Every finding on record at Oakview Nursing and Rehabilitation

Based on observation, clinical record review, and staff interviews, the facility failed to ensure 1 of 4 residents (Resident #16) treated with dignity when a mechanical lift sling left under the resident while they used a bed pan, and failed to turn off a bedroom light upon the residents' repeated request. The facility reported a census of 54 residents. Findings include: 1. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3 out of 15, which indicates a severe cognitive impairment. The MDS identified Resident #16 dependent for toileting hygiene and rolling left and right; and able to make self understood by others and understands others. The list of diagnosis included non-Alzheimer's dementia and fracture of left fibula (bone in lower leg). The Care Plan dated 6/16/26 revealed the following focus areas: a. Resident is at risk for skin breakdown r/t (related to) incontinence, impaired mobility, COPD (chronic obstructive pulmonary disease), risk of malnutrition. Interventions initiated 6/16/26, included, in part: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible; and Use incontinence products to maintain personal hygiene and dignity. b. The resident has impaired cognition r/t dementia. Interventions initiated 6/16/26, included in part: Keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. During an observation on 7/20/26 at 10:51 AM, Resident #16 door open while she laid in her bed. A mechanical lift sling noted to be in position underneath the resident. Resident #16 queried if she had pain and she stated yes, because she is using the bed pan. Resident #16 had a sheet laid over her. During an interview on 7/23/26 at 11:47 AM, Staff E, Certified Nurse Aide (CNA) queried about a resident in bed with a mechanical sling under the resident, and Staff E stated some staff forget to take it out. Staff E stated it shouldn't be underneath the resident and the sling was not hard to take in and out in bed. During an interview on 7/23/26 at 12:33 PM, the Director of Nursing (DON) queried if a mechanical sling could be left on the resident in bed and the DON stated no, not unless the resident's care plan addressed it. The DON stated mechanical slings are not left under a resident due to the risk of skin breakdown and dignity. The DON stated it is her expectation that mechanical lift slings are not left under a resident when they are in bed. 2. During an observation on 7/22/26 at 7:28 AM, Resident #16 in her room, in bed with the room light on. Resident #16 heard repeatedly yelling turn off my light. Staff B, Registered Nurse (RN) went Resident #16 doorway and stated that staff would ger her up in a minute and that is why the light was on. Resident #16 stated she wants her light turned off. Staff B left the residents door way without turning off the light. During an interview on 7/23/26 at 1:09 PM, the Administrator stated if a resident requested to have their light turned off, staff should do so. Review of the facility policy titled Residents' [NAME] of Rights revised 12/23, revealed, in part: A. Resident Rights. The resident has a right to a dignified existence and self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. 1. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizes each resident's individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to involve a resident in decision making options in a timely manner after a medication supply ran out and a refill could not be obtained due insurance recently having paid for a home supply 1 of 1 resident (Resident #23) reviewed for informed decision making. The facility reported a census of 54 residents. Findings include: Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 on the, which indicated intact cognition. The list of diagnoses included chronic pancreatitis and congestive heart failure. The MDS listed a facility admission date of 7/8/26 from a short-term hospital stay. Review of the electronic health record (EHR) revealed a Physician order for Viokace Oral Tablet 10440-39150 UNIT (Pancrelipase) (Lipase-Protease-Amylase)) give 3 tablets by mouth three times daily related to diverticulitis of the intestine, part unspecified, without perforation or abscess with bleeding; other congenital malformations of pancreas and pancreatic duct. Start date: 7/08/26.Review of the July 2026 Medication Administration Record (MAR) revealed the following administration history of Viokace:a. On 7/21/26:1. 8:00 AM scheduled time frame - a 9 documented (per the MAR Chart Codes a 9 is used to indicate Other/See Progress Notes).i. Per an Administrative note in the EHR entered on 7/21/26 at 8:33 AM: Viokace.Resident only had 1 tab left, will notify PCP (Primary Care Provider).2. 12:00 PM scheduled time frame - a 5 documented (per the MAR Chart Codes a 5 is used to indicate Hold/See Progress Notes).i. Per an Administration Note in the EHR entered on 7/21/26 at 11:07 AM: Viokace.On order from pharmacy, secure message to PCP advising not given.3. 7:00 PM scheduled time frame - a 5 documented.i. Per an Administration Note in the EHR entered on 7/21/26 at 6:17 PM: Viokace.Pending pharm (pharmacy) arrival. PCP aware.b. On 7/22/26:1. 8:00 AM scheduled time frame - a 5 documented.i. Per an Administration Note in the EHR entered on 7/22/26 at 8:29 AM: Viokace.Unavailable. Pharmacy and provider notified.2. 12:00 PM scheduled time frame - a 5 documented.i. Per an Administration Note in the EHR entered on 7/22/26 at 11:02 AM: Viokace.unavailable. provider and pharmacy notified.3. 7:00 PM scheduled time frame - a 5 documented.i. Per an Administration Note in the EHR entered on 7/22/26 at 6:26 PM: Viokace.on hold, pcp aware on hold.c. On 7/23/261. 8:00 AM - scheduled time frame a 9 documented.i. Per an Administration Note in the EHR entered on 7/23/26 at 7:47 AM: Viokace.Unavailable will contact pharmacy's.During an interview on 7/22/26 at 12:46 PM, Resident #23 stated she was out of the pills she took for pancreas for the last day and a half. Resident #23 explained she was supposed to take 3 pills with each meal. Resident #23 stated she would like to have the medication because she had had pancreatitis in the past. During an interview on 7/22/26 at 3:59 PM, Staff G, Pharmacist queried on the availability of Viokace and Staff G stated the facility requested a refill, however insurance would not approve the refill until 8/16/26 because the prescription had been last filled by the resident via a mail order pharmacy. Staff G explained when the facility made the refill request on the 7/18/26, the pharmacy sent back a message it was too soon to refill, and the medication could not be refilled until 8/16/26. Staff G stated the facility could follow up with the resident and family to see if the resident had a supply at home.During an interview on 7/23/26 at 8:01 AM, Resident #23 queried if she received the pills for pancreas yet and Resident #23 stated no, the nurse told her the pills wouldn't be here until Monday and today was the third day without them. Resident #23 stated she had pancreatitis four times in the past.During an interview on 7/23/26 at 10:39 AM, Resident #23 stated the Care Group spoke to her at 10 this morning and her husband was now going to bring in the medication from home. Resident #23 stated 10:00 AM on this date was the first time the facility had spoken to her and her husband about bringing in the pills and Resident #23 asked if her husband could do it. Resident #23 stated it was better than waiting until Monday to get the medications and she was hoping to get the medication before supper. During an interview on 7/23/26 at 10:51 AM, Staff F, Licensed Practical Nurse (LPN) queried on Resident #23 Viokace and Staff F stated she called the pharmacy on Monday [July 20, 2026] and the medication was supposed to be here, but she was off on Tuesday and Wednesday so it was on her agenda to call them again today. Staff F stated she told the provider about the medication being out and contacting the pharmacy. During an interview on 7/23/26 at 12:35 PM, the Director of Nursing (DON) queried on Resident #23 Viokace and the DON stated she expected communication with the pharmacy and notifying the physician to give suggestions and see if the family could bring in the medication. The DON stated sometimes the pharmacy said the medication would be sent and then the medication didn't come.Review of the EHR revealed a Plan of Care Note entered on 7/23/26 at 1:15 PM: Care conference today with resident, her husband [name redacted], therapist's [names redacted]. Resident brought up the fact that that she did not have her medication Viokase. Pharmacy wouldn't approve it since she had just gotten a home supply. Husband asked to bring in home meds to give to nurse to use and that was ok.Review of the facility policy titled Residents' [NAME] of Rights revised on 12/2023 revealed, in part: Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment including: The right to request meetings and the right to request revisions to the person-centered plan of care.

