Every finding on record at Northrise Wellness & Rehabilitation

Based on observation, record review, and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 2 (R #24, and R #25) of 3 (R #24, R #25, and R #26) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that may cause harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of the facility Care Plan Policy, dated June 2020 revealed the following: 1. The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. 2. The Baseline Care Plan will be updated to reflect changes in the residents' condition or needs occurring prior to the development of the Comprehensive Care Plan. R #24 B. Record review of R #24's admission Record, no date, revealed the following: 1. R #24 was admitted to the facility on [DATE]. 2. R #24 was discharged on 04/28/26. 3. R #24 had the following diagnosis: a. Acute Pyelonephritis (a sudden and severe kidney infection. It causes the kidneys to swell and may permanently damage them. Pyelonephritis can be life-threatening). b. Hypothyroidism, unspecified (an abnormally low activity of the thyroid gland, resulting in metabolic changes). c. Type 2 Diabetes Mellitus without complications. C. Record review of R #24's medical record revealed staff did not document a baseline care plan for R #24's. R #25 D. Record review R #25's admission Record, no date, revealed she was admitted to the facility on [DATE] with the following diagnosis: 1. Urinary Tract Infection, site not specified (an infection in the organs of your urinary tract, which includes the bladder and kidneys). 2. Vascular Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a type of cognitive impairment caused by reduced blood flow to the brain, often due to stroke, atherosclerosis, or hypertensive cerebrovascular disease). 3. Difficulty in walking, not elsewhere classified (refers to an impairment in gait or mobility without a specific underlying diagnosis). E. Record review of R #25's base line care plan dated 06/09/26 revealed staff did not document a baseline care plan within 48 hours of R #25's admission to the facility. F. On 06/16/26 at 1:30 PM, during an observation and interview with R #25, R #25 was in bed and appeared pleasantly confused. R #24 stated she had no concerns at this facility. G. On 06/18/26 at 11:24 AM, during an interview, the DON confirmed the following: 1. Staff did not document a baseline care plan for R #24. 2. Staff did not document a baseline care plan for R #25 within 48 hours of admission to the facility. 3. DON's expectation is that staff complete a baseline care plan within 48 hours upon admission for residents.

Based on record review and interview, the facility failed to ensure care plan revisions occurred for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for care plan accuracy, when staff failed to revise R #1's care plan with the most current resident information. This deficient practice could likely result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status. The findings are: A. Record review of the facility Care Planning Policy, dated June 2020 revealed the following: 1. A Licensed Nurse will initiate the Care Plan. 2. The plan will be updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. B. Record review of R #1's admission Record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 was discharged on 05/28/26. 3. R #1's diagnoses include difficulty in walking not elsewhere classified (refers to an impairment in gait or mobility without a specific underlying diagnosis). C. Record review of R #1's Occupational Therapy (OT; focuses on enabling people to engage in everyday occupations of life, which include self-care activities such as dressing, bathing, and preparing food) notes revealed the following: 1. OT Evaluation note dated 05/13/26 the OT documented the following: a. R #1 can bathe or shower himself independently. b. R #1 can transfer himself in and out of the tub or shower independently. 2. OT Treatment note dated 05/15/26 the OT documented the following: a. R #1 can bathe or shower himself independently. b. R #1 can transfer himself in and out of the tub or shower independently. 3. OT Discharge summary dated [DATE] the OT documented the following: a. R #1 can bathe or shower himself independently. b. R #1 can transfer himself in and out of the tub or shower independently. D. On 06/22/26 at 12:42 PM, during an interview, the OT confirmed the following: 1. R #1 can bathe or shower himself independently. 2. R #1 can transfer himself in and out of the tub or shower independently. 3. R #1 did not require any assistance to shower or bathe himself. E. Record review of R #1's care plan, dated 05/15/26, revealed the following: 1. R #1 has decreased ability to perform activities of daily living: a. Bathing/showering: R #1 requires physical assistance of one staff participation with bathing/showering. F. On 06/22/26 at 12:42 PM, during an interview, the DON confirmed the following: 1. R #1's care plan did not reflect R #1's level of function for bathing or showering as determined by R #1's OT Discharge summary dated [DATE]. 2. R #1's care plan should have been revised to accurately reflect R #1's level of function related to bathing and showering himself independently.

Based on interview and record review, the facility failed to ensure that a resident who enters the facility with diagnosis of urinary tract infection (UTI) received appropriate treatment for 1 (R #24) of 2 (R #24 and R #25) residents reviewed for UTI, when they failed to ensure that a resident received all doses of antibiotic as prescribed to treat the UTI. This deficient practice could result in residents being susceptible to worsening infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues). The findings are:A. Record review of the facilities policy for UTI's, dated June 2014 revealed the following: As part of the initial assessment, the physician will help identify individuals who have a history of symptomatic urinary tract infections, and those who have risk factors (for example, an indwelling urinary catheter, urinary outflow obstruction, etc.) for UTIs. 1. The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatment accordingly. 2. Decisions should be made primarily on the basis of clinical signs and symptoms. The goal of treatment in most cases is to control signs and symptoms of infection, not to eliminate bacteriuria. 3. Follow-up urine cultures after antibiotic treatment are not indicated routinely but may be helpful if the symptoms are not resolving or complications are present. 4. When someone's urinary tract infection persists or recurs after treatment with an initial course of antibiotics, the physician should review the situation carefully with the nursing staff and possibly examine the individual before prescribing repeated courses of antibiotics. 5. Physicians should justify continuing or resuming antibiotic treatment beyond an initial course of treatment, especially if based solely on a positive culture result. B. Record review of R #24's admission Record, no date, revealed the following: 1. R #24 was admitted to the facility on [DATE] 2. R #24 was discharged on 04/28/26. 3. R #24 had the following diagnosis: a. Acute Pyelonephritis (a sudden and severe kidney infection. It causes the kidneys to swell and may permanently damage them. Pyelonephritis can be life-threatening). b. Hypothyroidism, unspecified (an abnormally low activity of the thyroid gland, resulting in metabolic changes). c. Type 2 Diabetes Mellitus without complications. C. Record review of R #24's hospital discharge instructions for medication reconciliation report dated 04/17/26 revealed: 1. Continue antibiotic medication, taking: Augmentin (prescription medication to treat a wide range of bacterial infections including infections of the bladder or kidneys caused by susceptible bacteria.) 500 mg by mouth two (2) times a day for six (6) more days. End date for Augmentin 500 mg is 04/26/26. D. Record review of R #24's MAR for April 2026 revealed the following: 1. Staff did not document an order for Augmentin. 2. Staff documented an order dated 04/28/26 for Levaquin (is a fluoroquinolone antibiotic used to treat various bacterial infections, including urinary tract infections) give 500 mg by mouth one time a day for UTI. E. Record review of R #24's Skilled Evaluation progress note, dated 04/22/26 revealed the following: 1. Urine color: dark yellow, 2. Urine clarity: cloudy, 3. Urine has foul odor, 4. Urine analysis ordered. F. On 06/17/26 at 11:32 AM, during an interview, the Physician stated the following: 1. If R #24 was admitted with orders to continue a medication for UTI from the hospital, then it should be followed on admission to the facility. 2. When the staff receive results from a urine analysis the staff should call the physician and get the order put in. G. On 06/18/26 at 1:50 PM, during an interview, the DON confirmed the following: 1. R #24 had convalescent orders from the hospital to continue Augmentin antibiotics, and the order was not placed in the system. 2. The admission nurse should have caught this, and DON when the audit is done the next day. 3. When a resident comes from the hospital, the staff are to follow the orders unless the doctor changes it. 4. Staff did not document contacting the physician to change the order from Augmentin to Levaquin. 5. On 04/22/26 staff took the urine sample from R #24. 6. The facility receive R #24's results on 04/26/28. 7. Staff did not obtain orders until 04/28/26 for Levaquin.

Based on record review and interview, the facility failed to ensure resident record were complete and accurate for 1 (R #24) of 3 (R #24, R #25, and R #26) residents reviewed for pressure ulcers, when they failed to obtain an order and documentation R #24's wound care treatment. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are:A. Record review of the facilities Wound Management policy, dated June 2020, revealed the following: 1. A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. Upon identification of a new wound the Licensed Nurse will: a. Measure the wound (length, width, depth); b. Initiate a Wound Monitoring Record sheet; c. A Wound Monitoring Record will be completed for each wound. d. See Staging Guidelines for more information about assessing wounds. e. The Wound Monitoring Record is optional for recording skin tears, lacerations, cuts, and abrasion. If the Wound Monitoring Record is not used, documentation will be recorded within then medical record which may include nursing notes, treatment records or care plans. f. Implement a wound treatment per physician's order. g. An assessment of care needs for pressure injury and wound management will be made with emphasis on, but not limited to: i. Identifying Risk Factors ii. Treatment iii. Mechanical offloading and pressure reducing devices iv. Reducing skin friction, sheer, and moisture v. Nutritional status vi. Evaluating and modifying interventions for a resident with an existing PU/PI. B. Record review of R #24's admission Record, no date, revealed the following: 1. R #24 was admitted to the facility on [DATE] 2. R #24 was discharged on 3. R #24 had the following diagnosis: a. Acute Pyelonephritis (a sudden and severe kidney infection. It causes the kidneys to swell and may permanently damage them. Pyelonephritis can be life-threatening). b. Hypothyroidism, unspecified (an abnormally low activity of the thyroid gland, resulting in metabolic changes). c. Type 2 Diabetes Mellitus without complications. C. Record review of R #24's admission Evaluation dated 04/17/26 revealed a small open shearing area on R #24's coccyx (or tailbone, is the small triangular bone at the base of the spine, formed by the fusion of three to five rudimentary vertebrae, serving as an attachment site for muscles, ligaments, and supporting weight while sitting. D. Record review of R #24's physician orders revealed no orders for the small open shearing area on R #24's coccyx. E. Record review of R #24's Treatment Record revealed no treatments for wound care on the small open shearing area on R #24's coccyx. F. Record review of R #24's 5-day MDS assessment, dated 04/23/26 revealed staff did not document the small open shearing area on R #24's coccyx. G. On 06/18/26 at 1:28 PM, during an interview with the Wound Care Nurse (WCN), she stated the following: 1. R #24 did have a shear and blanching tissue on his coccyx area. 2. R #24 had no treatment besides the barrier cream that was not on the orders. R #24 should have had an order for treatment. 3. The WCN did not know why R #24's order did not come in on admission for the shear and blanching tissue on R #24's coccyx area. H. On 06/17/26 at 1:50 PM, during an interview with the DON, she confirmed the following: 1. There was a small shearing area on R #24's coccyx on admission. 2. The admission nurse did not obtain orders for the small open shearing area on R #24's coccyx. 3. Her expectation is for the staff to obtain orders when upon admission of the resident. 4. The admission nurse should have obtained orders for the small open shearing area on R #24's coccyx.

