concerns identified. Review of a physician progress note dated 02/09/23 revealed no specific behavioral concerns and no nursing concerns identified. Observations on 04/10/23 at 1:41 P.M.; 04/11/23 at 2:54 P.M., 4:27 P.M., and 5:25 P.M.; 04/12/23 at 7:10 A.M., 11:18 A.M., 3:55 P.M., and 4:22 P.M.; and on 04/13/23 at 9:41 A.M. revealed Resident #36 in bed with the television on during each of the observations. No behavioral concerns were observed. Interview on 04/12/23 at 3:55 P.M., with Interim Director of Nursing (IDON) #613 verified Resident #36 had no psychiatric diagnosis to support the use of Seroquel, other than dementia. In addition, IDON #613 verified Resident #36 had no behaviors documented from 01/01/23 through 04/12/23 and nurse practitioner notes dated 01/09/23 and 03/17/23 and physician note dated 02/09/23 also revealed no specific behaviors were identified for Resident #36. IDON #613 stated hospice prescribed Seroquel for Resident #36 and there had been an on-going concern related to hospice prescribing too many medications. Interview on 04/12/23 at 4:22 P.M., with State tested Nurse Aide (STNA) #632 revealed Resident #36's behaviors typically consisted of yelling out and attempting to get out of bed when she was in pain or if her brief was soiled. STNA #632 stated Resident #36 calmed down once her needs were addressed. STNA #632 denied Resident #36 was ever combative. Interview on 04/12/23 at 4:28 P.M., with Licensed Practical Nurse (LPN) #631 revealed Resident #36 could become agitated. LPN #631 stated the agitation typically presented as yelling or trying to get out of bed. LPN #631 stated most of the time, Resident #36's behaviors subsided once her needs were addressed. LPN #631 was unaware of Resident #36 being combative. Review of Medscape Seroquel (quetiapine - generic medication name) prescribing information, located at https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984#0, revealed the medication was prescribed to treat Schizophrenia and Bipolar Disorder in geriatric populations. In addition, off-label (not approved) prescribing for psychosis and agitation in Alzheimer's dementia. Further review revealed a Black Box Warning indicting the medication was not approved for dementia-related psychosis; elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death, as shown in short-term controlled trials; deaths in these trials appeared to be either cardiovascular (for example, heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Review of the policy titled Antipsychotic/Psychotropic Medications and GDRs, revised January 2019, revealed if an order for an antipsychotic/psychotropic medication is written by the attending physician/nurse practitioner, he or she have assessed, properly diagnosed , and documented in the medical record the resident requires the use of the antipsychotic/psychotropic medication. 2. Review of Resident #48's medical record revealed an admitted [DATE]. Diagnoses included aftercare following explanation of knee joint prosthesis, presence of cardiac pacemaker, obstructive sleep apnea, chronic pulmonary embolism, presence of right artificial knee joint, morbid obesity, irritable bowel syndrome, asthma, chronic kidney disease, fibromyalgia, right heart failure, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of a plan of care focus area, initiated 03/09/23, revealed Resident #48 had potential for drug related complications associated with use of psychotropic medication related to antidepressant and antianxiety medication use. Interventions included observing, documenting, and reporting signs and symptoms of drug related complications and consulting with the pharmacy and physician regarding Gradual Dose Reduction (GDR) when clinically appropriate. Review of a physician order, with a start date of 02/24/23, revealed Resident #48 was ordered alprazolam (antianxiety medication) 0.5 milligrams (mg) three times daily as needed for anxiety. The order did not contain a stop date for the medication. Review of the Medication Administrator Record (MAR) from 02/24/23 through 04/12/23 revealed Resident #48 received alprazolam beyond the initial 14 days (03/09/23) on the following dates: 03/11/23, 03/15/23, 03/16/23, 03/17/23, 03/19/23, 03/20/23, 03/22/23, 03/28/23, 03/29/23, 03/31/23, and 04/12/23. Review of a pharmacy recommendation dated 03/27/23 revealed all as needed (PRN) psychoactive medications must initially be limited to 14 days in duration. The prescriber must then reassess the resident to continue the PRN order. The pharmacy requested documentation of rational for