Based on observation, clinical record review, facility policy review, resident and staff interview the facility failed to ensure residents were assessed for self-administration prior to medications being left with the resident for 2 of 2 residents (Resident #23 and Resident #22) reviewed for the self-administration of medications. The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition intact. The list of diagnoses included acute on chronic systolic congestive heart failure, atrial fibrillation, and renal insufficiency. The MDS identified Resident #23 as taking medications in the high-risk drug classes of anticoagulants, diuretics and opioids. During an interview on 7/22/26 at 8:08 AM, Resident #23 queried if the nurse watched the resident take her medications or left the medications on the bedside table and Resident #23 stated the nurses did both. Resident #23 stated she took too many pills and liked her water to be room temperature to take a few of her medications. During an observation on 7/23/26 at 8:01 AM, Resident #23 had 2 cups of pills on her bedside table. Resident #23 stated she had questions about two of the oblong pills in the cup and thought they looked like her Vicodin but she already took her Vicodin earlier. Resident #23 stated she thought they could be Tylenol. The pills in the cups were white, green and red and had a green pill that looked like a Tums on a washcloth on the bedside table. Resident #23 had 5.5 pills in one cup and 8 pills and 2 half pills in the other cup. Review of the electronic health record (EHR) revealed on 7/23/26 during the 8:00 AM medication pass, Resident #23 had the following medications scheduled to be administered: a. Amiodarone HCL (hydrochloride) 200 mg (milligrams) – 1 tablet by mouth. b. Amlodipine 10 mg – 1 tablet by mouth. c. Calcium carbonate antacid (TUMS) – 1 tablet by mouth. d. Cetirizine HCL 10 mg – 1 tablet by mouth. e. Ferrous sulfate 325 mg - 1 tablet by mouth. f. Metoprolol succinate ER (extended release) 100 mg – 1 tablet by mouth. g. Potassium chloride ER 20 MEQ (milliequivalent) – 1 tablet by mouth. h. Vitamin B12 1000 mcg (microgram) – 1 tablet by mouth. i. Vitamin D3 25 mcg – 1 capsule by mouth. j. Acetaminophen 500 mg – 2 tablets by mouth. k. Cimetidine 400 mg – 1 tablet by mouth. l. Eliquis 2.5 mg – 1 tablet by mouth. m. furosemide 40 mg -1 tablet by mouth. n. sulfasalazine 500 mg – 1 tablet by mouth. During an interview on 7/23/26 at 10:51 AM, Staff F, Licensed Practical Nurse (LPN) asked if Resident #23 assessed for self-administration and Staff F stated she didn't think so. Staff F informed Resident #23 pills left on her bedside table and Staff F stated yes, and explained Resident #23 is particular on how she took them and it took Resident #23 a half an hour to take her pills. Staff F stated she always watched Resident #23 take her narcotic. Staff F stated she placed the pills on Resident #23 table and would go back and check to see if Resident #23 took them. During an interview on 7/23/26 at 12:35 PM, the Director of Nursing (DON) queried on oral medications being left at bedside and the DON stated that practice was not okay because staff was documenting the resident took it. The DON stated it was a safety concern, the residents could have only taken a few. The DON stated the staff had to watch residents take their pills. 2. Review of Resident #22's MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnoses included heart failure, respiratory failure, anxiety disorder, depression, and osteoarthritis. The MDS identified Resident #22 as taking medications in the high-risk drug classes of antianxiety, antidepressants, antibiotics, diuretics, opioids, and anticonvulsants. Review of the EHR revealed a Health Status Note, dated 2/15/26 at 3:46 PM: Secure message to provider: Notification of missed 4:00 AM medications this morning, Hydrocodone (opioid medication used to treat severe pain), Buspar (antianxiety and Ropinirole (medication used to treat restless legs syndrome) as they were found at bedside by another nurse. Resident vital signs stable. Resident reports increased pain and took as needed ibuprofen, she reports helped. Medications were wasted by 2 nurses this afternoon. All parties notified. Review of the February 2026 Medication Administration Record (MAR)indicated that medications scheduled for 4:00 AM included a. Hydrocodone-Acetaminophen 7.5-325 mg - 1 tablet by mouth. b. Buspirone 30mg - 1 tablet by mouth. c. Ropinirole 1mg - 1 tablet by mouth. Review of EHR found no assessment to indicate if Resident #22 able to self-administer medications. Review of a facility provided document titled, Medication Error Report, dated 2/15/26 at 4:00 AM, revealed that the medications ordered: Hydrocodone, Buspirone, and Ropinirole were not administered and left at Resident #22's bedside. The report indicated an outcome was Resident #22 had reported increased pain. The report listed corrective action taken as nurse was written up and terminated. During an interview on 7/23/26 at 8:20 AM, Staff D, Registered Nurse (RN) stated there were no residents currently in the facility that she was aware of who could self-administer medications. Staff D reported that if there were they would have an assessment completed in EHR, but to her knowledge no residents have this assessment. During an interview on 7/23/26 at 3:15 PM, the DON stated that Resident #22 did not have an assessment to self-administer medications and that medications should not be left unattended at bedside in Resident #22's room. Review of the facility policy titled, Medication Administration, dated 10/10/19, revealed the Policy Statement: Medications shall be stored in a locked medication cart and/or medication room. Keys to locked medication storage shall be maintained by a licensed nurse/Oral Medication Technician (OMT)/DON. Medications shall be administered per physician order.

