Every finding on record at Luxe at Wellington Rehabilitation Center the

Based on observation, interview and record review, the facility failed to provide accommodation of needs to 1 of 1 sampled resident as evidenced by the air mattress not providing proper support and ensuring the call light was functional for Resident #11.The findings included:Review of the facility policy titled, Equipment Maintenance with no date listed under revision date, documented in part, Responsibilities-Staff: Reports malfunctioning equipment immediately and removes the unsafe items from service.Review of the record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Low Back Pain and Lymphedema. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating intact cognition.The assessment documented that Resident #11 had skin conditions and risk of pressure ulcers. Review of Physician Orders for Resident #11 dated 12/02/25 documented, Low Air Loss Mattress: Check pressure and function every shift.An initial interview was conducted on 03/09/26 at 11:04 AM with Resident #11 who stated that her call light was broken. She further explained that she was having a problem with her bed; the air mattress was not working, and it felt like she was sitting on bones. At that time, Staff F, Licensed Practical Nurse (LPN) came in to check on Resident #1. The resident informed Staff F that her call light and the air in her mattress was not working. Staff F checked the call light and agreed that it was not working and stated that she would go call for Maintenance.An interview was conducted on 03/10/26 at 9:01 AM, and Resident #11 stated that her call light had been replaced but they still had not fixed the air in the bed.On 03/11/26 at 9:11 AM, Staff F and Staff D, Certified Nursing Assistants (CNA) came in to assist with repositioning Resident #11 in her bed and were advised that the resident felt like the air was not working in the air mattress. Staff F checked the mattress under Resident #11's hip area and agreed that the mattress felt sunken and stated that she had talked to someone from Maintenance on 03/09/26 about Resident #11's light and mattress. Staff F stated that they did fix the call light, but they may not have fixed the mattress.On 03/11/26 at 10:47 AM, Staff F was asked if she had contacted maintenance and replied that someone had contacted Maintenance for her and that she would go downstairs to get them.An interview was conducted on 03/11/26 at 11:02 AM with Staff E, Maintenance Assistant who has worked in the facility for one year. Staff E was asked if he had fixed the call light for Resident #11 on 03/09/26 and he stated that he did fix the call light but was not told about the mattress issue. He was able to show on the TELS system where the work orders had been placed for Resident #11 to address her air mattress on 10/13/25, 01/08/26 and 01/21/26. Staff E stated that he had assessed the air machine for low pressure and replaced the machine and mattress during previous reports of issues with Resident #11's mattress. A work order entered on 03/11/26, after surveyor intervention.

Based on record review and interviews, the facility failed to honor the shower preference and schedule for 1 of 4 sampled residents reviewed for choices for (Resident#129). The findings include:Review of the electronic record for Resident #129 revealed she was admitted to the facility on [DATE]. Record review revealed the resident's Care Plan documented the following for her ADLs (Activities of Daily Living): Resident has an ADL self-care deficit related to a diagnosis of Cholelithiasis ADL needs and participation varies over the course of the day/week, generalized muscle weakness, Impaired balance, Limited Mobility. The interventions included Encourage and assist with all ADL tasks as indicated and as tolerated by resident and based on resident's strengths; Encourage resident to do as many ADL tasks for themselves as possible. ADL Care: the resident may need assistance; CNA (Certified Nursing Assistants) Bathing: The resident needs assist of 1-2 based on fatigue, weightbearing, weakness. Further review of her record documented her shower/bathe schedule were Monday, Wednesday and Friday. Her task sheet that documents the shower/bathe schedule documented a yes next to 03/06/26 and 03/10/26. There was also a refusal documented on 03/06/26. The task sheet does not document if this was a shower or bath. A review of a task sheet titled, bath revealed the dates 03/04/26-03/10/26. There were no check marks under the word showers. Under the word sponge bath, there was documentation indicating the resident had one on 03/04/26, 03/06/26, 03/08/26, 03/08/10/26 and 03/12/26. On 03/07/26 the schedule documented the resident had a full body bath.During an interview on 03/12/26 at 9:10 AM, Resident #129 resident was alert and oriented and able to respond to all questions asked. She stated that she has never had a shower and wants one. She expressed that she really wants her hair washed. She stated that the full sponge bath she had, she did herself.During an interview on 03/12/26 at 9:24 PM with the Regional MDS (Minimum Data Set) Coordinator, she reviewed the shower book and could not find any documentation of showers for Resident #129. She then went into the resident's room and the resident advised her, she wants a shower after lunch.During an interview on 03/12/26 at 9:45 AM with Staff J, Certified Nursing Assistant, she was asked about Resident #129's shower schedule. Staff J stated that she hasn't asked her (Resident #129), but she hasn't asked for one.

Based on policy review, observation, record review, and interview, the facility failed to ensure fingernail care for 2 of 5 sampled residents reviewed for Activities of Daily Living, as evidenced by the failure to trim and clean the fingernails of Resident #1 and Resident #21.The findings included:Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed January 2026, documented in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1) Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented the resident needed partial to moderate assistance from staff for personal hygiene. Review of the current care plan initiated on 11/06/25 and revised on 03/06/26 documented the resident had an ADL self-care deficit, and participation varied, related to fatigue and chronic medical conditions. This care plan documented the resident may need limited to extensive assistance from staff for all ADL care. During an interview and observation on 03/10/26 at 12:08 PM, Resident #1 was observed with excessively long fingernails, with the nail extending nearly a quarter inch past the ends of the fingers. When asked if he preferred his nails at that length, the resident stated he did not and wanted them clipped. When asked if staff had offered to assist with his nail care, the resident stated they had not. During a supplemental observation on 03/11/26 at 3:40 PM, the resident's fingernails remained elongated. During an interview on 03/11/26 at 4:16 PM, when asked who was responsible for cleaning and trimming the resident's fingernails, Staff B, Licensed Practical Nurse (LPN)/ First Floor Unit Manager stated the CNAs (Certified Nursing Assistants) should be cleaning and filing fingernails with morning care for their residents. The Unit Manager observed the resident's fingernails and agreed with the findings. 2) Record review revealed Resident #21 was admitted to the facility on [DATE]. Her diagnoses included: Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction without residual Deficits, Muscle Weakness, and Need for Assistance with Personal Care. Per the Minimum Data Set (MDS) assessment dated [DATE], this resident's Brief Interview for Mental Status (BIMS) score equaled 01. This indicated that Resident #21 had severe cognitive impairment. The Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #21 required maximal assistance with the ADL to clean herself. An intervention listed in Resident #21's Care Plan for ADL self-care deficit, dated 02/24/26, was to keep the resident clean, dry, and well-groomed. An observation of Resident #21 in her room on 03/09/26 at 5:30 PM revealed her fingernails were long. There was dark brown-black matter beneath her fingernails. Some of the fingernails extended one quarter to one half of an inch past the fingertips. Photographic Evidence Obtained. During an interview with Resident #21 on 03/09/26 at 5:30 PM it was revealed that she preferred her fingernails to be shorter. An observation of Resident #21 in her room on 03/11/26 at 1:30 PM revealed that her fingernails were long. There was dark brown-black matter beneath her fingernails. Resident #21 stuck her left-hand fingernails in the ground meat with gravy that was on her meal plate. Her left-hand fingernails had more brown-black matter than the fingernails on her right hand. Photographic Evidence Obtained. An interview on 03/11/26 at 5:25 PM was conducted with Staff A, CNA, who provided care to Resident #21. When Staff A was asked to describe Resident #21's fingernails, she said that they were of medium length. She asked Resident #21 if she would allow her to cut and clean her nails after she finished eating dinner. Resident #21 nodded her head in agreement and said yes. An observation on 03/12/26 at 9:20 AM revealed that Resident #21's fingernails were short and clean.