Based on record review and interview, the facility failed to provide infection control training (training that helps staff recognize various infection control prevention to help stop the spread of infections) for 4 (LPN #1, LPN #2, LPN #3 and CNA #1) of 4 (LPN #1, LPN #2, LPN #3 and CNA #1) staff sampled for enhanced barrier precautions (EBP; Infection control measures in nursing homes that require staff to wear gowns and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms [MDRO's bacteria or fungi that are resistant to one or more classes of antimicrobial agents]) training. This deficient practice has the potential to affect all 26 residents in the facility (residents identified by the matrix provided by the administrator on 04/29/26) and could likely result in inadequate infection control, can lead to increased spread of resistant organisms, and risk of infections among residents and staff. The findings are:A. Record review of staff training revealed:No record of EBP training for LPN #1, LPN #2 and LPN #3.No record of EBP training for CNA #1. B. On 05/05/26 at 3:25 PM, during an interview, the Regional Clinical Nurse stated that they do not have access to the training curriculum for LPN #1, LPN #2, LPN #3 and CNA #1 and cannot determine that they received EBP training.

Based on interview and record review the facility failed to have a qualified activity professional to direct an ongoing program of activities for 2 (R #31 and R #59) of 2 (R #31 and R #59) residents sampled for activities, when staff failed to ensure the Activities Director (AD) had the qualifications necessary to perform the duties of an AD. This deficient practice could lead to a less engaging and beneficial program for residents and could negatively impact residents' well-being and quality of life. The findings are: A. Record review of AD personnel file revealed the following:1. A hire date of 11/06/25. 2. Her Resume did not include the following: a. A license or registration as a therapeutic recreation specialist or if she was eligible to become licensed or accredited as a therapeutic recreation specialist. b. Two years of experience in a social or recreational program within the last five years. c. Qualifications of an occupational therapist or occupational therapy assistant. d. Completion of a training course for activities professionals that was approved by the State. B. Record review of the AD Job Description, dated December 2023, revealed qualifications for an AD were: 1. Accreditation as a Certified AD; Completion of a state approved AD training course, 2. Bachelor's degree in recreation therapy or related area. Should be licensed or registered either nationally or by the State in which practicing, 3. One-year experience as an AD in long term care, 4. Two years of experience conducting social/recreational programs within the past five years, one of which was fulltime in a resident activities program in a health care setting. D. On 05/05/26 at 9:25 AM, during an interview, the Administrator stated the following: 1. The AD was recently hired and does not have a license or experience in activities. 2. The AD was scheduled to attend the [name of the state accrediting body] 40-hour course for AD on July 29, 2026. 3. The AD was supervised by the Administrator, and the Corporate AD oversees the AD's work at the facility. E. On 05/06/26 at 12:21 PM, during an interview, the Corporate AD stated the following: 1. She had recently started with the company (she did not give a specific date).2. She was mostly a consultant for the AD. 3. She had never been to the facility.

Based on record review and interview, the facility failed to provide the required discharge or transfer information for 3 (R #38, R #40, and R #57) of 7 (R #15, R #30, R #31, R #38, R #40, R #47, and R #57) residents reviewed for discharges and hospitalizations when staff failed to: 1. Notify R #38, R #40, or R #57 and their representative(s) of the residents' discharge or transfer to the hospital in writing and in a language and manner they understand. 2. Ensure the discharge or transfer notices for R #38, R #40, or R #57 included: a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. b. The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman (an advocate for residents in nursing homes and assisted living facilities).3. Send a written copy of R #38, R #40, or R #57 discharge or transfer notices to the Ombudsman. 4. Ensure R #38 and their representative(s) receive a written notice of the bed hold policy which indicated the duration the bed would be held.5. Ensure staff completed a discharge summary that included a recapitulation of stay, summary of the resident's status, and reconciliation of medications for R #40 and R #57.These deficient practices could likely result in the residents and/or their representatives not knowing the reason for the discharge or transfer, the location of the transfer, their rights to advocate and make informed decisions regarding the residents' healthcare, or not having the most updated information for the resident's care at the time of discharge. The findings are: R #38 A. Record review of R #38's admission Record, no date, revealed R #38 was admitted to the facility on [DATE] and discharged from the facility on 02/09/26. B. Record review of R #38's eInteract Transfer Form, dated 02/09/26, revealed the following: 1. R #38 was sent to the hospital due to chest pain radiating to her left arm. 2. The form did not include: a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. b. The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman. C. Record review of R #38's medical record, no date, revealed staff did not document a Bed Hold Notification for R #38's transfer to the hospital on [DATE]. D. On 05/04/26 at 2:24 PM, during an interview, the DON confirmed the following: 1. R #38 was transferred to the hospital on [DATE]. 2. Staff did not document a transfer notification that included how to appeal the transfer or how to contact the Ombudsman when R #38 transferred to the hospital on [DATE]. 3. Staff did not document a Bed Hold Notification when R #38 transferred to the hospital on [DATE]. 4. Staff were expected to complete a Bed Hold Notification and a Transfer Notification that included how to appeal a transfer and how to contact the Ombudsman whenever residents were transferred or discharged from the facility. R #40 E. Record review of R #40's admission Record, no date, revealed R #40 was admitted to the facility on [DATE] and discharged on 03/14/26. F. Record review of R #40's medical record, no date, revealed the staff did not document following: 1. Discharge notice for R #40. 2. A recapitulation of stay for R #40's discharge on [DATE]. 3. Whether a home health agency was contacted to provide care for R #40. 4. Whether any DME was ordered for R #40. 5. Medications or a list of medications were provided to R #40 at the time of his discharge. 6. If R #40 had any follow-up appointments. G. On 05/01/26 at 1:41 PM, during an interview, the DON confirmed the following: 1. Staff did not provide a discharge notice. 2. Staff did not document a discharge summary that included the following: a. a recapitulation of R #40's stay, b. a final summary of R #40's status, c. a reconciliation of R #40 medications, or d. any follow-up appointments R #57 had. 3. Staff were expected to complete the above information prior to R #40's discharge. R #57 H. Record review of R #57's admission Record, no date, revealed resident was admitted to the facility on [DATE] and discharged on 04/29/26. I. Record review of R #57's medical record, no date, revealed the following: 1. Staff did not document a discharge notice for R #57. 2. Staff did not document when R #57 left the faciity on [DATE], who R #57 left with, or what information was provided to R #57 or her family regarding her discharge on [DATE]. 3. Staff did not document R #57's status when she left the faciity on [DATE]. 4. Staff did not document a recapitulation of stay for R #57's discharge on [DATE]. 5. Staff did not document whether a home health agency was contacted to provide care for R #57. 6. Staff did not document whether any durable medical equipment (DME, medical, therapeutic, or monitoring equipment prescribed by a provider for home use to manage chronic conditions or injuries) was ordered for R #57. 7. Staff did not document whether medications or a list of medications were provided to R #57 or her family at the time of her discharge. 8. Staff did not document whether R #57 had any follow-up appointments. J. On 05/04/26 at 8:59 AM, during an interview, the DON confirmed the following: 1. R #57 discharged from the facility on 04/29/26. 2. She contacted home health to provide care for R #57 after discharge. 3. She did not document information in R #57's medical record regarding home health needs for R #57. 4. Staff did not complete a discharge notice. 5. Staff did not complete a discharge summary that included a recapitulation of R #57's stay, a final summary of R #57's status, a reconciliation of R #57's medications, or any follow-up appointments R #57 had. 6. Staff were expected to complete a discharge notice and discharge summary including a recapitulation of stay, resident status, reconciliation of medications, and any follow-up appointments prior to resident's discharge, and give a copy of the documents to the resident or their representative. 7. She emails a list of residents who were discharged or transferred from the facility to the Ombudsman weekly. 8. She does not send a copy of the discharge or transfer notices to the Ombudsman.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident upon their admission to the facility) within 48 hours of admission for 5 (R #20, R #38, R #46, R #47, and R #49) of 5 (R #20, R #38, R #46, R #47, and R #49) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that may cause harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #20 A. Record review of R #20's admission Record, no date, revealed she was admitted to the facility on [DATE]. B. Record review of R #20's medical record revealed staff did not document a baseline care plan within 48 hours of her admission to the facility. C. On 05/05/26 at 3:50 PM, during an interview, the DON confirmed staff did not document a baseline care plan for R #20 within 48 hours of her admission to the facility and staff should complete a baseline care plan within 48 hours of admission for all residents. R #38 D. Record review of resident's admission Record, no date, revealed resident was admitted to the facility on [DATE] and discharged from the facility on 02/09/26. E. Record review of R #38's medical record, no date, revealed staff did not document a baseline care plan within 48 hours of R #38's admission on [DATE]. F. On 05/04/26 at 2:24 PM, during an interview, the DON confirmed staff did not document a baseline care plan for R #38. Staff were expected to document a baseline care plan within 48 hours of admission for all residents. R #46 G. Record review of R #46's admission Record, no date, revealed she was admitted to the facility on [DATE]. H. Record review of R #46's medical record revealed staff did not document a baseline care plan within 48 hours of her admission to the facility. I. On 05/04/26 at 1:27 PM, during an interview, the DON confirmed staff did not document a baseline care plan for R #46 within 48 hours of her admission to the facility. R #47 J. Record review of R #47's admission Record, no date, revealed R #47 was admitted to the facility on [DATE]. K. Record review of R #47's medical record, no date, revealed staff did not document a baseline care plan within 48 hours of R #47's admission. L. On 05/01/26 at 1:58 PM, during an interview, the DON confirmed staff did not complete a baseline care plan for R #47. The DON stated the baseline care plan should have been completed within 48 hours of admission. R #49 M. Record review of R #49's admission Record, no date, revealed he was admitted to the facility on [DATE]. N. Record review of R #49's medical record revealed staff did not document a baseline care plan within 48 hours of his admission to the facility. O. On 05/04/26 at 2:14 PM, during an interview, the DON confirmed staff did not document a baseline care plan for R #49 within 48 hours of his admission to the facility.

