Every finding on record at Merriam Gardens Healthcare & Rehabilitation Center

Based on record review and interview, the facility failed to ensure one of the five Certified Nurse's Aides (CNA) reviewed had yearly performance evaluations completed. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA N, hired 04/16/2024, had no yearly performance evaluation upon request.On 08/12/2026 at 09:10 AM, Administrative Nurse D stated the director of nursing was responsible for nursing staff's performance evaluations. He stated the facility had identified that the reviews were not all completed and had started a Performance Improvement Plan (PIP).The facility's Evaluation Process dated 08/27/2025 documented It was the policy of the facility to review the work performance of employees with a formal written evaluation annually. At the time the evaluation is given, the facility may or may not make salary/wage adjustments. There was no guarantee that a salary/wage rate increase will be given automatically each year. Factors that would be considered in making decisions about salary/wage adjustments include, but are not limited to job performance, achieving preset goals, attendance record, adherence to workplace policies, etc.

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility. Findings included:- During an initial tour of the kitchen on 08/10/2026 at 07:27 AM, the following areas of concern were noted:1. Two white, three-tiered plastic carts used to transfer clean dishes to and from the dishwashing area had food ground into the corners of each tire.2. Six wire racks in the two-doored, reach-in refrigerator were missing several areas of the plastic protective coating.3. The rubber seal around one of the doors of the two-door, reach-in refrigerator hung loosely beneath the door.4. Three wire racks in the two-door, reach-in freezer had several areas of the plastic protective coating missing.5. Six wire racks in the three-door, reach-in refrigerator had several areas of the plastic protective coating missing.On 08/12/2026 at 08:30 AM, Dietary Staff CC confirmed the noted areas needed replacement.The facility policy Sanitation Inspection, revised 01/01/2026, included: It is the policy of the facility to ensure food service areas are clean and sanitary.

Based on record review and interview, the facility failed to ensure five of the five Certified Nurse Aide (CNA) staff reviewed had the required 12 hours of in-service education. Findings included:- Review of the information facility's in-service records revealed the following CNAs were employed with the facility for more than 12 months: CNA O, hired on 12/28/2023, had not completed the required in-services in the past 12 months.CNA N, hired on 04/16/2024, had not completed the required in-services in the past 12 months.CNA P, hired on 11/15/2022, had not completed the required in-services in the past 12 months.On 08/12/2026 at 09:15 AM, Licensed Nurse (LN) K stated the facility did have online education. She stated the staff could do the in-services when there was downtime, or after their shift.On 08/12/2026 at 10:15 AM, Administrative Staff A stated human resources oversaw the staff's in-services. He stated in the last few weeks the facility was aware the facility and staff were falling short in this area and had started a Performance Improvement Plan (PIP)On 08/12/2025 at 11:46 AM, Administrative Nurse D stated the human resource facility department, she stated the facility had gotten computers for staff to do in-services. She stated the staff could do in-services in their downtime or after their shifts.The facility did not provide an in-service policy as requested on 08/12/2026.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate below five percent. Twenty-five medication administrations were observed, with 5 errors identified, resulting in a medication error rate of 20 percent (%). Findings included:- Resident (R) 18's Electronic Health Record (EHR) documented the following orders:Levetiracetam oral solution 100 milligrams (mg)/milliliter (ml), give five ml via gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) two times a day.Oxybutynin chloride oral tablet five mg, give five mg by mouth two times a day.Acetaminophen 160 mg/five ml oral liquid, give 30 ml via G-tube three times a day.Carbidopa 25 mg/levodopa 100mg oral tablet, give one tablet via G-tube three times a day.Diltiazem HCI tablet 60 mg, give one tablet via G-tube four times a day.R18's EHR lacked orders for medications to be crushed and/or mixed.Observed on 08/11/2026 10:14 AM, Licensed Nurse (LN) H crushed R18's oral tablet medications and mixed them all into a cup with liquid medication. At 10.23 AM, LN H provided R18 with her crushed and mixed medications via her G-tube.On 08/11/2026 at 02:21 PM, LN H stated all oral medication tablets were crushed and mixed with R18's acetaminophen and levetiracetam oral suspensions. LN H verified that R18 lacked an order for her medications to be crushed and mixed. He confirmed there should have been an order to crush and combine the medications.On 08/12/2026 at 11:53 AM, Administrative Nurse D stated that when combining medications via a G-tube there should be an order in place. The facility charge nurse is to monitor orders for G-tube medication administration. Administration and Pharmacy should also perform monthly audits of G-tube medication administration orders.The facility's policy Medication Administration via Enteral Tube dated 06/16/2026, documented it is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines.

Based on observation, record review, and interview, the facility failed to ensure that medications were stored safely and securely as required. Findings included:- R6's Electronic Health Record (EHR) documented diagnoses that included altered mental status (state of awareness that was different from the normal awareness of a person) and blindness in both eyes. Observed on 08/11/2026 at 07:28 AM, A tube of Coloplast/Triad Wound Care prescription medication cream was left on R6's bedside table located next to R6's bed. The prescription treatment cream was not secured in the treatment cart. Observed on 08/11/2026 at 11:07 AM, a medication cart on 400 hall was unsupervised with a card of celecoxib (nonsteroidal anti-inflammatory drug used to treat mild to moderate pain and help relieve symptoms of arthritis) 100 milligrams with 23 tablets in the card. The card was face down on the medication cart. Licensed Nurse (LN) J walked out of R20's room and returned to the medication cart. Observed on 08/12/2026 at 07:37 AM, a treatment cart on Hall 300 was unlocked and unattended. It contained resident identified medication that included cream-ointment in the top drawer and the third drawer and glucose testing supplies in the second drawer. During an interview on 08/11/2026 at 07:36, Certified Nurse Aid (CNA) M stated the prescription medication cream should not have been left in R6's room. During an interview on 08/11/2026 at 07:49 AM, LN H stated the prescription medication cream should never be left in the room on a table at bedside. The prescription medication should have been in the locked treatment cart. During an interview on 08/11/2026 at 11:07 AM, LN J stated that medication was never supposed to be left unattended; it should always be kept locked in the medication cart or locked in the medication storage room. During an interview on 08/11/2026 at 11:13 AM, Administrative Staff B stated that medication should never be left unattended. Medication should be placed in the medication carts and locked before walking away from the cart. If it was to be removed from the cart, then it was to be placed in the locked medication storage room. During an interview on 08/12/2026 at 07:41 AM, LN G stated that the treatment cart was supposed to always be locked when unattended. She had not checked it before starting her shift to see if it was locked. During an interview on 08/12/2026 at 11:45 AM, Administrative Nurse D stated that medication should never be left unattended. It should be kept in a locked medication cart or locked medication storage room. Medication carts should always be locked before staff were to walk away from them. Administrative Nurse D stated that treatment carts should never be left unlocked and unattended. During an interview on 08/12/2026 at 11:46 AM, Administrative Nurse D stated the expectation is that any prescription medication should not have been left in a room on a bedside table. The treatment cart is where all prescription medications should have been stored as soon as a treatment had been provided. The facility's Medication Storage policy dated 03/31/2026 documented it was the policy of that facility to ensure all medications housed on their premises would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.

Based on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to use a barrier before laying a glucose monitor on the dining room table, failed to store Resident (R)86's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask in a sanitary manner and failed to transport linens in a sanitary manner. Findings included:- On 08/10/2026 at 07:56 AM observation revealed a clear bag of trash laid on the floor in R14's room.On 08/10/2026 at 7:57 AM Licensed Nurse (LN)I laid the glucose monitor on the dining room table without a sanitary barrier. LN I picked up the glucose monitor and pushed R47 to the hallway to check his blood sugar using the monitor.On 08/11/2026 at 7:52 AM R86's CPAP mask lay on her bedside table without a container. R86 stated she was able to take the CPAP mask off by herself. She stated she did not have a bag for her CPAP mask. R86 stated she could not put the mask into a container or a bag by herself.On 08/12/2026 at 08:15 AM observation on the 200 hall revealed a clear bag of trash that contained a soiled incontinence brief lay in the hallway, in front of a resident room.On 08/12/2026 at 08:17 AM Certified Nurse's Aide (CNA)P carried a green bed spread, and a stack of sheets down the hall, holding the linens next to her body and in contact with her uniform.On 08/12/2026 at 9:00 AM CNA Q stated she was unsure how a CPAP mask should be stored. She stated she had seen some residents with containers. CNA Q stated if the mask had a container, it should be placed back in the container. She stated trash should never be left on the floor and it was all staff's responsibility to ensure there was no trash on the floor. CNA Q stated linens should be in a covered cart or carried away from the staff's uniforms. On 08/12/2026 at 9:10 AM LN L stated linens should be carried away from the staff's uniforms. She stated CPAP masks normally have their own containers and the mask should be placed into the CPAP mask container. LN L stated trash bags should never be placed on the floor, and any staff member should immediately pick the bags up and place them in the trash containers. The facility's Oxygen Administration dated 05/21/2026 documented oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.The facility's Handling Soiled Linen 07/07/2026 documented it is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. This policy pertains to soiled linen.The facility's Infection Prevention and Control Program undated This facility had established and maintained an infection prevent and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection diseases and infections as per accepted national standards and guidelines.

Based on interviews and record review, the facility failed to provide the correct Center for Medicare and Medicaid (CMS) Form 10055, Advanced Beneficiary Notice (ABN), for Resident (R)33 and R96. Findings included:- The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to receive specified services listed and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but I can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment of services. (3) I do not want the listed services. The facility's Medicare ABN form staff provided to R33 (or their representative) was form CMS-R-131 for the last Medicare Part A covered day of 07/22/2026. The facility's Medicare ABN form staff provided to R96 (or their representative) was form CMS-R-131 for the last Medicare Part A covered day of 05/28/2026. On 08/11/2026 at 09:27 AM, Social Service X stated the CMS-R-131 was provided to her approximately four months prior by the therapy director; and she was instructed to use that form. On 08/11/2026 at 09:33 AM, Administrative Staff A expected the facility to review to make sure they are using the right form. The facility's Advance Beneficiary Notices policy, dated J05/27/2026, documented the current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055.