Based on clinical record review, facility policy review and staff interviews the facility failed to re-notify the provider that a prescribed medication was unavailable for administration after 30 days for 1 of 1 resident (Resident #12) reviewed for respiratory care; and failed to notify the provider of weight fluctuation for 1 of 4 residents (Resident #12) reviewed for a daily weight order. The facility reported a census of 54 residents. Findings include: 1. Review of Resident #12's Minimum Data Set (MDS) annual assessment dated [DATE], revealed a list of diagnoses which included respiratory failure, pneumonia, chronic obstructive pulmonary disease (COPD), cancer, and anxiety disorder. The MDS identified that Resident #12 had shortness of breath or trouble breathing with exertion, with rest, and when lying flat, utilized oxygen and required a non-invasive mechanical ventilator.Review of Resident #12 Care Plan dated 4/22/24, revealed a Focus area to address altered respiratory status related to emphysema and respiratory failure. Interventions instructed the following, in part:a. Give medications as ordered. Monitor/document any side effects and effectiveness.b. Monitor for signs and symptoms of respiratory distress and report to the provider as needed.Review of the electronic health record (EHR) revealed:a. A Health Status Note entered on 5/15/26 at 1:34 PM: This nurse found notes and orders from 5/12/26. (Name redacted, Nurse Practitioner (NP)] sent message to [name redacted, Medical Doctor (NP)] on 5/11/2026 to inform that resident was seen by her in most recent hospitalization and ordered Anoro Ellipta and resident has poor inspiratory effort and cannot effecie4 use the inhaler is there something else she can use equivalent that is a neb. [name redacted, MD] gave new orders to [name redacted, NP] to change to.Yupelri ( an inhalant solution) QD (daily).b. An Order Administration Note entered on 5/16/26 at 8:29 AM: Yupelri Inhalation Nebulization Solution.Will not have until 5/18/26.c. A Health Status Note entered on 5/18/26 at 10:13 AM: This nurse got a report that the pharmacy had called and needed approval for the facility to pay for resident's breathing Tx (treatment) Yupelri. This nurse called [name of pharmacy redacted] and explained that resident is not skilled, so her insurance will to be ran for medication covered.d. A Health Status Note entered on 5/19/26 at 2:18 PM: Spoke with the pharmacy, and they stated they sent a prior authorization to resident's insurance today to see if medication is covered.e. An Order Administration Note entered on 5/22/26 at 7:13 AM: Yupelri .Waiting for insurance approval PCP (primary care provider) aware and POA (power of attorney) aware.Review of the May and June 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed an order for Yupelri (Revefenacin) inhalation nebulization solution 175 micrograms (mcg) per 3 milliliters (mL) with instructions to inhale one vial orally via nebulizer one time a day related to COPD. Start date: 5/16/26. Discontinue date: 6/25/26. The MAR revealed the code 9 or other/see nurses note for each scheduled daily administration from 5/16/26 through 5/31/26, and from 6/1/26 to 6/5/26, 6/8/26 to 6/10/26, 6/12/26 to 6/15/26, 6/17/26 to 6/25/26 with a discontinuation date of 6/25/26.Review of EHR revealed a Health Status Note entered on 6/25/26 at 9:32 AM: . Call placed to Pulmonology at 9:29 AM, may discontinue Yupelri due to insurance denial. Orders updated in EHR. Notified resident's POA.During an interview on 7/23/26 at 9:22 AM, Staff I, NP stated expectation that the facility would notify provider about ongoing and repeated medication omissions within a couple of days of not getting an ordered medication. Staff I explained that they might need to get involved with the pharmacy for prior authorization of a prescribed medication for insurance.During an interview on 7/23/26 at 8:20 AM, Staff D, Registered Nurse (RN) stated that if a medication is not available, the provider would need to be notified to see what they want to do.During an interview on 7/23/26 at 12:29 PM, the Director of Nursing (DON) stated she expected that medication orders be put on hold if waiting for insurance authorization so it's not documented as not available every day, then remove the hold when the medication is received. The DON unable to provide documentation of provider notification that Resident #12 had not started Yuperlri due to difficulty with insurance approval after the communication on 5/22/25 until the medication was discontinued on 6/25/26. 2. Review of Resident #12's Care Plan, initiated on 4/22/24, revealed a Focus area for diuretic therapy related to respiratory failure. Interventions instructed the following:a. Administer diuretic as ordered. Date initiated: 4/22/24. b. Daily weights. Date initiated: 3/14/25c. Monitor for side effects and notify the nurse/provider. Common diuretic side effects: increased urination, electrolyte disturbance, headache, muscle cramps, increased thirst, high blood sugars, abnormal heart rhythm, weakness, fatigue, dizziness, loss of appetite, nausea, high risk for falls. Date initiated: 4/22/24. Review of the May 2026 MAR/TAR revealed an order to check a daily weight and notify the provider if weight is greater than 3 pounds in a week, every day shift. Start date: 2/18/25. Daily weights were recorded as follows: a. 5/15/26: 235.6 poundsb. 5/16/26: 239.9 pounds (4.3 pounds gain in a day)c. 5/17/26: 240.1 poundsd. 5/18/26: 240.3 poundsReview of Resident #12's HER lacked documentation of provider notification related to the weight gain greater than 3 pounds in a day, recorded between 5/15/26 and 5/16/26. Review of the June 2026 MAR/TAR, revealed daily weights were recorded as follows: a. 6/20/26: 233.9 poundsb. 6/21/26: 237.2 pounds (3.3 pounds gain in a day)Review of Resident #12's EHRs lacked documentation of provider notification related to the weight gain greater than 3 pounds in a day, recorded between 6/20/26 and 6/21/26. During an interview on 7/23/26 at 12:24 PM, the DON stated the weight gains for resident with a daily weight order should be reported to the provider. Review of a facility policy titled Physician Notification Policy dated 10/10/23 revealed the physician will be notified promptly of a change of condition which requires a significant alteration in treatment; or a significant change in resident condition which has potential for clinical complication.