Based on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plans for 8 (R #13, R #15, R #28, R #30, R # 31, R #41, R #54, and R #59) of 8 (R #13, R #15, R #28, R #30, R # 31, R #41, R #54, and R #59) residents reviewed for comprehensive care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents and worsening of the pressure ulcers. The findings are: R #13 A. Record review of R #13's admission Record, no date, revealed R #13 was admitted to the facility on [DATE]. B. Record review of R #13's physician's orders revealed the following orders; 1. Dated 03/15/26 and discontinued 04/13/26, for hydrocodone-acetaminophen (a prescription opioid combination used to treat moderate to severe pain) 5-325 mg every 6 hours PRN for pain. 2. Dated 04/13/26, for hydrocodone-acetaminophen 5-325 mg every 4 hours as needed for pain. 3. Dated 03/16/26 for Lovenox (a prescription low molecular weight heparin (LMWH) injection used to treat and prevent deep vein thrombosis (DVT, a serious condition where a blood clot forms in a deep vein) and pulmonary embolism (PE)) injection 40mg/0.4mL once a day for DVT prophylaxis (to prevent diseases). C. Record review of R #13's admission MDS, dated [DATE], revealed staff documented R #13 was taking the following high-risk medications (drugs with a heightened risk of causing significant patient harm, or even death): 1. Anticoagulants (often called blood thinners, prevent or reduce blood clot formation by interfering with the body's coagulation process). 2. Opioid medication (powerful, regulated pain-relievers used for moderate-to-severe pain). D. Record review of R #13's care plan, dated 03/16/26, revealed staff did not document that R #13 was taking anticoagulant or opioid medications. E. On 05/04/26 at 2:21 PM, during an interview, the DON and Regional Clinical Nurse (RCN) confirmed the following: 1. R #13 had orders for anticoagulants and opioid medications. 2. Anticoagulants and opioid medications were high-risk medications. 3. Staff did not document R #13's anticoagulant or opioid medications on her care plan. 4. Staff were expected to document all high-risk medications on the care plan and include interventions for monitoring the high-risk medications. R #15 F. Record review of R #15's admission Record, no date, revealed she was admitted to the facility on [DATE]. G. On 04/29/2026 at 11:32 AM, during an interview, R #15 stated her plan is to go home with home health services when she is discharged from the facility. H. Record review of R #15's physician orders revealed an order dated 03/31/206: Lantus (long-lasting insulin designed to provide a steady 24-hour release of the medication to help regulate blood sugar levels) inject 15 units subcutaneously (medication given by injection just below the skin) one time daily for diabetes mellitus. I. Record review of R #15's Care Plan revealed the following: 1. Staff did not document R #15's discharge plan. 2. Staff did not document that R #15 was taking insulin. J. On 05/05/26 at 3:33 PM, during an interview, the DON confirmed staff did not document R #15's insulin use or her discharge plan on R #15's care plan. R #28 K. Record review of R #28's admission Record, no date, R #28 was admitted to the facility on [DATE]. L. Record review of R #28's admission Assessment, dated 03/28/26, revealed R #28 had pressure ulcers (localized damage to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony prominences like the hips, heels, or tailbone. They range from stage 1 (discolored skin) to stage 4 (deep crater with bone/muscle exposure)) on his right and left buttocks. M. Record review of R #28's physician's orders revealed the following orders: 1. Dated 03/30/26 and discontinued 04/21/26, for wound care to the bilateral buttocks. 2. Dated 04/21/26, for zinc barrier cream (create a protective, water-resistant layer that shields skin from moisture, chafing, and irritants) to the bilateral buttocks. N. Record review of R #28's care plan, dated 04/14/26, revealed staff did not document that R #28 had pressure wounds on his buttocks or interventions in place to treat or prevent worsening of his wounds. O. On 05/04/26 at 2:48 PM, during an interview, the DON and RCN confirmed the following: 1. R #28 had pressure wounds on his buttocks when he was admitted to the facility. 2. R #28's care plan did not include that he had pressure wounds or any interventions to treat or prevent R #28's pressure wounds from worsening. 3. Staff were expected to document all wounds and interventions to treat or prevent wounds from getting worse in the resident's care plan. R #30 P. Record review of R #30's admission Record, no date, revealed R #30 was admitted to the facility on [DATE]. Q. On 05/01/26 at 1:46 PM, during an interview, R #30 stated that staff had not discussed her discharge plan with her. R. Record review of R #30's order, dated 04/29/26, revealed enhanced barrier precautions (EBP, an infection control intervention) should be worn when providing high contact resident care. S. Record review of R #30's care plan, dated 04/14/26, revealed staff did not document R #30's discharge plan. Staff did not document EBP for R #30. T. On 05/01/26 at 1:46 PM, during an interview with the DON, she stated they don't have an SSD. The DON also stated that not all residents are getting the discharge planning when it is supposed to be done. The DON confirmed staff did not complete R #30's discharge goals or plans in the care plan. The DON confirmed staff did not document interventions for R #30's EBP. R #31 U. Record review of R #31's admission record, no date, revealed R #31 was admitted on [DATE]. V. On 04/29/26 at 10:25 AM, during an interview, R #31 stated the facility didn't have any activities that she liked. W. Record review of R #31's admission MDS, dated [DATE], revealed the following are very important: 1. Having books, newspapers and magazines. 2. Having music. 3. Being around animals. 4. Keeping up with the news. 6. Doing things with groups of people. 7. Doing favorite activities. 8. Going outside to get fresh air. 9. Participating in religious services. X. Record review of R #31's physician's order, dated 04/11/26, revealed an order to weigh R #31 weekly for four weeks, and monthly after that. Y. Record review of R #31's care plan, dated 04/14/26, revealed staff did not document R #31's activity preferences or to monitor weight as ordered. Z. On 05/01/26 at 2:00 PM, during an interview, the DON confirmed that staff did not complete R #31's activity preferences or weekly weights in her care plan. The DON stated that staff should have care planed them for R #31. R #41 AA. Record review of R #41's admission Record, no date, revealed he was admitted to the facility on [DATE]. BB. Record review of R #41's Nursing Progress notes revealed the following: 1. Skilled evaluation note, dated 02/02/26, edema present to bilateral lower extremities (BLE), mild pitting (occurs when excess fluid accumulates most commonly in the legs, feet, and ankles leaving a visible indentation [pit] when pressure is applied to the area), slight indentation. 2. Skilled evaluation note, dated 02/07/26, edema present BLE, ankles, feet, deep pitting (edema in which pressing on a swollen area produces a deep indentation that takes a long time to refill. Clinically, it is graded as 3+ or 4+ meaning the dent is noticeably deep [four to 6 millimeters or more] and persists for several seconds to minutes), indentation remains for a short time, leg looks swollen. 3. Skilled evaluation note, dated 02/12/26, edema present BLE, moderate pitting (typically corresponds to a two to four millimeter indentation that disappears within 10–25 seconds and is deeper than mild edema but not as severe as grades +3 or +4, which involve deeper pits and longer refill times), indentation subsides rapidly. 4. Skilled evaluation note, dated 02/14/26, edema present BLE, mild pitting, slight indentation. 5. Skilled evaluation note, dated 02/21/26, edema present BLE, ankles, feet, moderate pitting, indentation subsides rapidly. 6. Skilled evaluation note, dated 02/22/26, edema present BLE, ankles, feet, moderate pitting, indentation subsides rapidly. 7. Skilled evaluation note, dated 02/28/26, edema present BLE, ankles, feet, deep pitting, indentation remains for a short time, leg looks swollen. 8. Skilled evaluation note, dated 03/01/26, edema present BLE, ankles, feet, deep pitting, indentation remains for a short time, leg looks swollen. CC. Record review of R #41's Physician's Progress notes revealed the following: 1. Encounter note, date of service 02/03/26: +4 (the most severe grade of pitting edema, characterized by very deep swelling that lasts more than 2–5 minutes and causes gross distortion of the affected area) pretibial edema (swelling in the front part of the lower legs, just over the shin bones, caused by fluid accumulation in the tissues). 2. Encounter note, date of service 02/04/26: Patient with severe dependent edema (serious form of swelling where excess fluid accumulates in the lower body due to impaired circulation, often worsened by gravity) patient is refusing to elevate legs DD. Record review of R #41's Care Plan revealed that staff did not document resident's edema and his refusal to elevate legs. EE. On 05/05/26 at 3:30 PM, during an interview, the DON confirmed staff did not document R #41's edema and refusal to elevate legs on his care plan. She stated that it should be documented on the care plan due to being a significant medical issue for R #41. R #54 FF. Record review of R #54's admission Record, no date, revealed R #54 was admitted to the facility on [DATE]. GG. On 04/29/26 at 11:01 AM, during and observation and interview, the following was revealed: 1. An oxygen concentrator (a medical device that filters ambient air, providing a 90%–95% concentrated oxygen supply for patients with low oxygen levels) was sitting next to R #54's bed. 2. R #54 said she used oxygen when she lays down in bed. HH. Record review of R #54's Convalescent Care Orders (written orders for admission to a nursing facility, detailing necessary therapies (e.g., physical therapy), medications, and wound care), dated 04/15/26, revealed an order for oxygen by nasal cannula (a lightweight, flexible device used to deliver supplemental oxygen) PRN. II. Record review of R #54's admission MDS Assessment, dated 04/24/26, revealed staff documented R #54 used oxygen intermittently (at irregular intervals). JJ. Record review of R #54's care plan, dated 04/24/26, revealed staff did not document that R #54 uses oxygen or any interventions in place for R #54's oxygen use. KK. On 05/05/26 at 9:58 AM, during an interview, the DON and RCN confirmed the following: 1. R #54 used oxygen at night. 2. Staff did not document R #54's oxygen use on her care plan. 3. Staff were expected to document oxygen use and any interventions for oxygen use in resident care plans. R #59 MM. Record review of R #59's admission record, no date, revealed R #59 was admitted on [DATE]. NN. On 04/29/26 at 11:07 AM, during an interview, R #59 stated he went to dialysis. OO. Record review of R #59's care plan, dated 04/28/26, revealed staff did not document where and how often R #59 received dialysis. PP. On 04/30/26 at 2:56 PM, during an interview, the DON confirmed staff did not document where or when R #59 went to dialysis. The DON confirmed the care plan should document R #59's dialysis information.

