Every finding on record at Meadow Wind Health Care Center

Based on record review, staff and resident interview, and review of facility policy, the facility failed to ensure Resident #44 received treatment and care in accordance with professional standards of practice for treatment of urinary tract infection.Actual harm occurred to Resident #44 on 06/07/26, when the facility failed to notify the nurse practitioner (NP) of abnormal urine analysis and culture results, which were positive for Klebsiella pneumoniae ESBL (extended spectrum beta-lactamase) bacteria greater than 100,000 colony-forming units per milliliter, causing a delay in treatment for a urinary tract infection (UTI). The results were not reported to the NP until 06/16/26 at approximately 9:51 P.M. At approximately 11:00 P.M. on 06/16/26, Resident #44 was found by Licensed Practical Nurse (LPN) #515 during medication pass to slowly respond to questions but not open her eyes and had an abnormal pulse of 44 beats per minute. At 12:35 A.M. on 06/17/26 Resident #44 was transported by emergency medical services (EMS) to the local hospital and admitted for low heart rate (bradycardia) and unresponsiveness. Resident #44 was diagnosed with acute kidney injury on chronic stage three kidney disease and urinary tract infection. Urine analysis and culture results in the hospital resulted positive for Escherichia coli (E-coli) and Klebsiella pneumoniae. Resident #44 required a nine-day hospital stay which included an infectious disease consult, and insertion of a peripherally inserted central catheter (PICC) to administer intravenous antibiotics. Resident #44 returned to the facility on [DATE]. This affected one (Resident #44) of two residents (Resident #44 and Resident #96) reviewed for hospitalization. The facility census was 77. Findings include:Review of the medical record for Resident #44 revealed an admission date of 02/07/25 with diagnoses including need for assistance with personal care, muscle weakness, stage three pressure ulcer of sacral region, moderate protein-calorie malnutrition, noninfective gastroenteritis and colitis, other iron deficiency anemia, heart disease and other dysphagia.Review of the care plan for Resident #44, date initiated 02/07/25 and revised 06/10/25, revealed bladder incontinence related to generalized weakness requiring assistance with activities of daily living (ADL) care and toileting. Interventions included clean peri-area with each incontinence episode, have call light within easy reach, maintain resident dignity with care, and monitor and document signs and symptoms of urinary tract infections: pain, burning, blood-tinged urine, cloudiness, no urine output, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/21/26, revealed Resident #44 was cognitively intact, required a wheelchair for mobility, was dependent for toileting hygiene, required substantial/maximal assistance for showering and all dressing, and was frequently incontinent of both bowel and bladder. The resident was medically complex and had no significant weight loss. Review of progress notes dated 05/27/26 authored by Nurse Practitioner (NP) #617 revealed Resident #44 was being seen for management of chronic diseases and symptomatic hypotension over the weekend which was suspected to be related to post EGD (esophagogastroduodenoscopy) procedure on 05/22/26. Current midodrine (anit-hypotension medication) was increased and use of compression hose when out of bed. The resident was noted to have a history of urinary tract infection with acute cystitis and positive urine culture which had been treated with antibiotics in 03/2026. The resident was noted to be resting comfortably in bed and was alert and oriented to person, place and time on exam but noted to not seem herself and was tearful. No complaints or problems with urination or pain with urination were noted. A psychiatric consult was ordered to address depression symptoms.Review of a progress note written by NP #612 on 06/01/26 revealed Resident #44 was seen for altered mental status which included being tearful at times with some confusion over the past week. Resident #44 was awake, alert, and in no distress. The plan was for a complete blood count (CBC), basic metabolic panel (BMP), and a urinalysis with culture and sensitivity to be obtained on 06/02/26.Review of a progress note written by Registered Nurse (RN) #504 on 06/02/26 at 9:07 P.M., revealed laboratory results were reviewed and (unnamed) NP aware.Review of a progress note written by NP #613 on 06/02/26 revealed Resident #44 was seen for follow up of altered mental status and to re-evaluate for hypotension. The resident was alert, oriented and able to participate by answering questions appropriately during the examination. Lab results dated 05/28/26 were reviewed as WBC (white blood cells) 5.4 (normal), glucose 69 (normal), sodium 144 (normal), potassium 4.6(normal), chloride 109 (normal), BUN (blood urea nitrogen) 32 (high), creatinine 1.3 (high), calcium 9.1 (normal), protein 5.1 (low), albumin less than 3.0 (low), hemoglobin 10.6 (low), and hematocrit 32.2 (low). A TSH (thyroid stimulation hormone) dated 05/22/26 was 6.091 (high). It was noted the elevated TSH could be contributing to symptoms, so Synthroid medication was added and to check a complete blood count (CBC) and basic metabolic panel (BMP) on Thursday (in one week). The note also indicated the urinalysis with culture and sensitivity was ordered but had not yet been obtained. Review of a progress note written by Licensed Practical Nurse (LPN) #650 on 06/03/26 at 6:11 A.M. revealed the order for urinalysis with culture and sensitivity had been obtained.Review of a progress note written by NP #613 on 06/05/26 revealed Resident #44 was seen for follow up of altered mental status. Resident #44 was awake, alert and oriented to person, place and time, in no distress, sitting up in her wheelchair, and able to answer questions appropriately. Resident #44 was noted to be having no pain with urination and no blood in the urine. 06/01/26 labs results were reviewed and recorded as WBC (white blood cells) 5.8 (normal), glucose 69 (normal), sodium 143 (normal), potassium 4.3 (normal), chloride 106 (normal), BUN (blood urea nitrogen) 37 (high), creatinine 1.2 (normal), calcium 9.0 (normal), hemoglobin 11.0 (low), and hematocrit 33.5 (low). The note indicated the urinalysis with culture and sensitivity was pending positive.Review of the document titled Lab Reports Result, dated 06/07/26, for Resident #44 revealed the urine specimen was collected on 06/03/26 and reported to the facility on [DATE] at 2:38 P.M. but did not indicate to whom the report was given for the results. The results indicated the resident's urine culture was positive for Klebsiella pneumoniae ESBL (extended spectrum beta-lactamase). ESBL was highly resistant to many common antibiotics including penicillin and cephalosporins. Review of progress notes dated 06/07/26 through 06/15/26 revealed no evidence the facility reported the 06/07/26 urine culture and sensitivity results for Resident #44 to the NP or physician. Progress notes indicated on 06/14/26 that Resident #44 was at baseline for vitals and level of alertness.Review of a progress note for Resident #44 dated 06/16/26 at 11:09 P.M., written by RN #504, indicated urine culture results from 06/07/26 were reviewed and [unnamed] NP aware. New orders were received for Nitrofurantoin Macrocrystal (antibiotic used to treat UTI) oral capsule 100 milligram (mg) one capsule by mouth every shift for abnormal urine results for five days.Review of a progress note for Resident #44 dated 06/17/26 at 12:46 A.M., written by Licensed Practical Nurse (LPN) #515 revealed at 11:00 P.M. on 06/16/26 during medication pass, the resident was slow to respond to commands. She would not open her eyes, had no response to sternal rub, but was answering questions. Her heart rate was 44 and her blood pressure was 108/63. The resident was sent to the emergency room at 12:35 A.M. on 06/17/26. Two EMS providers were called due to the first being unable to provide transport, and the second one was able to provide transport within 45 minutes. Review of the hospital record for Resident #44 revealed she was sent to the hospital by the nursing home due to altered mental status, as she was not aroused when attempting to wake her. EMS was able to arouse her with voice and sternal rub. In the emergency room she was awake, alert and able to answer questions appropriately and not complaining of any pain or discomfort. Resident #44 was admitted to the hospital on [DATE] with bradycardia. On 06/20/26 a urinalysis with culture was obtained resulting in a diagnosis of urinary tract infection positive for ESBL E-coli and Klebsiella pneumoniae bacteria in the urine. Ceftriaxone (antibiotic) one-gram intravenous (IV) daily was ordered and on 06/22/26 the antibiotic was changed to ertapenem 500mg IV daily after infectious disease consult indicated due to the urine culture, which was done in the hospital being positive for, the ertapenem was the more appropriate antibiotic. A peripherally inserted central catheter (PICC) was inserted on 06/23/26 to support more long-term antibiotic use. The resident remained hospitalized until 06/26/26. Final diagnoses included acute kidney injury on chronic kidney disease.An interview on 06/23/26 at 2:11 P.M. with RN #504 revealed when labs are ordered at the facility and results finalized at the lab, the lab results were faxed to the nurse's station and also automatically sent to the electronic medical record from the lab. The nurse who would get the labs from the fax machine should call the provider and notify the provider if there were abnormal results. When asked why the urine with culture lab results dated 06/07/26 for Resident #44 did not get reported to an NP or physician until 06/16/26, RN #504 stated he did not know how it got missed because someone should have been looking for it within three days of collection. RN #504 stated he found the lab result sitting on the top of a desk in the middle of a pile of stuff on 06/16/26 and reported the result to the provider immediately as well as the Director of Nursing (DON). RN #504 stated he believed the late reporting of the results caused a delay in treating Resident #44 with the appropriate medications for the UTI.An interview on 06/23/26 at 3:50 P.M. with Regional RN (RRN) #609 confirmed there was a delay in care when urine analysis and culture laboratory results for Resident #44 were not reported for nine days after they had been received by the facility.An interview was attempted by phone on 06/29/26 at 3:30 P.M. with Licensed Practical Nurse (LPN) #515 and no return contact was received. An interview on 06/29/26 at 3:43 P.M. with NP #213 revealed Resident #44 had a delay in getting her urine tested from when it was originally ordered on 06/01/26 but did not know why. NP #213 confirmed Resident #44 was admitted to the hospital with bradycardia and unresponsiveness. NP #213 stated she could not say for certain if the urinary tract infection caused the bradycardia and unresponsive episode or not. NP #213 confirmed there had been a delay in reporting the lab results showing a UTI from 06/07/26 to 06/16/26. An interview on 06/30/26 at 1:00 P.M. with Resident #44 revealed she was alert and oriented to person, place, and time and answered questions appropriately. Resident #44 stated she did not recall the events which led to her hospitalization; however, she knew she had been sick. Resident #44 stated she was feeling better and had no more confusion.Review of a facility policy titled Lab and Diagnostic Test Results Clinical Protocol, revised September 2012, revealed a physician would identify and order diagnostic and lab testing based on needs. A nurse would review all results. The nurse should discuss, when reporting the results, why the test was obtained. The nurse would identify the urgency of communicating the results to the provider, the seriousness of the abnormality, and the individual's current condition. Situations which required prompt physician notification included a result which should be conveyed to a provider regardless of other circumstances (the abnormal result was problematic) or the resident's clinical status was unclear or worsening.This deficiency represents non-compliance investigated under Complaint Number 2715972.