Based on observation, interview, and record review, the facility failed to provide privacy to Residents (R)16 and R 65 while the residents were in their rooms. Findings included:- 1. R16's electronic medical record (EMR) documented a diagnosis of dementia.R16's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severe cognitive impairment. He required partial to moderate staff assistance to turn left and right while in bed.R16's Activity of Daily Living (ADL)/Functional Capacity Care Area Assessment (CAA), dated 05/29/2026, did not trigger.R16's Quarterly MDS, dated [DATE], documented a BIMS score of zero, which indicated severe cognitive impairment. He required partial to moderate staff assistance to turn left and right while in bed.R16's Care Plan, revised 05/18/2026, instructed staff that he required assistance with ADLs related to dementia and weakness.R16's EMR from 07/142026 through 08/10/2026 (30 days) documented he was dependent on staff to turn left and right while in bed.On 08/11/2026 at 02:00 PM, R16 rested in his bed on his right side with his back side to the room's open door, and the privacy curtain was not drawn. R16's bare legs and brief were visible to other residents and staff who passed his room. 2. R65's EMR documented a diagnosis of obesity.R65's admission MDS, dated [DATE], documented a BIMS score of 12, which indicated moderately impaired cognition. He required substantial to maximum staff assistance to turn left to right while in bed.R65's ADL CAA, dated 03/03/2026, documented he had decreased functional abilities due to impaired strength and mobility.R65's Quarterly MDS, dated [DATE], documented a BIMS score of 12, which indicated moderately impaired cognition. He required supervision and touching assistance from staff to turn from left to right while in bed.R65's Care Plan, revised 05/27/2026, instructed staff that he required assistance with ADLs.R65's EMR from 07/14/2026 through 08/10/2026 (30 days) documented that he required substantial to dependent assistance from staff to turn from left to right while in bed.On 08/10/2026 at 08:05 AM, an unidentified staff exited the resident's room. When the staff opened the door to R65's room, he lay in his bed in his incontinence brief and was exposed.On 08/12/2026 at 09:05 AM, Licensed Nurse (LN) I stated staff should have kept residents' doors closed or the privacy curtain drawn to allow the residents privacy while they were in their beds.On 08/12/2026 at 11:46 AM, Administrative Nurse D stated it was expected that staff would ensure residents' privacy when they entered or exited the residents' rooms.The facility policy Promoting/Maintaining Resident Dignity, revised 01/01/2026, included: Staff shall maintain resident's privacy at all times.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R)6 and their representatives received a written notification of transfer that included a statement of the residents' rights, the transfer location, reason for the transfer, and the state ombudsman information, as soon as practicable upon their transfer to the hospital. Additionally, the facility failed to notify the office of the Long-Term Care Ombudsman (LTCO) of the transfers. Findings included:- R6's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) dated 05/24/2026, which documented an unplanned discharge to an acute hospital with a return anticipated.R6's Licensed Nurse Progress Note dated 05/24/2026 documented R6 was sent to the hospital by ambulance on 05/24/2026 at 10:36 AM. R6's clinical record lacked evidence that a written notification of transfer was provided to R6 or their representative. Upon request, the facility was unable to provide evidence of the written notification.On 08/12/2026 at 10:28 AM, Administrative Staff A stated the facility had not provided R6 (or their legal representatives) with written notice of their transfer to the hospital, and confirmed the LTCO was not notified. Administrative Staff A stated the social service department was responsible for the notification.The facility transfers and discharge policy dated 07/14/2025 documented the facility's transfer/discharge notice will be provided to the resident and resident representative in a language and manner in which they can understand. The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on interviews and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment in the required 92-days for Resident (R)42 and R68. Findings included:- Review of R42's Electronic Medical Record (EMR) revealed she had a Quarterly MDS dated 04/11/2026 with the next quarterly assessment reference date (ARD) set as 07/12/2026. The EMR indicated the MDS was In Progress.Review of R68's EMR revealed he had a Quarterly MDS dated 04/09/2026 with the next quarterly ARD set as 07/10/2026. The EMR indicated the MDS was In Progress.On 08/12/2026 at 10:15 AM, Administrative Nurse E stated she had overlooked R42 and R68's quarterly assessment. Administrative Nurse F stated she was currently working on completing the MDS.On 08/12/2026 at 11:50 AM, Administrative Nurse D stated Administrative Nurse F was responsible for ensuring each resident's MDS was completed as indicated.The facility's MDS 3.0 Completion policy dated 01/01/2026 documented residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Quarterly assessments are completed using the ARD, which is not greater than 92 days from the most recent prior quarterly or comprehensive assessment.

Based on observation, record review, and interviews, the facility failed to provide care and services to prevent further decline in range of motion when staff failed to provide Resident (R)13's adaptive eating utensils and further failed to have a consistent method of communication for R9, whose primary language was not English. Findings Included:- 1. R13's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of the left upper arm, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and need for assistance with personal care and feeding difficulties.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R13 had an impairment on one side of his upper and lower body. The MDS documented R13 needed set up or clean up assistance with eating and needed a mechanically altered diet.R13's Communication Care Area Assessment (CAA) dated 06/06/2026 documented communication would be addressed in R13's plan of care. R13's CAA documented staff were to communicate in a calm and friendly manner and allow adequate time for R13 to make his needs known. The CAA documented staff were to monitor for any changes in R13's ability to communicate.R13's Care Plan documented the following:06/24/2024-Staff were to assist R13 with meals. Staff were to encourage R13 to eat all meals in the dining room for increased staff observation.R13 was to have setup and clean up assistance with eating.05/08/2025- R13 was to be served a mechanical soft diet. Staff was to educate R13 about what was compliant for his diet.06/05/2026-R13 was to use adaptive equipment with eating, including a divided plate, utensils with thin black handles for increased grip, a five-millimeter (ml) Euchon (a cup that limits fluid) cup, and no straws.R13's EMR under Orders revealed the following physicians' orders:Regular general diet, ground mechanical soft texture. Regular thin consistency, with a flow controlled five ml Euchon cup for liquids, no straws. Alternate bites and drinks. Use utensils with thin black handles for all meals for increased grip. Mighty shakes with all meals. Divided plate and encouraged to eat in the dining room.R13's Meal Ticket revealed a diet of regular mechanical sift with thin liquids, a divided plate, black built-up utensils and no straw.On 08/10/2026 at 08:55 AM, R13 sat in his room in his wheelchair. R13's plate sat on his bedside table, the plate was covered with a warmer food cover, with regular silverware wrapped in a napkin. R13 had a divided plate and an Euchon cup with a dark brown liquid. R13 did not have the slim black handled built-up silverware. On 08/10/2026 at 02:10 PM, R13 sat in his room in his wheelchair. R13 had a divided plate that was covered with a warmer food cover and an Euchon cup with a dark brown liquid. R13 had a regular fork and spoon wrapped in a napkin. R13 did not have the slim black handled silverware.On 08/11/2026 at 08:40 AM, PM R13 sat in his room in his wheelchair. R13 had a divided plate, that remained covered with a food cover warmer, and an Euchon cup with a dark brown liquid. R13 had a regular fork and spoon wrapped in a napkin. R13 did not have the slim black handled silverware.On 08/12/2026 at 09:00 AM, Certified Nurse's Aide (CNA)Q stated the dietary was to place the built-up silverware on R13's plate. She stated whoever passed his tray should uncover the tray, set it up, and ensure the built-up utensils were on his tray. On 08/12/2026 at 09:10 AM, Licensed Nurse (LN)K stated whoever passes R13's tray should ensure the built-up utensils were on his tray. She stated staff should make sure the tray was set up and ready for R13 to start eating.On 08/12/2026 at 09:57 AM, Dietary Staff CC stated the kitchen staff was to put R13's silverware on his tray, and ensure he had an Euchon cup. She stated each resident had a Meal Ticket that kitchen staff was to follow when setting up trays.On 08/12/2026 at 11:46 AM, Administrative Nurse D stated the staff should set up R13's tray and have it ready for him to start eating. She stated the dietary department had a ticket that states what diet and any special instructions each residents needed. Administrative Nurse D stated the staff member passing the tray should ensure each resident had what that needed before leaving the tray in a room.2. R9s Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), dependence on renal dialysis (a procedure where impurities or wastes are removed from the blood), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).The Quarterly Minimum Data Set (MDS) dated 07/16/2026 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R9's preferred language was Spanish. R9's Communication Care Area Assessment (CAA), dated 09/26/2025, documented she only spoke broken English. Her native language was Spanish. She was able to communicate via an interpreter.R9's Care Plan, documented the following interventions:06/30/2024 - Her preferred language was Spanish. On 08/10/2026 at 08:30 AM, R9 laid on her bed in the lowest position. She indicated she was unable to communicate in English. Facility staff stated R9 had a translation app on her phone. R9 refused to allow surveyor to use her phone for communication. Staff stated there was a staff member that assisted R9 with communication with other staff to make her needs known.On 08/10/2026 at 09:45 AM, Certified Nurse Aide (CNA) P stated staff would use R9's cell phone and if she refused staff would download a translation app onto their phone. CNA P stated there was a staff member that would assist with communication, but she only worked on dayshift.On 08/12/2026 at 10:01 AM, Licensed nurse (LN) I stated there was staff member that would assist with communication with R9. LN I stated there was not a Spanish speaking staff on night shift. LN I stated the staff would use R9's phone or their phones for communication. LN I stated there was a phone number for translation but did not know where that number was written down. LN I stated she was not sure if that information was posted anywhere to assist with the ability to have private conversations with R9.On 08/12/2026 at 11:50 AM, Administrative Nurse D stated the staff would use R9's phone or staff would use their phones to assist with translation and communication in Spanish. Administrative Nurse D stated the facility did use the medical records staff and housekeepers to assist R9 with her communication in Spanish. Administrative Nurse D stated the facility did not have an interpreter phone to assist R9 with communication. Administrative Nurse D stated staff used the medical records staff to assist R9 with her private conversation.The facility's Culturally Competent Care policy dated 03/04/2026 documented It is the policy of this facility to provide culturally competent care in accordance with professional standards of practice. The facility has established an environment that treats each resident with respect and dignity as an individual. The facility supports and/or enhances residents' feelings of self-worth and encourages personal control over choices and cultural preferences.The facility's Activities of Daily Living (ADL) policy dated 12/01/2025 documented the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration was unavoidable.

Based on observation, interview, and record review, the facility failed to provide appropriate activities of daily living (ADL) cares for two Residents (R)16 and R13, regarding bathing. Findings included:- 1. R16's electronic medical record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R16's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He was dependent on staff for bathing. R16's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 09/29/2026, did not trigger. R16's Quarterly MDS, dated [DATE], documented a BIMS score of zero, indicating severe cognitive impairment. He was dependent on staff for bathing. R16's Care Plan, revised 05/18/2026, instructed staff R16 required staff assistance with ADLs related to dementia. R16's EMR from 07/13/2026 to 08/10/2026 (30 days), revealed he received showers on 07/13/2026, 07/23/2026, 07/27/2026 and 08/03/2026. No other bathing activities were documented. On 08/10/2026 at 01:58 PM, R16 sat in his wheelchair by the nurse's station. He had dirty, greasy hair. On 08/11/2026 at 08:40 AM, R16 sat in his wheelchair at the dining table. He had dirty, greasy hair. On 08/11/2026 at 11:00 AM, Certified Medication Aide (CMA) S stated R16 can be combative at times, so his showers are not always done twice weekly. On 08/11/2026 at 01:56 PM, Licensed Nurse (LN) I stated R16 becomes combative at times, so staff try to give him something to calm him down before bathing. LN, I confirmed the resident was not always bathed twice. On 08/12/2026 at 11:46 AM, Administrative Nurse D stated R16 required two staff to bathe him, so he does not always get two showers per week. - R13's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right non-dominant side, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), contracture of left upper arm, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and the need for assistance with personal care and feeding difficulties.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R13 had an impairment on one side of his upper and lower body. The MDS documented R13 needed set up or clean up assistance with oral hygiene, was dependent on staff for personal hygiene, and needed substantial/maximal staff assistance for bathing. R13's Communication Care Area Assessment (CAA) dated 06/06/2026 documented communication would be addressed in R13's plan of care. R13's CAA documented staff were to communicate in a calm and friendly manner and allow adequate time for R13 to make his needs known. The CAA documented staff were to monitor for any changes in R13's ability to communicate.R13's EMR under Task documented bathing/shower from (07/11/2026-08/12/2026).Bathing/shower completed on 07/15/2026, 07/18/2026, 07/22/2026, 07/29/2026, 08/04/2026, and 08/05/2026.( six times for the entire month reviewed.R13's EMR under Task documented one refusal for bathing on 08//08/2026.On 08/10/2026 at 08:55 AM, R13 sat in his room in his wheelchair. R13's hair was matted on the back of his head. R13 had a blue shirt on that had food or drink stains in the front. R13 had food crumbs in his beard. R13's fingernails had a brown substance under his nails on his right hand.On 08/11/2026 at 08:40 AM, R13 sat in his room in his wheelchair. R13's hair was matted on the back of his head. R13's fingernails had a brown substance under his nails on his right hand.On 08/12/2026 at 09:00 AM, Certified Nurses Aide (CNA) Q stated all CNAs were assigned bathing for their residents daily. She stated a bath sheet was filled out and turned in for each bath given. She stated if a resident refused bathing, she would report to the nurse for that resident. CNA Q stated the nurse would follow up with the resident before documenting a refusal.On 08/12/2026 at 09:10 AM, Licensed Nurse (LN) K stated bathing was assigned for different residents on each shift. She stated the CNAs on the assigned shifts would offer bathing. LN K stated if a resident refused bathing, the CNAs were to let the nurse know. LN K stated the nurse would document in a progress note any bathing refusal. On 08/12/2026 at 11:46 AM, Administrative Nurse D stated the CNAs offered bathing to residents assigned for their shift. She stated if a resident refused to bathe, the CNA would let the nurse know. She stated the nurse would talk to the resident and try to set bathing for a time that would work with the resident. Administrative Nurse D stated the nurse should document in the resident's progress note any refusals. The facility policy Resident Showers, revised 01/01/2026, included: It is the practice of the facility to assist residents with bathing to maintain proper hygiene.