Based on record review and interview, the facility failed to ensure care plan revisions occurred for 3 (R #13, R #28, and R #57) of 9 (R #13, R #15, R #28, R #30, R # 31, R #41, R #54, R #57, and R #59) residents reviewed for care plan accuracy, when staff failed to:1. Ensure the IDT members participated in a care plan meeting within 7 days of the completion of the admission MDS assessment for R #13, R #28, and R #57.2. Revise R #13's care plan with the most current resident information. These deficient practices could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: Timing of IDT MeetingR #13A. Record review of R #13's admission Record, no date, revealed R #13 was admitted to the facility on [DATE]. B. On 04/29/26 at 2:24 PM, during an interview, R #13 stated she had not attended an IDT meeting to discuss her care plan. C. Record review of R #13's admission MDS Assessment, dated 03/17/26, revealed the assessment was completed on 03/25/26. D. Record review of R #13's medical record, no date, revealed staff did not document that an IDT meeting was held to discuss R #13's status and care plan. E. On 05/04/26 at 2:18 PM, during an interview, the DON and Regional Clinical Nurse (RCN) confirmed the following:1. R #13's admission MDS Assessment was completed on 03/25/26.2. An IDT meeting was not conducted to discuss R #13's status and care needs.3. Staff were expected to have an IDT meeting to discuss resident care and update care plans within 7 days of the completion of the admission MDS. R #28F. Record review of R #28's admission Record, no date, revealed R #28 was admitted to the facility on [DATE]. G. On 04/30/26 at 9:25 AM, during an interview, R #28 stated he had not attended an IDT meeting to discuss his care plan. H. Record review of R #28's admission MDS Assessment, dated 03/31/26, revealed staff completed the MDS assessment on 04/14/26. I. Record review of R #28's medical record, no date, revealed staff did not document that an IDT meeting was held to discuss R #28's status and care plan. J. On 05/04/26 at 2:38 PM, during an interview, the DON and RCN confirmed the following:1. R #28's admission MDS Assessment was completed on 04/14/26.2. An IDT meeting was not conducted to discuss R #28's status and care needs. R #57K. Record review of R #57's admission Record, no date, revealed R #57 was admitted to the facility on [DATE] and was discharged on 04/29/26. L. On 04/29/26 at 11:36 AM, during an interview, R #57's Family Member (FM) stated he had not attended an IDT meeting to discuss R #57's care plan. M. Record review of R #57's admission MDS Assessment, dated 04/10/26, revealed staff completed R #57's MDS on 04/21/26. N. On 05/04/26 at 3:54 PM, during an interview, the DON and RCN confirmed the following:1. R #57's admission MDS Assessment was completed on 04/21/26.2. An IDT meeting was not conducted to discuss R #57's status and care needs. RevisionsR #13O. Record review of R #13's provider progress notes revealed the following:1. On 04/17/26 the provider documented that R #13 had an appointment for a Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) placement on 04/23/26.2. On 04/24/26 the provider documented that R #13 had a PEG tube in place. P. Record review of R #13's physician's orders revealed an order dated 04/29/26, for Enhanced Barrier Precautions (EBP, an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as dressing, bathing, or wound care) related to PEG tube. Q. Record review of R #13's care plan, revised 04/29/26, revealed staff did not revise R #13's to include that staff were expected to follow EBP when providing high contact care for R #13 after R #13's PEG tube was placed. R. On 05/05/26 at 9:54 AM, during an interview, the DON confirmed the following:1. R #13 had a PEG tube placed while she was a resident.2. R #13 should have been on EBP after she returned to the facility with a PEG tube.3. Staff did not document in R #13's care plan that staff were to follow EBP when providing high-contact care for R #13.4. Staff were expected to revise resident care plans to include EBP.

Recite from complaint survey on [DATE]Based on record review and interview, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 3 (R #30, R #31, and R #46) of 3 (R #30, R #31, and R #46) residents reviewed for code status, when they failed immediately document R #30's, R #31's, and R #46's code status in their medical record. This deficient practice is likely to delay potentially lifesaving measures if staff are not immediately aware of residents' preferences for resuscitation. The findings are:R #30 A. Record review of R #30's admission Record, no date, revealed R #30 was admitted to the facility on [DATE]. B. Record review of R #30's Convalescent Care Orders (CCO specialized, short-term medical instructions provided by a physician), dated [DATE], revealed full code status. C. Record review of R #30's physicians orders, dated [DATE], revealed R #30's full code status was not documented in the R #30's medical record until four days after admission. R #31 D. Record review of R #31's admission Record, no date, revealed R #31 was admitted to the facility on [DATE]. E. Record review of R #31's CCO, dated [DATE], revealed full code status. F. Record review of R #31's physicians orders, dated [DATE], revealed R #31's full code status was not documented in the R #31's medical record until two days after admission. G. On [DATE] at 11:10 AM, during an interview, the DON confirmed R #30's and R #31's code status was documented in their CCO. The DON confirmed their code status was not documented in their medical record upon admission. The DON stated the code status should be verified upon admission and documented in the medical record. R #46 H. Record review of R #46's admission record, no date, revealed she was admitted to the facility on [DATE]. E. Record review of R #46's CCO's revealed resident was a full code status. F. Record review of R #46's physicians orders revealed an order dated [DATE] for R #46's full code status. The order was not entered in the resident's medical record until two days after admission. G. On [DATE] at 3:44 PM, during an interview, the DON confirmed R #46's code status was documented in their CCO's. The DON confirmed their code status order was not entered in the medical record until two days after admission.

Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 2 (R #31 and R #59) of 2 (R #31 and R #59) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: R #31 A. Record review of R #31's admission Record, no date, revealed an admission date of 04/04/26. B. On 04/29/26 at 10:25 AM, during an interview, R #31 stated there were not any activities that she was interested in. R #31 stated that there were not any church services at all. C. Record review of R #31's Annual MDS assessment dated [DATE] revealed the following activity preferences are very important: 1. Having books, newspapers and magazines. 2. Having music. 3. Being around animals. 4. Keeping up with the news. 5. Doing things with groups of people. 6. Doing favorite activities. 7. Going outside to get fresh air. 8. Participating in religious services. D. Record review of R #31's care plan dated 04/14/26 revealed R #31's care plan did not include her personal preferences from the Annual MDS Assessment. R #59E. Record review of R #59's admission record, no date, revealed he was admitted on [DATE]. F. On 04/29/26 at 11:07 AM, during an interview, R #59 stated he had not been made aware of activities in the facility. R #59 is Spanish speaking only. G. On 04/30/26 at 2:14 PM, during an interview, the AD stated she does activities at 9:30 AM and 2:00 PM. She stated at 9:30 AM, she will pass out the daily chronicle which includes puzzles and coloring pages. The AD stated that she prints them in Spanish also. The AD stated at 2:00 PM, they do a big activity. The AD stated she will do crafts, go outside, or play BINGO. The AD stated she does an assessment at admission with each resident. The AD stated that a church group goes to the facility once a month. The AD stated she plans themed activities based on current events. The AD stated that she does not plan activities based on assessments, but if a resident told her they would like to do something, she tries to get it done. The AD stated there are not any evening or weekend activities. The AD stated she provides the chronicles for residents on the weekends. The AD does not speak Spanish or have activity staff that speak Spanish.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #13, R #38 and R #57) of 5 (R #13, R #20, R #38, R #54 and R #57) residents reviewed for accuracy of documentation, when staff failed to: 1. Document information when R #13 left the facility to have a Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) tube placed and after she returned from having a PEG tube inserted. 2. Document administration of R #13's enteral feedings and residual amounts.3. Thoroughly document information for circumstances leading R #38 to be transferred to the hospital on [DATE].4. Document information regarding R #57's discharge from the facility. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: R #13A. Record review of R #13's admission Record, no date, revealed R #13 was admitted to the facility on [DATE]. B. Record review of R #13's hospital discharge documents, dated 04/21/26, revealed R #13 had a PEG tube inserted and was able to start using PEG tube for feeding and medications at 3:40 PM on 04/21/26. C. Record review of R #13's physician's orders revealed the following:1. An order dated 04/23/26, for staff to hold tube feeding for resident care and activities for up to 4 hours a day. Document how long the tube feeding was held. 2. An order dated 04/23/26, for continuous enteral feedings and water flushes for 20 hours a day. 3. An order dated 04/23/26, to document total enteral feed volume infused every 24 hours. 4. An order dated 04/23/26, to document residual volume before medication administration. Hold feeding and notify the provider if residual volume is greater than 60 mL. D. On 04/29/26 at 2:25 PM, an observation of R #13 revealed the following:1. R #13 had a feeding pump with formula hanging next to the bed.2. R #13's feeding pump was off and not connected to R #13's PEG tube. E. On 04/30/26 at 11:59 AM, during an observation and interview with R #13, the following was revealed:1. R #13 stated she had her PEG for a couple of weeks (could not recall the date).2. R #13 stated staff administer feedings through the PEG tube twice a day.3. R #13 stated she was not sure how long she was supposed to be connected to the feeding pump every day. 4. R #13 was not connected to the feeding pump. F. On 04/30/26 observations of R #13 revealed the following:1. At 1:38 PM, R #13 was observed sitting at common area table. R #13 was not connected to feeding tube. 2. At 3:14 PM, R #13 was observed in bed and was connected to feeding pump. G. On 05/01/2026 observations of R #13 revealed the following:1. At 8:25 AM, R #13 was observed eating breakfast in the dining room. R #13 was not connected to feeding pump. 2. At 12:05 PM, R #13 was observed sitting at the table in the common area. R #13 was not connected to the feeding pump. H. Record review of R #13's Administration Record, dated April 2026, revealed staff did not document the following:1. R #13's enteral feeding administration and water flushes on the following dates and times: a. 04/23/26 in the afternoon or evening b. 04/24/26 in the morning, afternoon, or evening c. 04/25/26 in the evening d. 04/26/26 in the evening e. 04/27/26 in the morning, afternoon, or evening f. 04/28/26 in the morning, afternoon, or evening g. 04/29/26 in the morning, afternoon, or evening h. 04/30/26 in the morning, afternoon, or evening3. R #31's total enteral feed volume infused between 04/23/26 to 04/30/26.4. Checking R #13 residual volume on the following dates: a. 04/24/26 b. 04/27/26 c. 04/28/26 d. 04/29/26 e. 04/30/26 I. Record review of R #13's medical record, no date, revealed staff did not document the following:1. When R #13 left the facility to have a PEG tube inserted.2. When R #13 arrived at the facility after having PEG tube inserted.3. An assessment of R #13's status after PEG tube was inserted.4. How long R #13's enteral feeding was held each day.5. The residual volume R #13 had each day. J. On 05/01/26 at 12:49 PM, during an interview, LPN #16 confirmed the following:1. She disconnected R #13 from the feeding pump in the mornings and reconnected her to the feeding pump after lunch.2. She did not document in R #13's medical record how long R #13 was disconnected from her enteral feedings.3. She was unable to determine how much enteral feed volume R #13 had received each day since R #13 received her feeding tube on 04/21/26.4. She was unable to determine how long R #13's enteral feedings had been held each day since she received her feeding tube on 04/21/26.5. She checked R #13's residual volume before reconnecting her to the feeding pump.6. She did not document in R #13's medical record that R #13's residual volume was checked or the amount of residual volume R #13 had.7. R #13 had orders to be connected to the feeding pump for 20 hours a day.8. R #13 had orders to check R #13's total enteral feed volume each day.9. R #13 had orders to check R #13's residual volume with medications. K. On 05/04/26 at 1:51 PM, during a joint interview with the DON, Dietitian, and Regional Clinical Nurse , the following was confirmed:1. Staff did not document R #13's enteral feeding administrations, volumes, or residuals as ordered.2. Staff were expected to document resident enteral feeding administration, volumes, and residuals.3. Staff did not document how long R #13 was off the feeding pump daily. 4. Staff were expected to document how much time R #13 was off the feeding pump daily. R #38L. Record review of R #38's admission Record, no date, revealed resident was admitted to the facility on [DATE] and discharged from the facility on 02/09/26. M. Record review of R #38's eInteract Transfer Form, dated 02/09/26, revealed R #38 was sent to the hospital due to chest pain rated at a 10 and radiating to resident's left arm. N. Record review of R #38's medical record, no date, revealed staff did not document:1. Situation leading to R #38 being transferred to the hospital on [DATE].2. Who was contacted regarding R #38's chest pain.3. Who was notified that R #38 was transferred to the hospital. O. On 05/04/26 at 2:24 PM, during an interview, the DON confirmed the following:1. R #38 went to the hospital on [DATE] due to chest pain.2. Staff did not document in the medical record regarding the situation that let R #38 to be sent to the hospital, who ordered for R #38 to be sent to the hospital, or who was notified that R #38 was sent to the hospital.3. Staff were expected to document a change in condition progress note that included the what the change in condition was, what provider was contacted and any orders that were received, and who was notified about the resident's situation and transfer to the hospital. R #57P. Record review of R #57's admission Record, no date, revealed R #57 was admitted to the facility on [DATE] and discharged on 04/29/26. Q. Record review of R #57 medical record, no date, revealed staff did not document the following:1. When R #57 discharged from the facility.2. R #57's status at the time of discharge.3. Who R #57 discharged with.4. Any education that was provided to R #57 or her family.5. Any medication or equipment that was sent with R #57 when she discharged . R. On 05/04/26 at 8:59 AM, during an interview, the DON confirmed the following:1. R #57 discharged on 04/29/26.2. She was unable to determine what time R #57 left the facility, who R #57 was discharged with, if any medications or equipment was sent with R #57, or what education was provided to R #57 or her family.3. Staff were expected to document information regarding resident discharge in the medical record.4. Staff were expected to document resident status, who resident discharged with, what medications or equipment were provided, and any education provided at discharge.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program for 4 (R #13, R #30, R #49, and R #54) of 5 (R #13, R #28, R #30, R #49, and R #54) residents reviewed for Transmission Based Precautions (additional infection control measures used in healthcare settings alongside Standard Precautions. They prevent the spread of known or suspected pathogens) when staff failed to:EBP A. Record Review of the [Name of Federal Agency] Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: 1. MDRO transmission is common in long term care (LTC) facilities. 2. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. a. Examples of high-contact care activities include: i. Dressing ii. Bathing/showering iii. Transferring iv. Changing linens v. Providing hygiene vi. Changing briefs or assisting with toileting vii. Device care or use: Central line, urinary catheter, feeding tube, or tracheostomy viii. Wound Care: any skin opening requiring a dressing 3. EBP are indicated for residents with wounds or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. R #13 B. Record review of R #13's admission Record, no date, revealed R #13 was admitted to the facility on [DATE]. C. review of R #13's physician's orders revealed an order dated 04/29/26, for Enhanced Barrier Precautions (EBP, an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as dressing, bathing, or wound care) related to Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly). D. On 04/29/26 at 2:25 PM, an observation and interview with R #13, revealed the following: 1. R #13 had a feeding pump with formula hanging next to the bed. 2. R #13's stated she had a feeding tube. 3. An EBP sign was on R #13's door. 4. PPE was located outside the room next to R #13's room (about 8 feet away from R #13's door). 4. R #13 stated staff did not wear a gown when transferring her to her wheelchair, showering her, or connecting her enteral feedings to her feeding tube. R #30 E. Record review of R #30's admission record, no date, revealed R #30 was admitted to the facility on [DATE]. F. Record review of R #30's physician's orders revealed the following: 1. An order dated 04/29/26, EBP related to an open wound to the right foot. 2. An order dated 04/05/26 for daptomycin (used to treat serious infections caused by gram-positive bacteria, including MRSA), intravenous 500 mg, use 993 mg intravenously one time a day for osteomyelitis (serious infection and inflammation of the bone). G. On 04/29/26 at 12:15 PM, during an observation of R #30's room, revealed the following: 1. An EBP sign was observed on the wall next to R #30's room. 2. PPE was not observed to be located outside R #30's room. H. On 04/29/26 at 12:15 PM, during an interview, the IP confirmed the following: 1. She had placed the EBP sign near R #30's room earlier that day. 4. There was no PPE located outside R #30's room. 5. R #30 should have had an EBP sign and PPE since she was admitted . I. On 04/29/26 at 12:45 PM, during an observation and interview with R #30, revealed an intravenous stand next to her bed. R #30 stated she had an infection and took IV antibiotics for the infection. R #30 stated that staff wear gloves when they are administering her IV antibiotics. R #30 stated staff did not wear gowns. R #30 stated when staff provide wound care they wear gloves and a mask but do not wear gowns. R #49 J. Record review of R #49's admission Record, no date, revealed R #54 was admitted to the facility on [DATE]. K. Record review of R #49's nursing admission evaluation dated 04/23/26 revealed the following: Urinary section: Foley catheter intact draining reddish urine. Skin integrity section: resident has a wound dressing in place to left great toe. L. Record review of R #49's physician's orders revealed that staff did not document an order for EBP. M. On 04/29/26 during an interview with CNA #1 she stated the following: 1. She is the CNA working with R #49. 2. He is not on EBP at this time. 3. If someone is on EBP there are signs on their door and PPE outside of the room. 4. She confirmed R #49 did not have a sign on his door and no PPE was set up for staff to use when caring for him. R #54 N. Record review of R #54's admission Record, no date, revealed R #54 was admitted to the facility on [DATE]. O. Record review of R #13's physician's orders revealed an order dated 04/29/26, for Enhanced Barrier Precautions (EBP, an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as dressing, bathing, or wound care) related to Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly). P. On 04/29/26 at 10:52 AM, an observation and interview with R #54, revealed the following: 1. She had Peripherally Inserted Central Catheter (PICC line, a thin, flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart for long-term intravenous (IV) treatment) so staff could give her antibiotics due to an infection on her foot. 2. There was no EBP sign observed on R #54's door or outside her door. 3. There was no PPE located outside R #54's door. 4. R #54 stated staff did not wear a gown when administering antibiotics through her PICC line or changing her catheter. Q. On 04/29/26 at 12:15 PM, an observation and interview with the Infection Preventionist (IP), revealed the following: 1. An EBP sign was observed on the wall next to R #54's room. 2. PPE was not observed to be located outside R #54's room. 3. The IP confirmed she had placed the EBP sign near R #54's room earlier that day. 4. The IP confirmed there was no PPE located outside R #54's room. 5. The IP confirmed R #54 should have had and EBP sign and PPE since she was admitted . R. 04/29/26 between 12:33 PM and 12:41 PM, an observation of R #54's room, revealed the following: 1. The ADON entered R #54's room wearing a mask and gloves. 2. The ADON was not wearing when he entered R #54's room. 3. The ADON exited R #54's room at 12:41. He was wearing a mask and gloves. 4. The ADON was not wearing a gown when he exited R #54's room. S. On 04/29/26 at 12:45 PM, during an interview, R #54 stated the following: 1. The ADON changed the dressing on her PICC line. 2. The ADON wore gloves and a mask when changing the dressing on her PICC line. 3. The ADON did not wear a gown when changing the dressing on her PICC line. T. On 05/04/26 at 10:53 AM, during an interview, the IP confirmed the following: 1. An EBP sign and PPE should be placed outside the rooms of all residents who have wounds, foley catheters, or PICC lines. 2. Staff were expected to wear a gown and gloves whenever they have close contact with resident's on EBP. 3. Close contact included transferring residents, changing residents, showering residents, performing wound care, or handling indwelling devices including foley catheters and PICC Lines. Nasal Cannula R #54 U. On 04/29/26 at 11:01 AM, during and observation and interview, the following was revealed: 1. An oxygen concentrator (a medical device that filters ambient air, providing a 90%–95% concentrated oxygen supply for patients with low oxygen levels) was sitting next to R #54's bed. 2. R #54 said she used oxygen when she lays down in bed. 3. R #54's nasal cannula did not have a date indicating when it was last changed. 4. R #54 was not sure when her nasal cannula was last changed. V. On 04/29/26 at 11:24 AM, during an interview, the ADON confirmed the following: 1. R #54's nasal cannula did not have a date when it was last changed. 2. He was unable to determine when R #54's nasal cannula was changed. 3. Staff were expected to change all nasal cannulas on Sunday evenings. 4. Staff were expected to label the nasal cannula with the date it was changed.

Based on record review and interview, the facility failed to ensure the MDS was accurate for 1 (R #15) of 7 (R #13, R #15, R #28, R #30, R #31, R #41 and R #57) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #15's admission Record, no date, revealed she was admitted to the facility on [DATE]. B. Record review of R #15's physician orders revealed an order dated 03/31/26: Lantus (long-lasting insulin designed to provide a steady 24-hour release of the medication to help regulate blood sugar levels) inject 15 units subcutaneously (medication given by injection just below the skin) one time daily for diabetes mellitus. D. Record review of R #15's admission MDS assessment dated [DATE] revealed the following: 1. Under the insulin section of the MDS, staff documented R #15 received insulin for the previous two days since her admission to the facility. 2. Under the high-risk drug classes of the MDS staff did not document that R #15 was receiving insulin. E. On 05/05/26 at 4:26 PM, during an interview, with the MDS Coordinator she confirmed that R #15 was receiving insulin and that staff should have documented the insulin on the high-risk drug section of the MDS.