Based on medical record, policy review and facility staff interviews, the facility failed to provide, timely, baseline care plans to Residents #2, #73, #75, and #90. The affected four of four residents reviewed for baseline care plan completion. The facility census was 77. Findings include: 1.Review of the medical record for Resident #73 revealed admission to facility on 12/12/25 for diagnoses including paraplegia, neuromuscular dysfunction of bladder, chronic kidney disease, depression, heart failure, high blood pressure, and anemia, atrial fibrillation (an irregular heart rate). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/11/26 for Resident #73 revealed a brief interview for mental status (BIMS) score of 15/15 indicating she was cognitively intact. Further review of the MDS assessment revealed Resident #73 required substantial to maximum assistance for showering/bathing, dressing, and personal hygiene and was dependent on staff for toileting hygiene, transfers, and used a wheelchair for mobility. Resident #73 required a urinary cathter for urination and was incontinent of bowel. Review of the baseline care plan completed on 12/12/25 revealed no evidence of Resident #73 or Resident #73 representative receiving a printed copy of the baseline care plan list of ordered medications. Interview on 06/29/26 at 2:45 P.M. with Regional Registered Nurse (RNN) #609 revealed he could not provide any evidence that baseline care plans were provided to Resident #73. 2.Review of the medical record for Resident #90 revealed admission to the facility on [DATE] for diagnoses of end-stage renal disease, renal dialysis, heart failure, dysphagia (difficulty swallowing), and a dialysis fistula (surgically created for access for permanent dialysis generally on the arm). Review of the initial comprehensive MDS 3.0 assessment completed on 03/09/26 for Resident #90 revealed she required a hearing aide and use of glasses with no significant impairments and able to make self-understood and understood others. Resident #90 required substantial to maximum assistance with oral hygiene, toileting, dressing, and transfers and partial to moderate assistance with showering/bathing. Review of the baseline care plan completed on 03/02/26 revealed no evidence of Resident #90 or Resident #90 representative receiving a printed copy of the baseline care plan list of ordered medications. Interview on 06/29/26 at 2:45 P.M. with RNN #609 revealed he could not provide any evidence that baseline care plans were provided to Resident # #90. 3. Record review of Resident #75 revealed an admission date of 05/15/26 with diagnoses of chronic venous hypertension, major depressive disorder, and chronic obstructive pulmonary disease with acute exacerbation. Resident #75 was cognitively intact. Review of the baseline care plan completed on 05/15/26 revealed no evidence of Resident #75 or Resident #75 representative receiving a printed copy of the baseline care plan. Interview on 06/29/26 at 2:45 P.M. with the RNN #609 revealed he could not provide any evidence that baseline care plans were provided to Resident #75. 4.Record review of Resident #2 revealed an admission date of 03/11/26 with diagnoses of acute respiratory failure with hypoxia, benign prostatic hyperplasia, chronic obstructive pulmonary disease. Resident #2 was cognitively intact. Review of baseline care plan completed on 3/11/26 revealed no evidence of Resident #2 or Resident #2 representative receiving a printed copy of the baseline care plan. Interview on 06/29/26 at 2:45 P.M. with the RNN #609 revealed he could not provide any evidence that baseline care plans were provided to Resident #2. Interview on 06/25/26 at 2:37 P.M. with Registered Nurse (RN) #503 revealed she worked primarily on the skilled/rehab hall and did frequent admissions of residents to facility. RN #503 further revealed the floor nurse was responsible for developing the baseline care plan for residents after obtaining resident assessments verifying provider orders. RN #503 acknowledged that she reviews the resident's medications with them verbally and some of the baseline care plan but does not provide a copy unless the resident or family would request then she could get them a copy. RN #503 reported that residents receive a copy of the care plan when they have a meeting with the interdisciplinary team (IDT) during the first week after their admission. Interview on 06/25/26 at 2:43 P.M. with Licensed Practical Nurse (LPN) #514 revealed she worked primarily on the long-term care hall and did not frequently do resident admissions to the facility. LPN #514 reported that the floor nurse develops the baseline care plans for the residents and it was reviewed by the IDT in the first week after the resident was admitted to the facility. LPN #514 acknowledged that she did not provide copies of the baseline care plan to the residents or representatives, but it had been such a long time since she had completed an admission that she could not recall if she did print them off. Review of the facility policy titled Care Plans-Baseline, and dated 10/10/22 revealed residents and/or representatives are provided a written summary of the base line care plan. Further review also revealed, Provision of the summary of the resident and/or resident representative is documented in the medical record.

Based on medical record review, facility policy review, and resident and staff interviews, the facility failed to revise care plans for new diagnoses or changes in condition for Residents #15, #68, #73, and #90. This affected four (Residents #15, #68, #73, and #90) of four records reviewed for care plan revisions. The facility census was 77. Findings include: 1.Review of the medical record for Resident #15 revealed admission to facility on 05/27/22 for diagnoses including cerebral palsy, lung disease, diabetes, bipolar disorder (mood disorder), irritability and anger, heart failure, high blood pressure, anxiety, and GERD (gastric reflux).Review of the quarterly Minimum Data Set (MDS)3.0 assessment completed on 06/04/26 for Resident #15 revealed a brief interview for mental status (BIMS) score of 13/15 indicating no significant cognitive impairment. Further review of the MDS revealed Resident #15 had impairment in both lower extremities, required the use of a wheelchair for mobility, and was dependent on staff for toileting, bathing/showering, and dressing, and needed a mechanical lift for transfers.Review of history and physical completed by the Primary Care Provider (PCP) #617 and dated 02/03/26 revealed Resident #15 was hospitalized from [DATE] to 02/01/26 for diagnoses of gastric ulcer and coffee ground emesis (indicating old blood in the stomach). Further review of the history and physical revealed Resident #15 was started on oral medication for gastritis and gastric ulcer to include Carafate (a medication used to coat the stomach and protect it) four times a day and a proton pump inhibitor (a class of medication used to reduce acid in the stomach) twice a day. Resident #15 was also referred to a gastroenterologist (stomach specialist) for recommended follow up testing and re-evaluation and recommended a low fiber diet.Review of the care plan for Resident #15 revealed no evidence of a care plan revision related to the updated diagnoses of gastric ulcer or the prescribed treatment.Interview on 06/22/26 at 2:36 P.M. with Resident #15 revealed he had a hospitalization in the past four months for stomach ulcers. Resident #15 denied having any current issues with his stomach. Interview on 06/29/26 at 3:15 P.M. with the MDS coordinator, registered nurse (RN) #505 revealed the MDS coordinators are responsible for revision of care plans when the quarterly and annual MDS assessments are completed. RN #505 further reported that the MDS coordinators also look at the 24-hour reports daily or the 72-hour reports from the weekend for any changes with residents and new diagnoses or hospitalizations. RN #505 could not provide evidence of a care plan revision or update related to the new diagnosis or treatment for Resident #15 related to gastric ulcers.2. Review of the medical record for Resident #68 revealed admission to facility 08/02/25 for diagnoses including metabolic encephalopathy (water on the brain), dementia (progressive forgetfulness and confusion), depression, lung disease, anemia (low blood count), constipation, and anxiety. Review on 06/24/26 of the current care plan for activities of daily living revised on 08/22/25 for Resident #68 revealed no evidence of an update or revision indicating Resident #68 had a history of refusing personal care or treatments.Review of the quarterly MDS 3.0 assessment completed on 03/26/26 for Resident #68 revealed a brief interview for mental status (BIMS) score of 15/15 indicating she was cognitively intact. Further review of the MDS assessment revealed Resident #68 had adequate vision, hearing, and was able to understand others and communicate her needs. Resident #68 required partial to moderate assistance with activities of daily living including toileting, bathing/showering, and dressing. Resident #68 required supervision for mobility and transfers.Review of a 30 day look back from 05/28/26 to 06/21/26 of the bathing documentation in the electronic medical record for Resident #68 revealed a bathing schedule of every Sunday and Thursday. Further review revealed Resident #68 refused a shower/bath on 05/28/26 and on 06/07/26 through 06/18/26. There was no documentation of why Resident #68 refused or any interventions implemented for the refusals.Interview on 06/24/26 at 1:27 P.M. with certified nursing assistant (CNA) #580 revealed Resident #68 had a history of refusing baths and showers and did not like to get her hair wet.Interview on 06/24/26 at 1:32 P.M. with CNA #599 revealed that Resident #68 needed full assistance for showering or bathing and that Resident #68 often refused showers.Interview on 06/24/26 at 1:54 P.M with unit manager, Licensed Practical Nurse (LPN) #519 revealed Resident #68 had a history of refusing showers, Resident #68 did not like getting her hair wet. LPN #519 further reported it was all in the way Resident #68 was approached whether or not she would be agreeable to a bath or shower and LPN #519 had to coax Resident #68 into getting a shower last week.Interview on 06/29/26 at 3:15 P.M. with MDS coordinator, RN #505 revealed if she was aware of any resident's having a pattern of refusal then the MDS coordinators would add this to the care plan to ensure staff are aware of the behavior. RN #505 verified there was no evidence in the care plan of Resident #68 having a history of refusals of care. RN #505 further reported that the refusal of car by Resident #505 was just recently brought to her attention earlier today.3.Review of the medical record for Resident #73 revealed admission to facility on 12/12/25 for diagnoses including paraplegia, neuromuscular dysfunction of bladder, chronic kidney disease, depression, heart failure, high blood pressure, and anemia, atrial fibrillation (an irregular heart rate).Review of the quarterly MDS 3.0 assessment completed on 06/11/26 for Resident #73 revealed a brief interview for mental status (BIMS) score of 15/15 indicating she was cognitively intact. Further review of the MDS assessment revealed Resident #73 required substantial to maximum assistance for showering/bathing, dressing, and personal hygiene and was dependent on staff for toileting hygiene, transfers, and used a wheelchair for mobility. Resident #73 required a urinary catheter for urination and was incontinent of bowel.Review of the medical record indicated Resident #73 was diagnosed and treated for a UTI on 06/16/26. Review of the most current care plan for Resident #73 revealed no evidence of revision or update for the diagnosis or treatment of the UTI occurring on 06/16/26.Interview on 06/29/26 at 3:15 P.M. with the MDS coordinator, RN #505 revealed there was no evidence of a care plan revision for the UTI diagnoses and treated on 06/16/26. RN #505 further reported that the infection preventionist would typically be responsible for updated infection-related care plans but recently there has been transition of the position and it must have been missed.4.Review of the medical record for Resident #90 revealed admission to the facility on [DATE] for diagnoses of end-stage renal disease, renal dialysis, heart failure, dysphagia (difficulty swallowing), and a dialysis fistula (surgically created for access for permanent dialysis generally on the arm). Review of the initial comprehensive MDS 3.0 assessment completed on 03/09/26 for Resident #90 revealed she required use of a hearing aid and use of glasses with no significant impairments and able to make self-understood and understood others. Resident #90 required substantial to maximum assistance with oral hygiene, toileting, dressing, and transfers and partial to moderate assistance with showering/bathing.Review of the nurse practitioner visit note dated 03/24/26 and authored by Nurse Practitioner (NP) #612 revealed Resident #90 was diagnosed with bilateral chronic conjunctivitis (eye infection). Warm compresses three times a day for three days were recommended. Review of the physician order summary from 03/02/26 through 05/14/26 for Resident #90 revealed a discontinued order on 03/02/26 reading Ok to utilize facility ancillary services for psychiatrist, psychologist, social services, optomology, dentist, vision, hearing, podiatrist, certified nurse practitioner, and wound services.Further review revealed an order for Resident #90 dated 03/24/26 for warm compresses to both eyes three times a day for three days ending on 03/28/26.Additional review of orders revealed an order for an antibiotic eye drop, Ciprofloxacin HCL ophthalmic solution 0.3% 1 drop in both eyes every morning and bedtime for seven days. An additional two weeks of treatment was prescribed on 04/21/26 to continue Ciprofloxacin HCL ophthalmic solution 0.3% 1 drop in both eyes twice a day until 05/05/26.Review of the nursing progress note dated 04/26/26 at 11:09 A.M. revealed Resident #90 refused the antibiotic eye drops due to affecting vision. On 04/23/26 at 7:53 P.M. a progress note revealed Resident #90 refused eye drops again and due to making eyes blurry and the physician was notified.Review of the NP note dated 04/24/26 by NP #612 revealed she evaluated Resident #90 and discontinued the Cipro eye drops due to resident refusing them.Review of the NP note dated 04/28/26 by NP #612 revealed she evaluated Resident #90 for continued conjunctivitis and had discussion with Resident #90 family regarding treatment options and prescribed a lubricating eye drop to be started.Interview on 06/29/26 at 3:15 P.M. with RN #505 revealed confirmation that there was no evidence that a care plan revision or updates related to the eye issues Resident #90 was having.Review of the facility policy titled, Care Plans, Comprehensive Person-Centered and revised on 03/2022 revealed, care plans are revised as information about the residents and the residents' condition change. Further review revealed updates to the care plan are made when there has been a significant change in residents' condition, readmission to facility after a hospital stay, and when desired outcomes are not being met.