Based on record review, observation, and interviews, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being of Resident (R) 16. Findings included:- R16's electronic medical record (EMR) documented a diagnosis of dementia.R16's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severe cognitive impairment. The MDS documented it was very important for him to have snacks between meals, listen to music, be around animals, such as pets, and to participate in his favorite activities.R16's Activity Care Area Assessment (CAA), dated 05/29/2026, did not trigger.R16's Quarterly MDS, dated [DATE], documented he had a BIMS score of zero, which indicated severe cognitive impairment.R16's Care Plan, revised 05/18/2026, instructed staff that he required assistance to attend group activities and special events. R16's care plan informed staff that he enjoyed pet visits, snacks, and all music events.R16's EMR from 07/14/2026 through 08/10/2026 (30 days) documented that he was a passive participant in four activities. R16's EMR lacked further activity documentation.On 08/11/2026 at 01:12 PM, Activity Staff BB stated R16 was only able to participate passively in activities, and the facility had not provided one-to-one (1:1) activities.On 08/11/2026 at 01:23 PM, Certified Nurse Aide (CNA) Q stated R16 had not participated in activities due to his cognition.On 08/11/2026 at 01:56 PM, Licensed Nurse (LN) H stated R16 had not participated in activities.On 08/12/2026 at 11:46 AM, Administrative Nurse D stated R16 would have benefited with 1:1 activities since he was unable to actively participate in group activities due to his cognition.The facility policy Activities, revised 01/01/2026, included: It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their preferences.

Based on observation, interview, and record review, the facility failed to provide appropriate wheelchair positioning for one Resident (R)16. Findings included:- R16's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R16's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. He had functional limitation in range of motion (ROM) on one side of his upper and lower extremities (UE/LE). He was dependent on staff for locomotion in his wheelchair. R16's Activity of Daily Living (ADL) Care Area Assessment (CAA), dated 05/29/2026, did not trigger. R16's Quarterly MDS, dated [DATE], documented he had a BIMS score of zero. He had a functional limitation in ROM on one side of his UE and LEs and was dependent on staff for locomotion in his wheelchair. R16's Care Plan revised 05/18/2026, instructed staff that he had limited mobility due to weakness. On 08/10/2026 at 01:58 PM, R16 sat partially reclined in his wheelchair in the hallway. His right foot had fallen off the footrest, which caused his right leg to hang, unsupported, from the wheelchair. On 08/11/2026 at 09:09 AM, R16 sat partially reclined in his wheelchair in the hallway. His right foot had fallen off the footrest, which caused his right leg to hang, unsupported, from the wheelchair. On 08/11/2026 at 11:00 AM, Certified Medication Aide (CMA) S stated R16 was unable to keep his foot up on the footrest of the wheelchair. CMA stated when the resident's foot came off of the footrest, his right leg would hang from the side of the wheelchair. On 08/11/2026 at 01:56 PM, Licensed Nurse (LN) I confirmed R16's right leg hung from the side when his wheelchair was reclined. She stated R16 needed something to keep his leg in place while he was reclined in his wheelchair. On 08/12/2026 at 11:46 AM, Administrative Nurse D confirmed R16's leg would not stay positioned on the footrest while his wheelchair was reclined. The facility did not provide a policy regarding wheelchair positioning.

Based on interviews, observation, and record review, the facility failed to ensure a fall intervention was implemented for Resident (R) 36 and fall intervention was in place for R40 to prevent further falls. Findings included:- 1. R36's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of unsteadiness on feet, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Quarterly Minimum Data Set (MDS) dated 07/17/2026 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R36 had at least one fall since her admission. R36's Falls Care Area Assessment (CAA), dated 01/28/2026, documented she had fallen one time and was at risk for further falls.R36's Care Plan documented the following interventions:01/10/2025 - Staff would anticipate and meet her needs.Staff would ensure her call light was within reach and encourage her to use it for assistance as needed.Staff would ensure prompt response to all requests for assistance.Staff would ensure that she was wearing appropriate footwear when mobilizing in the wheelchair.Staff would follow the facility's fall protocol.Therapy would evaluate and treat as ordered or as needed. 02/11/2025 - Staff placed a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) to her wheelchair.02/24/2025 - Anti-roll back brakes repaired.02/28/2025 - Staff would continue current interventions on the at-risk plan. Staff would monitor, document, or report as needed to the physician for any signs or symptoms of pain, bruises or changes of condition.Pharmacy consult would evaluate medications. Staff would provide activities that promoted exercise and strength building where possible.Staff would provide one-on-one activities if she was bedbound. 04/29/2025 - Equipment failure and a work order was placed.03/13/2025 - Staff educated her on not using her head to hold the door open. 05/14/2025- Staff educated R36 on safety while sitting, not to lean forward in the chair.10/07/25- Staff educated her on proper positioning when sitting in the wheelchair and lying on the bed. 12/08/2025 - Anti roll back brakes fixed by maintenance.Staff would check R36's range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) (specify number of times) daily.Staff would assess for any apparent acute injury and determine and address causative factors of the fall. 12/16/2025 - Staff was educated on proper blocking during transfers.01/09/2026 - Her bed was moved against the wall, and removed the top sheet because she did not want to use the top sheet. 07/13/2026 - Staff provided re-education on the need to call for assistance with transfers. Staff would ensure non-skid footwear was in place. Staff would ensure her bedside table was within her reach.Staff reminded her to lock her wheelchair to prevent it from rolling backwards.07/20/2026 - Staff placed grip strips halfway under her bed. R36's EMR under the Progress Notes tab revealed the following Nurse's Note dated 07/02/2026 at 04:01 PM documented R36 was found sitting on the floor in front of her bed. R36 had complained of lower back pain and left knee pain, staff had her assessed by the physician assistant. He found no injuries at the time of assessment.On 08/11/2026 at 08:13 AM, R36 laid on the edge of her bed asleep. Bed was in the lowest position, and nonskid strips on the floor next to the bed were slightly under the bed. 2. R40's EMR from the Diagnosis tab documented diagnoses of repeated falls, dementia (a progressive mental disorder characterized by failing memory and confusion), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain).The Quarterly MDS dated 06/13/2026 documented a BIMS score of three, which indicated severely impaired cognition. The MDS documented R40 had at least one fall in the facility. R40's Falls CAA dated 03/16/2026 documented he had fallen prior to his admission to the facility. R40 had one non-injury fall since his admission.R40's Care Plan documented the following interventions: 03/05/2026 - Staff would follow facility fall protocol.Staff would ensure his call light was within reach and encourage him to use it for assistance as needed.Staff would answer the call light promptly to all requests for assistance.Staff would educate R40, his family, and caregivers about safety reminders and what to do if a fall occurred.03/13/2026 - Staff would continue interventions on the at-risk plan.Staff would provide activities that promote exercise and strength building where possible. Staff provide one-on-one activity if bedbound. Therapy would consult for strength and mobility. 03/16/2026 - Staff would encourage him to participate in activities that promoted exercise, physical activity for strengthening, and improved mobility.Staff would ensure that he was wearing appropriate footwear when ambulating or mobilizing in a wheelchair. Staff would provide a safe environment with even floors, free from spills, clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, and personal items within reach. 03/25/26 - Staff would assist him back to bed after meals. 04/05/2026 - Staff would ensure bed was in the lowest position.05/27/2026 - Medication review would be completed. Staff was educated on proper positioning of the wheelchair and use of a gait belt during transfers.06/12/2026 - Staff would assist R40 back to bed after meals and ensure the footrests on his wheelchair are in the open position. Medication adjustments for pain 06/22/2026 - Staff would ensure there were fall mats beside bed06/23/2026 - Behavior of placing self on the floor has been added to care plan. 06/30/2026 - Call light highlighted.Staff placed a sign in his room to remind him to call for assistance with transfers08/03/26 - Psych services would complete a medication regimen review.08/10/2026 - Pain medication regimen adjusted. On 08/10/2026 at 08:40 AM, R40 laid on his bed. The bed was in the lowest position, the fall mat was leaned against the wall, his wheelchair was out of his reach, his call light was on the floor between the bed and wall, and the call light box was pulled from the wall and laid on the side of the bed. On 08/10/2026 at 09:45 AM, Certified Nurse Aide (CNA) P stated R36 and R40 were very high risk for falls. CNA P stated it was everyone's responsibility to ensure fall interventions are in place. CNA P stated the fall interventions could be found on the Kardex (nursing tool that gives a brief overview of the care needs of each resident), which contained the care planned fall interventions.On 08/12/2026 at 10:01 AM, Licensed Nurse (LN) I stated everyone had access to the Kardex and care plans. LN I stated R36 and R40 were high fall risks. LN I stated it was everyone's responsibility to ensure fall interventions were in place. LN I stated after a fall, the staff that worked in that area would do a huddle meeting to discuss the fall and come up with a new intervention. LN I stated that the intervention would not be started until the director of nursing could review the fall intervention and change if needed. On 08/12/2026 at 11:50 AM, Administrative Nurse D stated the staff would gather and discuss a resident's fall to come up with a new fall intervention. Administrative Nurse D stated she would expect all fall interventions to be on the care plan. Administrative Nurse D stated new interventions would be communicated by word of mouth, care plan, Kardex, tasks, and on the resident's orders.The facility's Fall Prevention program policy dated 10/06/2025 documented each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observation, record review, and interviews, the facility failed to complete and document a post-hemodialysis (a procedure where impurities or wastes are removed from the blood) assessment for Resident (R) 9. Findings included:- R9s Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), dependence on renal dialysis (a procedure where impurities or wastes are removed from the blood), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).The Quarterly Minimum Data Set (MDS) dated 07/16/2026 documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R9 had received dialysis treatment during the observation period.R9's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/26/2025, documented she had occasional incontinence and requires some assistance with toileting hygiene.R9's Care Plan documented the following interventions: 09/18/2024 - staff would communicate with the dialysis center regarding medications, diet, and lab results.Staff would coordinate care in collaboration with the dialysis center. Staff would monitor vital signs pre- and post-dialysis.Staff would notify the physician of any significant abnormalities.R9's EMR under the Misc tab revealed the following Dialysis Communication Form reviewed from 05/01/2026 to 08/10/2026 revealed the following eleven days post dialysis assessment was completed: 05/04/2026, 05/06/2026, 05/11/2026, 06/10/2026, 06/12/2026, 06/15/2026, 06/24/2026, 06/26/2026, 07/20/2026, 08/07/2026, and 08/10/2026. On 08/10/2026 at 08:30 AM, R9 laid on her bed in the lowest position. She indicated she was unable to communicate in English. Facility staff stated R9 had a translation app on her phone. R9 refused to allow surveyor to use her phone for communication. Staff stated there was a staff member that assisted R9 with communication with other staff to make her needs known.On 08/10/2026 at 09:45 AM, Certified Nurse Aide (CNA) P stated she would assist R9 with getting ready for dialysis appointment. CNA P stated she would ensure R9 had her communication book with her when she left for dialysis. On 08/12/2026 at 10:01 AM, Licensed nurse (LN) I stated she would obtain R9's vital signs and weight pre and post dialysis treatments. LN I stated if R9 returned before the end of dayshift she would complete the post-dialysis assessment and document the assessment on the communication sheet.On 08/12/2026 at 11:50 AM, Administrative Nurse D stated she expected the charge nurse to complete the post dialysis assessment for R9 upon her return for dialysis. Administrative Nurse D stated the dialysis communication sheet would then be placed in a folder for medical records to scan into R9's EMR.The facility's Hemodialysis policy dated 11/25/2025 documented the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.