Based on observation, interview, and record review, the facility failed to ensure appropriate and timely care and services for 3 of 24 sampled residents as evidenced by the failure to coordinate care with a consultant physician to ensure continued administration of antibiotics for Resident #4; failure to ensure care for a skin tear to the left lower extremity of Resident #116; and failure to ensure documented blood pressure readings at the time of administration of an antihypertensive (blood pressure) medication with physician ordered parameters for Resident #116; and failure to follow physician ordered parameters for antihypertensive medications for Resident #127.The findings included:1) Review of the record revealed Resident #4 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident was on an intravenous (IV) antibiotic medication. Review of the current physician order revealed as of 03/09/26 Resident #4 was to receive Daptomycin (an antibiotic) via IV once daily until 03/19/26. Previous physician orders revealed the resident received the Daptomycin from 02/07/26 through 03/05/26. The record lacked any evidence of antibiotic administration or reason for the lack of administration on 03/06/26, 03/07/26, and 03/08/26. A progress note dated 03/03/26 confirmed Resident #4 went to the infectious disease (ID) physician that day. A physician's order from the ID physician dated 03/03/26 documented the resident was to continue the IV Daptomycin until 03/16/26. During an interview on 03/10/26 at 11:35 AM, Resident #4 explained she had gone to the ID physician last Tuesday (03/03/26), had received written orders to extend the antibiotics for two weeks. Resident #4 stated she took a photo of the order and handed it to the nurse upon return from the consultant physician's office. Resident #4 stated by Friday morning (03/06/26), she was not getting the antibiotic. The resident stated she spoke with a supervisor on that Friday and told her the issue. The supervisor responded she would take care of it, but never heard from her or anyone else again. Resident #4 stated she went through the weekend and Monday without the antibiotics for her MRSA (Methicillin Resistant Staph Aureus, an infection that was difficult to treat), of her left hip wound, and they finally got the antibiotics restarted Monday evening. During an interview on 03/12/26 at 10:43 AM, when asked about the process for new orders when a resident goes out to a consultant physician appointment, Staff B, Licensed Practical Nurse (LPN)/Unit Manager, explained when the resident returns from the appointment, they give the new order to a nurse. The Unit Manager stated if the resident does not provide an order, the nurse is to ask the residents if they received one, and if not, they are to document the lack of an order in the medical record. When asked what happened to Resident #4's antibiotics on 03/06/26 through 03/08/26, the Unit Manager stated she was unaware of any issue. When told of the consultant's physician order to continue the IV daptomycin and that it did not get put into place upon return from the office visit, the Unit Manager had no explanation but agreed with the findings. 2) Review of the record revealed Resident #116 was admitted to the facility on [DATE]. Review of the initial nursing assessment from 02/28/26 lacked any skin issues to the resident's left leg. Review of the weekly skin assessment on 03/03/26 documented the resident had a skin tear to his left lower leg after having sustained a fall on that same day. The weekly skin checks for 03/04/26 and 03/11/26 lacked any mention of the skin tear. Review of physician orders lacked any order for care to the resident's left leg. During an observation and interview on 03/09/26 at 10:01 AM, a large (approximately 4 inches by 6 inches) white wound dressing, that was curled up along the edges and had a faded date of 03/03/26 along the edge was noted to the resident's left leg. Upon observation a bloody-like area about 2 inches in diameter was seen through the dressing. When asked how long the dressing had been on his leg, the resident stated, about a week or so. Photographic evidence obtained. During the medication pass observation with Staff K, Registered Nurse (RN), on 03/10/26 at 9:45 AM, the same wound dressing was noted to the resident's left leg. During an observation on 03/11/26 at 4:09 PM, the same wound dressing remained on the resident's left leg. When shown to Staff B, LPN/Unit Manager, she agreed with the findings. 3) Review of the record revealed Resident #116 was admitted to the facility on [DATE] with diagnosis to include essential hypertension. Review of the physician orders revealed as of 02/28/26 Resident #116 was to receive the medication Metoprolol 50 mg (milligrams) twice daily at 9 AM and 5 PM, but to hold the medication for a systolic blood pressure less than 100 (the top number of the blood pressure reading) or a heart rate less than 60 beats per minute. Review of the corresponding Medication Administration Record (MAR) for March 2026 lacked any documented blood pressure or heart rate readings with the medication. During a medication pass observation for Resident #116 on 03/10/26 at 9:19 AM, Staff K, Registered Nurse (RN) held the resident's Metoprolol because the blood pressure reading was 99/64. Review of the MAR documented a blood pressure reading of 112/58, clearly not taken at the time of the medication pass observation. Further review of the MAR documented daily vital sign reading for the day shift (7 AM to 7 PM) and the night shift (7 PM to 7 AM). This entry lacked any specific time for the vitals, thus there was no way to know if the blood pressures and heart rates were taken with the medication. This documentation also lacked two entries on the day shift to incorporate both doses of medications on that shift. Review of the vital sign summary documentation lacked any vitals at 5 PM for 9 of 11 days. During a side-by-side review of the record and interview on 03/12/26 at 10:43 AM, Staff B, Unit Manager, agreed with the lack of documented blood pressure and heart rates. 4) Review of the electronic records for Resident #127 revealed that he was admitted to the facility on [DATE] with a readmission from the hospital on [DATE] and 12/24/25. His diagnosis included Chronic Diastolic Heart Failure, Type II Diabetes, Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD), Generalized Muscle Weakness and Malignant Neoplasm of the Bronchus or Lung. Further review of the physician's order revealed he had an order for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, to give 1 tablet by mouth two times a day for hypertension Hold for systolic blood pressure (SBP) less than 100 or Diastolic blood pressure (DBP) less than 60 or heart rate (HR) less than 60 start. The start date was 08/18/25 and the end date 09/15/25. Further review of this medication on the Medication Administration (MAR) revealed the following dates this medication was given and should have been held per the physician parameters. On 08/21/25 the 09:00 AM dose of Metoprolol, the blood pressure was 106/58. The diastolic of 58 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/22/25 the 09:00 AM dose of Metoprolol, the blood pressure was 102/53. The diastolic of 53 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/22/25 the 05:00 PM dose of Metoprolol, the blood pressure was 111/52. The diastolic of 52 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/23/25 the 09:00 AM dose of Metoprolol, the blood pressure was 110/54. The diastolic of 54 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/23/25 the 05:00 PM dose of Metoprolol, the blood pressure was 119/58. The diastolic of 58 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/25/25 the 09:00 AM dose of Metoprolol, the blood pressure was 127/58. The diastolic of 58 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/25/25 the 05:00 PM dose of Metoprolol, the blood pressure was 105/51. The diastolic of 51 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. On 08/27/25 the 09:00 AM dose of Metoprolol, the blood pressure was 101/50. The diastolic of 50 is below the parameters of 60 and should have been held. A checkmark with no code documented it was given. During an interview on 03/12/2026 at 10:15 AM with the Director of Nursing (DON), he reviewed the MAR (Medication Administration Record) for 08/25 and acknowledged the findings. During an interview on 03/12/26 at 1:02 PM Staff H, LPN (Licensed Practical Nurse) She reviewed the MAR for 08/25 and stated she would not give it but acknowledged she had a check mark next to the resident's name and gave it when she shouldn't have.

Based on observations, interviews, and record review, the facility failed to ensure 1 of 1 sampled resident with a voiced complaint of being unable to hear, received treatment to maintain her ability to hear. The findings included: A review of the Centers for Disease Control (CDC) resources on reducing the risk of Dementia, includes preventing or correcting hearing loss. Hearing loss is a known factor that increases a person's risk for Dementia (Reducing Risk for Dementia | Alzheimer's Disease and Dementia | CDC - published 08/27/24). Hearing loss leads people to be less socially engaged which consequently decreases intellectual stimulation. A review of the medical record revealed that Resident #93 was admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #93 had a Brief Interview for Mental Status of 10. This indicated she had moderate cognitive impairment. Review of Section B of the MDS assessment dated [DATE] documented Resident #93 had minimal difficulty hearing and did not have hearing aids. A review of Resident #93's medical records showed no plan of care initiated to address this resident's difficulty hearing. An observation on 12/23/25 at 1:15 PM revealed that Resident #93 was sitting up on the side of her bed when the surveyor entered the room. The surveyor asked the resident how she was, and the resident said, I can't hear you. The surveyor continued to try and interview the resident and the resident repeated I can't hear you. Three times the resident's response was I can't hear you. After the unsuccessful attempt to interview Resident #93, the surveyor used a hand motion to communicate to the resident that it was ok she didn't hear what was said. The surveyor turned to leave the room, and the resident looked frustrated and quickly laid down in her bed. An interview with Resident #93's family member conducted on 03/09/26 at 5:00 PM, revealed that Resident #93 had her ear wax cleaned out on more than one occasion prior to admission to the facility. He explained that one time after the earwax was cleaned out of her ears, there was a lot removed, and the dislodged wax was a very long tubular shape. The family member said that after that process, Resident #93 complained the TV was too loud. The family member said that when he visited the resident on 03/09/26, he requested that nursing follow-up on cleaning out her ear wax. When asked if he also requested that prior to 03/09/26, the family member explained that he initially requested it approximately 2 weeks ago. He did not remember which nurse he spoke to. An interview was conducted on 03/12/26 at 11:40 AM with Staff B, who was a Licensed Practical Nurse and the Unit Manager. When asked if there was a plan in place to address the family member's two requests to have Resident #93's earwax cleaned out, Staff B said she was not aware of those requests. She searched through Resident #93's medical record and she did not see any notes about the request. She did not find any documentation or orders to follow-up on earwax removal for Resident #93.

Based on observation, record review and interview the facility failed to ensure care and services for an indwelling catheter for 1 of 3 residents as evidence by failure to have an anchor for a Foley Catheter, and failure to follow the physicians order by notifying the physician of the change in the color of the urine for Resident #128. The findings included:Observations of Resident #123 on 03/09/26 at 1:00 PM and 03/10/26 at 10:29 AM revealed a Foley Catheter bag containing urine was noted to be dark orange in color. The water cup at the bed was observed to be full.Observations of Resident #123 on 03/12/26 at 9:00 AM revealed a Foley Catheter bag containing urine was noted to be dark brown in color. There was no anchor attached to the catheter tubing. The water cup at the bed was observed to be full.Review of the electronic record for Resident #128 revealed that she was admitted to the facility on [DATE] with a diagnosis to include Fracture Femur, Obstructive and Reflux Uropathy, and Dementia. A review of the physician's orders revealed indwelling Urinary Catheter: Monitor Q (every) Shift. Notify the physician of changes in urinary appearance (color, consistency, odor, etc.) and\/or no urinary output. every shift. The care plan documents the resident has a risk for injury/infection related to use of indwelling secondary to a diagnosis of obstructive uropathy. The interventions included encourage and assist resident with fluid intake as tolerated; Monitor for signs and symptoms of bacteriuria: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Report abnormalities to nurse/MD as needed; and Teach resident or caregiver on use of indwelling catheter, importance of adequate fluids, signs and symptoms of dehydration and infection such as confusion, fever, cloudy urine output, lethargy, and foul-smelling urine.During an interview on 03/12/26 at 9:30 AM with Staff I, LPN (Licensed Practical Nurse) the surveyor asked the nurse to come to the resident's room and to look at her foley catheter. The nurse confirmed that the resident did not have an anchor. The surveyor then asked what the process is if the urine is dark in color. She stated the resident needs hydration, she would offer her water and she would reach out to the physician. The surveyor then asked if she had reached out to the physician since the resident's urine has been like this since Monday and today (Thursday), she replied no, but I will.During an interview on 03/12/26 at 10:41 AM with the Director of Nursing (DON) he stated that he called the resident's physician and he ordered IV (Intravenous) fluids 1 liter (1,000 ml) to run at 100/ml (milliliters) for 1 hour for 1 liter. CBC/CMP (Complete Blood Count/Comprehensive Metabolic Panel) and urinalysis with Culture and Sensitivity. He stated the nurse should have called the physician, there is an order to do so. The DON added that an anchor should always be on, unless the resident refuses it or doesn't want it.