Based on interview and record review, the facility failed to ensure that residents were aware of the process to file a grievance for 1 (R #30) or 1 (R #30) resident sampled for missing items. If the facility does not ensure that residents know how to file grievances, then residents are likely to feel that their issues and/or concerns are not taken seriously. The findings are: A. On 04/29/26 at 12:38 PM, during an interview, R #30 stated staff did not tell her how to file a grievance. B. On 05/01/26 at 10:06 AM, during an interview with the Administrator, he stated the grievance process is gone over during resident council meetings. The Administrator stated if residents do not go to resident counsel that SSD will go over how to file a grievance with the resident. The Administrator stated the facility does not currently have an SSD. The Administrator stated if a resident tells staff they are missing items, he would talk to the resident and file a grievance for them. C. On 05/01/26 at 10:23 AM, during an interview, the AD stated she thought she was supposed to file grievances for the residents. The AD stated if a resident told her they had a missing item she would let them know she would file a grievance for them. The AD stated she had not gone over how to file a grievance during resident council or with residents individually.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #28 and R #54) of 5 (R #13, R #15, R #28, R 46, and R #54) residents reviewed for unnecessary medications, when staff failed to ensure PRN psychotropic medications were not prescribed for longer than 14 days without a written rationale from the provider. This deficient practice could likely result in residents receiving medications longer than needed without a rationale from the provider causing a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #28A. Record review of R #28's admission Record, no date, revealed R #28 was admitted to the facility on [DATE]. B. Record review of R #28's physician's order, dated 04/27/26, revealed an order for alprazolam (a psychotropic medication used to treat anxiety disorder) 1 mg every 8 hours PRN for anxiety/agitation. The order did not have an end date. C. Record review of R #28's medical record, no date, revealed the provider did not document a clinical rationale for why R #28 needed PRN alprazolam for longer than 14 days. D. On 05/04/26 at 2:50 PM, during an interview, the DON and Regional Clinical Nurse (RCN) confirmed the following:1. R #28 had an order for alprazolam 1 mg PRN.2. R #28's PRN alprazolam order was ordered indefinitely.3. R #28's medical record did not have a rationale from the provider for why he needed PRN alprazolam longer than 14 days. R #54E. Record review of R #54's admission Record, no date, revealed R #54 was admitted to the facility on [DATE]. F. Record review of R #54's physician's order, dated 04/22/26, revealed an order for alprazolam 0.25 mg PRN every 24 hours at bedtime for anxiety. The order did not have an end date. G. Record review of R #54's medical record, no date, revealed the provider did not document a clinical rationale for why R #54 needed PRN alprazolam for longer than 14 days. H. On 05/05/26 at 10:08 AM, during an interview, the DON and RCN confirmed the following:1. R #54 had an order for PRN alprazolam 0.25 mg.2. R #54's PRN alprazolam order was ordered indefinitely.3. R #54's medical record did not have a rationale for why she needed PRN alprazolam longer than 14 days.4. Staff were expected to ensure PRN psychotropic medications were not ordered for longer than 14 days without a clinical rationale documented in the medical record by the provider.

Based on record review and interview, the facility failed to implement an effective discharge planning process for 2 (R #40 and R #57) of 6 (R #15, R #30, R #31, R #40, R #47, and R #57) residents reviewed for discharge, when staff failed to: 1. Conduct IDT discharge planning for R #40 and R #57. 2. Update comprehensive care plans and discharge plans with treatment preferences and needs for R #40 and R #57.3. Document a discharge plan of care that included treatment preferences and needs for R #57. These failures have the potential for unsafe discharge and an increased risk of resident harm. The findings are: R #40 A. Record review of R #40's admission Record, no date, revealed R #40 was admitted to the facility on [DATE] and discharged on 03/14/26. B. Record review of R #40's progress note, dated 03/14/26, revealed R #40 was insistent on going home. The provider was notified and gave approval for R #40 to be discharged . C. Record review of R #40's care plan, dated 03/03/26, revealed staff did not document a discharge plan for R #40. D. Record review of R #40's Discharge MDS, dated [DATE], revealed staff documented R #40 discharged from the facility on 03/14/26. E. Record review of R #40 medical record, no date, revealed the following: 1. Staff did not document R #40's discharge plans. 2. Staff did not document conversations with R #40 regarding discharge plans. 3. Staff did not document a post discharge plan of care for R #40. F. On 05/01/26 at 1:41 PM, during an interview, the DON confirmed staff did not have R #40's discharge plan. The DON confirmed staff did not conduct an IDT meeting with R #40 to plan for discharge. The DON confirmed that staff should complete discharge plans in the care plan. The DON stated discharge planning should start on admission. R #57 G. Record review of R #57's admission Record, no date, revealed R #57 was admitted to the facility on [DATE] and discharged on 04/29/26. H. On 04/29/26 at 11:36 AM, during an interview, R #57's Family Member (FM) stated the following: 1. Staff asked him to go to the facility on [DATE] for a meeting to discuss R #57 care. 2. When he arrived 04/21/26, there were no staff available for the meeting. 3. He went to the facility on [DATE] and the DON and Business Office Manager (BOM) told him R #57's insurance wouldn't cover her care at the facility after 04/27/26. 4. The DON and BOM told him R #57 could stay if he agreed to pay $217 per day. 5. Staff had not met with him to discuss discharge plans or what was needed for R #57 to have a safe discharge home. 6. He could have gotten things ready at home if staff had notified him earlier about when R #57 would need to be discharged . 7. He was going to pick R #57 up from the facility at 5:00 PM on 04/29/26. I. Record review of R #57's care plan, revised 04/17/26, revealed staff did not document a discharge plan for R #57. J. Record review of R #57's medical record, no date, revealed the following: 1. Staff did not document R #57's discharge plans. 2. Staff did not document conversations with R #57 or her family regarding discharge plans. 3. Staff did not document a post discharge plan of care for R #57. K. On 05/04/26 at 8:59 AM, during an interview, the DON confirmed the following: 1. R #57 was supposed to have a care plan meeting on 04/21/26 to discuss discharge plans. 2. The Social Services Worker was not at the facility on 04/21/26 and they did not have a care plan meeting for R #57. 3. R #57's FM came to the facility on [DATE] and was told R #57's last day for insurance to fully cover R #57's care would be 04/28/26 (contradicting R #57's FM, see finding H). 4. R #57's FM said he would pick her up on 04/28/26. 5. On 04/28/26, R #57's FM was unable to pick R #57 up but said he would pick her up in the evening on 04/29/26. 6. An IDT meeting did not take place to discuss R #57's discharge. 7. Discharge planning began upon admission. 8. Staff did not document R #57's discharge plans in R #57's care plan. 9. Staff were expected to have an IDT meeting with the residents and their families to make plans for a safe discharge. 10. Staff were expected to document discharge plans in the resident's care plan.

Based on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #28) of 3 (R #15, R #28, and R #41) residents reviewed for pressure ulcers. This deficient practice could likely result in residents' needs not being met. The findings are: A. Record review of R #28's admission Record, no date, revealed R #28 was admitted to the facility on [DATE]. B. Record review of R #28's admission MDS Assessment, dated 03/31/26, revealed staff completed the MDS on 04/14/26 (not within 14 days of resident's admission on [DATE]). C. On 05/04/26 at 2:48 PM, during a joint interview, the DON and Regional Clinical Nurse confirmed R #28's admission MDS Assessment was not completed within 14 days of his admission on [DATE]. Staff were expected to complete admission MDS Assessments within 14 days of admission.

Based on record review and interview, the facility failed to complete and transmit an MDS assessment after discharge for 1 (R #4) of 1 (R #4) residents reviewed for MDS assessment. This failed practice could lead to the facility not reporting information in a timely manner (within 14 days) to the Federal Agency. The findings are: A. Record review of R #4's admission Record, no date, revealed R #4 was admitted to the facility on [DATE] and discharged from the facility on 12/06/25. B. Record review of R #4's medical record, no date, revealed staff did not document a Discharge MDS Assessment after R #4 discharged from the facility on 12/06/25. C. On 05/04/26 at 2:55 PM, during a joint interview, the DON and Regional Clinical Nurse confirmed the following:1. R #4 was discharged from the facility on 12/06/25.2. R #4's medical record did not have a Discharge MDS Assessment. 3. Staff were expected to complete a Discharge MDS Assessment after residents were discharged from the facility.