Based on observation, record review, and interviews, the facility failed to ensure a functional call light system for Resident (R)28 to convey his needs to staff. Findings included: R28's Electronic Medical Record (EMR) showed a diagnosis of muscle weakness, repeated falls, encephalopathy (a broad term for any brain disease that alters brain function or structure), syncope (fainting or passing out) and collapse, weakness and cognitive impairment (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and a need for assistance with personal care. The admission Minimum Data Set (MDS), dated 7/23/2026, documented a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. R28's Care Plan dated 07/20/2026 stated R28 was at risk for falls due to multiple falls at home prior to arrival, encephalopathy, syncope and collapse, weakness, and cognitive impairment. Make sure his call light was within his reach and encourage him to use it for assistance as needed. Observed on 08/11/2026 at 03:21 PM, R28 pushed his call light and had no notification to alert staff on the call system monitor. Observed on 08/12/2026 at 07:36 AM, R28 had pushed his call light, and there was no alert to staff on the call system monitor. During an interview on 08/11/2026 at 03:21 PM, R28 stated that his call light did not work and he had called for help and no one came. During an interview on 08/12/2026 at 07:48 AM, Licensed Nurse (LN) G stated that the call light should always be in R28's reach and working. If a call light was not in working order, then a bell would be given to him, and a work order for it to be fixed would be placed in the computer tracking system called TELS that would alert maintenance on the computer that the call light was not working. During an interview on 08/12/2026 at 07:51 AM, Certified Nurse Aide (CNA) Q stated that if a call light was found not working, then she would go find maintenance by looking for them or place a work order in the TELS system for maintenance. She would also notify the nurse. During an interview on 08/12/2026 at 08:42 AM, Maintenance U stated that when they get a work order, it will tell them if it is critical or not. They worked on the critical work orders first and went down the list. Maintenance U said there were two maintenance staff members, and they will both work together and go through all the work orders alerted to them on the TELS and finish them all before leaving for the day. He stated that maintenance checked the call lights daily by going to each unit and checking one room to see if it is working and documenting it on the computer. He stated that the call lights take batteries to operate so the nursing staff was supposed to be checking the residents on their units daily. Maintenance U said the staff was to send a work order notifying them if the call light was not working. He stated that he did not have a work order for R28's room for a call light not working, so he was not aware it was not working. Maintenance U then went and checked the call light in R28's room and verified the battery was dead. During an interview on 08/12/2026 at 11:45 AM, Administrative Nurse D stated that the call light should always be working and in R28's reach. The nursing staff should be checking the call lights when a new resident comes in, but it was up to maintenance to check all the lights once a month. She stated that the call light should notify the staff by the call system and stay on if the battery were to go dead. R28's room had not alerted the staff that the battery was dead. The policy Call Lights: Accessibility and Timely Response dated 12/01/2025 documented that the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Ensure the call system alerts staff members directly or goes to a centralized staff work area.

Based on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). Findings included:- The PBJ Staffing Data Report CASPER Report 1705D provided by the Centers for Medicaid and Medicare (CMS) for Fiscal Year (FY) 2026 Quarter (Q), Q2, and Q4 documented excessively low weekend staffing.Review of the facility's actual working schedule sheets from 02/11/2025 to 08/11/2026 revealed the facility maintained and had the same number of staff scheduled and worked as during the week: Two nurses for day shift, and two nurses for evening and night shift; six to eight nurse aides on day shift, and five to seven nurse aides on evening and four to five nurses' aides on night shift; and two medication aide on day and evening shift.The facility's Facility Assessment revised on 01/15/2026 documented the specific needs of each resident in the community were identified, and staffing was adjusted as needed. The facility assessment included staffing for each shift. The direct care staff was to have two licensed nurses for day shift, and two licensed nurses for evening and night; two to three medication aids on day and evenings; six to eight nurse aids on day shift and six to seven nurse aides on evening shift, and four to five nurse aids' night shift.On 04/21/26 at 08:06 AM, Administrative Staff A stated he was unsure why the PBJ triggered for excessively low weekend staff. He stated the facility had been fully staffed for the last six months with its own employees. Administrative Staff A stated the PBJ was generated by the corporate office. He stated the corporate office sends the report to him to review and look for any discrepancies before submitting.The facility's Payroll Based Journal dated 02/05/2025 documented it was the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

The facility identified a census of 74 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's staffing list revealed the following: CNA N, hired on 09/01/22, had no yearly performance evaluation upon request. CNA P, hired 09/07/22, had no yearly performance evaluation upon request. CNA Q, hired on 11/15/22, had no yearly performance evaluation upon request. On 10/01/24 at 01:28 PM Administrative Staff C stated she did not have the performance reviews for the three CNAs. On 10/02/24 at 02:24 PM, Administrative Nurse D stated she was responsible for completing the nursing staff's yearly performance reviews. The facility ' s Evaluation Process policy dated 12/01/19 documented it was the policy of our facility to review the work performance of employees with a formal written evaluation annually. The facility failed to ensure three of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 74 residents. The facility had one main kitchen. Based on observation and interview, the facility failed to ensure staff stored food items in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food). Findings included: - The initial tour of the kitchen on 09/30/24 at 07:13 AM revealed a large open bag of oats stored on the floor of the dry storage area. The refrigerator contained open and undated condiments. Another refrigerator contained an undated and uncovered silver pan with two heads of lettuce in an unsealed bag on top of wilted lettuce. The side-by-side freezer contained an undated and uncovered silver pan of a dessert. On 10/02/24 at 01:48 PM, Dietary Staff BB stated all items should be labeled, dated, and stored off the floor. Dietary Staff BB stated all food in the freezers and refrigerator must be covered, sealed, labeled, and dated. The Facility ' s undated Food Storage (Dry, Refrigerated and Frozen) policy documented that food would be stored on shelves in a clean, dry area free from contaminants. Food would be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items would be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The facility failed to ensure dietary staff stored food items in accordance with the professional standards for food service safety. These deficient practices placed residents at risk for contamination and food-borne illness.

The facility identified a census of 83 residents. The sample included 2 residents for medication errors. Based on record review, observation and interview, the facility failed to prevent a significant medication error for 1 resident (#1) when staff failed to clearly identify him/her and administered another resident's (#3's) medications to resident#1. This resulted in resident #1's need for emergency care and hospitalization . Findings included: - Resident #1's electronic medical record (EMR) recorded he/she readmitted to the facility on [DATE] after hospitalization for Poisoning by unspecified drugs, medicament (a substance used for medical treatment), and biological substances accidental, unintentional, subsequent encounter (the condition produced by a poison or by a toxic substance). The quarterly minimum data set ((MDS) dated [DATE] documented staff assessed the resident with a Brief interview for Mental Status (BIMS) Score of 12 which indicated his/her cognition was moderately impaired. The resident had no behaviors during the 7-day assessment period. The MDS documented the resident required extensive assistance of one to two staff with most activities of daily living (ADL's) was 5 feet 11 inches tall, weighed 197 pounds and received anti-depressant (medication used to relieve symptoms of feeling down, sadness) and diuretic medications (medication used to remove excess fluid from the body). The 5-day readmission MDS dated [DATE] documented the resident with a BIMS score of 5 which indicated severely impaired cognition. No other functional changes were noted. Review of the electronic medication record, revealed resident 1 received daily, [MEDICATION NAME] (medication to relieve fluid from the body), insulin injections for Diabetes Mellitus, (a condition where the body cannot produce insulin to break down sugar), a [MEDICATION NAME] ([MEDICATION NAME] medication for excessive oral secretions), [MEDICATION NAME] (a medication to assist with sleeping) and [MEDICATION NAME] ( anti-anxiety medication to relieve feelings of restlessness). Review of the facility's investigation of a medication error for resident #1 revealed: on 9/28/18 at 8:45 A.M. Resident #1 received another resident's (#3's) morning medications. The EMR documented resident #3 had [DIAGNOSES REDACTED]. Resident 3's EMR recorded he/she received daily the following Black Box Warning (BBW) medications (according to the food and drug administration (FDA.Com) a BBW is a medication with potential life-threatening side effects). [MEDICATION NAME] (an antipsychotic medication used to treat certain mental/mood conditions) with warnings and side effects of: constipation, weight gain, headache, dry mouth, upset stomach, gas, stuffy nose, drowsiness, dizziness, and a BBW of: Increased Mortality in Elderly Patients With Dementia-Related [MEDICAL CONDITION] [MEDICATION NAME] (an antipsychotic medication used to treat certain mental/mood disorders) with warnings and side effects of: sudden, often jerky, involuntary motions of the head, neck, arms, body, or eyes, dizziness, tiredness, drowsiness, fatigue, fever, weight gain, feeling hot or cold, Respiratory Depression, and a BBW of: Elderly patients with age related [MEDICAL CONDITION] are at increased risk for death . [MEDICATION NAME], a opioid narcotic pain reliever used to treat severe pain, with a BBW of: Respiratory Depression serious, life-threatening, or fatal cases may occur even with recommended use; monitor for respiratory depression especially during Treatment start or after dose incur; instruct patients to swallow ER (extended release) tabs whole; crushing, dissolving, or chewing ER tabs can cause rapid release and absorption of potentially fatal [MEDICATION NAME] dose; instruct patients to swallow ER caps whole or sprinkle contents on applesauce and swallow immediately without chewing; crushing, dissolving, or chewing pellets with/in ER cap can cause rapid release and absorption of potentially fatal [MEDICATION NAME] dose accidental ingestion of even one dose, esp. by children, can result in fatal [MEDICATION NAME] overdose. On 9/28/18 at 8:45 A.M. licensed nursing staff H administered these medications to resident #1. A nurse's progress note dated 9/28/18 at 8:45 A.M. recorded a change of condition in resident 1 wherein the resident's blood pressure dropped to 76 mm/hg, systolic over 41 diastolic mm/hg (Normal blood pressure is a reading below 120/80.) The advanced registered nurse practitioner (ARNP) was notified and gave order for the resident to be hospitalized . A nurse's progress note dated 9/28/18 10:49 P.M. documented this writer called the hospital for follow-up on resident (#1) and was informed the resident admitted to the hospital and was in the intensive care unit (ICU) on an intravenous [MEDICATION NAME] drip (a medication used to block the effects of opioids, especially in overdose., sleepy and drowsy). A nurse's progress note dated 10/2/18 at 5:53 P.M. documented the facility readmitted the resident (from hospital) and recorded his/her vital signs were within normal limits and blood pressure of 123 mg/hg, over 56 mg/hg. On 10/24/18 at 12:01 P.M. the resident sat in a wheelchair in the dining room alert, well groomed, wearing billed truck driver type hat. The resident remembered having been to the hospital but thought it was a surgery. He/she was unable to remember medications he takes but stated the nurses have a list of them. Licensed nurse H notarized witness statement dated (MONTH) 1, (YEAR), recorded: On 9/28/18 at around 8:45 A.M. I was walking down the hall ready to administer (resident #3) medications. In the process of looking for the resident I looked for a cap, which typically he/she wore. I noted a resident who I thought looked like (resident#3) and I handed him/her the medication. (licensed nurse I) was present when the incident occurred. After (resident 1) took the medication, I looked at his/her face and noted that it was not resident #3. I immediately notified the Director of nursing and was asked to notify the ARNP. (licensed nurse I) notified the residents responsible party. The Director of nursing provided me with the 5 Rights of Medication Administration. I took the residents vital signs and informed the resident that I had given him/her the wrong medication. Licensed nurse I notarized witness statement dated (MONTH) 1, (YEAR) recorded: On 9/28/18 at around 8:45 A.M. I was coming down the hallway when I saw (licensed nurse H) administering medication to (resident #1). I asked (resident #1) if he wanted something to drink. At this point (licensed nurse H) realized that he/she had given (resident #1) the wrong medication. (licensed nurse H) stated he/she gave the wrong medication) I asked him/her to contact the director of nursing, which he/she did. (Licensed nurse H) then called the nurse practitioner and requested the resident be sent to the hospital. Upon arrival the paramedics administered intravenous fluids and [MEDICATION NAME] was given as well. Resident #1 was arousable and responsive to his/her name. Resident #1 was admitted to the hospital and given [MEDICATION NAME] to counteract some of the medication the resident was given to assist in diminishing any potential side effects. On 10/24/18 at 2:00 P.M. administrative licensed nurse D stated he she was not the administrative nurse at the time but conducted one-on-one training with Licensed Nurse H regarding the 5-rights of medication administration. According to the Institute for Healthcare (IHI.org), recommendations to reduce medication errors and harm was to use the five rights: the right patient, the right drug, the right dose, the right route, and the right time. On 10/24/18 at 3:46 P.M. administrative staff A acknowledged the medication error and attributed its cause to human error as the resident mistook the resident was wearing a hat. The facility Medication Error policy dated 1/2007 recorded: notes a significant Medication Error was one that causes the resident discomfort or jeopardizes his/her safety and health and Examples of medication errors include: Omissions, Unauthorized drugs, wrong dose, wrong route, before meal medications given after meal and or visa-versa; and drugs given 60 minutes later or earlier than scheduled time. The facility medication administration policy lacked documentation (of one of the 5 Rights) to ensure the Right Resident was given medications The facility failed to prevent a significant medication error for resident #1 a cognitively impaired dependent resident when he/she received another residents mood altering and nervous system depressant medications. This deficient practice was cited as past non-compliance when the facility implemented the following: Resident was identified by the nurse and immediately notified the DON, Nurse Practitioner, and Responsible Party. Nurse practitioner requested vital signs to be monitored, Abnormal vitals were noted and the Nurse Practitioner was made aware , at which time the order was was given to transfer the resident to the hospital for further evaluation and intervention. Nurse was suspended pending investigation. Any resident had the potential to be affected by this deficient practice. Nurse involved with incident was given a medication administration competency evaluation, and was successful at 100 percent. Nurse was also reeducated on the 5 Rights of Medication Administration as well as the policy on Two identifier to identify the resident prior to administering medication. Other licensed staff have also been reeducated on the 5 Rights of Medication Administration and the Two Identifier policy Nurse involved will have medication administration observation completed daily times one week and weekly times 4 weeks. This will involve 3 to 5 residents per observation. Any further issues related to medication administration errors will be brought to QAPI (Quality Assurance Performance Improvement) Committee for evaluation and intervention. Any licensed staff who has not been in-serviced by 10/3/18 will not be allowed to work until they have received the in-service. Date of compliance 10/3/18.