continued use and the duration. Further review revealed on 03/31/23, the physician provided rational of Generalized Anxiety Disorder (GAD) and extended the use of the PRN alprazolam for 30 days. Interview on 04/13/23 at 12:49 P.M., with Interim Director of Nursing (IDON) #613 verified the order for PRN alprazolam was continued beyond the initial 14 days without the physician assessing Resident #48 for continued use. In addition, IDON #613 verified the physician order was not updated with a stop date once reviewed by the physician on 03/31/23. Review of the policy titled Antipsychotic/Psychotropic Medications and GDRs, revised January 2019, revealed PRN psychotropic medication orders were limited to 14 days. The physician or nurse practitioner, if appropriate, may extend the PRN order beyond 14 days but should document their rationale in the resident's medical record and indicate the duration of the PRN medication. 45445 3. Review of the medical record for Resident #49 revealed an admitted [DATE], diagnoses included chronic kidney disease, dementia, chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively impaired and required the extensive assistance of one staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and required the limited assistance of one staff for walking and eating. In addition, Resident #49 received antipsychotic medication seven days of the look back period, with active diagnoses including chronic kidney disease, dementia, and chronic obstructive pulmonary disease. Review of a plan of care focus area initiated 12/15/22 revealed Resident #49 had potential for drug related complications associated with use of psychotropic medications. Interventions included observe, document, and report to the physician as needed signs and symptoms of drug related complications, monitor for target behaviors and document per facility protocol, and consult with the pharmacy and physician to consider dosage reduction when clinically appropriate. Review of current physician orders revealed Resident #49 was ordered Seroquel (antipsychotic medication) 75 milligrams (mg) at bedtime for agitation and restlessness, Seroquel 25 mg once daily at 4:00 P.M. for anxiety and restlessness and an as needed dose of Seroquel 25 mg at bedtime if the bedtime dose of Seroquel was not effective for dementia without behavioral disturbance. In addition, behavior monitoring each shift. Review of the Medication Administration Record (MAR) for January 2023 revealed Seroquel 25 mg had been administered nightly as ordered from 01/01/23 to 01/30/21. On 01/31/23 the bedtime dose of Seroquel was increased to 50 mg and was administered on 01/31/23. Review of the MAR for February 2023 revealed the bedtime dose of Seroquel was increased to 75 mg nightly and on 02/23/23 an additional dose of Seroquel 25 mg was ordered at bedtime if the 75 mg dose was ineffective. Resident #49 received Seroquel as ordered and had not received any as needed doses. Review of the MAR for March 2023 revealed Seroquel 75 mg at bedtime was administered as ordered and the as needed dose of Seroquel 25 mg had not been administered but continued to be reordered every 14 days. Review of the MAR for April 2023 revealed a dose of Seroquel 25 mg once daily at 4:00 P.M. had been added for restlessness. The daily 4:00 P.M. dose and the nighttime dose of Seroquel had been administered as ordered. An additional dose of Seroquel 25 mg was administered on 04/09/23 at bedtime. Review of nursing progress notes from 01/01/23 through 04/12/23 revealed no behaviors were documented for Resident #49. Review of nurse practitioner progress notes dated 01/12/23, 02/10/23 and 03/09/23 revealed no specific behavioral concerns and no nursing concerns identified. Observations on 04/10/23 at 3:12 P.M.; 04/11/23 at 3:20 P.M., 04/12/23 at 8:00 A.M., 12:06 P.M., and on 04/13/23 at 8:55 A.M. revealed Resident #49 was interacting with others and visiting with family at bedside during the observations. No behavioral concerns were observed. Interview on 04/12/23 at 4:00 P.M., with Interim Director of Nursing (IDON) #613 verified Resident #49 had no psychiatric diagnosis to support the use of Seroquel, other than dementia. In addition, IDON #613 verified Resident #49 had no behaviors documented from 01/01/23 through 04/12/23 and nurse practitioner notes dated 01/12/23, 02/10/23 and 03/09/23 revealed no specific behaviors were identified for Resident #49. IDON #613 stated hospice prescribed Seroquel for Resident #49 and there had been an on-going concern related to hospice prescribing too many medications.