Based on policy review, observation, interview and record review, the facility failed to ensure appropriate care and services for oxygen use for 2 of 2 sampled residents as evidenced by failure to follow physicians orders for oxygen administration and parameters, and to maintain sanitary conditions of the oxygen tubing for Resident #41, and to ensure a clean oxygen concentrator filter and change per request for Resident #1.The findings included:Review of the policy, Oxygen Administration dated January 2026, documented in part, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1) Review of the record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure with hypoxia (a lack of oxygen supply to the blood) and chronic obstructive pulmonary disease (a progressive lung disease causing sever breathing difficulties). Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented the resident used supplemental oxygen. Review of the physician orders revealed an order dated 03/06/26 for continuous oxygen at 2 liters per minute for Resident #1 for a diagnosis of COPD. Further review of the orders and care plans lacked any instructions for cleaning the oxygen concentrator filter. During an interview and observation on 03/10/26 at 12:35 PM, Resident #1 stated he had been asking for new tubing as the one he had was not working well. Observation of the tubing revealed a kink in the tubing as it was bent down near where it connected to the concentrator. The oxygen was running at 5 liters per minute. When asked if this was the correct rate of administration, the resident stated it was. Observation of the filter revealed it was gray and dust laden. Photographic evidence obtained. During an observation on 03/11/26 at 3:40 PM, the oxygen filter and tubing remained the same. During an interview on 03/11/26 at 4:16 PM, when asked about the process for oxygen maintenance regarding changing the tubing and cleaning the filters, Staff B, Licensed Practical Nurse (LPN)/ First Floor Unit Manager, stated the night shift does both on Wednesdays. The Unit Manager observed the resident's oxygen concentration filter and bent oxygen tubing and agreed with the findings. 2) Review of the record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Heart Failure and Pneumonia. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating intact cognition. Review of the Physicians Orders for Resident #41 revealed the following orders both dated 02/27/26 Respiratory-Oxygen: NC\/Mask. Encourage and assist resident to use Oxygen at 2 Liters\/min via Nasal Canula as needed for Oxygen saturation less than 92% as needed, and Respiratory-oxygen tubing change: Change oxygen tubing/mask/bag Q week and as needed (PRN) every night shift every Wednesday and as needed. During observations on 03/09/26, at 10:49 AM, Resident #41 was in bed with the oxygen concentrator running at 2 Liters, and the nasal cannula was located on the floor. Resident #41 had his breakfast tray in front of him on his bedside table. During another observation at 1:25 PM, Resident #41 was sitting upright in bed with his lunch tray on his bedside table and his oxygen tubing was still located on the floor. Photographic Evidence Obtained. Resident #41 pushed his call bell and Staff G; Restorative Aide came in and after surveyor intervention Staff G noticed that the nasal cannula was located on the floor while the oxygen machine was running. Staff G picked up the tubing off the floor and hung the tubing on the drawer of the bedside table instead of disposing of it. Staff G went to get Staff F, Licensed Practical Nurse (LPN) to let her know that Resident #41 did not have his oxygen on. Staff G failed to inform Staff F that the oxygen tubing was found on the floor. Staff F came into Resident #41's room and attempted to reinsert the nasal tubing into Resident #41's nose and was advised by the surveyor that the tubing had been on the floor and Staff F stated that she found it on hanging on the drawer of the bedside table and was not informed that it had been on the floor. Staff F was asked if she should take Resident #41's oxygen saturation since he had not had his oxygen on for at least 2 1/2 hours. Resident #41 stated to Staff F that he is now on room air and does not need oxygen. Staff F retrieved the oximeter from her cart and Resident #41's oxygen saturation level was 98 percent. Staff F advised Resident #41 that he had a Physician's order for oxygen and encouraged him to put the new nasal tubing on and that she would contact his doctor to see if Resident #41 still needs oxygen and Resident #41 gave in and agreed to let Staff F assist him with putting the nasal cannula in his nose. Observations on 03/10/26 at 08:55 AM, and 3:20 PM, on 03/11/26 at 9:58 AM, and on 03/12/26 at 10:23 AM, revealed Resident #41 was wearing the nasal cannula, and the oxygen concentrator was running at 2 Liters. Review of Vitals-Oxygen Saturation revealed that Resident #41's Oxygen Saturation was above 92 percent 22 out of 23 documented assessments while on room air 10 times and while on oxygen at 2 Liters 12 times. An interview was conducted on 03/11/26 at 12:35 PM with Staff F (LPN) who was asked about the oxygen order for Resident #41. She stated he was on 2 liters of continuous oxygen and then reviewed the oxygen order and stated that she was wrong that the order was for 2 liters of oxygen if residents oxygen saturation was below 92 percent. She was asked what should have occurred on 03/09/26 when Resident #41's oxygen saturation was 98 percent. Staff F stated that she shouldn't have put the oxygen back on Resident #41 since his oxygen was at 98 percent. She then confirmed that the oxygen order for Resident #41 had never been for continuous oxygen. An interview was conducted on 03/11/26 at 1:25 PM with Staff G, restorative aide, who confirmed that he found the nasal cannula on the floor on 03/09/26 in Resident #41's room and had forgot to tell Staff F that it was on the floor. He stated that he should have just thrown out the tubing and not hung it on the bedside table drawer.

Based on record review and interview the facility failed to ensure controlled substance reconciliation for 4 of 6 sampled residents as evidenced by the failure to document both on the declining inventory sheet and the Medication Administration Record (MAR) for Residents #4, #110 and #18; and failure to remove from inventory and destroy a discontinued controlled medication for Resident #12.The findings included:Review of the policy titled, 4.0 Schedule II Controlled Substance Medication documented in part, Dispensing of Controlled Dangerous Substances: . 3. A declining inventory sheet will be provided with each dispense prescription for controlled dangerous medications. The form will contain the following information: patient name, medication name, medication strength, dosage form, name of prescribing physician, amount dispensed, prescription number and date dispensed. 5. When a Controlled Dangerous Substance medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. Discontinuation of Controlled Substances: 1. Controlled medications, which have been discontinued due to physician order, patient discharge, or patient death, must be destroyed per facility policy. 1) During a controlled medication review on the first floor 300 wing medication cart on 03/11/26 at 1:03 PM, the declining inventory sheet for the oxycodone 15 mg (milligrams) for Resident #4 and corresponding MAR was reviewed with Staff L, Licensed Practical Nurse (LPN). Review of the February 2026 MAR documented Resident #4 was given one tablet of the oxycodone tablet on 02/21/26 at 5:29 AM. The corresponding declining medication record for the 15 mg tablets of oxycodone lacked any entry for that administration. The declining medication record jumped from 02/20/26 at 6:27 PM to 02/21/26 at 1:04 PM. When asked the process for administration of controlled medications, Staff L confirmed the medication must be documented on the declining medication record and the MAR and agreed with the findings. 2) During a controlled medication review on the first floor 100 wing medication cart on 03/11/26 at 1:42 PM, the declining inventory sheet for the Percocet 5/325 mg tablets for Resident #110 and corresponding MAR was reviewed with Staff I, LPN. The March 2026 MAR documented the Percocet was administered on 03/07/26 at 2:34 PM and 7:47 PM and there was no corresponding documentation on the declining medication record. The declining medication record documented an entry on 03/07/26 at 10:47 PM with no corresponding documentation on the MAR. Staff I agreed with the findings. 3) During the continued controlled medication review on the first floor 100 wing medication cart on 03/11/26 at 1:42 PM, the declining inventory sheet for the Percocet 10/325 mg tablets for Resident #12 and corresponding MAR was reviewed with Staff I, LPN. There were two declining medication records on the medication cart. One for the medication to be administered every four hours and one for every six hours, both on an as needed basis. Review of the declining medication record for the every 6 hour administration had seven entries between the dates of 03/04/26 and 03/10/26, in which five different nurses documented they had pulled out the medication to administer to Resident #12. Review of the March 2026 MAR lacked any order for the Percocet to be given every 6 hours. During an interview at this time, when asked the process for the controlled medications once the physician discontinues an order, Staff I stated the medication should be removed from the cart and given to the supervisor for destruction. 4)Review of the record revealed Resident #18 was initially admitted to the facility 10/17/25 with the primary diagnosis of Parkinson's disease and other diagnoses included, chronic pain syndrome and low back pain. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the Resident was cognitively intact. Review of Resident #18's care plan dated 01/13/26 documented Focus: Resident receives opiate medications related to: Pain not managed by alternate interventions. Goal: Resident risk for adverse effects related to use of opioids will be minimized through next review date. Interventions: Administer medication as prescribed by the physician (See current MAR & Physician orders for current dosage.) Review of Resident #18's current orders documented, Tramadol HCl Tablet 50 MG -Give 1 tablet by mouth every 8 hours as needed for moderate and severe pain- pain 4-10 dated 02/26/26. Review of the discontinued orders documented, Tramadol HCl Tablet 50 MG -Give 1 tablet by mouth every 8 hours as needed for moderate and severe pain start date 10/07/25; discontinued date 02/26/26. A medication storage review was conducted for Resident #18 on 03/11/26 at 8:50 AM with Staff C, LPN (Licensed Practical Nurse) where cart #3 was reviewed for medication storage and narcotics were reconciled. Upon the review of Resident #18's medication, Tramadol HCl Tablet 50 MG (a narcotic,) the last 3 administrations were documented on the narcotic log as follows: Date: 11/13 ;Time: 11:00; On hand 6; Amount given 1; Remaining 5 Date: 12/1 ;Time: 09:21; On hand 5; Amount given 1; Remaining 4 Date: 1/29/26; Time 14:02; On hand 4; Amount given 1; Remaining 3 A verification count was done with Staff C, LPN in which both surveyor and nurse counted 3 remaining pills in the medication pack as per the documented narcotic log. The MAR/TAR (Medical Administration Record/Treatment Administration Record ) was then reviewed for documentation of the above administrations where the November administration and the January administration was not documented in the record. Staff C, LPN was asked to pull up the MAR/TAR on her computer to see if she was able to see the documentation of the narcotic administrations; Staff C agreed she could not see it either. On 03/11/26 at 9:49 AM, during a side-by-side review of the medication storage findings, the Assistant Director of Nursing (ADON) stated in the month of November 2025 their system was down and most documentation had to be entered in another location and later provided the documentation for this administration. When asked about the January administration, the ADON pulled up the MAR/TAR and agreed that it was blank. When asked what the process was for logging out a narcotic during administration, the ADON stated as you give a medication, it should be signed out both in the narcotic log and in the MAR. She agreed that the January documentation was not there and should have been documented upon administration.

Based on record review and interview, the facility failed to follow pharmacy recommendations for 1 of 5 sampled residents (Resident #96).The findings included:Review of the record revealed Resident #96 was admitted to the facility on [DATE]. Review of the current physician order dated 02/22/26 documented lorazepam (an antianxiety medication/psychotropic) 1 mg (milligram) was to be administered every 6 hours PRN (as needed) for anxiety. This order lacked any duration or stop date. This order was entered by Staff K, Registered Nurse (RN).Review of the pharmacy recommendation for February 2026 revealed the pharmacist identified the order for the as needed lorazepam without a documented stop date or duration, and recommended the physician order a stop date. The physician agreed and ordered the medication to be stopped as of 03/09/26. As of the survey date on 03/12/26, the as needed lorazepam order remained active. During an interview on 03/12/26 at approximately 10:00 AM, when asked the duration of use for lorazepam that was ordered as needed, Staff K, RN, stated sometimes they (the physicians) order it with a specific timeframe and other times not. When asked if he was aware of any regulation for psychotropic medications related to the duration of use, the RN stated he did not. During an interview on 03/12/26 at 10:38 AM, when asked the duration of use for as needed Ativan, Staff B, Unit Manager, stated they usually order PRN lorazepam for 14 days, but the doctor may order it longer with justification and a definite timeframe, like 30 days. The Unit Manager agreed with the findings.During an interview on 03/12/26 at 11:25 AM, when asked about the duration of PRN lorazepam, Staff M, psychiatrist, stated, 14 days. When asked about Resident #96's lorazepam order, the psychiatrist stated that order came from the hospital and the nurse's entered it in as it was there.