Based on record review and interview, the facility failed to develop a comprehensive care plan for 2 (R#1 and R #2) of 4 (R #1, R#2, R#3, and R#4) residents reviewed for incidents when they failed to 1) care plan for the use anticoagulant medications (blood thinner medications that can put a resident at risk for bleeding) and 2) care plan for appropriate transfers. This deficient practice resulted in lack of monitoring the residents for side effects of the medication and improper transfers which resulted in bruising and hemorrhage. The findings are: R #1 A. Record review of R #1's face sheet revealed an admission date of [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. B. Record review of order summary report for R #1 with a date range of 02/14/17 to 03/13/17 revealed the following medications: [REDACTED]. C. Record review of R #1's Medication Administration Records (MAR) for February 2017 and March of 2017 revealed both aspirin 81 mg, one time a day and Xarelto tablet 10 mg, 1 tablet by mouth one time a day, were given daily starting on 02/14/17. D. On 04/10/17 at 8:00 am, during an interview, R #1's family member stated, The day she got a gash on her neck . When I walked in her room, she was bleeding . She would get bruises under her arms and around her chest . She bruises easily. It's the way they tried to pick her up out of the wheelchair . They would try to pick her up under her arms . (Name of R #1) does not remember a bit of this; she still does not remember. E. On 04/05/17 at 11:50 am, during interview, LPN #1 stated, They used a Hoyer lift (mechanical patient lift) because (name of R #1) would not help. F. On 04/05/17 at 12:49 pm, during interview, when asked how R #1 gets transferred, the DON stated, Sara lift (mechanical standing and raising aid). She wanted the staff to do the transfers themselves - we do not do two-man transfer. She was not a one-person transfer . She was unpredictable with her legs. G. Record review of assessments skilled note dated 03/02/17 revealed, Sara lift with transfer, toileting and bed mobility. H. Record review of Lift Transfer Reposition assessment dated [DATE] revealed R #1 is not able to tranfer independently or with supervison without using a device. I. On 04/05/17 at 2:20 pm, during interview, CNA #2 confirmed giving R #1 a shower on 03/13/17 and revealed the Physical Therapist (PT) helped transfer R #1 to the shower chair and CNA #1 helped transfer R #1 from the chair to the bed using a gate belt. CNA stated, We both got her from the arms and transferred her . Lifted her with a gate-belt and put her in bed . When we used a Sara lift, (name of R #1) would slide right off . PT told us (name of R #1) was able to sit and stand, just give her a walker . I used a Sara lift about 4 days prior to her leaving the facility (Name of R #1) refused a Hoyer lift. J. On 04/05/17 at 3:10 pm during interview, the PT stated, Me and CNA #2 transferred (name of R #1) a handful of times . We would do a stand and pivot transfer using a walker . I never used a Sara lift or a Hoyer . Every time we transferred her, it was a with a walker . We would use a gait-belt (to transfer resident). K. On 04/05/17 at 4:40 pm, during an interview, LPN #1 stated, (Name of R #1) was on blood thinners . I don't know if she was care planned for that . When she first came in, they were doing two person transfers; I told them she needed a Hoyer because it was safer for everyone; then she was hoyered. Then when she was doing therapy, she was doing Sara lifts . It was constantly changing. Last time I lifted her, it was with the Sara lift. L. Record review of R #1's care plan dated 02/15/17 revealed no mention of the use of anticoagulants or the possibility of bruising and no mention of type of lifts to be used. M. On 04/06/17 at 11:57 am during interview, the DON stated, R #1 should be care planned for lifts and of course, blood thinning medications and bruising should be care planned. R #2 N. Record review of facility documents revealed R #2 was admitted on [DATE] for orthopedic aftercare after a pathological fracture fo the left femur (upper leg bone). O. Record review of physician orders [REDACTED]. Inject 0.4 ml subcutaneously at bedtime for [MEDICAL CONDITION]. P. Record review of the care plan for R #2 dated 02/14/17 revealed there is no goals or interventions addressing the [MEDICATION NAME]. R. On 04/07/17 at 8:40 am, during an interview, the DON stated, The [MEDICATION NAME] should have been care planned.

Based on record review and interview, the facility failed to implement their Abuse and Neglect Policy by failing to ensure an injury of unknown origin was reported to the State Agency (SA) within 24 hours and by failing to report follow up investigation within 5 days for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) residents sampled for incidents with injuries. This deficient practice could have lead the resident being abused or neglected. The findings are: A. Record review of facility's Abuse Prohibition policy and procedures revealed, Injuries of unknown source are defined as an injury with both the following conditions: the course of the injury was not observed by any person or the source of the injury could not be explained by the patient; and the injury is suspicious because of the extent of the injury or the location of the injury . Injuries of unknown origin will be reported and investigated to determine if abuse or neglect is suspected . The person witnessing or suspecting the alleged abuse will - with assistance from supervisor - report within 24 hours (or the next business day if a weekend or holiday) the allegation of abuse, neglect or misappropriation of property to the (State Agency (SA)) by completing the (SA) Incident report Form . The Company Executive Director (CED)or designee will report findings of all completed investigations to officials (including the state survey and certification agency) within five (5) working days of the incident. B. Record review of hospital records and facility records revealed R #1 was discharged on [DATE] from a local hospital and admitted to the facility on the same date. [DIAGNOSES REDACTED]. C. Record review of Crime/Incident Report written by an officer from local police department dated 03/13/17 from 22:14 (10:14 pm) to 23:17 (11:17 pm) revealed the following: Officer advised to take a report at a local hospital in reference to possible senior abuse. The Officer observed bruising on R #1: A large skin tear that went from the upper jaw down to possibly the center of her throat, was surrounded by a large bruise . Bruising on the arm and on the right shoulder . Photograph's were taken of injuries to her backside . heavy bed sores were quite visible, (name of R #1) did have a laceration that appeared close to her vagina on her right leg. D. Record review of Incident Supplement dated 03/13/07 at 22:14 (10:14 pm) written by local police department detective revealed R #1 arrived at hospital at approximately 1900 (7:00 pm) . Arrived with large amounts of bruising under both arms that traveled from the back across both her breasts . Had a large skin tear on the right side of neck surrounded by redness consistent with bruising. When hospital staff called the facility to obtain a report, information given was vague and they could not explain the skin tear on R #1's neck. E. Evidence Technician (ET) made contact with R #1 in ER room and began taking photographs of R #1's neck area, arms and breast, both of which sustained heavy bruising and red marks, both breast were extremely bruised and extremely dark in color, the bruising extended all the way to the front of R #1's breast . It lighten as it went toward the areola closer to the center of her chest .R #1 had bruising up her arm, one specific that was fairly dark in color on the right arm. F. On 04/06/17 at 9:45 am, observations were made of 59 photographs of R #1 confirming 1) extensive bruising, dark purple in color, underneath the outside of R #1's breasts and underneath both arms extending to her back side, 2) the skin tear on the right side of her neck with dark purple and reddish bruising all around it, 3) several photographs of R #1's buttocks showing both healed and unhealed wounds surrounded by a large reddish purple circular area above her tail bone, and 4) bruising on the inner thighs. G. Record review of SA Incident Report revealed an incident of injury occurred to R #1 on 03/13/17 at unknown time was faxed to State Agency on 03/18/17 at 12:44 pm. H. On 04/05/17 at 4:15 pm, during interview, Administrator stated, We only report (to the State) abuse, neglect or misappropriation of funds. I. Record review of SA Complaint Narrative Investigation Report (5 day), undated, written by the DON, revealed the following: 1) Date of incident 03/13/17, 2) Date faxed to SA on 03/27/17 at 3:10 pm, and 3) I am not able to confirm the origin of this injury .is an injury of unknown origin. J. Record review of R #1's History and Physical from a local hospital dated 03/13/17 revealed the following: 1. Hospital staff called facility and was told patient (pt) has been having excessive bruising to right side of the neck and right side of the chest wall . Staff from (the facility) think that bruising is caused by the Hoyer lift. Extensive bruising. 2. Review of symptoms: Pt unresponsive. Nursing home had to use Hoyer lift. Pt has a large bruising under both axilla (the area on the human body directly under the joint where the arm connects to the shoulder). State I and II decubiti (skin ulcer over a bony part of the body) . Two decubiti in the buttock . abrasion skin tear, neck. K. Record review of facility's Risk Management System revealed that an incident of unknown origin (a skin tear to the neck) was observed on R #1 on 03/13/17, unknown time. The incident was filled out by LPN #1 on 03/15/17. K. On 04/05/17 at 11:50 am, during interview, LPN #1 revealed filling out an incident report for R #1 and stated, I noticed a bright red area on R #1's neck . a skin tear . I asked the aides (CNAs) what happened . CNA #2 gave her a shower, CNA #1 was R #1's CNA . There was a blame thing happening back and forth between the CNAs . She was admitted (to the facility) with them (bruising). She always had scratches on her neck, I think from the blood thinner. L. Record review of Dr's progress note dated 03/13/17 at 1:44 pm revealed, Resident present for the evaluation and management of lower extremity [MEDICAL CONDITION] (Leg swelling generally occurs because of an abnormal accumulation of fluid in the tissues of the lower extremity) patient with a single lesion. Bleeding associated with the lesion. Location includes the neck. M. On 04/05/17 at 12:45 pm, during interview, medical doctor (Dr) revealed seeing R #1 at the facility on 03/13/17 at approximately 1:45 pm; he noted bruises and a skin tear to her neck. N. On 04/05/17 at 12:49 pm, during interview, DON stated, (Name of R #1's) family member was there there with her all day (on 03/13/17) . Blood was found under R #1's fingernail . (Name of family member) did not say anything . The day I reported it to the State (on the 18th March 2017), I was made aware of the skin tear. DON was asked how R #1 gets transferred. DON stated, Sara lift (mechanical standing and raising aid) . She wanted the staff to do the transfers themselves - we do not do two-man transfer . She was not a one-person transfer . She was unpredictable with her legs . Sara lift could cause bruising behind the back and underneath the arms. O. Record review of assessments skilled note, dated 03/02/17, revealed, Sara lift with transfer, toileting and bed mobility. P. Record review of Lift Transfer Reposition assessment dated [DATE] revealed R #1 is not able to transfer independently or with supervision without using a device. Q. Record review of clinical competency validations revealed no training on lifts or transfers for CNA #2 (dated 07/07/16), CNA #4 (dated 07/08/16), CNA #5 (dated 07/06/16), and CNA #6 (dated 06/22/16). R. On 04/05/17 at 2:20 pm, during interview, CNA #2 confirmed giving R #1 a shower on 03/13/17 and revealed the Physical Therapist (PT) helped transfer R #1 to the shower chair and CNA #1 helped transfer R #1 from the chair to the bed using a gait belt. The CNA stated, We both got her from under the arms and transferred her . lifted her with a gait belt and put her in bed . When we used a Sara lift, (name of R #1) would slide right off . PT told us (name of R #1) was able to sit and stand, just give her a walker . I used a Sara lift about 4 days prior to her leaving the facility (Name of R #1) refused a Hoyer lift. S. On 04/05/17 at 4:30 pm, during interview, CNA #3 was asked if she was taught how to transfer residents, CNA #3 stated, I was trained in 2013 . No in-services on that . Physical therapy (PT) would often talk with us about transfers, but I was not officially taught. T. On 04/07/17 at 9:30 am, during interview, DON stated, There are no competency for any of CNAs on using a Hoyer, sit to stand or gait belt. U. On 04/07/17 at 9:30 am, during interview, Corporate Nurse (CN) stated, (The CNAs) Should be competent when coming to us . License guarantees competency . Verbal is okay, if you have watched them. V. Record review of order summary report for R #1 with a date range of 02/14/17 to 03/13/17 revealed the following medications: [REDACTED]. W. Record review of R #1's Medication Administration Records (MAR) for February 2017 and March of 2017 revealed Aspirin 81 mg, one time a day, starting on 02/14/17, and Xarelto tablet 10 mg, 1 tablet by mouth one time a day were given every day, starting on 02/14/17. X. Record review of R #1's care plan dated 02/15/17 revealed no mention of the use of anticoagulants and no mention of type of lifts to be used. Y. On 04/05/17 at 4:40 pm, during interview, LPN #1 stated, (Name of R #1) was on blood thinners . I don't know if she was care planned for that . When she first came in, they were doing two person transfers. I told them she needed a Hoyer because it was safer for everyone, then she was hoyered. Then when she was doing therapy, she was doing Sara lifts . It was constantly changing. Last time I lifted her, it was with the Sara lift. Z. On 04/06/17 at 11:57 am, during interview, the DON stated, R #1 should be care planned for lifts and of course, blood thinning medications and bruising should be care plan. AA. On 04/10/17 at 8:00 am, during an interview, R #1's family member stated, The day she got a gash on her neck . When I walked in her room, she was bleeding . She would get bruises under her arms and around her chest. It's the way they tried to pick her up out of the wheelchair . They would try to pick her up under her arms . (Name of R #1) does not remember a bit of this; she still does not remember.