The facility reported a census of 88 residents. The sample included 3 residents reviewed for accidents. Based on record review and interview, the facility failed to provide supervision and assistive devices to prevent a fall with injury during a transfer using a mechanical lift for 1 sampled resident (#1). Resident #1 fell , during a transfer, from a full body sling (a cradling soft harness attached to a mechanical lift) when staff improperly positioned the attachment straps and the resident sustained [REDACTED]. Findings included: - The (MONTH) (YEAR) physician's orders [REDACTED].#1 on 12/7/17 with [DIAGNOSES REDACTED].). The annual MDS (Minimum Data Set) dated 6/9/17 documented a Brief interview for Mental Status (BIMS) score of 15, which indicated intact cognition. He/she required total assistance of 2 staff with activities of daily living (ADLs) such as bed mobility, dressing, toilet use, transfers and personal hygiene. The MDS recorded the resident had range of motion difficulties, was unstable with surface to surface transfers, and used a wheelchair for mobility. This same assessment recorded the resident did not have any recent falls. The Care Area Assessment (CAA) dated 6/9/17 for ADLs documented the resident transferred using a Hoyer lift with the assistance of 2 staff. He/she used an electric wheelchair for mobility, could propel his/herself independently throughout the facility, and staff would develop a care plan to address this area. The fall CAA dated 6/9/17 recorded the resident was at risk for falls due to his/her medical conditions. He/she used quarter side rails and bolsters on his/her bed, and a seatbelt when in his/her power wheelchair. The 12/4/17 quarterly MDS lacked documentation of any cognitive, functional changes, or recent falls. The electronic record lacked documentation of a recent fall risk assessment and/or mechanical lift use assessment. The direct care staff's resident data sheet dated 1/29/18 documented the resident preferred to use the full body sling (for the Hoyer lift) only for bathing, and the partial body sling when staff transferred him/her to his/her wheelchair, so staff could remove the sling after he/she was seated. The care plan dated 12/14/17 for ADLs documented the resident required 1 to 2 staff assistance with ADLs. Staff were to keep the call light within reach and encourage its use, keep a hand mirror within reach, so the resident could see if the call light had been depressed, and use a soft touch call light. The care plan for falls directed staff to keep the soft touch call light within reach, and assist the resident with repositioning every 2 hours and as needed to ensure comfort. The care plan lacked documentation the resident used a Broda wheelchair (a specialized wheelchair with support, cushioning and reclining capabilities) and lacked information regarding how many staff the resident required for a transfer. The care plan lacked evidence of an intervention to address the resident's fall on 1/30/18. The nurse's progress notes dated 1/30/18 at 9:32 P.M. documented staff called the nurse to the resident's room. The nurse observed the resident on the floor. This note documented two direct care staff stated the resident fell from the Hoyer lift when they transferred him/her from the wheelchair to the bed. This note further documented staff transferred the resident to the hospital. The facility's investigation documented on 1/30/18 at approximately 8:00 P.M., staff transferred the resident from his/her wheelchair to the bed with the Hoyer lift. The resident refused to allow the sling to remain under him/her when he/she sat in the wheelchair, thus requiring staff to replace the sling every time before the next lift. Direct care staffs O and P placed the sling under the resident by lowering the head of the Broda chair. When staffs O and P lifted the resident from the chair, he/she fell approximately 2 feet through the sling and landed on the floor. Staff transferred the resident to the hospital, where the hospital report recorded he/she had a fractured left femur (a broken long bone in the leg). This investigation revealed the resident required three staff for transfers, including at least one nurse per the nursing assessment data sheet (NADS) and the care plan. Direct care staff O's witness statement dated 1/30/18 recorded he/she was unfamiliar with the resident, and did not consult the NADS. Direct care staff P told him/her the resident used a Hoyer Lift for transfers. The sling was not under the resident, so they laid down the back of the Broda chair, placed the sling behind the resident's back, and attached it to the lift. This statement included staff hooked the orange loops for the top of the sling and the blue loops for the bottom of the sling (these color coded loops caused a looseness in the sling related to the residents size and weight). Direct care staff P operated the lift and resident fell through the sling and landed on the floor. Direct care staff P's notarized witness statement dated 1/30/18 recorded he/she assisted direct care staff O to transfer the resident with the Hoyer lift. The statement documented they used the blue loops for the top of the sling, and the black loops at the bottom. As they lifted the resident, he/she fell out of the sling and landed on the floor. Licensed nursing staff H's notarized witness statement dated 1/31/18 recorded staff summoned him/her to the resident's room, where he/she found the resident on the floor. Staff advised him/her the resident fell from the Hoyer lift. Staff transferred the resident to the hospital for an evaluation. On 2/15/18 at 1:28 P.M. administrative nursing staff E stated the investigation into this incident revealed staff improperly attached the lift sling to the Hoyer lift, which created a gap between the leg straps and the resident fell out the side of the sling to the floor. On 2/15/18 at 1:30 P.M. administrative nursing staff D expected staff to attach all slings correctly to the Hoyer lifts, and acknowledged the resident fell due to the incorrect positioning of the sling on the Hoyer lift. On 2/15/18 at 2:44 P.M. direct care staff P was unavailable to confirm the facts of his/her notarized witness statement. On 2/15/18 at 3:30 P.M. direct care staff O confirmed the facts of his/her notarized witness statement. The facility's policy titled Fall Prevention and Management Program, revised 7/28/17, documented the risk of falling cannot be eliminated, but it can be reduced through the implementation of fall prevention interventions. The policy lacked documentation specifically to address the use of mechanical lifts. The facility failed to correctly attach the sling to the Hoyer lift, which resulted in a fall and a leg fracture for this mobility impaired, dependent resident. This incident was deemed past non-compliance when facility-wide education and training for the proper use of the Hoyer lift, was provided to the staff. All personnel including PT and OT, demonstrated completencies for the use of the Hoyer lift. The facility education was presented from 1/31/18 and ended on 2/7/18. The surveyors entered the building on 2/15/18.