Based on observation, interview and record review, the medication error rate was 8 percent. Two medication errors were identified while observing a total of 25 opportunities, affecting 1 of 6 residents observed (Residents #116).The findings included:A medication pass observation for Resident #116 was made on 03/10/26 at 9:19 AM with Staff K, Registered Nurse (RN). The RN pulled 9 pills from the medication cart that included one folic acid 1 mg (milligram) tablet. The RN also obtained 1 gram ampicillin (an antibiotic) with a 50 ml (milliliters) bag of Normal Saline (NS) to administer. The RN verified the 9 pills with one IV medication prior to entering the room.The RN gave the 9 pills to Resident #116. The RN then started to prepare the IV antibiotic, by breaking the seal between the NS bag and vial of medication, squeezing the NS bag to allow fluid to enter the vial of powdered antibiotic, and mixed the solution. The RN then turned the bag and vial to the upright position but failed to squeeze the NS bag prior to allow the vial to empty back in the NS bag to be administered. The RN hooked the IV tubing to the resident's IV line and started the IV pump to administer and left the room at 9:50 AM. Upon leaving the room a faint beeping was heard from the IV machine, and it was observed as occluded (the medication could not infuse), but the RN continued out of the room. An observation at this time revealed the vial remained full of the now mixed medication and was not in the bag of NS, thus was unable to be administered to the resident. A partially empty bag of NS was hanging from the IV pole. Continued observation of the room was made by the surveyor. At 9:57 AM a Certified Nursing Assistant went to the resident's room with the linen cart and entered the room to provide care. At 10:26 AM Staff K, RN, passed by the room but did not check the IV. At 10:34 AM a therapist went to the resident's door stating that he would have to come back later as the IV was still running. The therapist was heard telling Resident #116 that the IV was beeping. At 10:37 AM the RN returned to the room, removed the IV and tubing from the machine, and threw the IV set into the garbage. Photographic evidence obtained.On 03/10/26 at 10:40 AM, when asked if the IV antibiotic had completed, Staff K, RN, stated it did. Upon retrieval of the IV from the trash, the NS that was in the tubing and bag drained out onto the floor and the vial remained full of the medication. Photographic evidence obtained. When told the medication had not been infused as the vial was full and the IV pump had been beeping occlusion, the RN argued and disagreed, stating he had squeezed the bag. When told again that he did squeeze the bag, but the medication did not go back into the 50 ml bag to infuse, as he did not invert the vial back upright, the RN disagreed.The RN returned to the medication cart. The RN was asked to pull the folic acid pack and asked if he administered one or two tablets. The RN confirmed he only administered one tablet, and the physician order was for two tablets.Review of the record revealed the order dated 03/01/26 to administer two tablets of 1 mg Folic Acid daily. On 03/10/26 at 10:52 AM, Staff B, Licensed Practical Nurse (LPN)/Unit Manager was taken to the resident's room to observe the IV antibiotic and made aware of the observation. The Unit Manager agreed with the findings.

Based on observation, record review and interviews, the facility failed to ensure standards of practice for administration of medication for 1 of 3 sampled residents, as evidenced by failure to ensure Resident #4 received medication as prescribed and ensure medications are refilled in a timely manner. The findings included:Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of medical diagnosis documented a history of cerebral infarction with hemiparesis (stroke with paralysis on one side).During an observation of medication administration on 12/08/25 at 9:56 AM Staff A, Licensed Practical Nurse prepared Eldertonic (appetite supplement) 15milliliters (ml), Levetiracetam (seizure) 500mg (1 tablet) Pantopazole (acid reflux) 40 mg (1 tablet), and Lactulose (increase ammonia level) 15grams/15ml (30ml). After pouring 30 milliliters of Lactulose in a medicine cup, Staff A handed the surveyor the medicine bottle and stated He is out of this medication. It had to be reordered. Observation revealed the medicine bottle had a prescription label on it with a different resident's name. After preparing the medication Staff A went into the resident's room and administered the 2 pills which had been crushed in apple sauce, 15ml Eldertonic and 30ml of Lactulose. (photographic evidence obtained).During an interview on 12/08/25 at 10:18 AM, when she was asked when the Lactulose for Resident #4 was reordered, Staff A stated Today. (as she looked in the computer) When asked when the medication was reordered prior to today, she stated, On 10/22/25. She was asked how much Lactulose she administered to the resident and she said 30ml. Staff A was asked by the surveyor to look in the computer to verify the order and after doing so, she stated It says15ml. Well, it was 30ml they must have changed the order.Review of a physician orders for Resident #4, dated 04/07/25 instructed staff to administer Lactulose Encephalopathy Oral Solution 10 GM/15ML (Lactulose (Encephalopathy) Give 15 ml by mouth two times a day for Constipation.

Based on observations, interviews, record and policy review; the facility failed to protect a resident's right to be free from neglect by failure of staff to respond timely to the resident's change of condition which resulted in hospitalization for 1 of 2 residents sampled for change in condition (Resident #4). The findings included: The facility's policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin issued 08/2022 and revised 01/2024 revealed, Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident (s) requires but a facility fails to provide them, to the resident (s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Resident #4 was admitted to the facility on [DATE] post-acute care hospitalization . Diagnoses included Dysarthria following Cerebral Infarction, Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Asthma, Heart Failure and Unspecified Atrial Fibrillation. On the Discharge Return Anticipated Minimum Data Set with an assessment reference date of 04/05/25 her Brief Interview for Mental Status was unable to be conducted which indicated she was severely cognitively impaired. Review of the Electronic Health Record (EHR) for Resident # 4 revealed she was admitted to the facility in the evening of 04/03/25. On 04/04/25 at 7:03 AM a nursing skilled documentation note revealed Pt is alert and responsive, Skin warm and dry. Breathing even and unlabored. All care provided by assigned staff; Turning and repositioning done per facility protocol. Call light in reach; Bed in low position. Care continues. On 04/04/25 skin/wound documentation revealed skin changes which were reported to the physician. On 04/04/25 she was also seen by the Dietitian, the activities assistant and the Medical Director. There was no documentation from the primary nurse on the first shift. On 04/05/25 at 8:10 AM nursing documentation revealed, Patient remain stable, no acute respiratory distress, no c/o pain or discomfort noted. Safety maintained, call light within reach. Plan of care continues. A review of the Medication Administration Record (MAR) for April 2025 revealed, the resident took her medications on 04/04/25 and at 6:00 AM on 04/05/25. The medications were marked as refused for the 9:00 AM medications. On 04/05/25 at 9:20 AM, Staff H, a Licensed Practical Nurse (LPN), documented that the resident refused her medications. A record review of the Blood pressure (BP) for Resident #4 revealed: 4/5/2025 15:10 (3:10pm) -158 / 69 4/5/2025 09:19 - 101 / 82 4/4/2025 23:52 (11:52pm) 121 / 63 4/4/2025 10:04 - 116 / 58 4/4/2025 07:06 - 123 / 81 4/3/2025 19:12 (7:12pm) -115 / 83 A record review of the Pulse readings for Resident #4 revealed: 4/5/2025 15:10 - 78 bpm Regular (beats per minute) 4/5/2025 09:19 - 111 bpm Irregular - new onset 4/4/2025 23:52 - 61 bpm Regular 4/4/2025 10:04 - 68 bpm Regular 4/4/2025 07:06 - 71 bpm Regular 4/3/2025 19:13 - 68 bpm Regular The next entry into the nursing progress notes was on 04/05/25 at 2:45 PM which revealed, Resident transferred to [emergency room ] ER for evaluation and treatment. Resident observed by nurse at the bedside nonresponsive verbally, but responsive to touch. Resident able to move all extremities [with] w/ weakness in left upper extremity from previous CVA. Resident vital signs were assessed BP 158/69, HR-78, [Oxygen Saturation] O2-96, [Respirations] R-16, [Blood Sugar] BS-158. Resident unable to verbally express if experiencing any pain. Resident assessed by Nurses X3, on shift supervisors X2 at the bedside. P.A. was immediately notified of changes. Orders received to transfer resident out to [WRMC, a local hospital] for evaluation and treatment. A review of the facility's transfer form revealed, the resident had altered mental status, was not alert, and was transferred to the hospital on 04/05/25 at 3:09 PM. A telephone interview was conducted with Staff J, a Certified Nursing Assistant (CNA) on 04/16/25 at 2:10 PM. Staff J stated she was the primary CNA for Resident #4 on 04/05/25. Staff J stated the resident was moving but not opening her eyes during her rounds between 7:30 AM-8:00 AM on 04/05/25. When breakfast came, she set up her tray, called her name and she was moving but not opening her eyes. She left the tray there and reported it to the nurse. She checked her brief which was dry, she did not give her personal care or dress her because her eyes were closed the whole morning. When lunch came, she brought her tray. She was still moving but not opening her eyes. She did not eat lunch. She did not drink anything. The nurse called Staff D, a Physician Assistant, (PA) and another nurse tried to put in an IV (intravenous line). The daughter came in and was upset and the resident was not alert. Paramedics came and she went to the hospital. A telephone interview was conducted with Staff D, PA, on 04/16/25 at 2:32 PM. She was asked if she was notified that Resident #4 refused her morning medication. She stated she was notified around 2-2:15 PM on 04/05/25 that she did not eat breakfast or lunch, so she assumed she did not take her medication. She stated she was on call and not in the building to evaluate the resident. An interview was conducted via telephone on 04/16/25 at 4:12 PM with Staff G, Registered Nurse (RN), Unit Manager. Staff G stated that she worked that day and there was another manager there that she was helping. She stated she was not aware at all that day that Resident #4 had not opened her eyes all day. She was not aware that the resident did not eat breakfast or lunch. At about 3:02 PM, Staff J asked her to check the resident, she was told a nurse was trying to start an IV on the resident. She stated she went into the room and there was froth in the resident's mouth. She checked her pupils, and they were deviating to the right. She thought she may have had another CVA (cerebral vascular accident/stroke). Just at that time, the resident's daughters came into the room very upset. The paramedics came at the same time and asked the primary nurse when the last time it was that she saw the patient awake and she stated when she gave report to the night nurse yesterday. A telephone interview was conducted with Staff I, RN on 04/16/25 at 4:20 PM. Staff I stated she was asked to put in an IV for Resident #4. She stated it was about 2:50 PM on 04/05/25. She entered the room and looked at the resident. She was making a snoring sound. She did not respond to a sternal rub. Her pupils were dilated but uneven. 911 was called and the daughter came. A telephone interview was conducted with Staff H, LPN, on 04/16/25 at 4:31 PM. She stated she has been working in this facility for a year. She stated she was the resident's nurse on 04/05/25. She also had her on 04/04/25 and on that day she was in the chair and using the white board to communicate. On 04/05/25 she went into Resident 4's room with Staff J to say good morning and she moved her arms and legs. She did not respond verbally. It appeared she was sleeping, snoring. She did her vitals, blood pressure and blood sugar and she responded to pain. She assumed she was tired. Around 8:00 AM-9:00 AM she could not give her meds. Then around 12:30 PM, Staff J noticed she did not eat lunch. She asked another LPN working on another hallway to do an assessment on Resident #4. That nurse did an assessment and thought she was really tired and weak but she was still moving her lips and arms and her blood sugar 188. Staff H texted the PA at 12:30pm and said today she is not like herself and not as alert. The PA said to call the family to start an IV, stat chest x-ray, labs, and urine analysis. When asked if she asked the Unit Manager to check the resident, she stated that the Unit Manager was busy with another family at the time. She got a message from the receptionist that the daughter called around 1:30 PM. She called the daughter back about the change in condition and got the ok to start an IV. She asked Staff I to insert the IV. When she laid the resident back, the pupil assessment was unusual, and she texted the PA at 2:45pm to ask to send her to the hospital via 911. The two supervisors came into the room, the family came, and the paramedics came. The paramedics wanted to know when I saw her awake last, and I said she was sleeping this morning. They took her to the hospital. An interview was conducted with the Administrator on 04/16/25 at 3:24pm. The Administrator stated she was aware of Resident #4's condition on 04/05/25 since the resident's daughter had spoken to her about it on 04/07/25. On 4/5/2025, the resident was admitted to the Intensive Care Unit with a diagnosis of a CVA (Cerebrovascular Accident). A review of the hospital records for Resident #4 was conducted. A review of the History and Physical performed on Resident 4 on 04/05/25 at 5:33 PM, revealed the Glasgow Coma Scale results. The eye opening response was to pain, best verbal response was incomprehensible sounds, best motor response was flexes and withdraws to painful stimuli. The residents Glasgow Coma Score was 8. The Glasgow Coma Scale (GCS) is a system to score or measure how conscious you are. The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you're fully awake, responsive and have no problems with thinking ability or memory. Generally, having a score of 8 or fewer means you're in a coma. The lower the score, the deeper the coma is. Facility staff did not recognize a decline in Resident #4's condition on 4/5/25 until approximately 12:30 PM on 4/5/25 and Resident #4 was transferred to the hospital at 3:09 PM.