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to carry out hospital discharges orders for an infusion and a laboratory test for 1 of 1 resident (Resident #53) reviewed for professional standards. The facility reported a census of 54 residents.Findings included: The Minimum Data Set (MDS) assessment tool, dated 6/10/26, list of diagnoses for Resident #53 included heart failure, anemia, and chronic respiratory failure with hypoxia (low oxygen in the body tissues) and listed the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicating intact cognition. Review of a Internal Medicine Progress Notes, dated 6/2/26, revealed an Assessment/Plan section which included, in part: Patient needs to get 750 milligrams (mg) of IV iron as an outpatient in 1 week. Review of a hospital Discharge summary, dated [DATE], revealed a Discharge Plan which included, in part: Follow-up Appointments – INR (International Normalized Ratio, a test which measures the time taken for blood to clot) tomorrow [6/5/26], results to facility provider for further warfarin dosing and INR. Review of the electronic health record (EHR) revealed an admission Nursing Assessment Resident #53 dated 6/4/26 which documented an admission from [name of hospital redacted] on 6/4/26. Review of the June 2026 Medication Administration Record (MAR) listed an order for warfarin (a medication used to prevent and treat blood clots, an INR is often required with this medication) 3 milligrams(mg) 1 tablet at bedtime for clot prevention. Review of the EHR revealed a Health Status Note entered on 6/15/26 at 9:45 PM: At approximately 2140 (9:40 PM) [name redacted, Registered Nurse with hospital name redacted] called and stated that patient is being admitted .on acute care unit for acute CHF, chronic respiratory failure and an elevated troponin (cardiac enzyme). The clinical record lacked documentation Resident #53 received an iron infusion and INR testing completed the day [6/5/26] after hospital discharge. The facility lacked documentation related to setting up/scheduling an iron infusion. On 7/23/26 at 9:37 a.m., the Director of Nursing (DON) stated staff should carry out all orders from the hospital. She stated she would look to see if she could locate documentation for an iron infusion and INR for Resident #53. On 7/23/26 at 11:18 a.m., the DON stated (the hospital) was supposed to call the facility back to schedule the iron infusion. No further information provided by DON. The facility policy Medication Administration revised 6/30/23, stated staff would administer medications per the physician order and directed staff to check labels and verify the medication prior to administration.

Based on observation, clinical record review, and staff interviews, the facility failed to monitor the liquid intake for 2 of 4 residents (Resident #10 and Resident #5) reviewed for a fluid restriction. The facility reported a census of 54 residents. Findings include:1. The Minimal Data Set assessment dated [DATE] revealed Resident #10 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated a moderate cognitive impairment. The list of diagnoses included lymphedema and hypertension. The MDS indicated the resident prescribed diuretics. Review of the Care Plan revealed a focus area dated 7/8/25 to address Nutritional status related to dx (diagnosis) morbid obesity and lymphedema, on fluid restriction. Interventions included, in part:a. Fluid restriction as ordered. Initiated: 10/8/25b. Monitor/record intake at meals. Initiated: 7/8/25.Review of the electronic health record (ERH) revealed a Physician Order for 1500 ml (milliliter) fluid restriction, with no directives specified. Status: Active. Revision Date: 5/28/26. During an observation on 7/22/26 at 8:22 AM, Resident #10 had a glass of milk and half a glass of tea for breakfast. Review of a facility provided document titled Fluid Restriction form revealed: Resident: Resident #10. Fluid Restriction (cc's - 1 cc=1 ml): 1500 ml. Dietary Allowance (handwritten):a. Breakfast (cc's): 360 ml (1.5 cups or 12 oz (ounce)).b, Lunch (cc's): 360 ml (1.5 cups or 12 oz).d. Supper (cc's): 360 ml (1.5 cups or 12 oz).e. Nursing Allowance: 1. 1st Shift (cc's): 140 ml (4.6 oz).2. 2nd Shift (cc's): 140 ml (4.6 oz).3. 3rd shift (cc's): 140 ml (4.6 oz).The undated Fluid Restriction form provided did not indicate Resident #10's fluid intake per each meal or per each shift. A Fluid Restriction form had not been completed on a daily basis for Resident #10. The form observed to be taped onto the counter of POD A nurse's station for reference. Review of the EHR, which included July 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed no documentation of fluid intake for Resident #10. During an interview on 7/22/26 at 10:17 AM, Staff B, Registered Nurse (RN) queried on tracking Resident #10's fluid intake and Staff B stated the kitchen kept track and the staff did communication on the daily allowance sheet. Staff B reviewed the undated Fluid Restriction form with the handwritten amounts indicated per each meal and per each shift. Staff B stated the nurses also documented on the Medication Administration Record (MAR) every shift what the resident received. During an interview on 7/22/26 at 10:49 AM, Staff H, Dietary Aide queried on who was on a fluid restriction on A pod (area of facility) and Staff H stated Resident #10 and Resident #5. Staff H queried on who tracked fluid intake and Staff H stated dietary just gave Resident #10 one and half glasses of fluid. During an interview on 7/22/26 at 10:58 AM, Staff H, Dietary aide stated dietary had a paper they wrote on for fluid restrictions for Resident #10. During an interview on 7/23/26 at 10:47 AM, Staff F, Licensed Practical Nurse (LPN) asked how the facility monitored fluid intake for residents with a fluid restriction and Staff F stated the facility monitored what Resident #10 got in the dining room and the water drank with her pills. Staff F stated she believed the Certified Nurse Aides (CNA) documented the amounts.During an interview on 7/23/26 at 11:44 AM, Staff E, CNA queried on documenting resident fluid intakes and Staff E stated usually the nurses did it and the staff had a paper that showed who was on fluid restriction, which included Resident #10 and Resident #5. Staff E stated if the residents had a fluid restriction, the residents didn't get water passed in their room and the staff monitored what was on the table. Staff E stated the CNA documented the percentage of how much the residents drank, but not the amount. 2. Review of Resident #5's MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15, which indicated intact cognition. The list of diagnoses included acute on chronic combined systolic and diastolic heart failure, atrial fibrillation, and renal insufficiency. The MDS indicated Resident #5 dependent on staff to sit to stand, and for chair/bed to chair transfer. The MDS listed Resident #5 prescribed diuretics. Review of the Care Plan revised 6/16/26, revealed a Focus area to address Nutritional status related to potential for variable intake due to pain. Interventions included, in part: monitor weight as ordered, initiated 7/21/25. Review of the EHR revealed Resident #5 had a Physician Order for 1.5 L (liter) fluid restriction with a start date of 7/15/26.An Order Note dated 7/15/26 at 2:10 PM: Order obtained for resident to be on a 1.5 L (liter) fluid restriction. MAR updated. fluid restriction form initiated. resident aware. no concerns noted. PCP reviewed labs. no concerns noted.During an observation on 7/22/26 at 8:16 AM, Resident #5 sat at the dining room table and ate breakfast. Resident #5 had a cup of milk and a cup of water in front of her. Review of an undated facility provided document titled Fluid Restriction form revealed: Resident: Resident #5. Fluid Restriction: 1500 ml. Dietary Allowance: (amounts handwritten)a. Breakfast (cc's): 360 ml (1.5 cups or 12 oz (ounce)).b, Lunch (cc's): 360 ml (1.5 cups or 12 oz).d. Supper (cc's): 360 ml (1.5 cups or 12 oz).e. Nursing Allowance: 1. 