The facility identified a census of 102, and the sample was 24. Based on observation, record review, and interview, the facility failed to develop and implement timely and effective interventions to prevent pressure ulcer development for 3 of 24 residents sampled for pressure ulcers Unstageable #148, Stage II #114, Stage II, #115. Findings included: - Review of resident #148's unsigned physician order [REDACTED]. Review of the annual MDS (Minimum Data Set) dated 10/7/15 documented a BIMS (Brief Interview for Mental Status) score of 8, which indicated moderate cognitive impairment. The resident required extensive assistance of one staff with bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene; supervision of one staff with eating; did not participate in walking in corridor; and walked in room once or twice with one staff assistance. The resident was a risk for pressure ulcers and had two Stage II ulcers present upon admission. The most severe tissue type depth was new skin growing in superficial tissue. The resident required a pressure reducing device for his/her chair and bed, a turning program, nutrition and hydration interventions, and pressure ulcer care. The resident required no urinary program and was always continent of bowel and bladder. The resident had no known weight loss or gain, and was on a therapeutic diet. Review of the ADL CAA (Care Area Assessment) dated 10/7/15 documented the resident required extensive assist of one staff with bed mobility, transfers, dressing, toileting, hygiene, and bathing. The resident was able to ambulate with a walker with assist of one staff for short distances with therapy. Review of the Pressure Ulcer CAA dated 10/7/15 documented the resident admitted with a Stage II to his/her left buttock and a Stage II to his/her right buttock. He/she also exhibited moisture associated skin excoriation to his/her rectum upon admission with no incontinent episodes, and was being followed by the wound nurse. His/her Braden Score (used to evaluate the risk for developing a pressure ulcer) was 18, which promoted use of a Promat mattress, wheelchair cushion, and heel elevator. Review of the resident's care plan dated 10/14/15 documented to assist the resident with repositioning approximately every 2 hours and as needed or requested; observe skin daily with cares, ADLs, toileting, hygiene, and bathing; encourage to report any tender areas, cracked or torn skin, or reddened areas; provide a Promat plus pressure reducing mattress; provide a pressure reducing cushion to wheelchair; and elevate heels on heel bench while in bed. Staff revised the care plan on 11/18/15 for sacrum wound treatment per physician order. The incontinence care plan documented to assist the resident as soon as possible after the resident turned on the call light to avoid incontinence, observe for signs of infection, toilet upon request, and dress in regular underwear or pullups at times. The resident was to receive a diet as ordered, considering his/her likes and dislikes for meals and snacks. Staff were instructed to monitor weight and labs, consult the dietician as needed, administer vitamin replacements and nutritional supplements as ordered, observe for difficulty with swallowing, use the clock method to identify food, and provide adaptive equipment of divided plate. The resident required assistance of one staff with bed mobility, transfers, dressing, toileting, hygiene, and bathing; was able to feed his/herself after setup with supervision; and staff were directed to keep the call light and frequently used items within reach. Physician order [REDACTED]. Performed on 10/28/15, 11/2/15, 11/9/15, 11/18/15, and 11/23/15. Braden/Pressure Ulcer Assessments done on 9/30/15, 10/7/15, 10/14/15, 10/21/15, and all scores were 18 which indicated the resident was at risk for pressure sores. Weights: 10/7/15-154lbs. (pounds), 10/14/15-156lbs., 11/12/15-159lbs., 12/2/15-151lbs, 12/10/15 (3 weights documented)-145lbs,152lbs.,151lbs. Interventions present since admission on 9/30/15-Promat Plus alternating pressure mattress, Roho wheelchair cushion, and heel bench. The Comprehensive Resident Analysis dated 9/30/15 documented a diagram with an open area to the left buttock. The staff identified a left buttock wound on 9/30/15 and the wound resolved on 11/12/15. Speciality Mattress Screen dated 10/1/15 stated the resident moved in bed independently and condition and risk factors could benefit from a Convertible Air/foam mattress with pump. Unavoidable Pressure Ulcer form dated 10/1/15 documented not at risk due to not having any of the following primary risk factors for developing unavoidable pressure ulcers (semi comatose, life sustaining measures have been withdrawn, moribund/hospice/terminally ill, refusal to comply with treatment, existing wounds, and compromised mobility). The physician's orders [REDACTED]. Labs from 10/6/15 documented an [MEDICATION NAME] level (the most prevalent protein in blood plasma) of 3.5, within normal limits. The staff identified the right heel wound on 10/21/15 and the wound resolved 11/5/15. The staff identified a left buttock wound on 11/18/15 and resolved on 12/3/15. Pressure Ulcer Assessment from dated 11/18/15 documented a New Wound to the Sacrum Stage III (when a pressure ulcer extends into the tissue beneath the skin), 2.0 x 2.0 x 0.2 cm The Pressure Ulcer assessment dated [DATE] documented a sacrum wound initially identified on 11/18/15 and still present. The interventions included an alternating pressure mattress, Roho wheelchair cushion, and heel bench. The passive breaks (a spring underneath the wheelchair that prevents it from rolling backwards when a resident would sit in it) caused the new wound, and staff used a wheelchair seat insert was used to relieve pressure from the passive brakes. Dietary Assessment/notes dated 12/1/15 documented the resident to have a liberalize diet type to regular diet to improve resident satisfaction. The dietary notes on 12/7/15 documented the resident would have a normal diet and cottage cheese with lunch. The average meal intake was 78%. Promod 30mL (milliliters) twice a day for 30 days started on 11/19/15, and staff were directed to offer snacks. The assessment made note of the Stage III sacrum ulcer. Admission/New onset/ Weekly wound analysis dated 12/3/15 documented a Stage III pressure ulcer to the sacrum, identified on 11/18/15, #4 wound, 1.7 X 2.3 X 0.2, serous drainage (clear, thin, watery drainage), moist 80% yellow necrotic (dead tissue from inadequate local blood supply) tissue, 0 eschar (a dry, dark scab or falling away of dead skin), and edges intact. Treatment to the wound was to use wound cleanser and [MEDICATION NAME] Foam (wound dressing). During an observation on 12/14/2015 at 3:57 P.M. the resident was lying in bed on a pressure reducing mattress and his/her wheelchair had a special pressure reducing cushion. During an observation on 12/15/2015 at 12:46 P.M. the resident's empty bed had a pressure reducing mattress, and heel elevator. A foam mat was placed on the floor next to the resident's bed. During an observation on 12/15/2015 at 1:41 P.M. the resident was seated in his/her wheelchair next to bed. During an observation on 12/15/2015 the nurse entered the room at 1:47 P.M. and the resident was not offered to reposition by staff. During an observation on 12/15/2015 at 2:27 P.M. staff took the resident to the bathroom and asked if he/she wanted to go to bed or stay in the wheelchair. The resident did not want to go to bed until after dinner. During an observation on 12/16/2015 at 7:00 A.M. the resident slept in bed with the pressure reducing mattress and heel lifter used. During an observation on 12/16/2015 at 8:11 A.M. the resident sat at the breakfast table eating eggs, turkey bacon, toast, cereal, and juice. The resident was able to feed him/herself with a fork and hands. The staff did not provide any prompting to the resident. The resident ate 100% of the oatmeal, eggs, and bacon but did not eat the toast. During an observation on 12/16/2015 9:21 A.M. licensed staff H washed his/her hands and put on gloves to do a dressing change. The resident was able to move to his/her side slightly on own and licensed staff H provided minimal assistance. He/she cleansed the wound and sprayed a skin protectant around the wound. He/she applied a [MEDICATION NAME] dressing with normal saline over the wound. The wound was 1.4 cm (centimeters)x 2 cm [MEDICAL CONDITION], 95% pink, 5% yellow. The wound had approximated white edges with a pink center, and was shaped in a circle. During an interview on 12/14/2015 at 3:57 P.M. the resident stated the doctor comes every day to assess the wound and received dressing change treatment every other day. He/she stated that two staff help to treat his/her wound. The resident stated he/she was able to reposition his/herself in the bed but needed assistance getting to and from the bathroom. The resident would push the call light when needing to go to bathroom, and staff would assist him/her. The resident stated he/she had a cushion on the wheelchair and believed his/her mattress was a regular mattress. The resident did not believe he/she had any snacks for a supplement and did not eat all of his/her food at meals. During an interview on 12/16/2015 at 9:39 A.M. direct care staff AA stated the resident would let staff know when he/she needed to go to the bathroom, and they would check on the resident every two hours to see if he/she needed anything. During an interview on 12/16/2015 at 2:13 P.M. direct care staff U stated the resident was continent and would inform staff if he/she had to go to the bathroom or had any other needs. The staff stated the resident was not on a repositioning schedule but staff were to check on him/her every two hours. During an interview on 12/16/2015 at 11:29 A.M. licensed staff N stated the resident was continent of bowel and bladder except for times that he/she dribbled small amounts of urine. The resident wore panty liners and may wear a brief at night due to the resident not being able to tell staff in enough time that he/she had to go to the bathroom. He/she stated the resident was able to inform staff when needing to go to the bathroom, and his/her toileting schedule was every two hours and before meals. The resident was able to turn him/herself in bed during the day and staff would ask about repositioning every two hours. The licensed staff stated an aide would be the first to see if a resident had a pressure ulcer developing. The nurse would then do an assessment as well as informing the wound care nurse for him/her to do an assessment. The residents would be evaluated for use of dietary supplements, barrier cream would be used, nursing administration would be notified, the resident's wheelchair would be examined for pressure from the passive brakes, and a wheelchair cushion would be used. When an open skin area develops staff ask the doctor for additional treatment orders like Acquacel foam. During an interview on 12/16/2015 9:21 A.M .licensed staff H stated that when a resident was at risk for pressure ulcers, a Braden Scale would be done, a pressure reducing mattress would be used, and a wheelchair cushion or Roho air cushion would be applied. He/she stated that the resident's pressure ulcer started from the spring underneath the wheelchair adding pressure to the seat. Staff added a dense foam pad protector to the wheelchair and removed the passive brakes. The resident's Unavoidable Pressure Ulcer form dated 10/1/15 inaccurately documented that the resident did not have any existing pressures ulcers when staff identified the sacrum ulcer. Licensed staff H explained that the form was not filled out by him/her and he/she rarely saw those forms. He/she explained that it would not change his/her plan of care for treating the pressure ulcer. During an interview on 12/16/2015 1:17 P.M. administrative nursing staff D stated that when staff identified a pressure ulcer the doctor would be notified to get a treatment order, and the resident would be evaluate by the dietitian to review meal intake, for weight loss, be evaluated weekly by administrative nursing staff, and be assessed by the wound care nurse. A pressure reducing mattress would be used and therapy would be involved to determine what type of cushions would be needed for the resident's wheelchair. During an interview on 12/16/2015 at 4:32 P.M. Nurse Practitioner FF explained that it had been roughly an month since evaluating the resident's pressure ulcer. His/her expectation would be for the facility to implement offloading and use the equipment provided, such as boots and heel benches, to prevent development of a pressure ulcer. He/she would expect the facility to provide better care, such as toileting every 2-4 hours, turning, and offloading to promote wound healing. He/she stated the wound care nurse at the facility was really good, but they are short staffed at times and do not use the equipment as ordered. The facility Policy dated 01/10/2007 and revised 12/19/2013 documented It is the policy of this facility to promote the healing and enhance the resident's quality of life; all pressure ulcers and other wounds shall receive treatment. 1.) A review of each pressure ulcer or wound will be documented during the admission process or when a new wound is identified. 2.) The review will be communicated with the physician to establish treatment plan. 3.) The plan of treatment will be a part of the interdisciplinary plan of care and discussed with the resident and his or her legal representative. 4.) The wound will be monitored on an ongoing basis. The treatment plan will be altered as indicated. The facility failed to develop and implement timely and effective interventions to prevent the new development of two pressure ulcers for this cognitively impaired resident who developed a two Stage III pressue ulcers. - The physician's orders [REDACTED].#115 listed the following Diagnoses: [REDACTED].(slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The resident was identified to be at risk for developing pressure ulcers. No pressure ulcers were identified and he/she had pressure reducing devices for his/her wheelchair and bed. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 03 which reflected the resident was severely cognitively impaired. He/she required extensive assistance of two staff for bed mobility and transfer; and extensive assistance of 1 staff for walk in corridor, locomotion on/off the unit, toilet use and personal hygiene. The resident required supervision of 1 staff for eating The Annual MDS dated [DATE] documented a BIMS score of 03 which reflected the resident was severely cognitively impaired. He/she required extensive assistance of 2 staff for bed mobility, transfers; extensive assistance of 1staff for walk in corridor, locomotion on/off unit, toilet use, and personal hygiene; supervision of 1 staff was required for eating. The resident used a walker and wheelchair. He/she had no pain during the look back period. The resident had a stage 1 pressure ulcer or greater, and was identified to be at risk for developing pressure ulcers. He/she had an unstageable pressure ulcer with eschar (dead tissue) which measured 3.0 centimeters in length and 1.5 centimeter in width. The resident had a pressure reducing device for his/her bed and wheelchair. The Care Area Assessment (CAA) dated 11/20/2015 for skin integrity documented the resident had a right heel unstageable pressure ulcer due to eschar wound that developed on 09/30/2015. The wound nurse added bilateral float boots when in bed, this wound was mechanically debrided on 11/05/2015 leaving stable eschar. The resident was to continue to off load his/her heels. The resident had a pressure reducing mattress for his/her wheelchair and bed. The Activities of Daily Living CAA dated 11/20/2015 documented staff transferred the resident using a Hoyer lift. The Care Plan for alteration in skin integrity documented the resident had a right heel unstageable wound due to eshcar that developed on 09/30/2015; Approaches Assist the resident with repositioning 2) observe skin daily with cares, ADL toileting, hygiene and bathing, 3) encourage resident to report tender areas 4) provide pressure reducing mattress 5) provide pressure reducing cushion in wheelchair 5) observe skin underneath wanderguard for signs/symptoms of skin irritation and breakdown 6) 10/01/15 Wound nurse added bilateral float boots when in bed. This wound was mechanically debrided on 11/05/2015 leaving stable eschar, continue to offload with float boots and dressing initiated, and Promod added for wound healing. The resident was on a pressure reducing mattress and had a wheelchair cushion. The Care Plan dated 11/23/2015 for alteration in cognition documented he/she had dementia and paralysis agitans (obsolete term for Parkinson ' s), had impaired decision making skills and confusion. He/she was at risk for alternation in nutrition and received vitamins and supplements were ordered. He/she required adaptive utensils and a plate guard. The care plan for incontinence documented he/she would have no preventable skin breakdown. The chart review revealed the resident was at risk for alteration in nutrition due to declined food intake during the past three months, his/her weight decreased by 4-pounds. The resident also has suffered psychological stress or acute disease in the past 3-months. Nutritional Analysis dated 09/21/15 weight 161 no added salt, mechanical soft diet, no cranberry juice, no mash potatoes, average meal intake 63.3%, no supplements or snacks, no adaptive equipment, 8/25/15 NA 133 L, Glu 112 H, H/H 8.7L/28.9L, nutrition compromised, receives vitamin and mineral supplement. Resident receiving supercereal with breakfast no significant weight loss in the last 6 months. Weekly skin observations 06/02/15 through 09/22/15 documents no skin issues, skin intact. On 10/01/2015 at 07:45 A.M. (NN) resident noted to have a pressure ulcer to her right heed, this dark discolored area was a resolving deep tissue injury (DTI), due to her skin pigmentation this area was difficult to detect. The wound measures 4.0-centimeters x 6.0-centimeters dark purple tissue intact no drainage or redness. On 10/01/2015 (Wound Care Notes): Wound type pressure ulcer, initial stage deep tissue injury (DTI), measured 4-centimers by 6-centimers with dry necrotic tissue 100% intact dark purple resolving deep DTI, edges intact, peri-wound color brown, denies pain at wound area, expected duration one month unless otherwise specified. Initial treatment. 10/08/15 Wound type DTI 4 cm X6 cm dry no slough 100% intact dark purple resolving DTI, stable.10/15/15 DTI 4cm X 6cm dry, 100% dark purple resolving, periwound brown, slight contractures, heel bench wasn't off loading well, offload with floatboots when in bed. 10/22/15 no change in wound, 10/29/15 DTI 3 cm X 1.5 cm no drainage 10/27/15 flakey DTI mechanically debrided leaving area of stable black eschar, 100% stable black eschar 11/05/15 no change in wound 11/10/15 no change, expected duration one month unless otherwise specified 11/1915 no change in wound 11/25/15 no change in wound 12/03/15 2 cm X 1.5 cm dry, no pain edges intact, 100% black eschar, continue with off loading float boots, 12/10/15 no change in wound 12/17/15 no change in wound 2 cm X 1.5 cm, black eschar intact, wound dry, denies pain wound care continues clean with normal saline, apply ABD pad and wrap with Kerlix guaze. On 10/01/2015 an order to draw Total Protein was placed. Laboratory Draws: 10/20/2015 the lab results for Total Protein 6.0 (L) normal range 6.4-8.9 g/dL 10/02/15 [MEDICATION NAME] 17-34 reference range reisident 19 On 1105/2015 the physician ordered wound treatment: Cleanse right heel with normal saline, apply abdominal pad (ABD) and wrap with kerlix. Change dressing every day. On 11/12/2015 at 4:00 P.M. (NN) New order for physical to evaluate and treat as indicated. On 11/18/2015 at 1:P.M. the physician ordered Promod (protein nutritional supplement to promote wound healing) twice a day for 30-days for DTI on right heel. On 11/23/2015 at 09:45 A.M. (NN) Spoke with Occupational Therapist and they put the resident in a high back tilt recliner wheelchair. The resident used a Hoyer lift for transfers. An observation on 12/15/2015 at 2:50 P.M. licensed nursing staff H went into the resident ' s room for wound care. He/she closed the door and privacy curtain, explained the procedure and asked for the resident ' s permission. Licensed staff H removed the float boots, donned gloves and removed the old dressing, replaced gloves and cleansed the wound with normal saline. The wound area was dark black eschar, and the inner aspect of eschar appeared to be lifting on the edge, he/she dried the area by blotting the wound bed. He/she changed their gloves and place placed an ABD pad on the wound and then wrapped with kerlix and secured with tape. The resident ' s sock was replaced and the heels were floated. Bed placed in low position and fall mat beside the bed. An observation on 12/16/2015 at 1:49 P.M. direct care staff U and transferred the resident using the Hoyer lift. The float boots were on his/her feet. The resident was lowered onto the bed, rolled side to side and the sling was removed. An interview with licensed nursing staff H stated the heel bench they had in place for contractions did not elevate the resident ' s feet off the bed. We did not realize that his/her heels were not floated. Now we use float boots and therapy was working with her on the contractions. The wound on his/her right heel has gotten smaller, the wound now measures 2.7-centimeters in length by 1.5 centimeters in width. I spoke with the Nurse Practioner about [MEDICATION NAME] the eschar plug and using Santyl to promote healing. On 12/16/2015 at 1:22 P.M. administrative nursing staff D stated the wound could of been prevented with weekly skin assessments on the resident ' s bath assessments. We did a bed bench in-service for the CNA ' s on offloading with pillows and heel boots. The in-service included what to look for on the wound report, which documented he/she had slight contractions bilaterally on his/her knees, to place an abductor pillow between his/her legs. He/she eats in the assisted dining room and we should have put him/her back on weekly weights because lately he/she had to have more assistance when eating and was not eating well. I should not have let this happen, I ' m sure his/her heels were mushy. When this was reported to me I went into his/her room and checked his/her heels and they were soft. The dietitian ordered cottage cheese twice a day to increase protein. The physician also ordered Promod 30-ml (food supplement which provides concentrated protein to promote wound healing) on 11/18/2015 to promote wound healing. An interview on 12/16/2015 at 4:32 P.M. Nurse Practitioner FF explained that it had been roughly an month since evaluating the resident's pressure ulcer. His/her expectation would be for the facility to implement offloading and use the equipment provided, such as boots and heel benches, to prevent development of a pressure ulcer. He/she would expect the facility to provide better care, such as toileting every 2-4 hours, turning, and offloading to promote wound healing. He/she stated the wound care nurse at the facility was really good, but they are short staffed at times and do not use the equipement as ordered. The facility Policy dated 01/10/2007 and revised 12/19/2013 documented It was the policy of this facility to promote the healing and enhance the resident ' s quality of life; all pressure ulcers and other wounds shall receive treatment. 1.) A review of each pressure ulcer or wound will be documented during the admission process or when a new wound is identified. 2.) The review will be communicated with the physician to establish treatment plan. 3.) The plan of treatment will be a part of the interdisciplinary plan of care and discussed with the resident and his or her legal representative. 4.) The wound will be monitored on an ongoing basis. The treatment plan will be altered as indicated. The facility failed to assess and prevent the development of a deep tissue injury from forming within the facility for this cognitively impaired resident #119. - Resident #114's physician order [REDACTED]. The residents annual MDS (Minimum Data Set) dated 10/5/15 documented the residents had Brief Interview for Mental Status (BIMS) score of 13, which indicated his/her cognition was intact. The resident required extensive assistance of two staff with bed mobility and did not reject cares during the 7 day observation period. The resident had occasional urinary incontinence, was continent of bowel, had no pressure ulcers, was at risk for developing pressure ulcers, and had a pressure reducing device for his/her chair and bed. Review of the 10/5/15 ADL (Activities of Daily Living) CAA recorded the resident required extensive assistance for repositioning and transfers and had quarter bed side rails to aide him/her. Review of the 10/5/15 urinary incontinence CAA recorded the resident had occasional incontinence, was not on a scheduled toileting plan, used no pads or incontinent products and was toileted upon request. Review of the 10/5/15 Pressure Ulcer CAA recorded the resident's had a closed surgical wound which was open to air on his/her right hip. The assessment recorded his/her skin was dry and intact with no opened areas and encouraged him/her to report any cracked or torn skin. The 10/15/15 (14 day MDS), 10/30/15 (30 day MDS), and the 11/5/15 unscheduled MDS documented the resident had a Bims score of 14, required extensive's assistance of 1 to 2 staff with most ADL's and no pressure sores. The Braden Skin Risk Assessments (a numerical scale used to assess the potential for development of pressure sores) dated 10/15/15, 10/30/15, and 11/5/15 recorded the resident scored 16, which indicated he/she was a moderate risk for development of pressure ulcers. Review of the resident's revised care plan dated 11/16/15 recorded the resident was at risk for non pressure and pressure related skin impairment. The care plan directed staff to assist with bed mobility transfers and repositioning, monitor his/her ADL ability, inspect the resident's skin during showers, incontinence care and toileting. The care pan documented the resident used a fracture bed pan for toileting (a waste collection receptacle that is not as deep as a regular bedpan). Review of the weekly skin assessment dated [DATE] documented the resident had a right buttock gluteal partial thickness stage 2 open area which measured .5 centimeter (cm) long (l) by 0.3 cm wide (w) and no depth of the wound was recorded. The weekly skin assessment sheet recorded this wound was treated with a physician ordered aquarelle dressing and healed on the 12/9/15. Review of December 2015 physician's orders [REDACTED]. Review of the un-timed 12/14/15 nurses progress notes documented the resident had a stage two open area to his/her buttock (R) which measured 0.7 cm x 0.6 cm and no depth. The wound bed was 100% pink with a small amount of serosanquinous (clear and blood tinged) drainage. The nurse practioner ordered a fibersol under aquarelle foam dressing. The resident continued on a promat alternating pressure mattress and continues to use a bedpan. This wound is most likely caused by the bed pan as the wound and other areas are in a linear line. Resident encouraged not to sit on the bed pan for more than 10 minutes. During an observation on 12/14/2015 at 8:59 A.M. the resident was seated in a common area at a table with a nurse assisting his/her with A.M. medications. During an observation on 12/14/15 at 9:01 A.M. the resident right gluteal fold open area appeared healed. The resident had a reddened area to his /her upper right buttock and a 1 cm to 1.5 cm red line and just below a 0.7 cm x 0.6 cm open area to his/her right lower buttock Interviewed on Monday 12/14/15 at 7:30 A.M. (prior to wounds assessment), licensed nurse H stated the resident had some pressure ulcers from having sat on the bed pan for extended periods of time, but they were healed. Interviewed on 12/14/15 at 9:34 A.M. licensed nurse H acknowledged two areas of concern to the residents right buttock. Nurse H stated these areas were not present on Friday 12/11/15 and the resident not there on Friday must have sat on bed pan over the weekend. Interviewed on 12/15/2015 at 9:12 AM the resident stated his/her bottom was a little sore, the nurse told me what he would do, (to treat it) and It took a long time to heal. The resident explained the nurse stated this one should heal in a couple of days. He/she stated staff did not assist him/her with turning and he/she cannot do it his/herself. Interviewed on 12/15/2015 at 9:18 AM licensed nurse J stated he/she was aware of the residents pressure sore to his/her right gluteal fold healed on 12/11/15, but was unaware of any new pressure sores. Nurse J stated the resident had the hardware taken out of his/her left hip (due to an infection) and sometimes he/she had a lot of pain. He/she generally stayed in bed for breakfast, and got up for lunch and dinner, he/she had a slide board (for transfers) that he/she says he/she could not use, but I have seen him/her use it. Nurse J stated the resident would not allow staff to reposition him/her. He/she is mobile but sometimes just wants to lay in bed. Interviewed on 12/16/2015 8:30 AM part time direct care staff V stated the resident did not toilet on the commode, but used a fracture bed pan. Staff V stated he/she was here last Friday (12/11/15) and noted some redness on the residents bottom which we thought was caused by the fracture bed pan. Direct care staff v stated he/she told the nurse secured a larger (less rigid) bariatric type bed pan. (observation at this time revealed the resident was supplied one of these larger rounded top bed pans). Interviewed 12/16/2015 8:52 A.M. licensed nurse J stated he/she was told of the residents buttock redness but no open areas were present at that time. Review of the facility's Prevention of Pressure Ulcer Policy revised 12/19/13 documented: The wound will be monitored on an going basis and the treatment plan will be altered as indicated. The facility failed to timely re-assess the resident's use of a fracture bed pan and apply new interventions to prevent the development of stage two pressure sores for this mobi