Based on record reviews and interviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards by failing to recognize one out of 2 residents sampled (Resident #5), after admission to the nursing home was not on medication for a diagnosis of Atrial Fibrillation. The resident was readmitted to the hospital with a diagnosis of Bilateral Pulmonary Embolism. The findings included: Resident #5 was admitted to the facility post-acute care hospitalization on [DATE]. Her admitting diagnoses included Staphylococcal Arthritis of Left Knee, Cellulitis of Left Lower Limb and Unspecified Atrial Fibrillation. Her Brief Interview for Mental Status was 15 on the 5-day Minimum Data Set with an assessment reference date of 03/12/25. This revealed the resident had intact cognition. A review of the Electronic Health Record (EHR) revealed the resident was evaluated by a nurse practitioner (NP) on 03/07/25. The NP note revealed was found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. Atrial fibrillation (Afib) is an irregular and often rapid heart rhythm that can lead to various complications, including blood clots, stroke, and heart failure. (Atrial flutter is an abnormal heart rhythm in the heart's upper chambers (atria). The atria beats too fast. This may cause dizziness and fatigue.) A review of the Eliquis prescriber information revealed Eliquis is an oral anticoagulant used to prevent and treat blood clots. Eliquis is used to lower the risk of stroke or a blood clot in people with atrial fibrillation. Premature discontinuation of any oral anticoagulant, including ELIQUIS, increases the risk of thrombotic events. If anticoagulation with ELIQUIS is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant. On 03/09/25 the resident was seen by the same NP who wrote a progress note revealing the resident Was found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. In that same note the NP wrote Hospital/old records reviewed and new onset afib- on Eliquis. On 03/10/25 the pharmacist wrote a note revealing Medication Regimen reviewed: No recommendation made. On 03/11/25 a review of a physician note revealed Was found with new onset of afib/aflutter- started on Eliquis. The note continued to reveal I personally reviewed records including acute care hospital, skilled nursing facility, and therapy records. Summarization of the acute care course can be found in the HPI section. Discussed case with the primary medical team and/or leadership. On 03/11/25, the Medical Director wrote a progress note in the EHR revealing was found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. Hospital/old records reviewed, new onset afib- on Eliquis, dvt proph: Eliquis. (DVT is deep vein thrombosis and proph is prophylactic which indicates a drug used to prevent deep vein blood clots.) On 03/13/25 Staff D, a Physician Assistant (PA) wrote a progress note that revealed was found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. Hospital/old records reviewed, new onset afib- on Eliquis, dvt proph: Eliquis. On 03/14/25, the physician who wrote a note on 03/11/25 wrote another note revealing was found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. On 03/14/25 an APRN (Advanced Practice Registered Nurse) wrote a progress note that revealed was found with new onset of afib/aflutter- started on Eliquis. Pt stabilized and transferred to Luxe. On 03/15/25 a record review of Occupational Therapy (OT) notes revealed Patient reports feeling dizzy upon sitting EOB (edge of bed), before therapist could assist pt (patient) back to bed, pt passed out and was unresponsive x 30 sec (seconds). Pt regained consciousness, however diaphoretic and c/o (complained of) dizziness and possible passing out again. Pt's BP (blood pressure) =121/107. Pt's O2 (oxygen saturation) at 83 on room air. Pt placed on 2.5 liter O2 (oxygen) via face mask, after approximately 5 minutes, pt's O2 increased to 97%. Pt provided with cold was cloth. Nsg (nursing) staff assisted with pt and soon after pt was transported to hospital. A review of the March 2025 Medication Administration Record (MAR) indicated that the resident never received Eliquis while at the nursing home. A review of Physician orders revealed the resident never had an order for Eliquis at the nursing home. A review of the resident's care plan dated 03/10/25 revealed, The resident has altered cardiovascular status related to Hypertension, Hyperlipidemia and A-fib. Review of Resident #5's hospital records prior to admission to the nursing home which were included in the EHR revealed: Per hospital record documented on 03/05/25 - Cleared from cardiac standpoint. Stop heparin, restart Eliquis. Review of hospital records revealed AF/Flutter. New onset, was not in AF when she came in. TEE (transesophageal echocardiography which can detect blood clots in the heart) done no [NAME] (left atrial appendage which is a small sac in the muscle wall of the left atrium where blood could collect and form clots with someone with atrial fibrillation) clot. Cardioverted her during TEE but went back into rate controlled AF/ Flutter In and out of atrial flutter. Rate controlled. EF normal. Metoprolol Eliquis TELE [Telemetry] : Atrial flutter Cleared for discharge FU [follow up] in office 2-3 weeks for [Paroxysmal Atrial Fibrillation] PAF/Atrial flutter The physician note revealed a cardioversion (a procedure that uses electrical shock to restore an irregular heartbeat to a normal rhythm) was done in the hospital prior to discharge. This was done during a TEE. The TEE revealed no [NAME] clot. EF (ejection fraction is a percentage of how much blood the ventricles pump out with each heart contraction). TELE (telemetry which monitors heart rate and rhythm). A telephone interview was conducted with Staff D, Physician Assistant (PA) on 04/16/25 at 2:32 PM. She was asked why her note, and every Physician and NP note revealed the resident was on Eliquis. She stated that it should have been picked up that the resident was not on Eliquis. It was not on the medication discharge list, and it should have been questioned. She probably wrote her note based on the previous notes. A review was done of the Hospital emergency room record from 03/15/25 and hospital records from the admission on 03/15/25 to discharge on 03/24/25 revealed, the resident was admitted to the hospital with a diagnosis of Bilateral Pulmonary Embolism. An Inairi pulmonary thrombectomy was performed on 03/18/25. A bilateral pulmonary embolism is a clot in the veins of both lungs that occurs when a blood clot that has arisen from a different area obstructs the pulmonary arteries. Mechanical thrombectomy, or simply thrombectomy, is the removal of a blood clot (thrombus) from a blood vessel. 50370

Based on observation and interviews, the facility failed to provide residents with a dignified existence and communication with staff in and outside of the facility for 3 of 4 sampled residents reviewed for resident rights (Resident #6, #7 and #8). The findings included: 1). In an observation conducted on 04/16/2025 at 2:00 PM on the second floor of the facility, the surveyor noted that the nurses' station was empty. The surveyor walked around for 45 minutes and never saw a staff member. There were 40 residents on this second floor unit. 2). In an interview conducted on 04/16/2025 at 2:35 PM Resident #6's wife stated that she can never get in contact with the facility staff when she calls, she always must come to the facility if she has a question which is never answered because it seems that no one ever has an answer. Resident # 6's wife further stated that she doesn't see nurses nor CNA's (certified nursing assistants) around during her visits. Record review revealed Resident #6 was admitted on [DATE] post CVA (cerebrovascular accident). His Brief Interview of Mental Status (BIMS) score was 11 on the 5-day Minjimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/25. This indicated mild cognitive impairment. 3). In an interview conducted on 04/16/2025 at 2:20 PM Resident # 7's wife stated that she would love to see staff members come into her husband's room to care for him because she comes in the morning and leaves in the afternoon and the only time that she sees a staff member is for med pass and at lunch. If they need anything, no one is around to help them. She further revealed that her husband has been waiting to see a speech therapist for days now. And that exactly today she got a call from her insurance company saying that the doctor came to see her husband, but she spent the whole day with the husband and didn't see any doctor come around. Resident # 7's wife also stated that it's pointless talking to the front desk because their answer is always: I will investigate and get back to you which never happens. Record review revealed Resident #7 was admitted on [DATE] post CVA. His BIMS score was 14 on the admission MDS with an ARD of 04/13/25. This indicated intact cognition for this resident. 4). In an interview conducted on 04/16/2025 at 2:30 PM, Resident #8 stated angrily that she spent the whole day trying to find social services from the facility phone with no success. Every time she calls the front desk she gets transferred to Social Services and no answer. Resident # 8 stated that this facility is very big and nice, but the staff members are not so nice. Record review revealed Resident #8 was admitted on [DATE] for aftercare following joint replacement surgery. Her BIMS score on the 5-day MDS with an ARD of 04/14/25 was 15. This indicated the resident had intact cognition. On 04/16/25 at 3:20 PM, the Administrator was apprised of the interviews with the residents and representatives and stated that she receives messages on her phone from residents, and families come into her office all of the time to speak with her. During further interview, it was discussed regarding Resident #8 not being able to reach the social worker today, she responded that the social worker is off today.