Based on record review and interview, the facility failed to ensure resident account management authorizations were signed and witnessed. This affected three residents (Resident #39, #68 and #70) of five residents reviewed for personal funds. The facility census was 77.Findings include:1. Review of the medical record for Resident #39 revealed an admission date of 09/30/25 with diagnoses including dementia, anxiety disorder, and depressive disorder. Review of the Resident Fund Manage Service Authorization and agreement to handle resident funds dated 01/13/26 revealed the facility signed the authorization as Resident #39's representative payee. There was no witness to this authorization and no resident signature. Interview on 06/25/26 at 11:00 A.M. with Business Office Manager (BOM) #569 verified the authorization was not witnessed or signed by Resident #39. 2. Review of the medical record for Resident #68 revealed an admission date of 08/02/25 with diagnoses including dementia, anxiety disorder, and depressive disorder. Review of the Resident Fund Manage Service Authorization and agreement to handle resident funds dated 08/28/25 revealed the facility signed the authorization as Resident #68's representative payee. There was no witness to this authorization and no resident signature. Interview on 06/25/26 at 11:00 A.M. with BOM #569 verified the authorization was not witnessed or signed by Resident #68. 3. Review of the medical record for Resident #70 revealed an admission date of 01/06/26 with diagnoses including major depressive disorder, and anxiety disorder. Review of the Resident Fund Manage Service Authorization and agreement to handle resident funds dated 01/26/25 revealed the facility signed the authorization as Resident #70's representative payee. There was no witness to this authorization and no resident signature. Interview on 06/25/26 at 11:00 A.M. with BOM #569 verified the authorization was not witnessed or signed by Resident #70.

Based on record review and interview, the facility failed to provide bed hold notices in writing to the resident or resident representative as required. This affected one resident (Resident #70) out of five residents reviewed for discharges. The facility census was 77.Findings include:Review of the medical record for Resident #70 revealed an admission date of 08/29/25 with diagnoses including chronic respiratory failure, congestive heart failure and dependence on a mechanical ventilator. Resident #70's sister was noted as his healthcare power of attorney (POA).Review of Resident #70's admission and discharge history revealed he was transferred to the hospital on [DATE], 06/04/26 and 06/08/26. On 05/15/26 a bed hold notice was sent to the hospital to the resident. On 06/04/26 there was no evidence of a bed hold notice in writing provided to the residents or resident's representative. On 06/09/26 a bed hold notice was sent to the hospital to the resident which came back as return to sender. Interview on 06/09/26 at 2:32 P.M. with Regional Registered Nurse (RRN) #609 verified Resident #70's POA should have received the bed hold notice. He stated the notices should not have been sent to the resident at the hospital.

Based on record review and interview, the facility failed to ensure the accuracy of resident assessments. This affected two residents (Resident #9 and Resident #11) reviewed for accuracy of assessments. The facility census was 77. Findings include:1.Review of the medical record for Resident #9 revealed an admission date of 04/24/26. Diagnoses included acute respiratory failure with hypercapnia; acute bronchitis due to other specified organisms; dependence of respirator (ventilator); pseudomonas; muscle weakness, dysphagia; symbolic dysfunctions; weakness; need for assistance with personal care; pneumonia; acute and chronic respiratory failure with hypoxia; chronic obstructive pulmonary disease with exacerbation; benign prostatic hyperplasia with lower urinary tract symptoms; type two diabetes mellitus without complications. Review of medication orders, both current and discontinued, revealed no orders for insulin injections. Review of medication orders revealed on 05/23/26, Resident #9 was ordered Levaquin (antibiotic) 750 milligrams (mg) daily for seven days for bilateral pneumonia. Review of a quarterly Minimum Data Set (MDS) version 3.0 assessment, dated 05/26/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 on a 0-15 scale, which would indicate the resident was cognitively intact. Functionally, the resident used a walker, he required supervision for oral hygiene, moderate assistance for toileting, upper body and lower body dressing and putting on or taking off footwear, and maximal assistance for showering and bathing. Review of Section N of the MDS revealed the resident had been receiving insulin injections for the past seven days with no changes. Section N failed to reveal the resident to be taking a hypoglycemic (which would include insulin). It also revealed he was not taking antibiotics at the time of the assessment. On 06/29/26 at 9:15 A.M., an interview with MDS Nurse #513 confirmed she had incorrectly coded the MDS assessment dated [DATE] for Resident #9. He was on Levaquin at the time and had never been given any insulin injections during his stay at the facility. 2. Review of the medical record for Resident #11 revealed an admission date of 07/11/24 with diagnoses including chronic respiratory failure, quadriplegia and depression. She was admitted to hospice on 08/22/24. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was on hospice. However, on section J question J1400 staff had answered incorrectly that Resident #11 did not have a life expectancy of less than six months. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11 was on hospice. However, on section J question J1400 staff had answered incorrectly that Resident #11 did not have a life expectancy of less than six months. Interview on 06/29/26 at 9:40 A.M. with Licensed Practical Nurse (LPN) #513 verified Resident #11's MDS's on 01/22/26 and 04/20/26 were incorrect under section J as she was on hospice and the prognosis question should have been answered yes that she had a life expectancy less than six months.

Based on interview, record review and facility policy review the facility failed to ensure PASARRs were updated following a significant change in condition. This affected two residents (#6 and #10) out of four residents reviewed for PASARR screening. The facility census was 77. Findings include: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including anxiety disorders, major depressive disorder, schizoaffective disorder , movement disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/26, revealed the resident had intact cognition and a diagnosis of anxiety disorder. Review of Resident #6's medical record revealed Resident was sent to the emergency room on [DATE] with suicidal ideations. Resident re-admitted to facility on 03/25/26 from [NAME] Mount Hospital psychiatric unit. Further review of medical record revealed no PASARR completed at the time of re-admission from psychiatric unit. Interview on 06/25/26 3:30 P.M. with the Social Service Designee (SSD) #563 confirmed Resident #6 did not have a PASRR completed at the time the resident returned form [NAME] Mount Hospital psychiatric unit on 03/21/26. Review of the PASARR instructions revealed a resident review needs to be completed due to Nursing Facility readmission from a psychiatric facility/unit. 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including anxiety disorders, and major depressive disorder. Further review revealed on 03/07/24 schizoaffective disorder bipolar type was added to list of diagnosis during stay at facility. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/26, revealed the resident had intact cognition and a diagnosis of anxiety disorder. Review of Resident #10's medical record revealed a preadmission screening PASARR dated 07/14/22 did not list a diagnosis of schizoaffective disorder, bipolar type. No PASARR screening was found in Resident's medical record at the time schizoaffective disorder, bipolar type was added to Residents diagnosis list. Interview on 06/25/26 3:30 P.M. with the SSD #563 confirmed Resident #10 did not have a PASRR completed at the time the resident was diagnosed with an additional mental disorder. Review of the facility admission Criteria PASARR OH policy, dated 2001, revealed the level 1 PASARR screen must be completed within 72 hours of a significant change in condition for existing residents.

Based on record review, review of the facility investigation, staff and family interviews and review of facility policy, the facility failed to ensure advance directives were honored for residents. This affected one (Resident #91) of two residents reviewed for Cardio-pulmonary Resuscitation (CPR). The facility also failed to ensure advanced directives were accurate in the medical records. This affected one (Resident #28) of 29 residents reviewed for advance directives. The facility census was 77.Findings include: 1.Review of the closed medical record for Resident #91 revealed an admission date of [DATE] with diagnoses of acute respiratory failure with hypoxia, and pulmonary embolism and tracheostomy status. Resident #91 did not have a power of attorney or legal guardian. Resident #91's son was listed as the first emergency contact, and daughter-in-law was listed as the second emergency contact. Review of the physician order dated [DATE] for Resident #91 revealed the resident had a Do Not Resuscitate Comfort Care Arrest (DNRCCA which indicates lifesaving treatments would be utilized up to the point of cardiac arrest) order. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #91 was cognitively impaired. Resident #91 was totally dependent on staff for all activities of daily living (ADL). Review of Resident #91's care plan dated [DATE] revealed Resident #91 was a DNRCCA. Interventions included advocating for residents end-of-life wishes and ensure advance directives are implemented accordingly, effectively communicate DNR wishes by placing in the front of the chart. Review of the facility investigation dated [DATE] revealed on [DATE] at 1:54 P.M. a Certified Nursing Assistant (CNA) reported to the nurse that Resident #91 was having trouble breathing. At 1:55 P.M. the nurse notified the Respiratory Therapist (RT) going to Resident #91's room. At 1:57 P.M. the RT entered the room, noticed the resident was not breathing and initiated CPR. At 1:59 P.M. additional staff arrived to assist with the crash cart, CPR continued, and emergency medical services (EMS) were called. At 2:02 P.M. the Director of Nursing (DON) auscultated a strong apical pulse and at 2:03 P.M. EMS arrived to continue CPR and left the facility with the resident at 2:10 P.M. while continuing respiration assistance. Review of the witness statement dated [DATE] and authored by Licensed Practical Nurse (LPN) #615 revealed LPN #615 entered Resident #91's room after hearing someone call for a crash cart and found the RT doing chest compressions with another nurse present. Resident #91's spouse was present and standing in the corner. A staff member had the spouse exit the room to be with other family members in the hallway. LPN #615 assisted putting a backboard under the resident and deflating the air mattress and then went to get the code status from the chart. The resident's family (which family member not identified) was asked if they wanted the resident placed on life support if needed and they said yes and to do whatever was needed to save her. EMS arrived and took over. Review of the witness statement dated [DATE] and authored by CNA #587 revealed around 1:54 P.M. the family of Resident #91 got her and said Resident #91 was having a hard time breathing. When CNA #587 walked in, the resident was breathing heavy. The nurse was notified at 1:55 P.M. of the breathing difficulty and the nurse notified respiratory therapy (RT). CNA #587 was answering call lights when she heard the RT yelling for help. She and the nurse grabbed oxygen tanks and the crash cart. RT was doing chest compressions when the nurse relieved the RT then CNA #587 relieved the RT for three sets then Resident #91 had a faint pulse. 911 was called and the family was present. CNA #587 then left to answer call lights. An interview on [DATE] at 2:20 P.M. with Regional Registered Nurse (RRN) #609 confirmed Cardiopulmonary Resuscitation (CPR) was initiated on Resident #91 on [DATE] when it should not have been due to the resident having an order and advance directive for DNRCCA dated [DATE]. RRN #609 stated he did an investigation regarding the whole incident and determined when Resident #91 went unresponsive the husband of Resident #91 (who had dementia and was not the first or second emergency contact) wanted CPR to be done so the RT initiated CPR. An interview on [DATE] at 2:38 P.M. with DON #508 revealed they heard someone yelling for help around 1:55 P.M. on [DATE] and went running. The DON stated that she called a code and staff got the crash cart. DON #508 stated a respiratory therapist was doing CPR and the unit managers were helping on Resident #91. DON #508 stated family was removed from the room and the husband stated to do everything to save her. DON #508 stated staff was able to get a pulse prior to EMS arriving and Resident #91 was then taken to the hospital at 2:10 PM. An interview on [DATE] at 10:35 A.M. with admission Director (AD) #561 revealed Resident #91 was physically unable to sign paperwork and could not speak due to being on a ventilator but understood questions. AD#561 stated Resident #91 did not have a living will or power of attorney paperwork, but with a DNRCCA order the facility was to honor that status. An interview on [DATE] at 11:48 A.M. with Resident #91's family member revealed the family decided to make Resident #91 a DNRCCA after a hospitalization in January at the Cleveland Clinic, so Resident #91's code status was a DNRCCA upon admission to the facility. Resident #91's family member stated when her husband (Resident #91's first emergency contact) and her walked around the corner toward Resident #91's room they both heard someone screaming for help and to get a crash cart. Resident #91' family member stated when she and her husband walked into the room at the facility, they saw staff doing CPR on Resident #91. Resident #91's family member stated they did not tell them to stop because they were in complete shock by what they were seeing. Resident #91's family member stated Resident #91's husband had dementia and was not the emergency contact so he would not be the person to ask about code status. The family member verified they would not have wanted CPR to be started on Resident #91. An interview on [DATE] at 2:30 P.M. with Respiratory Therapist (RT) #614 confirmed on [DATE] LPN #512 asked her to go check on Resident #91 because family stated she was having breathing problems. RT #614 stated LPN #512 never assessed Resident #91 and never went into the room. RT #614 stated she went into the room right away by herself and the husband and son of Resident #91 were in there. RT #614 stated Resident #91 was not breathing, not wheezing, and her chest was not moving. RT #614 stated that she yelled for help and no one was coming so she had to send the family out to get staff for assistance. RT #614 stated she immediately started doing chest compressions when she noticed Resident #91 was not breathing. RT #614 stated DON #508 came in and just stood there and did nothing. RT #614 stated she yelled for her boss RT #616. RT #616 came in and they were able to ambu bag (a bag that provides air) Resident #91 after she held her finger over the trach. RT #614 stated they called 911 and CNA #587 came in and took over compressions. RT #614 stated when paramedics arrived Resident #91 had a heart rate. RT #614 stated the RTs used to be allowed to carry a sheet with the code status of each resident on it but that was stopped due to administration saying it was a privacy violation. RT #614 stated she had to look in the charts to get the code status and during the incident with Resident #91, RT #614 stated she did not have time to look in the chart. RT #614 stated the family didn't say anything during the incident and were in shock. An interview on [DATE] at 2:46 P.M. with DON #508 revealed they believe they told someone to go verify Resident #91's code status while they continued the code and got Resident #91's pulse back. DON #508 stated she didn't know if the confirmation of the code status was before or after Resident #91 regained a pulse. DON #508 stated LPN #512 never went into the room, and stated LPN #512 she was a newer nurse in the field. An interview on [DATE] at 3:30 P.M. with RT #616 revealed when he arrived at Resident #91's room the family was not in the room. RT #616 stated RT#614 was in the room and two other staff members along with a crash cart. RT #616 stated he started to assist RT #614 in bagging Resident #91, and stated Resident #91 had a pulse and he believed it was DON #508 who confirmed it. RT #616 stated they kept ventilating Resident #91 with 100 percent oxygen until the paramedics arrived. RT #616 confirmed he did not find the code status, and he did not talk to the family. An interview on [DATE] at 7:42 A.M. with LPN #615 revealed she was fired for unsatisfactory work performance related to the code of Resident #91. LPN #615 stated she was present for Resident #91's code and when she arrived to the room, CPR was already being performed. LPN #615 stated it was chaotic and the crash cart was there with RT #614 doing compressions, so LPN #615 assumed someone had already checked the code status of Resident #91. LPN #615 stated she removed the family out of the room and that they did not say anything. LPN #615 stated she was in the room and doing compressions and had CNA #587 take over. LPN #615 stated she then went out and confirmed the code status was DNRCCA and she went to speak to the family. LPN #615 stated the family didn't understand what was happening and because CPR had already been initiated, they decided to have the facility continue and send her out. An interview on [DATE] at 10:20 A.M. with LPN #520 verified that resident code status was kept in the front of the residents' hard chart. 2. Review of the medical record for Resident #28 revealed an admission date of [DATE] with diagnoses including hemiplegia, diabetes mellitus, respiratory failure, anxiety and depression. Review of the physician order dated [DATE] for Resident #28 revealed he was a do not resuscitate comfort care arrest (DNRCCA). Review of Resident #28's care plan dated [DATE] revealed he was a DNRCCA. Interventions included to effectively communicate DNR wishes by placing in the front the chart and/or when resident must be transferred outside the facility. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition. An interview on [DATE] at 2:09 P.M. with RN #504 verified Resident #28's code status in the electronic chart was for DNRCCA. He was unable to provide signed documentation that resident had chosen DNRCCA in his hard chart. A interview on [DATE] at 1:20 P.M. with RRN #609 verified Resident #28 did not have a signed code status paper in his medical record to verify he was a DNRCCA. RRN #609 stated he had spoken to the resident on [DATE] and he wanted to be a full code. Review of the facility policy titled, Advance Directives, dated [DATE], revealed if the resident had executed one or more advance directives or executes one upon admission, copies of these documents were obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The resident's wishes were to be communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care plan meetings. Advance directives are to be followed. A Do Not Resuscitate indicates that, in case of respiratory or cardiac failure, no CPR or other life sustaining treatments are to be used. If a resident does not have an advance directive, then the resident representative is given the option to accept or decline assistance. This deficiency represents non-compliance investigated under Complaint Number 3008139.