The facility census totaled 101 residents with 3 sampled. Based on record review and interviews, the facility failed to ensure one resident was free from significant medication errors (#1) related to the incorrect administration of intravenous (IV) solutions (medication given through a vein) which resulted in elevated blood sugar levels for 1 of 3 residents. Findings included: - Resident #1's Physician order [REDACTED]. The admission Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident received insulin (a hormone given by injection under the skin to absorb glucose from the blood) for 7 of the 7 day look back period. The Medicare required 5 day assessment dated [DATE] documented the resident received insulin for 7 of the 7 day look back period, and received IV medications. The Care Area Assessment for dehydration dated 1/19/15 documented the resident was at risk for dehydration as evidence by receiving a pureed diet and he/she required staff assistance with activities of daily living (ADLs). The revised care plan dated 2/22/15 documented the resident had an IV access to the right upper extremity. The approaches included to flush the line for use or maintenance per doctor's orders, evaluate for patency prior to each use, change the dressing to access site per doctor ' s order using central line dressing change procedure, evaluate for signs and symptoms of infection including pain, swelling, and drainage to the access location, and notify the doctor with any changes to the access site or slow/changed flow rates from resident's baseline during use. The resident received IV therapy due to poor oral intake. The approaches included to administer the medications per the doctor's order, flush the IV per the doctor's orders and after each infusion, observe for changes in skin turgor and hydration and food intake, administer the fluids per the doctor's order, and infuse the solution of normal saline (a sterile, nonpyrogenic (non fever producing) solution for fluid and electrolyte) as ordered. The nurse's note documented on 2/21/15 at 1:30 P.M. the resident's blood sugar was 493, staff called the physician and he/she ordered for staff to administer 16 units of [MEDICATION NAME] insulin. The nurse's note dated 2/22/15 at 6:10 P.M. documented the resident refused to open his/her mouth for medications and/or food. Staff called the physician and he/she ordered to obtain a PICC line access (a peripherally inserted central catheter which was a form of intravenous access that was used for a prolonged period of time) and start normal saline at 70 centimeters per hour (cc/hr). The physician progress notes [REDACTED]. The family requested to manage the resident in the facility. The nursing staff started intravenous fluids (IVF) and the resident became more alert. The resident denied any complaints and nodded his/her head that he/she would eat. The nurse's note dated 2/24/15 at 2:00 P.M. documented the resident's blood sugar after lunch, read HI (which indicated the blood sugar level was higher than the machine could register--Hi above 600 and lo below 20) on the blood glucose machine. Nursing staff called the physician who ordered 10 units of insulin and for nursing to re-check the blood sugar in 45 minutes. The physician progress notes [REDACTED]. The resident's order was for him/her to receive 2 liters of normal saline and continue to infuse the IV fluids at 70 centimeters an hour. The repeated urine analysis showed the urine was loaded with bacteria and yeast. The doctor ordered an oral antifungal and antibiotic. Nursing staff checked the resident's blood glucose level which read high on the glucose meter and the physician ordered extra insulin. On 2/24/15, after completion of the IV fluid of D5W with ? normal saline-a solution of [MEDICATION NAME]- sugar mixed with saline, from outside laboratory services checked the glucose level with the results of 632 which was high (normal fasting blood sugar level range was 70 milligram per deciliter (mg/dL) to 105 mg/dL after not eating (fasting) for at least 8 hours and less than 140 mg/dL within 2 hours after eating). The nurse's note dated 2/24/15 at 2:45 P.M. documented the blood sugar still read high, and the physician ordered additional insulin. The nurse's note dated 2/24/15 at 4:00 P.M. documented the resident's blood sugar continued to read high. The nurse's note dated 2/24/15 at 5:00 P.M. documented for staff to recheck the blood sugar in 2 hours and start an IV of normal saline. Nursing staff started an IV at 5:25 P.M. The nurse's note dated 2/25/15 at 7:00 A.M. documented the resident's blood sugar was 261 mg/dL. On 3/5/15 at 2:25 P.M. interview with licensed nursing staff H stated the night shift nurse left a bag of IV fluids from the E-Kit (emergency kit) on the counter in the medication room and told licensed nursing staff H that those were the fluids the resident was supposed to receive. Licensed nursing staff H asked administrative nursing staff E to hang the IV fluids. Licensed nursing staff H stated he/she did not check the physician's orders [REDACTED]. On 3/5/15 at 2:45 P.M. interview with administrative nursing staff E stated he/she hung one liter of IV fluids for the resident without reviewing the physician's orders [REDACTED]. On 3/5/15 at 4:45 P.M. interview with administrative nursing staff D stated physician extender staff HH told him/her the resident received the wrong IV fluids. Administrative nursing staff D and physician extender staff HH went to the resident's room and found the wrong IV fluids (D5W with ? normal saline) administered to this resident. The two nurses involved in the incident stated that neither one of them checked the Medication Administration Record [REDACTED]. On 3/5/15 at 2:45 P.M. interview with physician extender HH stated technically it was a medication error but he/she did not think the IV fluids contributed to his/her high blood sugars. The resident was hospitalized before coming here related to high blood sugar, the family was adamant that they did not want sliding scale insulin, and they did not want a dose of insulin higher than 12 units given to the resident. Physician extender HH stated there were several other issues that attributed to his/her high blood sugars like anorexia (lack of appetite), dehydration (that was why the IV fluids), urinary tract infection, and his/her uncontrolled diabetes. The undated facility policy "Regulating Intravenous Infusion Flow Rates" instructed the staff to review the resident's medical record for the physician's orders [REDACTED]. The rationale was to ensure the right IV fluid was administered. The facility staff failed to follow the physician's orders [REDACTED].? normal saline which resulted in a significant medication error and causing this insulin dependent diabetic resident to have an elevated blood sugar level nearly 6 times more than the normal range.