Based on observation, record review, and interview, the facility failed to ensure proper indwelling urinary catheter care and services for 1 of 3 sampled residents, as evidenced by the failure to assess for and or attempt to discontinue the indwelling urinary catheter for Resident #1. The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE], after hospitalization for back surgery. Review of the hospital record revealed the indwelling urinary catheter was placed at the time of the surgery. The hospital discharge instructions lacked any documentation related to the indwelling urinary catheter. The hospital record lacked any documented attempt at removal of the device. Review of the transfer form dated 09/04/24 from the hospital documented Resident #1 had a Foley catheter (indwelling urinary catheter) in place but lacked any indication for use and lacked information as to if the hospital made an attempt to remove the device. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating intact cognition. This MDS also documented the resident had an indwelling urinary catheter for neurogenic bladder, as did an order dated 09/06/24. The admission nursing assessment dated [DATE] documented Resident #1 was admitted with the indwelling urinary catheter. Review of all nursing and physician progress notes, along with all physician orders, lacked any documented assessment to remove the indwelling urinary catheter, or rationale as to why it needed to remain. The record also lacked a documented voiding trial, a process where the urinary catheter would be removed to allow the resident to urinate. The progress notes and orders also lacked any need for a urinary consult. Review of the record revealed an order for a surgical follow-up appointment scheduled for 09/26/24 at the physician's office. A progress note dated 09/26/24 at 2:15 PM documented Resident #1 was transported to the hospital following a doctor's appointment. Review of the post-operative progress note from the Resident's follow-up appointment documented, in part, that Resident #1 still had the Foley catheter in place. This note revealed Resident #1 told the nursing staff and doctors at the SNF (skilled nursing facility) that the catheter was meant to be removed and that she had not had any voiding trial. This note documented the Foley catheter was to be removed two to three days after admission to the facility. During a side-by-side review of the record and interview on 11/13/24 at 4:47 PM, when asked if there had been an assessment or attempt to remove the indwelling urinary catheter for Resident #1, the First Floor Unit Manager stated she could not find anything in the electronic record. When asked the process to ensure a resident does not have a urinary catheter longer than needed, the Unit Manager stated typically the physician would order a voiding trial shortly after admission.

Based on policy review, observation, record review, and interview, the facility failed to ensure proper care and services for the intravenous line for 1 of 1 sampled resident, as evidenced by the lack of dressing changes as per order for Resident #2. The findings included: Review of the policy Central Lines revised 05/2024 documented, in part, Procedure: . 2. Ensure infection control standards are maintained during the care of the central line including but not limited to: a. Change dressing routinely and per physician orders. Review of the policy Documentation revised 01/2024 documented, in part, Procedure: . 4. documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the record revealed Resident #2 was admitted to the facility on [DATE]. Review of the orders revealed the resident had had several peripheral IVs (intravenous access devices) placed throughout his stay at the facility, with the most recent being a midline (specific type of central line intravenous catheter) that was placed on 10/28/24. This order instructed the nurses to change the dressing every Tuesday and as needed using sterile technique. An order dated 10/28/24 also instructed the nurses to flush the midline twice daily with normal saline. Review of the Medication Administration Record (MAR) documented the same nurse changed the midline dressing on 10/29/24, 11/05/24, and 11/12/24. The MARs also documented nurses were flushing the midline twice daily starting on 10/28/24 through the survey date. During an observation on 11/13/24 at 12:10 PM, Resident #2 was in bed and the midline IV access was noted to his right upper arm. The top edge of the dressing was loose and pulling back from the skin. The label on the dressing had a nurse's initials, different from the nurse who had documented the provision of care on the MAR, and the date was from October, but unable to read the specific day of the month. Review of the employee roster revealed there was no current facility nurse with the initials documented on the midline dressing, which would indicate the observed dressing was from the technician who inserted the line on 10/28/24. During a side-by-side review of the record and interview, when told of the observation of the midline dressing for Resident #2, the First Floor Unit Manager stated she agreed with the findings. The Unit Manager stated the nurses were flushing the line twice daily and should have noted the need for a new dressing for the midline.