Based on record review and interview, the facility failed to ensure residents were free from neglect for 1 (R #1) of 4 (R #1, R #2, R#3, and R #4) residents reviewed for injuries of unknown origin when they failed to 1) identify and change their practices to avoid causing extensive bruising on R #1, a resident on Anticoagulant (blood thinners, substances that prevent or reduce coagulation of blood, prolonging the clotting time) medication, and 2) identify, monitor, and treat a pressure wound (localized damage to the skin and underlying soft tissue as a result of intense and/or prolonged pressure). This deficient practice likely resulted in excessive bruising, hemorrhaging and increased the risk of infection and pain. The findings are: A. Record review of facility's Abuse Prohibition policy and procedures revealed, Injuries of unknown source are defined as an injury with both the following conditions: the course of the injury was not observed by any person or the source of the injury could not be explained by the patient; and the injury is suspicious because of the extent of the injury or the location of the injury . Injuries of unknown origin will be reported and investigated to determine if abuse or neglect is suspected . The person witnessing or suspecting the alleged abuse will - with assistance from supervisor - report within 24 hours (or the next business day if a weekend or holiday) the allegation of abuse, neglect or misappropriation of property to the (State Agency (SA)) by completing the (SA) Incident report Form . The Company Executive Director (CED)or designee will report findings of all completed investigations to officials (including the state survey and certification agency) within five (5) working days of the incident. Bruising B. Record review of hospital records and facility records revealed R #1 was discharged on [DATE] from a local hospital and admitted to the facility on the same date. [DIAGNOSES REDACTED]. C. Record review of Crime/Incident Report written by an officer from local police department dated 03/13/17 from 22:14 (10:14 pm) to 23:17 (11:17 pm) revealed the following: Officer advised to take a report at a local hospital in reference to possible senior abuse. The Officer observed bruising on R #1: A large skin tear that went from the upper jaw down to possibly the center of her throat, was surrounded by a large bruise . Bruising on the arm and on the right shoulder . Photograph's were taken of injuries to her backside . heavy bed sores were quite visible, (name of R #1) did have a laceration that appeared close to her vagina on her right leg. D. Record review of Incident Supplement dated 03/13/07 at 22:14 (10:14 pm) written by local police department detective revealed R #1 arrived at hospital at approximately 1900 (7:00 pm) . Arrived with large amounts of bruising under both arms that traveled from the back across both her breasts . Had a large skin tear on the right side of neck surrounded by redness consistent with bruising. When hospital staff called the facility to obtain a report, information given was vague and they could not explain the skin tear on R #1's neck. E. Evidence Technician (ET) made contact with R #1 in ER room and began taking photographs of R #1's neck area, arms and breast, both of which sustained heavy bruising and red marks, both breast were extremely bruised and extremely dark in color, the bruising extended all the way to the front of R #1's breast . It lighten as it went toward the areola closer to the center of her chest .R #1 had bruising up her arm, one specific that was fairly dark in color on the right arm. F. On 04/06/17 at 9:45 am, observations were made of 59 photographs of R #1 confirming 1) extensive bruising, dark purple in color, underneath the outside of R #1's breasts and underneath both arms extending to her back side, 2) the skin tear on the right side of her neck with dark purple and reddish bruising all around it, 3) several photographs of R #1's buttocks showing both healed and unhealed wounds surrounded by a large reddish purple circular area above her tail bone, and 4) bruising on the inner thighs. G. Record review of R #1's History and Physical from hospital dated 03/13/17 revealed the following: 1) Hospital staff called facility and was told Patient (pt) has been having excessive bruising to right side of the neck and right side of the chest wall . Staff from (the facility) think that bruising is caused by the Hoyer lift (patient hoist, typically utilize hydraulic power). 2) Review of symptoms: Pt unresponsive. Nursing home had to use Hoyer lift. Pt has a large bruising under both axilla (the area on the human body directly under the joint where the arm connects to the shoulder). Stage I and II decubiti (skin ulcer over a bony part of the body) . Two decubiti on the buttocks . abrasion skin tear, neck. H. Record review of order summary report for R #1 with a date range of 02/14/17 to 03/13/17 revealed the following medications: [REDACTED]. I. Record review of R #1's Medication Administration Records (MAR) for February 2017 and March of 2017 revealed aspirin 81 mg, one time a day, starting on 02/14/17, and Xarelto tablet 10 mg, 1 tablet by mouth one time a day were given every day, starting on 02/14/17. J. On 04/05/17 at 11:50 am, during interview, LPN #1 confirmed she filled out an incident report for R #1 and stated, I noticed a bright red area on R #1's neck . A skin tear . I asked the aides (CNAs) what happened . CNA #2 gave her a shower. CNA #1 was R #1's CNA . There was a blame thing happening back and forth between the CNAs . She (R #1) was admitted (to the facility) with them (the bruising). She always had scratches on her neck; I think from the blood thinner. K. On 04/05/17 at 12:49 pm, during interview, the DON was asked how R #1 gets transferred. DON stated, Sara lift (mechanical standing and raising aid) . She wanted the staff to do the transfers themselves - we do not do two-man transfer . She was not a one-person transfer . She was unpredictable with her legs . Sara lift could cause bruising behind the back and underneath the arms. L. On 04/05/17 at 2:20 pm, during interview, CNA #2 confirmed giving R #1 a shower on 03/13/17 and revealed the Physical Therapist (PT) helped transfer R #1 to the shower chair and CNA #1 helped transfer R #1 from the chair to the bed using a gait belt. The CNA stated, We both got her from under the arms and transferred her . lifted her with a gait belt and put her in bed . When we used a Sara lift, (name of R #1) would slide right off . PT told us (name of R #1) was able to sit and stand, just give her a walker . I used a Sara lift about 4 days prior to her leaving the facility (Name of R #1) refused a Hoyer lift. M. On 04/05/17 at 4:30 pm, during interview, CNA #3 was asked if she was taught how to transfer residents, CNA #3 stated, I was trained in 2013 . No in-services on that . Physical therapy (PT) would often talk with us about transfers, but I was not officially taught. N. Record review of assessments skilled note, dated 03/02/17, revealed, Sara lift with transfer, toileting and bed mobility. O. Record review of Lift Transfer Reposition assessment dated [DATE] revealed R #1 is not able to transfer independently or with supervision without using a device. P. Record review of clinical competency validations revealed no training on lifts or transfers for CNA #2 (dated 07/07/16), CNA #4 (dated 07/08/16), CNA #5 (dated 07/06/16), and CNA #6 (dated 06/22/16). Q. On 04/05/17 at 4:40 pm, during an interview, LPN #1 stated, (Name of R #1) was on blood thinners . I don't know if she was care planned for that . When she first came in, they were doing two person transfers. I told them she needed a Hoyer because it was safer for everyone, then she was hoyered. Then when she was doing therapy, she was doing Sara lifts . It was constantly changing. Last time I lifted her, it was with the Sara lift. R. On 04/07/17 at 9:30 am, during interview, DON stated, There are no competency for any of CNAs on using a Hoyer, sit to stand or gait belt. S. On 04/07/17 at 9:30 am, during interview, Corporate Nurse (CN) stated, (The CNAs) Should be competent when coming to us . License guarantees competency . Verbal is okay, if you have watched them. T. Record review of R #1's care plan dated 02/15/17 revealed no mention of the use of anticoagulants and no mention of type of lifts to be used. U. On 04/06/17 at 11:57 am, during interview, the DON stated, R #1 should be care planned for lifts and of course, blood thinning medications and bruising should be care planned. V. On 04/10/17 at 8:00 am, during an interview, R #1's family member stated, The day she got a gash on her neck .When I walked in her room, she was bleeding . She would get bruises under her arms and around her chest . She bruises easily. It's the way they tried to pick her up out of the wheelchair . They would try to pick her up under her arms . (Name of R #1) does not remember a bit of this; she still does not remember. Pressure wound W. Record review of the discharge summary assessment from (Name of a local hospital), dated 02/14/17, revealed, Pressure ulcer Stage 3 left buttock, right side Stage 2. X. Record review of the progress note from the Wound Care Nurse from (Name of a local hospital) dated 02/09/17 resident had two Stage IIIs, on the left and right buttocks. Y. On 04/05/17 at 3:40 pm, during an interview, LPN #1 stated, She (R #1) was admitted with 2 wounds and one healed while she was here. I know when she went out (was discharged to the hospital on [DATE]) she just had the one (pressure wound) and it looked good and it was almost closed. Z. On 04/05/17 at 2:06 pm, during an interview with WCN #2, after reviewing the Skin Integrity Sheet initiated dated 02/14/17, stated, From what I remember, she only had the one wound. There was nothing else that I can think of, as far as her skin. AA. On 04/05/07 at 2:56 pm, during an interview, the DON stated, We only have a record of the one wound. BB. On 04/06/17 at 9:40 am, during an interview with Wound Care Nurse (WCN) #1 (from a local hospital where resident resided previous to admission to the facility) stated, (Name of R #1) left (was discharged ) with two Stage III wounds (wounds will full thickness skin loss), one to the right and one to the left buttocks. CC. Record review of the facility Initial (Admission) Nursing assessment dated [DATE] revealed, Integumentary (skin) Assessment: Skin impairment present. Site left buttock. There is no other documentation of skin impairment. DD. Record review of the physician's orders [REDACTED].#1 revealed: Stage III left buttocks: on shower days and PRN (as needed) cleanse with NS (normal saline-a mixture of water and salt) or wound cleanser and apply [MEDICATION NAME] (a medication used for wound treatment) and cover with [MEDICATION NAME] (a foam dressing) or similar dressing, every day shift every Monday, Wednesday, Friday. Nothing for the right side.