Based on record review and staff interviews, the facility failed to ensure vision services were provided to Resident #90. The affected one (Resident #90) of one resident reviewed for vision services. The facility census was 77.Findings include: Review of the medical record for Resident #90 revealed admission date of 03/02/26 for diagnoses of end-stage renal disease, renal dialysis, heart failure, dysphagia, and a dialysis fistula. Review of the facility admission packet for Resident #90 revealed a consent signed by Resident #90's daughter and dated 03/02/26 to receive services from 360 Care (ancillary service partner) for audiology, vision, and podiatry services.Review of the initial comprehensive MDS 3.0 assessment completed on 03/09/26 for Resident #90 revealed she required hearing aid and use of glasses with no significant impairments and able to make self-understood and understood others. Resident #90 required substantial to maximum assistance with oral hygiene, toileting, dressing, and transfers and partial to moderate assistance with showering/bathing.Review of physician orders dated April 2026 revealed an order for an antibiotic eye drop, Ciprofloxacin HCL ophthalmic solution 0.3% 1 drop in both eyes every morning and bedtime for seven days. An additional two weeks of treatment was prescribed on 04/21/26 to continue Ciprofloxacin HCL ophthalmic solution 0.3% 1 drop in both eyes twice a day until 05/05/26.Review of the nursing progress note dated 04/26/26 at 11:09 A.M. revealed Resident #90 refused the antibiotic eye drops due to affecting vision. On 04/23/26 at 7:53 P.M. a progress note revealed Resident #90 refused eye drops again and due to making eyes blurry and the physician was notified.Review of a Nurse Practitioner (NP) note dated 04/24/26 by NP #612 revealed she evaluated Resident #90 and discontinued the Cipro eye drops due to resident refusing them.Review of a NP note dated 04/28/26 by NP #612 revealed she evaluated Resident #90 for conjunctivitis and had discussion with Resident #90 family regarding treatment options and prescribed a lubricating eye drop to be started.Review of an email provided by Social Service Director (SSD) #563 revealed SSD #563 authored the email to 360 Care coordinator dated 04/28/26 and timed 4:14 P.M. requesting resident #90 be added for a visit on 04/29/26 and listed as priority to evaluated. There was no evidence of confirmation that the 360 Care coordinator confirmed or responded to the email prior to 04/29/26.Review of the medical record revealed a Resident Cancelled/Not Seen Visit Report from 360 care services dated 04/29/26 and timed 5:53 P.M. noting Resident #90 refused services on 04/29/26.Further review of email communication from SSD #563 to the 360 Care coordinator revealed an email sent by SSD#563 on 04/30/26 at 10:26 A.M. requesting an emergent appointment for Resident #90 due to not being seen yesterday 04/29/26 and her daughter was present and stated Resident #90 was not seen even though there was a note from 360 Care stating Resident #90 declined appointment. On 05/01/26 another email was sent from SSD #563 to follow up with the prior email and if any appointment could be made for Resident #90. There were no further emails provided regarding 360 Care and any appointments. An interview on 06/25/26 at 8:55 A.M. SSD #563 revealed she sent the referral for vision services for Resident #90 to 360 Care and she was supposed to be seen by vision provider on 04/29/26 and was on the list. SSD #563 further reported that she recalled on 04/29/26 in the afternoon maybe around 2:00 or 3:00 P.M. the daughter was at the facility with Resident #90 and was aware of her appointment with the vision team. Both the daughter and resident were waiting for her to be seen and went down to the treatment room, and the vision team was packing up for the day and reported they would not see Resident #90. The daughter became upset and had to leave the facility. SSD #563 reported that the administrator got involved and she would be able to elaborate more on the event. SSD#563 stated after that happened there was a process change to make all ancillary service providers report to the SSD on arrival and prior to leaving to make sure all residents are seen who needed services that day. SSD #563 recalled that the administrator was very upset about the events and called management at 360 Care over the situation.An interview on 06/25/26 at 12:05 P.M. via telephone with the facility Administrator revealed Resident #90 was assigned to the Administrator directly for caring angel program (program in which each administrative team member was assigned a resident to oversee and check in with regarding their care and experience). The Administrator reported that everyone was made aware of Resident #90 having an appointment for vision care on 04/29/26 including herself and Resident #90's daughter. The administrator continued to reveal that she wasn't made aware until late in the afternoon on 04/29/26 that Resident #90 was not seen by the vision team and that apparently the daughter went down to see them directly to see why her mom wasn't seen and they were closing up for day and said she wasn't seen. The Administrator stated that Resident #90's daughter was so upset she couldn't even discuss the issue with her that day and had to leave. The Administrator called and spoke with management at 360 Care that day and was told that they offered to see Resident #90, but she refused. The administrator reported that she talked with daughter and offered to attempt to get Resident #90 seen the next day, but the daughter had already called her regular vision provider and made a community appointment to be seen. The facility did not have a policy related to ancillary services or referrals. This deficiency represents non-compliance investigated under Complaint Number 3019055.