Based on clinical record review and interview, the facility staff failed to provide necessary care and services to ensure adequate monitoring for 2 of 3 sampled residents (Resident #1 and #2) who experienced significant changes in condition requiring hospitalization ; and the facility failed to assess skin changes for 1 of 3 sampled residents (Resident #3) after skin impairments were identified and treated to ensure resolution. The findings included: 1) Clinical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] after a short hospitalization due to Hematuria. Review of the Minimum Data Set, admission assessment with reference date of [DATE], documented the resident was assessed as independent for skills of daily decision making, has an indwelling urinary catheter and was receiving anticoagulant, antibiotic and hypoglycemia medications. The resident did not receive oxygen therapy. Review of Care Plans revised on [DATE], documented the following: The resident is at risk for potential fluid imbalance related to status post infection, sepsis and urinary tract infections. The interventions included: Lab/diagnostic work as ordered, notify MD (Medical Doctor) as indicated, monitor and document intake and output as per facility policy/MD order, monitor vital signs as ordered/per protocol and record. The resident has a risk for injury/infection related to presence of catheter secondary to chronic Foley catheter use, recurrent urinary tract infections and obstructive uropathy. The interventions included: Irrigate catheter as per MD order, monitor and document intake and output per MD orders and monitor for signs of bacteriuria: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Report abnormalities to nurse/MD as needed. Review of Progress Notes dated [DATE], documented patient in bed alert, no apparent distress noted. Tolerated medication well. Foley catheter in place with bright red blood noted, irrigation initiated. Practitioner aware and report given to upcoming nurse to continue monitor. Review of Practitioner Progress Notes dated [DATE], documented seen today in a bed. case discussed with nurse, hypotensive, weak, normal saline started, Foley flushed as hematuria worsening again, urinalysis and labs ordered, if continue with low blood pressure send out. Review of a document titled, SBAR Summary for Providers dated [DATE] documented, Situation: The Change In Condition reported Bleeding (other than GI). At the time of evaluation [DATE] at 11:20 AM resident's blood pressure ,d+[DATE], pulse 41 and pulse oximetry 91 percent via oxygen mask. Review of the Transfer to Hospital Summary dated [DATE] documented, Patient observe with labored breathing. Vital signs blood pressure ,d+[DATE], heart rate 100, oxygen saturation 85%. Patient placed on Non-Rebreather mask at 15 liters. Patient assessed at bedside by practitioner. Order receive for chest x-ray and intravenous fluids. Midline inserted, intravenous fluid in progress. Patient with profuse bleeding in diaper and at Foley catheter site. Vitals signs ,d+[DATE], heart rate 41, oxygen level 91% on non-rebreather mask and practitioner notified. Telephone orders received to transfer patient to hospital for further evaluation and treatment. 911 notified and patient left facility at approximately 11:45. Review of a Fire Rescue report dated [DATE] disclosed the emergency team arrived at the facility on [DATE] at 11:24 AM, Male patient found lying in bed unresponsive with blood-soaked sheets all over and a blood-soaked diaper. EMS (Emergency Medical System) rescue crew holding pressure to patient's penis stating that he was actively bleeding coming from the tip of his penis and they were unable to stop. Facility machine noted last blood pressure ,d+[DATE]. Staff was unable to provide accurate timeline of how long patient had been bleeding for, by the amount of blood in the bed it appeared patient had been bleeding for a while. EMS requested via phone a unit of blood, initially treating hemorrhagic shock, patient went into cardiac arrest and cardiopulmonary resuscitation started. Review of emergency room records dated [DATE] documented the medical screening exam at 12:01 PM, the patient presents in cardiac arrest. Per EMS they were called for excessive bleeding from the penis. Upon arrival he was hypotensive and had blood on the bed presumably from the penis. Patient was pulseless and apneic upon arrival . intubated, no evidence of trauma, ultrasound was placed on the heart, there was some mild quivering, but no cardiac output noted. No return to spontaneous circulation after multiple rounds of ACLS (Advance Cardiac Life Support) and defibrillation. Patient was pronounced not compatible with life at 12:50 PM. Interview with Staff A, Licensed Nurse, who cared for Resident #1 on [DATE], was conducted on [DATE] at 3:13 PM. Staff A recalled that she came in that morning and the resident was not feeling well, he was pale, his blood pressure was low, and she prioritize him. Staff A called the practitioner, she came in gave order for fluids and other tests, the IV (intravenous team) happened to be in the building and they inserted the line right away. So she started the fluids. Resident #1 had chronic hematuria, was previously sent to the hospital for a CBI (continuous bladder irrigation) and returned with the urinary catheter. Staff A was asked how the urinary output was and was the catheter draining, she replied the Foley was draining and after starting the fluids his blood pressure went up. Then, later on, the assigned aide went to clean him up and noticed the gross amount of blood, 'it was a lot, and called her to the room. Staff A then immediately called the provider and got orders to send him out and she called 911. Staff A stated that it was a good thing that the aide went to change him then, otherwise she would not have noticed the blood, he had the covers pulled up and there is no way she would have seen it. The nurse was asked what type of monitoring was conducted and stated she checked his blood pressure, and it was better, she thinks 103 or so, she can't recall the exact number and acknowledged there is no documentation of an assessment and monitoring after the change in condition and prior to the transfer to the emergency room . During interview with the Nurse Practitioner (APRN) conducted on [DATE] at approximately 10:30 AM revealed Resident #1 had chronic hematuria, he was sent to the hospital multiple times, and the urologist decided to only treat him with Flomax. The hematuria was improving. The date of the transfer, the resident's blood pressure was low, and the hematuria returned. The nurse called her, and she examined the resident and ordered fluids and blood work. The nurse told her the blood pressure was improving, then later on she received another call that the blood pressure and oxygenation had dropped, and he had significant bleeding, she sent him out to the emergency department. The APRN stated the resident had been cleared to continue his Pradaxa, anticoagulant medication, and that she ordered the fluids to manage the low blood pressure. Interview with Staff C, Certified Nursing Assistant, conducted on [DATE] at 1:54 PM revealed she was the aide assigned to care for Resident #1. That morning she came in and was passing breakfast and caring for her residents. Around mid-morning, she went to the resident, the resident next door wanted a shower and she decided to see Resident #1 first. When she entered the room, she asked him how are you?, and he could not respond, he was trying. She thought he was having a stroke, she then pulled the sheets off and saw all the blood all over the bed and starting yelling for the nurse emergency, emergency. The nurse came in and went out to get oxygen and supplies and told her to go ahead and give the shower to the resident next door and the nurse told her that she had it under control. She was not in the room when the medics arrived and was asked what type of report did she get from the night aide, or the nurse, and replied she did not get any, no one told her there was anything wrong with the resident. Interview with Staff G, the night shift nurse, conducted on [DATE] at 2:10 PM revealed the staff had no recollection of the resident, then after reading her notes, Staff G stated the resident had blood in the catheter and she called the practitioner and irrigated the catheter, but was unable to describe how much blood. Staff G stated she completed an assessment, the blood pressure was fine, his abdomen was not distended but was not sure if she documented the findings. Record review and interview revealed Resident #1 had a change in condition, identified by Staff G, the night nurse, who documented as bright blood in the resident's urinary catheter. The nurse reported the findings to the provider, irrigated the catheter and gave report to Staff A, the day nurse. Staff G did not document an assessment after the change in condition, there were no vital signs, blood pressure and pulse, there was no documentation as to the amount of blood or urine in the Foley catheter and there is no documentation of an assessment or finding after the irrigation. Staff A obtained vital signs, documenting low blood pressure ,d+[DATE] and heart rate of 100 on [DATE] at 8:25 AM and received orders from the practitioner. There was no evidence of a subsequent assessment monitoring the amount of blood in the urinary bag, patency of the catheter, abdominal distention, or any active bleeding, or vital signs. The next assessment was documented on [DATE] at 11:20 AM, the resident had profuse bleeding, blood pressure ,d+[DATE], heart rate 41 and oxygen level 85% on room air. There was no evidence the staff assessed and closely monitored the patient for signs of bleeding. 2) Clinical record review revealed Resident #2 was admitted to the facility on [DATE] for rehabilitation after a knee replacement. Minimum Data Set, admission assessment with reference date of [DATE] documents the resident was independent was skills of daily decision making, had occasional pain and received opioids and antiplatelet medications. Review of Resident #2's Care Plan titled, Resident is at risk for potential fluid imbalance related to the use/side effects of medication, status post Hyponatremia dated [DATE] documents the resident will remain free of signs of fluid overload through review date, as evidenced by decrease in or absence of edema, anxiety, agitation, restlessness, confusion, changes in mood or behavior, nausea/vomiting, dyspnea, congestion, orthopnea, easily fatigued, jugular vein distension. The interventions included: Lab/diagnostic work as ordered. Notify MD (Medical Doctor) as indicated and monitor vital signs as ordered/per protocol and record, notify MD of significant changes. Review of an IDT (Interdisciplinary Team) Note, dated [DATE] documented Patient referred to skilled speech by rehab services, reported decline with oral intake/cough with thin liquids. Daughter at bedside; patient lethargic and unable to follow commands, no verbalization/vocalization. Daughter requested transfer to hospital; APRN (Advance Practitioner Registered Nurse) following and collaborated with family following request. Daughter reported plan to initiate fluids. Per aide all solids/liquids deferred during the morning. Patient is not alert for oral intake. Did not follow one step command however utilized simple hand gestures with no verbalizations. Daughter aware regarding current status and not safe for oral intake. Nurses notes dated [DATE] documented Patient alert with confusion. New orders received. IV fluids started to prevent dehydration, chest x-ray and electrocardiogram done. EKG result sent to MD. Doppler of LE (lower extremity) ordered. Patient is sleeping most of the day, complained of abdominal discomfort. Pain medication given as scheduled, and effective. MD notified and report given to the night shift nurse to follow up. Review if Physician order dated on [DATE] at 11:03 AM documented STAT complete blood count, basic chemistry profile and urinalysis for confusion. A Physician's order dated [DATE] at 11:35 AM documented STAT ultrasound to bilateral left lower extremities rule out blood clots. Review of Physician/Practitioner Progress Notes dated [DATE], documented *Patient also seen by myself yesterday, confusion and groggy-arousable. similar symptoms with UTI (Urinary Tract Infection) last week and improved with intravenous fluids and antibiotic, appeared dry, little water intake per daughter at bedside, patient reports some abdominal discomfort with palpation, patient has been having bowel movements per staff. Recently treated for urinary tract infection with antibiotics and improvement in white count and was doing well after treatment, Daughter reported she was doing well after treatment and that these new symptoms started ,d+[DATE]. Ordered multiple imaging studies, restart antibiotic, stat labs, intravenous fluids discussed with RN yesterday. Not all of above studies resulted. Reviewed electrocardiogram with medical doctor as well last night, possible tachycardia from dehydration. This AM similar symptoms and recommended pt transfer to emergency room for more in-depth work up. Review of progress notes dated [DATE], documented Resident received in bed, alert and responsive to herself. Round 7:40 vital signs was stable blood pressure ,d+[DATE], pulse 95, oxygen saturation 97% room air. At 8:50 AM, recheck vital signs blood pressure ,d+[DATE], pulse 128, temperature 97.4, respiration 19. IV fluid given,nebulizer treatment and oxygen for comfort per ARNP. Resident transferred to hospital via 911. Her daughter was at the bed side. Resident #2's record provides no evidence of the results of the ultrasound and blood work ordered STAT on [DATE]. The record provides no evidence of nursing reassessments after Staff C identified a blood pressure reading of ,d+[DATE] documented at 8:40 AM and there are no subsequent monitoring prior to the transfer to the emergency room at 10:53 AM. Review of the Fire Rescue report documented that on [DATE] at 10:53 AM, Resident #2 was found lethargic, slow to respond. The [family member] states that the patient has been lethargic over the past several days and this morning her blood pressure was found to be lower than normal. Emergency Medical System, staff on the scene documented systolic blood pressure only can be obtained manually and below 80. During transfer patient was upgraded to sepsis alert. emergency room records revealed the medical screening exam dated [DATE] at 12:12 PM. The exam documented Resident #2 presents with complaint of altered mental status, per daughter this has been ongoing for the last couple of days. Emergency medical system was called to the scene due to patient being unresponsive and hypotensive. Laboratory studies revealed critical white blood cell count of 72 (normal range 3XXX,d+[DATE].8). Interview with the Physician Assistant on [DATE] at approximately 10:35 AM revealed Resident #2 started to exhibit changes the day before the transfer, she was previously treated for a urinary tract infection with Ceftriaxone and fluids and responded well. This time she had the same symptoms, so she ordered STAT labs, electrocardiogram, chest x-ray and ultrasound. The next day, the resident was still not feeling better, and Resident #2 was sent out to the hospital. The STAT orders are completed within four hours, she received the electrocardiogram result and reviewed it with the physician but did not get the rest of the labs or ultrasound results, she was not sure if it was done. Interview with Director of Nursing (DON) on [DATE] at 12:53 PM revealed the nursing staff is to complete a nursing assessment after changes in condition are identified. The DON reviewed Resident #1 and Resident #2 clinical records and confirmed there is no documentation of assessment and monitoring after the changes in condition were identified. The DON was asked for a policy on how the staff handles medical emergencies. It was not provided. Interview with Staff C, the Registered Nurse, assigned to care for Resident #2, was conducted on [DATE] at 1:34 PM. Staff C recalled entering the resident's room and saw the resident attached to the blood pressure machine, she pushed the machine and the vital signs were okay. Then later the [family member] came to her and told her that the resident was declining, she pointed to the physician assistant that was in the hallway and stated that the [family member] should talk to the PA. Staff C stated she saw them both talking, but nothing was said to her. Staff C went back in the room and repeated the vital signs, the blood pressure was low, she started to go through the medications, to see what she could do to help her and noticed that she did not have intravenous fluids going, and gave her intravenous fluids that had been ordered, a nebulizer treatment and oxygen. Staff C was asked three times to confirm her notes, documenting the blood pressure reading of ,d+[DATE] was obtained at 8:50 AM and confirmed that was correct. The staff was asked how she continued to monitor the resident and stated she obtained another blood pressure, and it went up to the 100's and that she completed an assessment, but it was not documented. Furthermore, Staff C shared text messages between her and the PA (physician assistant) validating the nurse contacted her requesting a call back, then sent another text stating Resident #2 needs to go out 911 and the PA responded that she had told the unit manager that Resident #2 could go to the hospital via AMR (regular ambulance transport) but if unstable to call 911. Staff C stated she was not made aware of the recommendation. Interview with the DON and the Chief Nursing Officer conducted on [DATE] at approximately 4 PM revealed the STAT orders for Resident #2 were inputted under the prescriber tab instead of telephone or verbal. This means the staff has to go in the electronic system and move the order from one section to another for implementation. The DON showed the computer screen where the providers continue to enter the orders in this format and the staff must go in multiple times a day to correct them. There is no evidence the diagnostic tests, STAT ultrasound and STAT laboratory studies were completed. 3) Clinical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of Heart Failure. Upon admission Resident #3 was assessed with a Braden score 08, low risk of developing pressure ulcers. Review of the Minimum Data Set, admission assessment with reference date of [DATE], documented the resident had no pressure wounds on admission. Review of the Care Plan titled, Resident is at risk for skin impairment elated to decreased mobility, Diabetes and Malnutrition, dated [DATE] documented the resident will be free from any new skin impairment through the review date. The interventions included: Encourage and assist resident to minimize pressure to bony prominence's as tolerated, encourage and assist resident to turn and reposition as tolerated and skin checks weekly and as indicated, and report any signs of skin breakdown to physician and wound team as indicated. Physician orders and treatment administration records documented Resident #3 received Zinc Oxide ointment 10 percent for skin condition, redness to the buttocks from [DATE] thru [DATE]. The clinical record failed to provide evidence of a skin assessment of the skin condition, redness blanchable or non-blanchable and evidence that the area of concern had resolved after the seven-day treatment was completed. Review of the Weekly skin check dated [DATE], documented the resident's skin was intact. Subsequent skin check dated [DATE] provided no documentation. Interview with the Chief Nursing Officer (CNO) on [DATE] at approximately 4 PM revealed there are no nurses' notes assessing the skin impairment and documentation that it had resolved. The CNO provided provider notes dated [DATE] thru [DATE], all the notes documented pressure ulcers as per RN notes and skin checks per RN, wound care per facility protocol, RN to notify primary of skin changes or decubitus ulcers. There were no description of the skin impairment. Record review and interview confirmed the clinical staff failed to complete pertinent nursing assessments and monitoring after changes in condition were identified involving Resident #1 and Resident #2. Resident #1 expired in the emergency room and Resident #2 was still hospitalized as of [DATE]. In addition, the clinical staff failed to ensure skin condition was properly assessed to determine if the skin impairment met criteria for pressure wound and failed to document resolution or worsening of the skin condition after the prescribed treatment was completed for Resident #3.