Based on surveyor observation, staff interview, medical record review, and review of the facility's skin management protocol, the facility failed to follow facility protocol to complete an assessment and contact the physician for treatment at the time a pressure ulcer was discovered. Actual harm occurred when one (#1) of three residents reviewed with pressure ulcers, was found to have an unstageable pressure ulcer on the coccyx, four days after the initial discovery of the open area was made. The facility identified five residents with current pressure ulcers. The facility census was 113. Findings include; Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the 08/16/14 minimum data set (MDS) assessment identified the resident to be severely cognitively impaired, dependent on staff for the completion of activities of daily living, including repositioning, and unable to communicate her needs. On 07/30/14 the resident was assessed to be at high risk for developing pressure ulcers and a plan of care was developed. Interventions included to follow facility skin protocol, immediately report any redness or skin breakdown to charge nurse, measure open areas at least weekly, and apply a pressure reducing mattress. On 07/30/14 at 6:05 P.M. a resident assessment was completed and the resident had no pressure areas. On 07/30/14 a physician order [REDACTED].#1 to elevate her heels, apply a low air loss mattress to bed and check function every shift. The order also indicated Barrier cream was to be applied to the buttocks every shift and as needed. The head of the bed was to be elevated 30 degrees when the resident was in bed. Review of the facility Certified Nurse Aide (CNA) skin check detail report, completed on 08/07/14 at 6:00 A.M., revealed State tested Nurse Aide (STNA) #1 documented the resident had an open area on her bottom that was bleeding. No further documentation regarding the open area was documented in the medical record. Review of the skin alteration document dated 08/12/14 at 10:15 A.M. revealed an open area was discovered to Resident #1's coccyx. The area was identified as unstageable, containing 30% slough (necrotic tissue) on the wound bed. The pressure ulcer area measured 3.5 centimeters (cm) by 11 cm, with a depth of 10.2 cm. The physician and family were notified, and a treatment was initiated to the area. On 08/18/14 wound management documentation identified the coccyx wound to be a Stage III pressure ulcer, with the wound bed containing 40 % slough. The pressure ulcer measured 4.0 cm by 10 cm, and was 2 cm deep. On 08/22/14 a surgical debridement was performed on the pressure ulcer, which resulted in the wound increasing in size. After the debridement the wound was identified as a Stage IV pressure ulcer, with 100 % granulation, excessive red drainage, and measured 4 cm by 10 cm by 4 cm deep. On 09/15/14 at 12:00 P.M., observations were made of the wound treatment, with Licensed Practical Nurse (LPN) #11, Registered Nurse (RN) #4 and RN Unit Manager #5 present. The pressure ulcer was noted to measure 5.7 cm by 10 cm by 2 cm deep, with undermining tunneling, deepest at ten o'clock, measuring five cm. The wound was draining a moderate to large amount of serosaguanous drainage. Review of the facility skin management protocol, revised September 2013, revealed upon identification of new alteration in skin integrity, interventions are to include: complete a skin grid, complete a skin alteration investigation form, notify the physician and obtain treatment orders, transfer new orders to treatment sheet, and notify the director of nursing and dietitian of all new skin issues. On 09/15/14 at 12:30 P.M., interview with the Director of Nursing (DON), Administrator, and Corporate Nurse, revealed the area to the residents coccyx was discovered by LPN #22 on 08/07/14. The nurse was informed of the area by STNA #1. LPN #22 placed a dressing on the wound, however, LPN #22 failed to document the wound and treatment in the medical record. LPN #22 did not initiate the wound policy or inform the physician to obtain a treatment order. The staff verified the medical record lacked documentation of the wound until 08/12/14 at 10:15 A.M. The DON confirmed she was not made aware of the wound until 08/12/14. This deficiency substantiates Complaint Number OH 062.

Based on medical record review, observation, staff interview, review of facility policy, and review of National Pressure Ulcer Advisory Panel (NPUAP) staging guidelines, the facility failed to accurately assess, identify a potential pressure ulcer risk area and provide appropriate preventative measures to prevent the development of a pressure ulcer. This resulted in actual harm for Resident #216 who developed an avoidable Stage III pressure ulcer on the left foot second toe that deteriorated to an unstageable pressure ulcer. In addition, the facility failed to accurately assess, provide ongoing assessment, implement preventative measures, and provide physician ordered treatments to promote healing of pressure ulcers for two residents (#3 and #10). This deficient practice affected three (#216, #3 and #10) of three residents reviewed for pressure ulcers. The facility identified a total of five residents with in-house acquired pressure ulcers. The facility census was 125. Findings include: 1. Review of Resident #216's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] indicated the resident did not have any pressure ulcers upon admission. According to the admission Braden skin assessment dated [DATE], the resident was assessed as being moderately at risk for the development of a pressure ulcers. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident was assessed as being at risk for the development of pressure ulcers. The assessment also indicated the resident had memory problems with modified independence in decision making and required extensive assist of one person for dressing/grooming and personal hygiene. Review of the care plan for self-care deficit, initiated 12/03/13, revealed the resident currently required extensive assist for activities of daily living. The care plan in place for at risk for skin integrity, initiated 12/03/13, noted the resident was to receive treatment as ordered and weekly skin assessments. There was no documentation of the resident having developed a pressure ulcer, or of the required interventions and treatments to aide in the healing of a pressure ulcer. Review of the skin alteration form dated 12/07/12 at 6:30 P.M. revealed the nurse removed a toe spacer and noted a sore between the left great toe and the second toe measuring 1.0 centimeter (cm) by 1.2 cm by 0.1 cm with slough to the center of the wound and the surrounding tissue was red. Review of a skilled nurse's note dated 12/07/12 at 7:00 P.M. revealed the nurse documented at approximately 6:00 P.M. she was called to the resident's room per the state tested nurse aide (STNA). The space between the left great toe and second digit toe revealed an open area that measured 1.0 cm by 1.2 cm by 0.1 cm with moderate serous drainage. The surrounding skin was red and swollen with purple discoloration noted. The physician visited and assessed the area with new orders received. Review of the physician progress notes [REDACTED]. The physician observed a 1.0 cm by 1.0 cm ulcer to the second toe on the left foot. The ulcer area had eschar and [DIAGNOSES REDACTED] with exudate. The toe spacer was discontinued. Further review of the medical record revealed there was no information before 12/07/13 that identified the resident as having a toe spacer between the toes to prevent the toes from rubbing against each other. Review of the "Wound/Skin Care Management Documentation Form" dated 12/07/12 revealed the second digit on the left foot had a Stage III pressure ulcer measuring 1.0 cm in length by 1.2 cm in width by 0.1 cm in depth with 75% slough (dead tissue) and a moderate amount of drainage and odor present. The area of skin surrounding the wound (periwound) presented with [MEDICAL CONDITION], [DIAGNOSES REDACTED] (red) in color, and macerated but without pain. A treatment was received from the physician. On 12/11/12, the wound was described as a Stage II pressure ulcer that measured 1.0 cm in length by 0.9 cm in width by 0.01 cm in depth. The wound bed had 50% slough and 50% granulation with no odor. The periwound presented with [MEDICAL CONDITION], [DIAGNOSES REDACTED], maceration and pain. There was no new order received at this time. On 12/18/12, the area was assessed as a Stage II pressure ulcer that measured 0.8 cm in length by 0.9 cm in width by 0.1 cm in depth. The wound bed had 100% slough, with a scant amount of yellow colored drainage and the periwound was tender. There were no new orders obtained at this time. The wound documentation narrative dated 12/18/12 indicated the left foot second toe open area had 100% slough and some tenderness at the sit. A Jacobi bunion splint was applied to the open area and wrapped with gauze Review of the MDS assessments dated 12/10/12 and 12/22/12 revealed the resident still required extensive assist of one person with dressing and personal hygiene. The assessments also indicated the resident did not have any pressure ulcers. Review of the Podiatrist visit progress note dated 12/17/12 revealed the resident had an ulcer on the second left toe. A new treatment was ordered, the toe spacer was discontinued and a Jacobi bunion splint was also ordered. The splint is to be worn at all times to help pull the big toe off the ulcer site and only be removed to wash foot and treat the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP) staging guidelines (http://www.npuap.org) revealed the current staging guidelines of a Stage II was "partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister." According to the guidelines, a Stage III is defined as "full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. Additionally, a the depth of a Stage III varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. The NPUAP defines an unstageable pressure ulcer as "full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description stated, until enough slough and/or eschar is removed to expose the base of the wound, the true depth, staging cannot be determined. Interview with the MDS Nurse #23 on 02/20/13 at 4:24 P.M. verified Resident #216 required extensive assist for dressing and personal hygiene. In addition, MDS Nurse #23 verified the resident's MDS assessments were inaccurate and should have been coded for the presence of the pressure ulcer. She indicated the assessment should have reflected an unstageable pressure ulcer. MDS Nurse #23 also verified the nurses incorrectly assessed/staged Resident #216's pressure ulcer on the wound grid sheets as a Stage II pressure ulcer. She verified the wound bed contained 75% slough on 12/07/12 (discovery date) and 50% slough on 12/11/12 and should have been documented as a Stage III pressure ulcer. In addition, MDS Nurse #23 verified the wound bed contained 100% slough on 12/18/12, and should have been documented as an unstageable pressure ulcer. Interview with the Director of Nursing (DON) on 02/21/13 at 9:15 A.M. verified Resident #216 required extensive assist with activities of daily living and was at risk for the development of pressure ulcers. The DON stated that although staff was providing extensive assistance with care, the staff was not aware the resident had a toe spacer in place. She confirmed Resident #216's second left toe ulcer was not discovered until after it had already progressed to a Stage III pressure ulcer with slough. The DON was unable to provide documented evidence that Resident #216's toe spacer had ever been removed by staff to assess the skin under it. Review of the facility's policy entitled "Skin Management Protocol" revised 04/2012 revealed when a resident is identified as mild to moderate risk