Based on record review, interview and review of facility policy the facility failed to inform the nurse practitioner of a dietary recommendation to address hydration needs for Resident #96. This affected one resident (Resident #96) of four residents reviewed for change of condition. The facility census was 77.Findings include:Review of the closed medical record for Resident #96 revealed an admission date of 10/01/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic systolic congestive heart failure, need for assistance with personal care, muscle weakness, hypothyroidism, mild gastritis and gastrointestinal bleed. Resident #96 was discharged to the hospital on [DATE] and did not return to the facility.Review of the care plan for Resident #96, initiated 10/05/24 and revised on 05/21/26, revealed she was at risk for altered nutrition and fluid imbalance related to hypothyroid, gastrointestinal bleed, stroke, mild gastritis, congestive heart failure, behaviors, episodes of meal intake less than 50 percent, history of significant weight loss and fluid shifts. Interventions, initiated 10/05/24, included to monitor weight every month and report and concerns to the physician, family and resident, update food preferences and provide foods resident likes, supplements as ordered, water pitcher within reach of resident, responsible party/physician will be notified of weight loss/weight concerns, diet as ordered, monitor nutritional labs routinely, encourage fluid intake at meals and record, and monitor for signs and symptoms of dehydration. The care plan also indicated Resident #96 was frequently incontinent of urine.Review of progress notes for Resident #96 revealed on 05/19/26 the resident was seen by Nurse Practitioner (NP) #613. Resident #96 was seen for fatigue and was very tired during the exam. A chest X-ray, complete blood count (CBC), a basic metabolic panel (BMP) and a thyroid stimulating hormone (TSH) level were to be drawn on 05/20/26. The NP noted there was no suprapubic tenderness and would hold off on any IV (intravenous) fluids.Review of a progress note for Resident #96 dated 05/20/26 at 11:59 P.M. written by NP #612 revealed results of the chest X-ray on 05/19/26 indicated left basilar infiltrates and Doxycycline (antibiotic) treatment regimen dated 05/20/26 to 05/27/26 ordered for pneumonia.Review of a dietary note dated 05/21/26 at 12:58 P.M., written by Dietitian Technician (DT) #537 revealed 05/20/26 labs included BUN (blood urea nitrogen) of 32 milligrams per deciliter (mg/dL) (normal range 7 to 26 mg/dL), creatinine 1.4 mg/dl (normal range 0.41 to 0.95 mg/dL), and GFR (glomerular filtration rate) 44 milliliters per minute (ml/min with normal being greater than 60 ml/min). Recommend NP to review for IV fluids. Nursing aware and will contact NP.Review of a progress note dated 05/21/26 at 2:45 P.M. written by RN #509 revealed lab results were reported to the provider (none specified) and new orders were received at 1:03 P.M. to repeat CBC and BMP on 05/22/26. There was no evidence that the recommendations from DT #537 were relayed to the provider.Review of a progress note dated 05/22/26 at 10:39 A.M. authored by NP #613 revealed follow-up for pneumonia, labs reviewed and new orders for additional antibiotics. There was no indication in the note that the NP had been advised of the dietary recommendation to review for IV fluids. Review of progress notes and physician orders dated 05/22/26 revealed Resident #96 was ordered Ceftriaxone Sodium (antibiotic) inject two grams intramuscularly one time only for pneumonia for one day. Further review of progress notes and physician orders through 05/23/26 revealed no evidence of follow-up on DT #537's recommendation for IV fluids.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #96 was cognitively intact, used a wheelchair for mobility, was dependent with toileting hygiene, showering and dressing. Resident #44 required supervision for oral hygiene, and maximal assistance with personal hygiene. An interview on 06/29/26 at 1:06 P.M. with Licensed Practical Nurse (LPN) #615 revealed she took care of Resident #96 on 05/21/26 and updated the NP on labs results and took orders. LPN #615 stated she did not recall which NP she spoke with and knew she did not speak to DT #537 or a dietitian about IV fluids. LPN #615 stated she was told in nursing report that Resident #96 was improving. LPN #615 stated Resident #96 was not feeling the greatest and was alert and oriented but very tired.An interview on 06/29/26 at 3:43 P.M. with NP #612 revealed Resident #96 had been sent to the hospital for pneumonia. NP #612 stated nurses and the dietary manager would notify her of any dietary recommendations. NP #612 stated she was not aware of anyone addressing any recommendation for IV fluids and whether or not she would order any depended on the resident's overall medical condition. An interview on 06/30/26 at 11:50 A.M. with NP #613 revealed she noticed Resident #96 had been more restless and fatigued as of 05/19/26 as she was normally very with it. NP #613 verified she was not made aware of the recommendation by DT #537 nor a dietitian for IV fluids or she would have considered it but probably would have given subcutaneous fluids instead. An interview on 06/30/26 at 4:30 P.M. with DT #537 revealed she thought Resident #96 had medical problems which were affecting her oral intake. DT #537 stated she gave her recommendations verbally to a nurse on 05/21/26 for an NP to review for possible IV fluids. DT #537 stated normally she would write the recommendation, and she did not recall which nurse she gave the verbal recommendation to for the NP to review for IV fluids.Review of a facility policy titled Acute Condition Changes Clinical Protocol, revised March 2018, direct care staff would be trained in recognizing subtle but significant changes in the resident (for example decrease in food intake, increased agitation, changes in skin condition or color) and how to communicate these changes to the nurse. Before contacting a physician about someone with an acute change in condition, the staff would collect pertinent details to report to the physician, including the resident's current symptoms and status. The provider would be contacted based on the urgency of the situation. This deficiency represents non-compliance investigated under Complaint Number 2715972 and 2571934.

Based on observation, interview and record review, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected three (Residents #35, #67 and #70) of four residents reviewed for respiratory care. The facility census was 77. Findings include:1. Review of the medical record for Resident #35 revealed an admission date of 09/14/23 with diagnoses including chronic respiratory failure, tracheostomy status, and dependence on respiratory ventilator status. Review of the physician's orders revealed Resident #35 was to have his oxygen tubing and set-up changed every Thursday and as needed dated 11/03/25. Review of the Treatment Administration Record (TAR) for June 2026 revealed Resident #35's oxygen tubing was to be changed on 06/18/26 and staff had not completed this as ordered. Observation and interview on 06/22/26 at 10:18 A.M. of Resident #35 with Respiratory Therapist (RT) #535 revealed his oxygen tubing was dated 06/12/26. RT #535 verified his oxygen tubing should have been changed on 06/18/26. She verified the respiratory department was in charge of changing the oxygen tubing if a resident was on mechanical ventilation. 2. Review of the medical record for Resident #67 revealed an admission date of 12/01/23 with diagnoses including chronic respiratory failure, tracheostomy status, and dependence on respiratory ventilator status. Review of the physician's orders revealed Resident #67 was to have his oxygen tubing and set-up changed every Thursday and as needed dated 09/25/25. Review of the Treatment Administration Record (TAR) for June 2026 revealed Resident #67's oxygen tubing was to be changed on 06/18/26 and staff had not completed this as ordered. Observation and interview on 06/22/26 at 10:19 A.M. of Resident #67 with RT #535 revealed his oxygen tubing was dated 06/12/26. RT #535 verified his oxygen tubing should have been changed on 06/18/26. She verified the respiratory department was in charge of changing the oxygen tubing if a resident was on mechanical ventilation. 3. Review of the medical record for Resident #70 revealed an admission date of 08/29/25 with diagnoses including chronic respiratory failure, tracheostomy status, and dependence on respiratory ventilator status. Review of the physician's orders revealed Resident #70 was to have his oxygen tubing and set-up changed every Thursday and as needed dated 01/08/26. Review of the Treatment Administration Record (TAR) for June 2026 revealed Resident #67's oxygen tubing was documented as changed on 06/04/26. Observation and interview on 06/22/26 at 10:20 A.M. of Resident #70 with RT #535 revealed his oxygen tubing was dated 05/14/26. RT #535 verified his oxygen tubing should have been changed on 06/04/26 and on 06/19/26 when he returned from the hospital after a hospital admission. She verified the respiratory department was in charge of changing the oxygen tubing if a resident was on mechanical ventilation. The facility was unable to provide a policy and procedure of respiratory staff changing the oxygen tubing for residents on mechanical ventilation. This deficiency represents non-compliance investigated under Complaint Number 2571934

Based on record review, interview and review of the facility assessment, the facility did not ensure licensed nursing staff completed competencies on hire and demonstrated competencies and skill sets necessary to provide care and services based on residents assessed needs. This affected two (Resident #44 and #96) of two residents reviewed for competent nursing services. The facility census was 77.Findings include:1.Review of the medical record for Resident #44 revealed an admission date of 02/07/25. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, noninfective gastroenteritis and colitis, muscle weakness, pressure ulcer of sacral region, stage three, peptic ulcer, moderate protein-calorie malnutrition, bradycardia, hypotension, and intestinal bypass and anastomosis status. Review of the medical record for Resident #44 revealed on 06/03/26, Resident #44 had a urinalysis completed with culture and sensitivity that was positive for urinary infection. The result of the culture was reported to the facility on [DATE] however the results were not reported by the nursing staff to the nurse practitioner (NP) until 06/16/26. The resident was admitted to the hospital on [DATE], where she was treated for bradycardia, unresponsiveness and given Intravenous (IV) antibiotics for a urinary tract infection caused by ESBL (extended spectrum beta-lactamase) Klebsiella pneumoniae , which was highly resistant to many common antibiotics including penicillin and cephalosporins, and Escherichia coli, more commonly known as E. coli. An interview on 06/23/26 at 2:11 P.M. with Registered Nurse (RN) #504 confirmed the urine with culture lab results dated 06/07/26 for Resident #44 did not get reported to an NP or physician until 06/16/26. RN #504 stated he did not know how it got missed because someone should have been looking for it within three days of collection. RN #504 stated he found the lab result sitting on the top of a desk in the middle of a pile of stuff on 06/16/26 and reported the result to the provider immediately as well as the Director of Nursing. RN #504 stated the nurse was responsible to report the results to the practitioner. 2. Review of the closed medical record for Resident #96 revealed an admission date of 10/01/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic systolic congestive heart failure, need for assistance with personal care, muscle weakness, hypothyroidism, mild gastritis and gastrointestinal bleed. Resident #96 was discharged to the hospital on [DATE] and did not return to the facility.Review of physician orders dated 05/21/26 for Resident #96 revealed blood glucose level to be obtained twice daily.Review of the Medication Administration Record (MAR) dated May 2026 revealed blood glucose levels were only obtained once instead of twice on 05/22/26 at 9:19 A.M.Review of a dietary note dated 05/21/26 at 12:58 P.M., written by Dietitian Technician (DT) #537 revealed 05/20/26 labs included BUN (blood urea nitrogen) of 32 milligrams per deciliter (mg/dL) (normal range 7 to 26 mg/dL), creatinine 1.4 mg/dl (normal range 0.41 to 0.95 mg/dL), and GFR (glomerular filtration rate) 44 milliliters per minute (ml/min with normal being greater than 60 ml/min). Recommend review for IV fluids and change in condition. Nursing aware and will contact NP.Further review of progress notes through 05/23/26 revealed no evidence of follow-up on DT #537's recommendation for IV fluids.An interview on 06/29/26 at 1:06 P.M. with Licensed Practical Nurse (LPN) #615 revealed she took care of Resident #96 on 05/21/26 and updated the NP on labs results and took orders. LPN #615 stated she did not recall which NP she spoke with and knew she did not speak to DT #537 or a dietitian about IV fluids.An interview on 06/29/26 at 3:43 P.M. with NP #612 confirmed she was not aware of anyone addressing any recommendation for IV fluids.An interview on 06/30/26 at 11:50 A.M. with NP #613 revealed she noticed Resident #96 had been more restless and fatigued as of 05/19/26 as she was normally very with it. NP #613 verified she was not made aware of the recommendation by DT #537 nor a dietitian for IV fluids or she would have considered it but probably would have given subcutaneous fluids instead.Review of the employee files for Registered Nurse (RN) #507 (hire date of 09/10/25) and LPN #518 (hire date of 03/12/26) revealed licensed nursing staff did not have nursing competencies completed on hire to ensure they were knowledgeable and skilled. An interview on 06/30/26 at 10:29 A.M. with Regional Registered Nurse (RRN) #609 verified RN #507 and LPN #518 had not had nursing competencies completed on hire. RRN #609 stated the facility had not been ensuring the licensed nursing staff all had nursing competencies on hire. RRN #609 stated the facility had recently revised their mentor program for new nursing staff to ensure they were competent to care for their residents. Review of the Facility Assessment, updated 06/30/25, revealed on page 11: Training and Competencies for the nursing department would include monthly education for nurses by the Director of Nursing, and new hires would participate in orientation and training in their fields. On page nine and 10, identification of resident change in condition utilizing assessments and diabetic blood glucose testing were listed under competency skills sets. This deficiency represents non-compliance investigated under Complaint Number 2571934 and 2581134.