Based on observation, interview and record review, the facility failed to implement care practices to prevent excessive tension on the indwelling urinary catheter to minimize complications. The failure affected 1 of 1 sampled resident (Resident #6). The findings included: Review of CDC recommendations for catheter care include the following: Properly secure catheters to prevent movement and urethral traction, maintain a sterile closed drainage system, maintain good hygiene at the catheter urethral interface, maintain unobstructed urine flow and maintain drainage bag below level of bladder at all times. Observation of catheter and wound care for Resident #6 was conducted on 10/29/24 at 9:38 AM. Staff D, a Certified Nursing Assistant, the Wound Care Nurse and the Unit Manager assisted with the provision of care. Staff D and the Wound Care Nurse prepared their supplies, performed hand hygiene and donned proper personal protective equipment. Staff D started the provision of care with the Wound Care Nurse by opening the resident's brief and turning the resident to place a pad underneath. It was noted the resident's catheter was not anchored to prevent pulling, there was a blue clamp, and a securement device attached to the catheter tubing. The device was wrinkled up and not attached to the resident's skin and the blue clamp was not in use as well. When the staff turned the resident to right side to place a pad, the resident moaned, the staff asked what hurt and the resident responded her back. It was noted the catheter tubing was pulling as the catheter bag remained attached to the side of the bed. Staff D provided catheter care, and the Wound Care Nurse was observed removing the crumbled-up securement device from the urinary catheter tubing and discarded it. Then the Wound Care Nurse and the aide turned the resident to the left side, again the catheter tube was pulling as it was not secured. The Unit Manager then intervene by placing the catheter bag on top of the bed, at the same level as the bladder, and the wound nurse performed wound care. The Wound Care Nurse and the aide then repositioned the resident and placed the catheter bag back to the side of the bed, and did not secure the catheter with the blue clamp or obtain another securement device for the urinary catheter. Interview conducted on 10/29/24 at 10:05 AM with the Unit Manager confirmed the resident's urinary catheter was not secured during the provision of care and the urinary bag was placed on top of the bed to minimize pulling, the manager stated the Wound Care Nurse was going to replace the securement device. Review of the Minimum Data Set assessment with reference date of 10/22/24 documented Resident #6 was assessed as severely impaired for skills of daily decision making and has an indwelling urinary catheter. Review of the Care plan titled, resident has a risk for injury/infection related to the presence of catheter secondary to a diagnosis of obstructive uropathy, dated 10/17/24, documented interventions as check catheter tubing for patency as indicated/needed and monitor for signs of bacteria and position catheter bag and tubing so that it promotes dignity and drainage.

Based on policy review, record review and interview, it was determined, the facility failed to ensure licensed nurses were able to demonstrate competency related to the provision of medication administration and following physician's orders. This failure affected 2 of 3 sampled residents (Resident #2 and #3). The findings included: 1) Clinical record review revealed Resident #3 was admitted to the facility for rehabilitation services with multiple diagnoses including Heart Failure and Hypertension on 10/07/24. Review of Physician's orders dated 10/08/24, documented Amlodipine Besylate 5 milligrams give 1 tablet by mouth two times a day, scheduled at 9 AM and 9 PM and Carvedilol Tablet 6.25 milligrams, give 1 tablet by mouth every 12 hours for Hypertension, scheduled at 9 AM and 5 PM. The medications have prescribed parameters, hold for systolic blood pressure less than 110 or heart rate less than 60. Review of the Medication Administration Record dated 10/2024, documented Resident #3 received the prescribed medications identified above with no evidence of blood pressure monitoring on the following days: 10/09/24, 10/10/24, 10/11/24, 10/16/24, 10/17/24, 10/21/24 and 10/22/24. 2) Clinical record review revealed Resident #2 was admitted to the facility for rehabilitation services on 09/09/24 with multiple diagnoses including Heart Failure and Hypertension. Review of Physician's orders dated 09/16/24, documented Methocarbamol Oral Tablet 500 mg, give 1 tablet by mouth every 12 hours for spasms, and hold for systolic blood pressure less than 105 or heart rate less than 60, hold for lethargy/drowsy. Review of the Medication Administration Record dated 10/2024, documented Resident #2 received the prescribed medications on 10/04/24 at 9 PM with blood pressure reading of 100/61 and on 10/22/24 at 9 AM with blood pressure reading of 104/69. Interview with the Director of Nursing and the Chief Nursing Officer on 10/29/24 starting at approximately 4 PM confirmed the staff who put in the order for Resident #3, did not add the field to document the vital signs. The DON confirmed the staff administered the medication to Resident #2 despite the prescribed parameters.

Based on observation, interview and record review, the facility failed to ensure sufficient staffing as evidenced by failure to provide timely administration of medications for 1 of 6 sampled residents (Resident #50 .refer to F684); ineffective communication for 2 of 2 sampled residents (Residents #29 and 394 (refer to F676); and numerous resident / family complaints from 13 of 31 sampled residents / representatives (Residents #394, #393, #192, #39, #66, #33, #4, #29, #193, #63, #1, #194, and #395). The findings included: 1) On 09/24/24 at 11:49 AM, Resident #50's family member was interviewed via telephone and stated that he felt [Resident #50] had declined due to not participating in therapy as much as she needed to because she was not being provided her medications in a timely manner. When she doesn't get her medications on time, it can affect her blood pressure, she becomes dizzy, and she doesn't want to get out of bed to attend therapy. A review of Resident #50's medication orders showed active orders for the following Parkinson's medications: Carbidopa-Levodopa Oral Tablet 25-100 MG Give 1 tablet by mouth three times a day for Parkinson (9 AM, 1 PM, and 5 PM); and Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG Give 1 tablet by mouth two times a day for Parkinson (6 AM and 9 PM). A review of the Medication Administration Record revealed the following for the administration of Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG (8 AM and 8 PM): 09/08/24 - medication was not recorded as being given at 8 AM. 09/14/24 - medication was given at 10:09 PM (1 hour and 9 minutes late); 09/16/24 - medication was given at 11:10 PM (2 hours and 10 minutes late); 09/25/24 - medication was given at 10:09 PM (1 hour and 9 minutes late). A review of the Medication Administration Record revealed the following for the administration of Carbidopa-Levodopa Oral Tablet 25-100 MG (9 AM/900, 1 PM/1300, and 5 PM/1700): 09/20/24 - medication was given at 10:49 AM (1 hour and 49 minutes late); 09/20/24 - medication was given at 2:25 PM (1 hour and 25 minutes late); 09/21/24 - medication was given at 10:07 AM (1 hour and 7 minutes late); 09/22/24 - medication was given at 10:26 AM (1 hour and 26 minutes late); 09/22/24 - medication was given at 10:09 PM (1 hour and 9 minutes late); 09/24/24 - medication was given at 6:14 PM (1 hour and 14 minutes late); 09/26/24 - medication was given at 11:53 AM (2 hours and 53 minutes late); 09/26/24 - medication was given at 3:19 PM (2 hour and 19 minutes late); 09/27/24 - medication was given at 11:21 AM (2 hours and 21 minutes late); 09/27/24 - medication was given at 3:02 PM (2 hours and 2 minutes late). On 09/27/24 at 4:37 PM, an interview was conducted with the Director of Nursing (DON). She confirmed that medications are to be given within 1 hour prior and 1 after the prescribed time of the medication, per physician order. The DON was provided evidence showing Resident #50's medications have not consistently been provided within the allowed time frames. 2) On 09/23/24 at 11:00 AM, the family member of Resident #29 stated, [Resident #29] only speaks Spanish and there is no staff available that speaks Spanish. I am concerned because there is no way for [Resident #29] to communicate with the staff. The family member also added, There needs to be more supervision. Staff do not come by and check on [Resident #29] very often. The response time to her call light is very long. On 09/23/24 at 11:46 AM, Resident #394, who has a Brief Interview for Mental Status (BIMS) score of 14, complained there is not enough staff. I ring the call light, and it takes about 20 minutes to respond. When I go to the bathroom, it takes 20 minutes or longer to get changed. It is often that this happens. It happens more at night. On 09/25/24 at 11:12 AM, during interview with Resident #394's family member, she stated she does not think there is sufficient staff to meet [Resident #394's] needs. There are no Spanish speaking personnel able to communicate with [Resident 394]. Before admission, they were told that there were Spanish-speaking personnel, and during the care plan meeting, they were told that nurses were trilingual, but they are not. The family member added, I have had to come into the facility to change [Resident #394] since staff were not answering the call light. No one was at the nurse's station to take my calls. I left messages, and no one return the calls. I asked the social worker during the care plan meeting where my voicemails were going, and I was told that she didn't know. No one is at the desk at night. I feel the staff are overwhelmed at night. 3) The following concerns were voiced by residents and family members during the survey process: a) On 09/23/24 at 11:15 AM, Resident #192, whose BIMS is 12, stated, The staff response time to call my light is long. It usually takes an hour for staff to respond. b) On 09/24/24 at 9:50 AM, Resident #194, whose BIMS is 15, stated, I ask staff for a cup of ice and gingerale, but they tell me they don't have soda and never provide it to me. I have also asked staff 2 days ago for some Ben Gay to rub on my shoulder, and still nothing. I asked for some lotion for my back 3 days ago, and I have not received it. The staff keep saying 'OK, OK', but they never do anything. c) On 09/23/24 at 10:50 AM, Resident #193, whose documented BIMS is 15, stated, Usually, there is only 1 nurse on the floor at times. The fastest response time is 25-30 minutes. Usually, it is 2-3 hours before staff answer my call light. 51137 d) On 09/23/24 at 2:35 PM, Resident #63, with a BIMS score of 11, indicating moderate cognitive impairment, stated there is not enough staff; she waits 2 & 1/2 hours to get changed. e) On 09/23/24 at 2:25 PM, Resident #71, who has a BIMS score of 13 said it feels like they are short staffed. There are long wait times to get changed, at least 2-3 times it has been over an hour. f) On 09/23/24 at 10:36 AM, Resident #393, whose BIMS score was 15 and was admitted on [DATE], stated that she had sat in soiled briefs for 5 hours, as she had watched clock. Her family member, who was at bedside, tried to help. The aide, who was unpleasant, told her, 'This is the 2nd time I have to change you'. The family added that [Resident #393] was not provided water and stated that this all occurred during the weekend. It was hard to find any staff to help. It was stated that on Friday night, a random resident walked into Resident #393's room and sat on her floor. The resident was very sweet, but it was a little frightening. g) On 09/23/24 at 12:12 PM, Resident # 66's representative said that this resident did not get changed and dressed until 11:30 AM today. She stated that it does not seem like there is enough staff to take care of the resident's needs. It is worse mostly on weekends. Resident #66 was not interviewable as her BIMS was 04 (severe cognitive impairment). h) On 09/23/24 at 2:47 PM, Resident #33, who has a BIMS score of 15, said the facility is short staffed. It takes at least 45 minutes to answer the call light. i) On 09/24/24 at 10:51 AM, Resident #4, who has a BIMS score of 15, stated, It takes over an hour, or sometimes several hours, to answer the call light. j) On 09/23/24 at 12:54 PM, Resident #395's family member voiced concern with lack of staff. She said, it takes about 45 minutes for [Resident #395] to get changed, and at night she often hears other resident's calling out for help. k. On a follow up interview on 09/27/24 at 9:31 AM, Resident # 395's family member stated she left [Resident 395's] curtain up at a specific height on purpose to see if staff would adjust it, but it was not adjusted at all, and [Resident 395's] TV was left on all night.