for pressure ulcers per the Braden scale, staff is to keep skin clean and dry; thoroughly wash and rinse soap from the resident, blot-never rub the skin, and use skin lubricant during morning and evening care. The policy also noted the resident will be monitored for changes in physical conditions. Under the skin assessment section, the policy indicated for all residents, full body skin observations are to be completed during the resident's shower/bath. Under the measurement and treatment change section of the policy, it noted if wounds show no sign of improvement in a two week timeframe, treatment should be evaluated and changed as recommended by the physician. Under the avoidable/unavoidable area, the policy indicated the facility was to have an assessment and documentation in the medical record if the resident's pressure ulcer is unavoidable which will be documented in the progress notes or on the form and should not be thinned from the chart. The physician must include supporting documentation as well as a statement to conclude the pressure ulcer was unavoidable. 2. Review of Resident #3's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated the resident was at risk for developing pressure ulcers. The resident was assessed as currently having a Stage II pressure ulcer. Under the preventive devices section, there was no devices assessed as being used in the chair for the prevention of pressure ulcers. Review of the wound documentation form dated 01/27/13 revealed the resident had developed a Stage II pressure ulcer to the coccyx area. Review of a physician telephone order dated 01/27/13 revealed staff was to apply a medicated patch dressing to the coccyx area every other day. On 02/12/13, a physician order [REDACTED]. Review of the January 2013 treatment administration record (TAR) for Resident #3 revealed the resident only received the wound treatment on 01/27/13. The rest of the month was not documented as the resident receiving treatment. Review of the at risk for skin impairment care plan, updated on 01/10/13, revealed no intervention of a pressure relieving device in the wheelchair or recliner. The acute care plan for the ulceration was started on 01/27/13 and there was no mention of pressure relieving devices being utilized. Observation on 02/21/13 at 1:45 P.M. revealed Resident #3 sitting in her recliner without pressure relieving devices in place. A device was observed sitting in the wheelchair next to the resident. Interview with Licensed Practical Nurse (LPN) #76 at 1:45 P.M. on 02/21/13 verified Resident #3 did not have a pressure relieving device in place in the recliner. She further verified there was an order for [REDACTED]. Interview with the DON on 02/21/13 at 1:20 P.M. verified the ordered treatments in January 2013 were not documented as being completed and the care plans were not updated to include interventions of a pressure relieving device. In addition, the DON stated she has always had a cushion in her chair, we just do not have that documented. 3. Review of Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A neurologic consultation completed at the hospital on [DATE] identified the resident to have a Stage III pressure ulcer on the left (no further specifications). The facility's resident data collection sheet from 11/19/12 identified the resident to have some type of skin area on the left buttocks. A treatment was obtained on this date for the use of [MEDICATION NAME] to the left buttocks and to change the [MEDICATION NAME] every three days and as needed. There was no wound management documentation form that identified the area on the left buttocks. The head to toe assessment completed on 11/19/12 identified the resident to have an open area on the right buttocks. There was no treatment for [REDACTED]. There were no further measurements of the area. The plan of care, developed 11/27/12, identified the resident to have impairment of the skin integrity related to Stage I and Stage II wounds, without identifying the location. Interventions included wound care as ordered and wound measurements weekly and as needed A review of the TAR for November 2012 revealed the treatment to the left buttocks was not completed after 11/26/12. The December 2012 TAR does not indicate the treatment to the left buttock was completed at any time from 12/01/12 through 12/04/12, the date the resident was discharged home. Additionally, the initial dietary note dated 11/26/12 indicated Resident #10 had a Stage III pressure ulcer to the left buttocks. The nutritional risk care plan developed on 11/26/12 indicated the resident had a Stage III pressure ulcer to the left buttocks. A consideration for nutrition intervention dated 11/30/12 indicated the resident has a healing Stage III pressure ulcer. None of the dietary documentation indicated the area currently was not presenting as a Stage III ulcer. An interview on 02/21/13 at 8:30 A.M. was conducted with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #15. LPN #15 indicated she observed Resident #10's pressure ulcer the day after his admission. She indicated the resident only had one pressure ulcer on the left buttocks that was a Stage II. LPN #15 indicated she had monitored the area, but verified she had not made any documentation on the wound management documentation form. During this interview, the DON indicated the dietary technician was documenting a Stage III ulcer from the neurological consult as a healing area. The DON did not know why there was no reference to the actual stage. The DON did verify during this interview the lack of weekly documentation of the pressure ulcer as per the facility policy. The DON also verified the treatment was not done the last week of the resident's stay at the facility. Review of the facility's policy entitled "Skin Management Protocol" revised 04/2012 indicates all wounds will be measured weekly (7 days) and documented on the wound/skin care documentation form.