Based on record review, staff and resident interview, and review of facility policy, the facility failed to promptly notify the ordering nurse practitioner of laboratory results that fell outside of normal clinical reference range for Resident #44. This affected one (Resident #44) of two residents (Resident #44 and Resident #96) reviewed for hospitalization. The facility census was 77. Findings include:Review of the medical record for Resident #44 revealed an admission date of 02/07/25 with diagnoses including need for assistance with personal care, muscle weakness, stage three pressure ulcer of sacral region, moderate protein-calorie malnutrition, noninfective gastroenteritis and colitis, other iron deficiency anemia, heart disease and other dysphagia.Review of the care plan for Resident #44, date initiated 02/07/25 and revised 06/10/25, revealed bladder incontinence related to generalized weakness requiring assistance with activities of daily living (ADL) care and toileting. Interventions included clean peri-area with each incontinence episode, have call light within easy reach, maintain resident dignity with care, and monitor and document signs and symptoms of urinary tract infections: pain, burning, blood-tinged urine, cloudiness, no urine output, increased pulse, increased temperature, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/21/26, revealed Resident #44 was cognitively intact, required a wheelchair for mobility, was dependent for toileting hygiene, required substantial/maximal assistance for showering and all dressing, and was frequently incontinent of both bowel and bladder. The resident was medically complex and had no significant weight loss.Review of a progress note written by NP #612 on 06/01/26 revealed Resident #44 was seen for altered mental status which included being tearful at times with some confusion over the past week. Resident #44 was awake, alert, and in no distress. The plan was for a complete blood count (CBC), basic metabolic panel (BMP), and a urinalysis with culture and sensitivity to be obtained on 06/02/26.Review of a progress note written by Registered Nurse (RN) #504 on 06/02/26 at 9:07 P.M., revealed laboratory results were reviewed and (unnamed) NP aware.Review of a progress note written by NP #613 on 06/02/26 revealed Resident #44 was seen for follow up of altered mental status and to re-evaluate for hypotension. The resident was alert, oriented and able to participate by answering questions appropriately during the examination. Lab results dated 05/28/26 were reviewed as WBC (white blood cells) 5.4 (normal), glucose 69 (normal), sodium 144 (normal), potassium 4.6(normal), chloride 109 (normal), BUN (blood urea nitrogen) 32 (high), creatinine 1.3 (high), calcium 9.1 (normal), protein 5.1 (low), albumin less than 3.0 (low), hemoglobin 10.6 (low), and hematocrit 32.2 (low). A TSH (thyroid stimulation hormone) dated 05/22/26 was 6.091 (high). It was noted the elevated TSH could be contributing to symptoms, so Synthroid medication was added and to check a complete blood count (CBC) and basic metabolic panel (BMP) on Thursday (in one week). The note also indicated the urinalysis with culture and sensitivity was ordered but had not yet been obtained. Review of a progress note written by Licensed Practical Nurse (LPN) #650 on 06/03/26 at 6:11 A.M. revealed the order for urinalysis with culture and sensitivity had been obtained.Review of a progress note written by NP #613 on 06/05/26 revealed Resident #44 was seen for follow up of altered mental status. Resident #44 was awake, alert and oriented to person, place and time, in no distress, sitting up in her wheelchair, and able to answer questions appropriately. Resident #44 was noted to be having no pain with urination and no blood in the urine. 06/01/26 labs results were reviewed and recorded as WBC (white blood cells) 5.8 (normal), glucose 69 (normal), sodium 143 (normal), potassium 4.3 (normal), chloride 106 (normal), BUN (blood urea nitrogen) 37 (high), creatinine 1.2 (normal), calcium 9.0 (normal), hemoglobin 11.0 (low), and hematocrit 33.5 (low). The note indicated the urinalysis with culture and sensitivity was pending positive.Review of the document titled Lab Reports Result, dated 06/07/26, for Resident #44 revealed the urine specimen was collected on 06/03/26 and reported to the facility on [DATE] at 2:38 P.M. but did not indicate to whom the report was given for the results. The results indicated the resident's urine culture was positive for Klebsiella pneumoniae ESBL (extended spectrum beta-lactamase). ESBL was highly resistant to many common antibiotics including penicillin and cephalosporins. Review of progress notes dated 06/07/26 through 06/15/26 revealed no evidence the facility reported the 06/07/26 urine culture and sensitivity results for Resident #44 to the NP or physician. Progress notes indicated on 06/14/26 that Resident #44 was at baseline for vitals and level of alertness.Review of a progress note for Resident #44 dated 06/16/26 at 11:09 P.M., written by RN #504, indicated urine culture results from 06/07/26 were reviewed and [unnamed] NP aware. New orders were received for Nitrofurantoin Macrocrystal (antibiotic used to treat UTI) oral capsule 100 milligram (mg) one capsule by mouth every shift for abnormal urine results for five days.Review of a progress note for Resident #44 dated 06/17/26 at 12:46 A.M., written by Licensed Practical Nurse (LPN) #515 revealed Resident #44 was sent to the emergency room at 12:35 A.M. on 06/17/26. Review of the hospital record for Resident #44 dated 06/17/26 revealed she was sent to the hospital where she was diagnosed with and treated for a urinary tract infection. Resident #44 discharged back to the facility on [DATE].An interview on 06/23/26 at 2:11 P.M. with RN #504 revealed when labs are ordered at the facility and results finalized at the lab, the lab results were faxed to the nurse's station and also automatically sent to the electronic medical record from the lab. The nurse who would get the labs from the fax machine should call the provider and notify the provider if there were abnormal results. When asked why the urine with culture lab results dated 06/07/26 for Resident #44 did not get reported to an NP or physician until 06/16/26, RN #504 stated he did not know how it got missed because someone should have been looking for it within three days of collection. RN #504 stated he found the lab result sitting on the top of a desk in the middle of a pile of stuff on 06/16/26 and reported the result to the provider immediately as well as the Director of Nursing (DON). RN #504 stated he believed the late reporting of the results caused a delay in treating Resident #44 with the appropriate medications for the UTI.An interview on 06/23/26 at 3:50 P.M. with Regional RN (RRN) #609 confirmed there was a delay in care when urine analysis and culture laboratory results for Resident #44 were not reported for nine days after they had been received by the facility.An interview was attempted by phone on 06/29/26 at 3:30 P.M. with Licensed Practical Nurse (LPN) #515 and no return contact was received. An interview on 06/29/26 at 3:43 P.M. with NP #213 confirmed there had been a delay in reporting the lab results showing a UTI from 06/07/26 to 06/16/26. An interview on 06/30/26 at 1:00 P.M. with Resident #44 revealed she was alert and oriented to person, place, and time and answered questions appropriately. Resident #44 stated she did not recall the events which led to her hospitalization; however, she knew she had been sick. Resident #44 stated she was feeling better and had no more confusion.Review of a facility policy titled Lab and Diagnostic Test Results Clinical Protocol, revised September 2012, revealed a physician would identify and order diagnostic and lab testing based on needs. A nurse would review all results. The nurse should discuss, when reporting the results, why the test was obtained. The nurse would identify the urgency of communicating the results to the provider, the seriousness of the abnormality, and the individual's current condition. Situations which required prompt physician notification included a result which should be conveyed to a provider regardless of other circumstances (the abnormal result was problematic) or the resident's clinical status was unclear or worsening.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure staff followed proper infection control procedures during incontinence care for Resident #55. The affected one resident (#55) of three residents reviewed for incontinence care. The facility census was 77.Findings include: Review of the medical record for Resident #55 revealed admission to the facility on [DATE] with diagnoses including hemiplegia of right side, dementia and bowel and urine incontinence.Review of the minimum data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #55 was not able to vocalize her care needs and unable to complete the brief interview for mental status. Further review of the MDS revealed Resident #55 was dependent on staff for all personal care including showering/bathing, dressing, mobility with a wheelchair, and transfers with a mechanical lift. Resident #55 required a feeding tube for nutrition.Observation on 06/23/26 at 1:30 P.M. of incontinence care provided to Resident #55 by certified nursing assistant (CNA) #595 and CNA #592 revealed both CNA's donned gown and gloves per enhanced barrier protocol (EBP) and gathered wash clothes and soap and began performing incontinence care. Resident #55 began having a bowel movement during care and CNA's cleaned up stool from the resident with disposable cloths. After using disposable cloths to removal stool, CNA #595 used a soapy wash cloth and cleansed rectal area then immediately applied a barrier cream then placed an adult brief under Resident #55 and rolled her onto her back. CNA #595 did not remove her gloves or wash her hands and proceeded to obtain a new clean soapy washcloth with the same contaminated, gloved hands and cleansed the pubic area and labia of Resident #55. CNA #592 did not remove her gloves or wash her hands after assisting with incontinence care and then proceeded to reposition Resident #55 making direct contact with her head then placing a C shaped pillow. Resident # 55 then began moving her bowels again prior to CNA #595 securing the adult brief. CNA #595 and CNA #592 voiced they would need to start the process again, so both CNA #595 and #592 did not remove gloves or wash hands before starting perineal care again. Both CNA's were stopped by the surveyor at the time to ask why they had at no time changed their gloves nor performed hand hygiene. An immediate interview with CNA #595 revealed she was educated that once she put on her gown and gloves and entered a resident room with EBP she could not remove her gloves at all because she could only remove everything (gown and gloves) at one time when she left the room and that is why she did not change her gloves after cleaning the rectal area of stool then returning to the front to clean Resident #55's labia area. CNA #592 reported she was just in CNA training and was never taught to remove or change gloves during incontinence care. CNA #595 verified that she did not change her dirty gloves prior cleanings the labial area of Resident #55. CNA #592 verified she also did touch Resident #55 head to place the C shaped pillow without removing her dirty gloves and washing hands. An interview on 06/23/26 at 1:10 P.M. with the Director of Nursing (DON) revealed that she had started her current position in January 2026 and had been overseeing the infection control program for past few months until a new infection preventionist was designated about 2 weeks ago. The DON stated she had not completed any training with the facility staff regarding incontinence care since starting her position. The DON stated she had not had a chance to look, and she was not sure what type of training was used to educate the staff on proper incontinence care. A follow-up interview on 06/23/26 at 2:38 P.M. with the DON revealed when asked what the proper procedure was for hand hygiene and glove usage during perineal care she would not confirm the appropriate process for performing incontinence care and just stated she would have to reference the facility policy to determine if the CNA's completed it appropriately. Review of the facility policy titled, Perineal Care, revised 10/2010, revealed for female residents, wash perineal area wiping front to back. Wash the labia area first using a downward front to back motion then moving from inside outward toward thigh. Have the residents turn to side and then wash rectal area. Do not reuse the same washcloth or water to clean the labia. Following cleaning of the rectum discard disposable items and remove gloves and wash and dry hands prior to touching resident's environment including bed covers and call light.This deficiency represents non-compliance identified under Complaint Number 2581134, 2571934 and 2705905.