1st Shift (cc's): 140 ml (4.6 oz).2. 2nd Shift (cc's): 140 ml (4.6 oz).3. 3rd shift (cc's): 140 ml (4.6 oz).The undated Fluid Restriction form provided did not indicate Resident #5's fluid intake per each meal or per each shift. A Fluid Restriction form had not been completed on a daily basis for Resident #5. The form observed to be taped onto the counter of POD A nurse's station for reference.Review of the EHR, which included the July 2026 MAR/TAR revealed no documentation of fluid intake recorded. During an interview on 7/22/26 at 1:44 PM, Staff J, CNA queried on how fluid restrictions tracked and Staff J stated the facility had papers and dietary and the nurse kept track of it. Staff J stated the CNA just didn't put a water mug in the resident's room if they were on fluid restriction. During an interview on 7/23/26 at 10:54 AM, Staff F, LPN queried on Resident #5 fluid restriction and Staff F stated Resident #5 knew how much she was supposed to drink and calculated it herself. During an interview on 7/23/26 at 12:24 PM, the Directed of Nursing (DON) queried on how the facility monitored fluid intake for residents on a fluid restriction and the DON stated dietary had sheets and the nurse had a copy by the nurse's station and the nurse would check to see if the fluid restriction followed. The nurses don't chart the amount but should be checking it off on the MAR and the DON would expect the staff to chart if the resident is non-compliant.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents observed during the Medication Pass (Resident #28) and failed to ensure a resident received the correct dose of antiparkinsonism medication for 1 of 1 resident (Resident #6) reviewed for change in condition. The facility reported a census of 54 residents.Findings include: 1. Resident #28's Minimum Data Set (MDS) assessment dated [DATE], list of diagnoses included diabetes, hemiplegia (one-sided paralysis), and muscle weakness. The Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS indicated Resident #28 taking hypoglycemic medication (medication that lowers blood sugar, includes insulin). The July 2026 Medication Administration Record (MAR) listed a 3/25/25 order for: Fiasp (a type of insulin) 12 units before meals. On 7/21/26 at 7:59 a.m., Staff A Registered Nurse (RN) drew up and administered 12 units of a Novolog insulin to Resident #28 subcutaneously (injected into the fatty tissues) in her right arm. On 7/21/26 at 11:23 a.m., Staff A stated with regard to the type of insulin, it depended on what the pharmacy covered. She stated she would contact the pharmacy and have them send the correct one. On 7/23/26 at 9:37 a.m., the Director of Nursing (DON) stated staff should check the MAR prior to giving medications. The facility policy Medication Administration revised 6/30/23, stated staff would administer medications per the physician order and directed staff to check labels and verify the medication prior to administration. 2. Review of Resident #6 MDS assessments revealed: a. The admission MDS dated [DATE], revealed a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included Parkinson's Disease and non-Alzheimer's dementia. Resident #6 required a substantial to maximal amount of staff assistance with transfers and hygiene tasks. b. The quarterly MDS, dated [DATE], revealed a BIMS score of 7 out of 15, which indicated severe cognitive impairment. The list of diagnoses included Parkinson's Disease and non-Alzheimer's dementia. Resident #6 was dependent on staff assistance for transfers and hygiene tasks. Review of Resident #6's Care Plan, initiated on 11/25/25, revealed a Focus area to address Resident has complaints of pain related to Parkinson's Disease, lymphedema, spinal stenosis, restless leg syndrome (RLS) and utilizes non-opioid pain medication. An intervention instructed to administer medications as ordered. Review of Hospital discharge orders dated 11/07/25, included a medication list which included, in part: Carbidopa-Levodopa (Sinemet) (a prescription medication used to treat Parkinson's Disease, stiffness, and tremors) 25 milligrams (mg)-100mg, with instructions to give one and a half tablets by mouth four times a day at 6:00 AM, 10:00 AM, 2:00 PM, and 6:00 PM. Review of Resident #6's November 2025 Medication Administration Records (MAR) revealed an order for Carbidopa-Levodopa 25-100mg oral tablet, with instructions to give 1 tablet by mouth at bedtime for Parkinson's Disease. Start date: 11/13/25. Discontinued date: 4/28/26. Review of the Order Summary, dated 7/21/26, revealed the following medication orders, in part: a. Carbidopa-Levodopa 25-100mg, give one tablet by mouth at bedtime for Parkinson's Disease, started on 11/13/25, had been discontinued. b. Carbidopa-Levodopa 25-100mg, give one and a half tablets by mouth four times a day related to Parkinsonism, started on 4/28/26, had been discontinued. c. Carbidopa-Levodopa 25-100mg, give one and a half tablets by mouth four times a day related to Parkinson's Disease without dyskinesia (difficulty with movement), started on 6/09/26, remained an active order. Review of electronic health record (EHR) reviewed the following Nursing Notes: a. On 3/02/26 at 1:26 PM: Certified Nursing Assistants (CNAs) report resident is not standing well this shift, have been trying to transfer with maximum assist x2 staff with gait belt and walker, resident required maximum assistance of 3 before and after breakfast. Encouraged staff to use non-mechanical lift with the resident, staff used after lunch and said Resident #6 did well. b. On 3/08/26 at 1:54 PM: This nurse and CNA tried to transfer resident from the bed to the wheelchair with assist of 2 using walker, resident was unable to turn. Used the non-mechanical lift with maximal assist of 3 staff due to resident having a lot of difficulty helping pull self up and tucking butt in, which makes it difficult to put down the seat on the non-mechanical lift. CNAs used the sit to stand (mechanical lift) after lunch with assist of 2 staff. Resident tolerated very well and told the staff he like it better. c. On 4/24/26 at 12:50 PM: Have noticed an increase in tremors in resident, making it difficult to eat and drink, resident also having difficulty talking, finding the words and getting the words out. Secure message sent to the Primary Care Provider to see about increase in Carbidopa-Levodopa. d. On 4/27/26 at 7:05 AM: Received secure message back 4/24/26: Per [name redacted] that would be a Neurologist order, whoever he sees for Neurology. I don't feel comfortable increasing it without some evaluation. This nurse responded: to this nurse's knowledge, the resident has never been to Neurology. Looked through the chart and the resident came with this order from the hospital when admitted in Jan of 2025 and doesn't look like he has been to Neurologist since. May we have a referral? Waiting for a response. e. On 4/28/26 at 9:39 AM: Secure message received 4/27/26, Per [name redacted], yes please consult Neurology. f. On 4/28/26 at 12:08 PM: Received referral form from Neurology, started filling