The facility identified a census of 107 residents. The sample included 9 residents. Based on interview and record review, the facility failed to notify the physician of the positive urine culture results received on 11/23/11 and elevated temperature for one resident in the sample (#1) resulting in the hospitalization with [DIAGNOSES REDACTED]. Findings included: - The December 2011 physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) of 10/12/11 identified the resident with additional [DIAGNOSES REDACTED]. The quarterly MDS 3.0 with an ARD of 10/12/11 further identified the resident with a Brief Interview for Mental Status score of 15, that indicated intact cognition. The MDS also noted the resident required staff assistance for all Activities of Daily Living (ADLs) and was non-ambulatory. The MDS identified the resident with a stage II pressure ulcer to part of his/her foot. The 7/26/11 pressure ulcer Care Area Assessment (CAA) identified the resident with a stage II pressure ulcer to his/her left heel and a diabetic wound to his/her left 5th metatarsal with impaired mobility and bowel and bladder incontinence and staff provided repositioning and perineal care. The 10/26/11 care plan addressed the left plantar foot wound and instructed the staff to provide treatment as ordered, obtain an arterial doppler, and to apply a float boot to left foot at all times. A physician's orders [REDACTED]. The 11/17/11 at 10:50 P.M. nurses notes documented the resident returned to the facility post hospitalization for left above the knee amputation with a temperature reading of 99.5 degrees Fahrenheit. The 11/20/11 at 2:45 A.M. nurses notes documented the resident with a temperature reading of 99.2 degrees (axillary) Fahrenheit. The 11/20/11 6 A.M.-6 P.M. nurses notes documented the resident's appetite continued to be poor with a 6 ounce house supplement consumed for lunch. The note further identified the resident with an indwelling Foley catheter with dark yellow cloudy urine, an order to obtain urine specimen for urinalysis with culture and sensitivity, and an elevated temperature of 99.4 degrees (axillary) Fahrenheit. The 11/21/11 3:05 A.M. nurses notes revealed the staff obtained the urine sample via clean catch from the indwelling Foley catheter. The 11/21/11 1:00 P.M. nurses notes documented the resident with a temperature of 100.8 degrees Fahrenheit. The note further revealed the staff administered Tylenol with effective results 4 hours later and a temperature of 99.8 degrees Fahrenheit. Staff notified the physician with orders obtained an order to remove the resident's catheter. The initial urinalysis report for the specimen collected 11/21/11 reported to the facility on [DATE] by the lab. A notation was made that the staff notified the physician by phone and received no new orders. However, the follow up urine culture and sensitivity report sent to the facility on [DATE] lacked documentation the staff notified the physician of the urinary tract infection with > 100,000/milliliters of [DIAGNOSES REDACTED] pneumonia (gram-negative bacteria). The 11/22/11 3:24 A.M. nurses noted identified the resident with a temperature of 100.5 degrees Fahrenheit at 11:00 P.M. with Tylenol administered. Further documentation revealed the staff removed the Foley catheter, as ordered, without difficulty. The 11/22/11 1:00 P.M. nurses note identified the resident with a temperature of 98.6 degrees Fahrenheit with intermittent confusion, but answered questions appropriately. The note further revealed the resident consumed no food, but staff encouraged fluids. The 11/22/11 6:00 P.M. nurses note identified the resident with a temperature of 96.8 degrees Fahrenheit. The 11/23/11 1:00 P.M. nurses note identified the resident with the following vital signs: Temperature 97.3 degrees, Pulse 79, Respirations 20, blood pressure 118/69, and oxygenation 96% on room air. The note identified the resident was very alert and answered questions appropriately. The 11/24/11 10:00 A.M. nurses note identified the resident with a temperature of 101.4 degrees axillary, pulse 84, and respirations 18. The note further revealed the staff administered a Tylenol suppository for because they were "unable to give the medication orally." The 11/24/11 2:00 P.M. nurses note identified the resident with a temperature of 101 degrees, pulse 100, respirations 22, blood pressure 137/78 and oxygen saturation at 88%. The note further revealed the resident unresponsive to verbal stimuli, very diaphoretic with skin cool to touch, and lungs diminished in bilateral bases. The facility noted at that time they notified the resident's family member to see if he wanted the resident hospitalized . The family member replied "Of course I want him/her sent to the hospital." The facility proceeded to notify the nurse practitioner and received orders to send the resident to the hospital. The 11/24/11 2:40 P.M. nurses note revealed the resident left facility at that time per ambulance. On 12/7/11 at 12:27 P.M. observation revealed the resident sat in a high back wheelchair in the assisted dining room. On 12/8/11 at 3:27 P.M., licensed nursing staff A revealed the reason he/she gave the resident a Tylenol suppository instead of oral Tylenol the morning of 11/24/11 was because the resident "was unresponsive" and "there was no way he/she could swallow." The facility failed to promptly notify the physician of the change in level of consciousness, positive urine culture results obtained on 11/23/11 and the clinical record lacked documentation staff notified the physician when the resident had an elevated temperature for 5 of 8 days after the resident's admission to the facility which resulted in hospitalization with the [DIAGNOSES REDACTED].