Based on observations, policy review, medical record review and interview, the facility failed to implement isolation protocols and failed to maintain infection control during tracheostomy care and blood glucose monitoring. This had the potential to affect all 75 residents in the facility. Findings include: 1. Review of Resident #178's medical record revealed diagnoses including history of malignant neoplasm of the breast and intestine and dyspnea. On 09/28/24, Resident #178 tested positive for COVID-19 and was placed in droplet isolation. The isolation was to be discontinued 10/09/24. On 10/07/24 at 12:47 P.M., Certified Occupational Therapy Assistant (COTA) #820 was observed opening Resident #178's door to exit into the corridor. The N95 mask she was wearing in Resident #178's room remained on. After opening the door, COTA #820 removed the N95. Without performing hand hygiene, COTA #820 reached around the door and into the isolation cart to obtain a new N95 mask and held it over her face. COTA #820 pushed the goggles she had been wearing onto the top of her head and walked down the hall without disinfecting the goggles or performing hand hygiene. COTA #820 stopped at room [ROOM NUMBER] and got a surgical mask from Resident #177's isolation cart. Resident #177 had orders for enhanced barrier precautions due to presence of a feeding tube. COTA #820 continued down the hall without performing hand hygiene or disinfecting the goggles or the drawers of Resident #177's or Resident #178's isolation carts. On 10/08/24 at 1:35 P.M., as State tested Nursing Assistant (STNA) #520 was being interviewed regarding the location of surgical masks as there were none in Resident #178's isolation cart and it was what the facility required to be worn outside the COVID isolation rooms. STNA #520 provided a box of surgical masks. Housekeeper #701, who was in the hallway and overheard the conversation, inquired of STNA #520 if she was supposed to change masks when going in and out of the droplet isolation rooms. STNA #520 responded it was required to prevent spreading COVID. Upon entering Resident #178's room on 10/08/24 after the interview, it was noted the isolation barrel by the door and the trash can by the sink in the room were overflowing with trash. Disposable gowns were noted flowing down the sides of both receptacles. On 10/08/24 at 1:40 P.M., Housekeeper #701 stated it was up to the nursing assistants to dispose of trash in the isolation rooms. On 10/08/24 at 2:48 P.M., STNA #520 verified Housekeeper #701 was unaware of the need to change masks when going in and out of droplet isolation rooms when she made the inquiry earlier that day. STNA #520 reported it was the responsibility of housekeeping to empty the isolation barrels and trash. On 10/08/24 at 2:48 P.M., STNA #520 was observed leaving Resident #178's (who was positive and in isolation for COVID-19) room. STNA #520 walked up the hall and got hand sanitizer from on top of a locked box by room [ROOM NUMBER]. No eye protection was observed being worn. STNA #520 indicated she did not know eye protection was required. On 10/08/24 at 3:05 P.M., Housekeeping Director #903 stated it was the responsibility of the housekeeping department to empty isolation trash and verified staff needed to change masks when entering/exiting covid rooms. On 10/08/24 at 3:15 P.M., COTA #820 verified she had left Resident #178's room on 10/07/24 and verified hand hygiene was not completed after removing the old N95 because there was no hand sanitizer. COTA #820 verified the goggles had been pushed up to the top of her head without disinfecting until she returned to therapy where she had disinfectant wipes because there were none available in the cart. On 10/08/24 at 3:48 P.M., Unit Manager (UM) #915 stated hand sanitizer should be available in the isolation carts. Disinfectant wipes were not kept in the isolation carts so they could be used when staff exited the room. Staff had to request the disinfectant wipes from the nurse. 2. Review of Resident #2's medical record revealed diagnoses including acute and chronic respiratory failure and tracheostomy status. On 10/07/24 an order was written for contact isolation for extended-spectrum beta-lactamases (ESBL) in the sputum. On 10/09/24 at 12:05 P.M., Licensed Practical Nurse (LPN) #308 was observed preparing medication for administration to Resident #2. Signs were posted for contact precautions and enhanced barrier precautions. Housekeeper #701 was in Resident #2's room cleaning. The only personal protective equipment (PPE) worn was a pair of gloves. On 10/09/24 at 1 P.M. Housekeeper #701 verified she had not worn a gown into Resident #2's room. Housekeeper #701 stated nobody informed her Resident #2 had been added to contact isolation. Review of the facility's policy titled Isolation Categories of Transmission-Based Precautions (revised January 2012) revealed transmission-based precautions would be used whenever measures more stringent than standard precautions were needed to prevent or control the spread of infection. For residents on contact precautions, a disposable gown should be worn upon entering the room or cubicle in addition to gloves. Surveyor: [NAME], APRIL 3. Observation on 10/09/24 at 9:55 A.M. revealed Respiratory Technician (RT) #407 conducting tracheostomy care for Resident #57. RT #407 donned Personnel Protective Equipment (PPE), including gloves, and entered Resident #57's room where Resident #57 was laying in bed covered with bed linens and a blanket. RT #407 placed the tracheostomy cleaning package, several packages of gauze sheets, the replacement inner cannula, a split gauze to cover the tracheostomy insertion site, and normal saline for cleaning the tracheostomy insertion site on the blanket at the foot of Resident #57's bed on top of Resident #57's legs. RT#407 opened the tracheostomy cleaning tray removing the sterile gloves package and placing the package on the blanket, there had been no sterile barrier sheet to place under the sterile gloves package. RT #407 donned the sterile gloves over the existing gloves which were already in place, removed the used inner cannula and placed the cannula on the packaging for the sterile gloves. RT #407 then placed the new inner cannula into the tracheostomy tube, retrieved the used inner cannula from the opened package and rolled the used inner cannula into one sterile glove and removed the other sterile glove while keeping the used inner cannula rolled into the gloves and disposed of the used inner cannula into the waste reciprocal. RT #407 donned a new pair of gloves and proceeded to clean the tracheostomy insertion site and placed the clean split gauze around the tracheostomy and removed the cleaning tray from the on top of the bed and disposed of all items in the waste reciprocal. RT #407 removed the PPE and gloves then washed hands and exited Resident #57's room. Review of Resident #57's medical record revealed readmitted [DATE] with diagnoses including chronic respiratory failure, high blood pressure, heart failure, and type two diabetes mellitus. Resident #57 was dependent on staff assistance for all cares and activities of daily living (ADL) tasks including tracheostomy care. Resident #57 had severely impaired cognition with a Brief Interview Mental Status (BIMS) score five out of a possible 15 total score dated 08/30/24 Review of Resident #57's physician orders revealed an order dated 09/01/24 for tracheostomy size #6 XLT Proximal Cuffed every shift for acute and chronic respiratory failure with hypoxia, an order dated 05/24/24 for Trach care Q-shift and as needed (PRN) every shift for chronic respiratory failure with hypoxia change inner cannula, cleanse area around the trach and neck, change trach ties every shift and PRN, and an order dated 07/31/24 to change trach tube every 90 days and PRN one time a day every 90 days. Review of Resident #57's Quarterly [NAME] Data Set (MDS) dated [DATE] revealed Section K: Swallowing/Nutritional Status marked with abdominal feeding tube (PEG) being used, and Section O: Special Treatments, Procedures, and Programs marked with tracheostomy being used. Review of the care plan for Resident #57 revealed a tracheostomy care plan dated 06/14/24 including intervention for tracheostomy care as ordered. Interview on 10/09/24 at 9:57 A.M. with RT #407 confirmed the tracheostomy cleaning supplies and sterile glove package had been placed on Resident #57 bed blanket on top of Resident #57's legs and there had been no sterile barrier sheet placed underneath the tracheostomy supplies. RT #407 stated the bedside table is usually used to keep the tracheostomy supplies off the bed and there should have been a sterile sheet placed for the tracheostomy supplies to be kept on during the procedure. Review of the facility's policy titled, Tracheostomy Care dated 10/23 revealed, Open tracheostomy cleaning kit. Set up supplies on sterile field. 4. Review of the medical record for Resident #34 revealed admitted [DATE] with diagnoses including epilepsy, type one diabetes mellitus (DM), anxiety, unspecified dementia, and high blood pressure. Resident #34 had severely impaired cognition and required assistance from staff to complete activities of daily living (ADL) tasks including administration of medications. Review of the physician orders for Resident #34 revealed an order dated 08/02/24 for Insulin Lispro 100 units per milliliter (ml) inject subcutaneously two times a day for DM with blood sugar readings and sliding scale dosing at 7:30 A.M. and 12:00 P.M. Review of the comprehensive care plan for Resident #34 revealed a diabetes mellitus care plan dated 08/02/23 with interventions including fasting blood sugar as ordered by the physician and diabetes medications as ordered by the physician. Review of Resident #34's Medication Administration Record (MAR) dated 10/01/24 to 10/09/24 revealed the blood sugar reading obtained at 12:20 P.M. results were recorded as 388 requiring six units of the Insulin Lispro to be administered per sliding scale dosing. Observation on 10/09/24 at 12:20 P.M. revealed Resident #34 sitting at a table in the main dining room facing the television with back to the majority of the room, eating the lunch meal. Licensed Practical Nurse (LPN) #822 approached Resident #34 at the table and explained blood sugar check and insulin administration needed to be completed. LPN #822 placed the glucometer, insulin pen, lancet, and several alcohol wipes directly on the table without a barrier in place. LPN #822 requested Resident #34 to hold out her right hand, then LPN #822 cleaned her right pointer finger with alcohol wipe, placed the used wipe directly on the table, pricked her finger with the lancet using another alcohol wipe to clean the blood from her finger and placed the used wipe on the table. LPN #822 then obtained the blood sugar reading, placing the glucometer directly on the table with the used strip still in the machine. LPN #822 then proceeded to administer Resident #34's insulin via a pre-filled insulin pen, once the insulin was administered, LPN #822 gathered up the supplies from the table and left the dining room. Interview on 10/09/24 at 12:28 P.M. with LPN #822 confirmed during the obtaining of Resident #34's blood sugar and administration of the Insulin Lispro, LPN #34 had not used a barrier for the required supplies storage on the tabletop, had placed used alcohol wipes directly on the table, and had placed the glucometer with the used blood strip on the table after obtaining a blood sample for testing. LPN #822 stated Resident #34 had been taken to the dining room for the lunch meal before completing the procedure for blood sugar checks and insulin administration. Review of the facility's policy tilted, Infection Control Guidelines for All Nursing Procedures dated 12/29/20 revealed, Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 47569

Based on observation, record review, and interview the facility failed to cover an indwelling urinary catheter drainage bag. This affected one resident (Resident #276) out of two residents reviewed for indwelling urinary catheters. The facility census was 75. Findings Include: Review of the medical record for Resident #276 revealed an admitted [DATE] with diagnoses including history of falls, history of urinary tract infection (UTI), chronic kidney disease, and type two diabetes mellitus. Resident #276 required assistance from staff for activities of daily living (ADL) tasks, used a front wheeled walker for ambulation assistance, and was receiving physical and occupational therapy services. Review of Resident #276 physician orders revealed an order dated 10/03/24 for foley catheter bag cover every shift, an order dated 10/04/24 for privacy cover to foley catheter drainage bag every shift for maintaining dignity, and an order dated 10/03/24 for foley catheter care every shift. Review of Resident #276 baseline care plan dated 10/03/24 revealed Resident #276 was admitted with an indwelling urinary catheter. Observation on 10/07/24 at 1:05 P.M. revealed Resident #276 resting in bed watching television, a partially filled urinary catheter drainage bag was hanging from the bed frame without privacy cover or bag in place. Observation on 10/08/24 at 3:14 P.M. revealed Resident #276 sitting at edge of bed watching television, a urinary catheter drainage bag was hanging from the bed frame without privacy cover or bag in place. Interview on 10/08/24 at 3:14 P.M. with State tested Nursing Assistants (STNAs) #527 and #543 confirmed Resident #276 indwelling urinary catheter drainage bag was uncovered and visible from the room's doorway. STNA #527 stated there should be a privacy bag or a drainage bag with an attached cover over the drainage bag and the lack of the privacy bag would be resolved by placing a privacy bag on Resident #276's indwelling urinary catheter drainage bag. Observation on 10/10/24 at 8:16 A.M. revealed Resident #276 sleeping in bed with the lights turned off. An empty urinary catheter drainage bag was hanging from the bed frame without privacy cover or bag in place. Interview on 10/10/24 at 8:16 A.M. with Licensed Practical Nurse (LPN) #314 confirmed Resident #276 indwelling urinary catheter partially filled drainage bag was hanging on the bed frame, uncovered and not placed in a privacy bag.

Based on observation, record review, interview and facility policy review, the facility failed to ensure enteral tube feeding bottles and water flush bags were properly labeled with the flow rate and the date and time the bottles/bags were hung for administration for Resident #176, and failed to ensure orders were obtained for Resident #177 regarding cleaning and flushing of an enteral feeding tube. This affected two residents (Resident #176 and #177) out of two residents reviewed for enteral tube feedings. The facility census was 75. Findings Include: 1. Review of the medical record for Resident #176 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), depression, anxiety, heart failure, and placement of a percutaneous endoscopic gastrostomy (PEG) tube. Resident #176 was cognitively intact and required assistance from the staff for activities of daily living (ADL) tasks including medication administration and tube feeding formula administration. Review of the physician orders for Resident #176 revealed an order dated 09/25/24 for two times a day (Enteral) Jevity 1.5 at 85 milliliters (ml) per hour for 12 hours (on at 7:00 P.M. and off at 7:00 A.M.) with water flush of 245 ml every four hours. Resident #176 also had an order dated 09/24/24 for a regular diet, pureed texture, honey consistency liquids. Review of Resident #176's Medication Administration Record (MAR) dated 10/01/24 to 10/10/24 revealed administration (Enteral) Jevity 1.5 at 85 milliliters (ml) per hour for 12 hours (on at 7:00 P.M. and off at 7:00 A.M.) with water flush of 245 ml every four hours. Observation on 10/07/24 at 10:35 A.M. revealed Resident #176 was in bed and a tube feeding administration pole was at the bedside. Hanging from the pole was an empty formula bottle of Jevity 1.5. The bottle had no flow rate, date, or time marked on it to indicate when it was first hung to be administered to Resident #176. The resident was not hooked up to the feeding at the time of the observation. Observation on 10/08/24 at 1:32 P.M. and 1:47 P.M. revealed Resident #176 resting in bed with the unattached tube feeding tube hanging from the pole at bedside. There was an empty bottle of Jevity 1.5 enteral formula with no rate, date, and time of when administered hanging from the pole. There was also a half-filled water flush bag hanging from the pole with no rate, date, and time labeled on the bag. An interview on 10/08/24 at 1:47 P.M. with Licensed Practical Nurse (LPN) #313 confirmed the above findings. Review of the facility's policy titled, Enteral Feedings Safety Precautions, dated 05/24, revealed, On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. 22653 2. Review of Resident #177's medical record revealed diagnoses including osteomyelitis of the left ankle and foot, cellulitis of the left lower extremity, abscess of the left foot, history of sepsis, type two diabetes mellitus, heart disease, schizophrenia, and gastrostomy. A nursing admission assessment dated [DATE] indicated Resident #177 had a feeding tube. Resident #177 required supervision with eating. Resident #177 had an order dated 10/03/24 for a low concentrated sweet diet with regular texture. Review of medication orders dated 10/03/24 revealed orders for medications including ferrous sulfate, provera, metoprolol tartrate, risperidone, ascorbic acid, quetiapine fumarate, amlodipine, atorvastatin calcium, pantoprazole sodium, and zinc sulfate which could be administered via mouth or through the feeding tube. There were no orders for care of the feeding tube (cleansing the insertion site or flushes). During an interview on 10/07/24 at 11:26 A.M., Resident #177 reported she had a feeding tube which she had staff use for some medication administration. On 10/07/24 at 4:44 P.M., Unit Manager (UM) #915 verified there were no orders for tube care or water flushes.