out and looking for correct documentation to send for referral. While this nurse was looking through the resident's chart, reviewed original admission orders from the hospital, orders were put in incorrectly. The correct order is Carbidopa-Levodopa 25mg-100mg, take one and a half tablets four times a day. Call placed to [name redacted], explained what this nurse had found. Per [name redacted], start the four times a day dose, disregard that Neurology consult at this time, and follow up in two in a half weeks when she is on rotation again. Order updated in Electronic Health Records (EHR). Assistant Director of Nursing (ADON) aware of order changes. g. On 5/08/26 at 1:25 PM: Resident has been on an increased dose of Carbidopa-Levodopa since 4/28/26. Have noticed an improvement in resident's tremors and resident is almost independently pulling himself up to standing position with the mechanical sit to stand lift. Will reach out to restorative. During an interview on 7/23/26 at 8:15 AM, Staff C, CNA, reported that Resident #6 was using a non-mechanical lift to transfer, then required a mechanical sit to stand lift due to weakness. Staff C stated Resident #6's tremors have been so much better recently and said his strength is also improving. During an interview on 7/23/26 at 8:20 AM, Staff D, Registered Nurse (RN) confirmed that she had identified the medication error for Resident #6 after sending the provider notification that Resident #6 was having increased tremors and upon completing the Neurology referral paperwork. Staff D stated that she notified the provider, family and Director of Nursing (DON) about the error. Staff D reported that she received orders to increase the Carbidopa-Levodopa to the dosage written on Resident #6's admission and hold off on the Neurology referral. Staff D stated that Resident #6's tremors and strength has much improved since the order for Carbidopa-Levodopa was corrected. During an interview on 7/23/26 at 12:29 PM, the DON, reported that Resident #6's admission orders had been done by a Corporate Nurse and typically the nurses do not have issues with transcribing admission orders, using a double check system. The DON identified that the medication error was found by a floor nurse who reached out to the provider to increase dosage, the DON explained that Carbidopa-Levodopa given once per day wasn't a typical order with Parkinson's Disease. The DON stated that Resident #6 was having more tremors and issues with transferring as a result of receiving the incorrect dose of Carbidopa-Levodopa and is doing a lot better since correcting the dosage. The DON reported that correcting the error has helped with Resident #6's tremors and understanding him more clearly with speech. Review of the facility provided document titled, Medication Error Report, dated 4/28/26, revealed that Resident #6's Carbidopa-Levodopa 25-100mg order should have been to give one and a half tablets four times a day and Resident #6 was given Carbidopa-Levodopa 25-100mg 1 tablet, once a day at bedtime. The Report identified that Resident #6 received the incorrect medication dosage from 11/13/25 until 4/28/26 (approximately 5 months, between 23 and 24 weeks). The Report listed the following corrective action taken for medication error: Order updated correctly in EHR.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to offer and obtain annual routine dental services to 1 of 2 residents(Resident #3) reviewed for dental services. The facility reported a census of 54 residents.Findings:The Minimum Data Set(MDS) assessment tool, dated 4/9/26, listed diagnoses for Resident #3 which included heart failure, diabetes, and anxiety. The MDS listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The MDS listed an admission date of 10/14/21. On 7/21/26 at 9:09 a.m., Resident #3 stated she had not seen a dentist since she was in the facility and stated it was time for a check up and cleaning. The facility lacked documentation of routine dental services provided or offered to the resident in 2026. On 7/23/26 at 1:09 p.m., the Administrator stated the dentist came to the facility every quarter. She stated the facility asked the resident at the start of 2025 if she would like to see a dentist and she said she didn't. The Administrator stated she did not have any documentation related to her telling them she did not want to see the dentist. The facility policy Dental Services, revised 6/7/17, stated the facility would arrange transportation for residents if dental services were provided outside the facility.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of pneumococcal vaccines and/or obtain declinations for the vaccines for 2 of 5 residents reviewed for immunizations (Residents #8 and Resident #38). The facility reported a census of 54 residents.Findings included:1. The Minimum Data Set (MDS) assessment tool, dated 6/24/26, listed diagnoses for Resident #8 which included high blood pressure, anxiety, and atrial fibrillation or other dysrhythmias(abnormal heart rhythms) and listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The resident's Clinical Immunizations report lacked documentation the resident received or was offered a pneumococcal vaccine. The resident's Pneumococcal Vaccine Informed Consent, dated 7/22/26, indicated the resident declined the vaccine.The resident's clinical record lacked documentation the facility offered the pneumococcal vaccine prior to the survey week (7/22/26). 2. The MDS assessment tool, dated 4/23/26, listed diagnoses for Resident #38 included malnutrition, muscle weakness, and altered mental status and listed her BIMS score as 10 out of 15, indicating moderately impaired cognition. The resident's Clinical Immunizations report documented the resident received the PPSV23 (a type of pneumococcal vaccine) on 9/17/13 and received the PCV13 (a type of pneumococcal vaccine) on 6/20/16. The report lacked documentation of a more recent pneumococcal vaccine offered. The resident's Pneumococcal Vaccine Informed Consent, dated 7/22/26, indicated the resident declined the vaccine.The resident's clinical record lacked documentation the facility offered the pneumococcal vaccine prior to the survey week (7/22/26). The facility policy Pneumococcal Vaccinations revised 12/20/24, stated the facility would provide vaccinations against pneumococcal disease to prevent the spread of infection and would follow current CDC guidelines. The Center for Disease Control and Prevention's(CDC's) Pneumococcal Vaccine Recommendations, dated 2/25/26, retrieved fromhttps://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html on 7/27/26 stated adults over the age of 65 years or older had the option to receive PCV 20 or 21(types of pneumococcal vaccinations) if they received both PCR13 and PPSV23 over the age of [AGE] years old.On 7/23/26 at 10:27 a.m., the Director of Nursing (DON) stated she started her role in October 2025 and the residents who did not have a pneumococcal vaccine offered admitted prior to this. She stated the facility was catching up on updating everyone. She stated currently, when resident admitted to the facility, the facility offered them an updated pneumococcal vaccine.