Based on record review and interview, the facility failed to ensure parameters were in place for the administration of pain medications. This affected one resident (Resident #2) of five reviewed for unnecessary medications. The facility census was 75. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included respiratory failure, cerebral palsy, depression, tracheostomy and scoliosis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was severely cognitively impaired. She was totally dependent for oral and personal hygiene, toileting, dressing and showering. She received hospice services. Review of the physician's orders for October 2024 revealed an order for Acetaminophen 500 milligrams (mg) 1 tablet via peg tube every eight hours as needed for pain which began on 07/25/24 and an order for Morphine 0.5 milliliters (ml) every two hours as needed for pain which began on 08/26/24. Review of the care plan dated 08/28/24 revealed Resident #2 had the potential for pain due to quadriplegia, convulsions, contractures and scoliosis. Interventions included anticipating the need for pain relief, administering medications as ordered, evaluating the effectiveness of pain interventions and monitoring and recording complaints of pain. Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #2 received one does of Morphine on 09/01/24 for a pain level of six and one dose for a pain level of eight, two doses on 09/02/24 for a pain level of seven, one dose on 09/03/24 for a pain level of three and two doses for a pain level of eight, one dose on 09/04/24 for a pain level of eight and one dose for a pain level of seven, two doses on 09/05/24 for a pain level of seven, one dose on 09/06/24 for a pain level of seven and one dose for a pain level of eight, one dose on 09/07/24 for a pain level of four and one dose for a pain level of eight, one dose on 09/08/24 for a pain level of four, one dose on 09/09/24 for a pain level of seven, two doses on 09/10/24 for a pain level of seven, one dose on 09/07/24 for a pain level of seven and one dose for a pain level of eight, one dose on 09/12/24 for a pain level of eight and one dose for a pain level of seven, one dose on 09/13/24 for a pain level of nine and one dose for a pain level of three, one dose on 09/14/24 for a pain level of seven and one dose for a pain level of eight, one dose on 09/15/24 for a pain level of seven and two doses for a pain level of eight, one dose on 09/16/24 for a pain level of eight and one dose for a pain level of five, one dose on 09/17/24 for a pain level of six and two doses for a pain level of eight, one dose on 09/18/24 for a pain level of four and one dose for a pain level of seven, one dose on 09/19/24 for a pain level of three, two doses of 09/21/24 for a pain level of two, one dose on 09/23/24 for a pain level of two, one dose on 09/24/24 for a pain level of three, one dose on 09/26/24 for a pain level of three, one dose on 09/27/24 for a pain level of eight and one dose on 09/29/24 for a pain level of four. The resident was never administered Acetaminophen. Review of the MAR for October 2024 revealed Resident #2 received one dose of Morphine on 10/01/24 for a pain level of two and two doses for a pain level of eight, one dose on 10/05/24 for a pain level of zero, one dose on 10/06/24 for a pain level of three, one dose on 10/07/24 for a pain level of zero and one dose for a pain level of eight, one dose on 10/08/24 for a pain level of three, two doses on 10/09/24 for a pain level of zero and three doses on 10/01/24 for a pain level of zero. Interview on 10/10/24 at 9:43 A.M. with Licensed Practical Nurse (LPN) #309 revealed she usually gave Morphine for a pain level of seven or above, she did not have guidelines for when it would be appropriate for administer Acetaminophen instead of Morphine for Resident #2. Interview on 10/10/24 at 1:12 P.M. with the Director of Nursing (DON) verified the above findings on the MARs and confirmed there were no parameters specified for when Acetaminophen would be administered instead of Morphine for Resident #2. Review of the facility policy titled Administering Pain Medications dated October 2010 revealed the facility would assess the residents' level of pain prior to administering medication and administer medication as ordered.

Based on record review and interview, the facility failed to completely and accurately report staff hours worked for the Payroll Based Journal (PBJ) report. This had the potential to affect all 75 residents residing in the facility. Findings include: Review of the PBJ report revealed excessively low weekend staffing for the third quarter of 2024. Review of the staffing schedules for the nurses and State tested Nurse Aides (STNA) for the third quarter of 2024 revealed on 05/24/24, 05/25/24 and 06/16/24 there was insufficient direct care staff in the facility to provided a minimum of 2.5 hours of direct care per resident per day. Interview on 10/10/24 at 2:00 P.M. with the Administrator revealed during the third quarter of 2024 when the facility utilized agency staff to cover shifts this data was not submitted to the corporate office for the PBJ so the data reported for the third quarter of 2024 was not accurate.

Based on record review, interview, and facility policy review the facility failed to accurately assess, document, and treat a new onset of a diabetic ulcer for Resident #80, who was dependent on staff for care. This affected one resident (#80) out of three residents reviewed for skin impairment. The facility census was 79. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with a discharge to the hospital on 04/18/24. Diagnoses included type two diabetes mellitus, Alzheimer's disease, high blood pressure, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had impaired cognition. Resident #80 was dependent for bed mobility, transfers, and was non-ambulatory. Review of Resident #80's behaviors revealed the resident would be combative and aggressive when receiving care from staff. Resident #80 was receiving dressing changes to the right foot. Review of the plan of care dated 07/10/23 revealed Resident #80 was at risk for skin impairment due to the diagnoses including type two diabetes mellitus and non-ambulatory status. Review of Resident #80's nurse progress notes dated from 01/11/24 to 01/12/24 revealed Resident #80 did not have documentation for a scabbed area located on the right lateral dorsal foot, and there was no wound assessment completed. Review of the wound care team's progress notes dated 01/12/24 revealed Resident #80 was evaluated for a right lateral dorsal foot/great toe diabetic ulcer, onset 01/11/24, measuring 2.0 centimeters (cm) by 0.7 cm with no depth. The area was 100% covered by a crust (scab), and there was no treatment in place. Interview on 04/30/24 at 11:35 A.M. with the Director of Nursing (DON) revealed Resident #80's initial scabbed area to the right lateral dorsal foot was reported on 01/11/24 to Registered Nurse (RN) #310 by an unknown nurse. The DON confirmed there were no progress notes or wound measurements, or assessment completed in Resident #80's medical record dated 01/11/24. Interview on 04/30/24 at 3:11 P.M. with RN #310 revealed no recollection of who reported Resident #80's initial scabbed area on the right dorsal lateral foot. Review of Resident #80's physician orders revealed an order dated 01/12/24 for cleansing the right lateral dorsal foot with normal saline, pat dry, apply Medihoney, cover with a foam dressing, and change three times per week. There were no orders for treatment dated prior to this order. Interview on 04/30/24 at 3:10 P.M. with facility wound nurse RN #310 revealed when skin impairment is identified the nurses are expected to enter a progress note, initiate, and complete a wound assessment, notify the physician or nurse practitioner, initiate a treatment order, and determine how the skin impairment developed. RN #310 confirmed Resident #80 did not have a progress note, a completed initial wound assessment, and there was no initial treatment order initiated for the scabbed area identified on Resident #80's right lateral dorsal foot. Review of the facility's policy titled, Skin Breakdown - Clinical Protocol dated 03/01/14 revealed, The nurse shall describe and document/report the following: full assessment including location, stage, length, width and depth, presence of exudate or necrotic tissue; pain assessment; resident's mobility status; current treatment; all active diagnosis. This deficiency represents non-compliance investigated under Complaint Number OH00153330.

Based on record review, observation, interview, policy review and manufacturer guidelines the facility failed to ensure interventions were in place to prevent a decline in a pressure ulcer for one resident (Resident #89). This resulted in actual harm for Resident #89 who experienced the decline of a Stage I pressure area to the right heel to an unstageable pressure ulcer. This affected one of two residents reviewed for pressure ulcers. The facility census was 77. Findings include: Review of Resident #89's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#89's most recent Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #89 required extensive assistance of two persons for bed mobility and transfers. Review of the weekly skin condition data tracking sheet revealed on 11/06/14 Resident #89 developed a Stage I pressure area to the right heel. The measurements of the right heel wound were 0.4 centimeters (cm) long by 0.2 cm wide with no depth. The wound bed was noted to be red. The skin condition tracking sheet noted on 11/20/14 the pressure area was advanced in stage to a deep tissue injury measuring 0.5 cm long by 0.3 cm wide with no depth and a purple wound bed. Review of the weekly skin data tracking sheet dated 12/03/14 revealed the right heel was noted to be 2.0 cm long by 1.9 cm wide with a depth of 0.1 cm. The wound base was red and white with purulent drainage noted. On 12/24/14 the facility staged the wound of the right heel as a Stage III pressure area. Review of the weekly skin data tracking sheet dated 12/24/14 revealed the area on the right heel measured 1.9 cm long by 0.9 cm wide with a depth of 0.1 cm. Continuous observation was made on 02/11/15 from 12:37 P.M. to 12:58 P.M. of Registered Nurse (RN) #88 performing the wound dressing change for Resident #89. Observation of the wound revealed a brown scabbed area approximately 0.3 centimeters long by 0.4 centimeters wide with no measurable depth. The skin surrounding the wound was dry and colored light purple. RN #88 touched the scabbed area in a patting motion with her gloved finger. RN #88 then removed her gloves washed her hands and applied clean gloves. RN #88 then retrieved the four by four soaked in normal saline and cleansed the area in a circular motion. Resident #89 moaned when RN #88 cleansed the wound. RN #88 briefly stopped Resident #89 stopped moaning and RN #88 continued with the dressing change. RN #88 confirmed this observation at the end of the dressing change. Review of the physician orders [REDACTED].M. revealed Resident #89 was in bed with bilateral heels resting on the alternating air mattress. Two pillows were noted under Resident #89's calves. State tested Nurse Aide (STNA) #31 confirmed the heels were not floated and indicated Resident #89 moved around in bed and dislodged the pillows at times. Interview and observation on 02/12/15 at 3:13 P.M. with RN #88 revealed the physician ordered Prevalon boots would help to float Resident #89's heels while in the bed or a chair. An observation of Resident's #89's room revealed no evidence of Prevalon boots. Review of the treatment administration record (TAR) for November, 2014; December, 2014; January, 2015 and February, 2015 revealed no evidence the Prevalon boots were applied to Resident #89's feet as ordered. RN #88 confirmed the above observation and record review. Review of the undated Prevalon Boot manufacturer information sheet revealed the Prevalon boot is designed with an open, floated-heel design which means the heel is completely floated. Review of the facility Pressure Ulcer Treatment policy revised February, 2014 revealed interventions for a stage one pressure area to redistribute pressure and interventions to off-load pressure.