3. Review of the MDS assessment for Resident #18, dated 4/8/25 revealed the resident scored 12 out of 15 on a BIMS exam, which indicated moderate impaired cognition. Per the assessment, the resident received antidepressant medication. Review of Resident #18's Care Plan revealed an undated Focus area to address Resident receives psychotropic antidepressant medication related to depression. Undated Interventions included, in part: Review continued need for medication with prescriber, attempt dose reduction as warranted. Review of Resident 18's Clinical Physician Orders for Sertraline (antidepressant) revealed the resident had been on Sertraline 50 milligrams (mg) since 2/24/2024. Review of the the Pharmacy Review Note, dated 9/29/24, revealed the following documentation: MRR - GDR. The clinical record lacked documentation of any other GDR in the last 12 months (6/1/24 to 6/18/25). On 6/18/25 at 3:40 PM, Resident #18's GDR, dated 9/29/24, requested via email from the facility's Administrator. On 6/19/25 at 11:15 AM, in a response via email, the Administrator reported that she was still working on trying to locate the GDR for Resident #18. On 6/19/25 at 12:22 PM, the Administrator emailed a GDR completed by the pharmacist and signed off by the Advanced Registered Nurse Practitioner (ARNP), dated 6/19/25, which indicated a GDR was contraindicated at this time. The facility failed to provide documentation related to the GDR recommendations, dated 9/29/24. Based on observation, interview, and record review, the facility failed to ensure timely Physician follow up to requests for Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) and failed to ensure rationale provided for declination of GDR for 4 of 5 residents (Resident #17, Resident #18, Resident #26, Resident #40) reviewed for unnecessary medications The facility reported a census of 49 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 5/8/25 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per the assessment, the resident received antipsychotic, antidepressant, opioid, antiplatelet, and hypoglycemic medications. Review of Resident #17's Physician Order dated 8/23/24 revealed, Seroquel Oral Tablet 25 MG (milligram) with directions to give 1 tablet by mouth at bedtime related to Alzheimer's Disease. Review of Resident #17's Physician Order dated 4/7/22 revealed, Sertraline HCl Tablet 50 MG with directions to give 1 tablet by mouth one time a day related to Alzheimer's Disease. Review of Resident #17's Note to Attending Physician/Prescriber printed 1/31/25 revealed the Pharmacist recommended a GDR for the resident's Seroquel Oral Tablet 25 MG (milligram), an antipsychotic medication, and for Sertraline HCL Oral Tablet 50 MG, an antidepressant medications. Review of the the Pharmacy Review Note dated 1/31/25 at 3:39 PM revealed, MRR - GDR. On 6/18/25 at 12:23 PM, Resident #17's GDR dated 1/31/25 requested via email from the facility's Administrator. On 6/18/25 at 2:17 PM, the Administrator response to the email request explained - for January [1/31/25] we are unable to locate a signed copy. 2. Review of the MDS assessment for Resident #40 dated 3/20/25 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Per the assessment, the resident received antianxiety, antidepressant, hypnotic, antibiotic, diuretic, opioid, and hypoglycemic medication. Review of Resident #40's Medication Administration Record (MAR) dated September 2024 revealed the resident took the following antidepressant medications: Amitriptyline 25 MG at bedtime started on 10/8/23, Mirtazapine 15 MG at bedtime started on 10/6/23, Trazodone 100 MG at bedtime started on 12/4/23, and Trazodone 25 MG started on 6/14/24. Per the MAR, the resident took the following anxiety medication: Buspirone 30 MG twice a day started on 10/10/23. The MAR further revealed the resident took the following hypnotic medication: Zolpidem Tartrate 5 MG at bedtime. Review of the Pharmacy Review Note dated 9/29/24 at 3:03 PM revealed, MRR - GDR amitriptyline, mirtazapine, buspar, trazodone, zolpidem. The Pharmacy Review Note dated 12/29/24 at 7:47 PM revealed, MRR - GDR - Repeating September GDR request as pharmacy did not receive response. Please verify in paper chart that documentation is present and resend. Patient also has MRSA (Methicillin-resistant Staphylococcus aureus) listed as the dx (diagnosis) for three times weekly azithromycin, please ensure that this is the correct diagnosis and update it. Thanks! On 6/23/25 at 11:12 AM, the facility's Administrator provided GDR recommendations from the Pharmacist dated 9/30/24, 12/31/24, and and 4/1/25. The Administrator explained via email that the GDRs were not addressed. On 6/23/25 at 1:53 PM, the Administrator provided the GDR dated 4/1/25, which revealed a response documented on 6/23/25. 4. Review of the MDS assessment dated [DATE] revealed Resident #26 scored a 15 out of 15 on the BIMS exam, which indicated intact cognition. The MDS indicated resident received antidepressant and antianxiety medications. Review of the electronic health record revealed the following Physician Orders: Clonazepam oral tablet 0.5 mg (milligrams) give 1 tablet by mouth at bedtime every other day started 11/16/23, Trazodone HCl (hydrochloride) oral tablet give 25 mg by mouth at bedtime started 11/16/23, and Sertraline HCl tablet 100 mg- give 1 tablet by mouth one time a day started 5/17/23 The Pharmacy Review Note dated 9/29/24 at 4:25 PM, revealed MMR (Monthly Medication Review)- GDR clonazepam, sertraline, trazodone. The Note to Attending Physician/Prescribed printed on 9/30/24 revealed a GDR for clonazepam oral tablet 0.5 mg, trazodone 25 mg oral tablet, and sertraline 100 mg oral tablet. The facility lacked documentation the provider addressed the GDR recommendation. The Pharmacy Review Note dated 12/29/24 at 4:08 PM, revealed revealed MMR-GDR. The Note to Attending Physician/Prescribed printed on 12/31/24 revealed a GDR for clonazepam oral tablet 0.5 mg, trazodone 25 mg oral tablet, and sertraline 100 mg oral tablet. The facility lacked documentation the provider addressed the GDR recommendation. The Pharmacy Review Note dated 5/29/25 at 11:31 PM, revealed MMR-GDR. The Note to Attending Physician/Prescribed printed on 6/4/25 revealed a GDR for clonazepam oral tablet 0.5 mg. On 6/18/25, the provider checked to maintain current dose without a rationale documented. Per the email from the Administrator on 6/23/25 at 11:04 AM, Resident #26 GDRs were not addressed. During an interview on 6/23/25 at 3:37 PM, the Director of Nursing (DON) queried on the process of the GDRs and the DON stated they reached out to the doctor about them and see if the GDR was needed. The DON asked what the facility did when the GDRs were not addressed and the DON stated they requested again or took them to the Medical Director. The DON queried about the provider not putting a rationale when a GDR declined and the DON stated [name redacted] didn't put the reasoning and there was currently a Performance Improvement Project (PIP) on [name redacted] to do the GDR the right way. The DON confirmed Resident #26 GDRs for September and December were not addressed and the facility was going to have the Nurse Practitioner do them because the Nurse Practitioner was more thorough. Review of the Facility Policy titled Drug Regimen Review, Monthly dated 11/28/17, revealed the following: Upon identifying any irregularity, pharmacist will provide a written report addressing the drug irregularities to the attending provider, the facility medical director, and the director of nursing. Attending provider's response will be documented in the resident's medical record indicating the identified irregularity has been reviewed and what, if any, action has been taken. If no change in medication, attending physician must document rationale in the medical record. Irregularities identified by the pharmacist that require urgent action to protect the resident will be immediately reported to the director of nursing or nurse in charge who will then notify the attending provider. The Facility Use of Psychotropic Medications Policy dated 4/28/25 for the following: a. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated in an effort to discontinue these drugs.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to treat 1 of 6 residents (Resident #30) with dignity and respect when staff took more than an hour to assist with a transfer request made by a resident who required substantial assistance. The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 5/20/25, revealed Resident #30 scored a 13 out of 15 on the Brief Interview for Mental Status exam, which indicated intact cognition. The MDS indicated Resident #30 required substantial/maximal assistance with chair/bed to chair transfers. The MDS list of diagnoses included cerebral infarction (stroke). Review of the Care Plan, dated 12/30/24, revealed a Focus area to address Resident at risk for falling r/t (related to) falls prior to admit resulting in a L hip fx (left hip fracture). Interventions included, in part: a. Ax2 c GB and NMSA (assist of 2 with gait belt and non-mechanical standing aid), dated 12/30/24. b. Encourage resident to sit in day room, dated 5/30/25 c, Non-ambulatory, dated 6/13/25. During a continuous observation on 6/18/25 starting at 9:28 AM, Resident #30 seated in her recliner. Staff A, Certified Nursing Assistant (CNA) entered the room to pass water, and Resident #30 asked to be assisted from the recliner to her wheelchair. Staff A stated she would transfer Resident #30 in a little bit. At 9:44 AM, Staff A, CNA observed to have finished the water pass in the pod (the facility set up in pods, Staff A passed water on the pod where Resident #30 resided) and then went to the nurse's desk and spoke with nursing and rehab staff. At 9:48 AM, Staff A observed telling the Director of Nursing and Staff B, RN (Registered Nurse) she was going to help another resident with a puzzle. At 10:25 AM, Staff B, RN observed in Resident #30 room. Resident #30 remarked to Staff B she wanted to get into her wheelchair. Staff B told Resident #30 she would let the CNA know when they came back to the pod. Resident #30 remained in her recliner, with her feet elevated. During an interview on 6/18/25 at 10:29 AM, Resident #30 asked how her day was going and Resident #30 stated not good and nothing was going right. Resident #30 stated she was tired of people not listening to her and she just wanted moved to a different chair. Resident #30 stated it was disgusting and she was tired of being in the same chair and just wanted to get into her wheelchair. Resident #30 stated Staff B, RN was just in her room and she told Staff B she wanted into her wheelchair. Resident #30 stated staff B told her she would let the CNA know. At 6/18/25 at 10:36 AM, Staff A, CNA observed to be on the pod where Resident #30 resided, and then left. Resident #30 observed to be in her recliner. At 10:43 AM, Staff A, CNA returned to the pod and went into Resident #30 room with the non-mechanical lift and told Resident#30 she would get her up in a little bit. During an observation on 6/18/25 at 10:50 AM, Staff A, CNA knocked on Resident #30 door and asked if Resident #30 was ready and Resident #30 asked ready for what. Staff A stated it was about lunch time and asked if Resident #30 needed to use the bathroom. Staff A and another CNA went into the room and closed the door. At 10:54 AM, the door to Resident #30's room opened, and Resident #30 observed sitting in her wheelchair. During an interview on 6/18/25 at 1:20 PM, Staff A, CNA queried on how Resident #30 transferred and Staff A stated Resident #30 required an assist of 2 with the non-mechanical lift. Staff A asked how long a resident should wait to be transferred. Staff A stated it depended on if the non-mechanical lift was being used. Staff A stated they only had one non-mechanical lift for all 3 pods. Staff A asked about this morning and Staff A stated she went over to C pod and grabbed it [non-mechanical lift]. Staff A queried about Resident #30's request to move from her recliner to her wheelchair, and she stated Staff B, RN told her and it only took a couple of minutes to go and get the non-mechanical lift. Staff A queried about when Resident #30 asked Staff A to move during the water pass, and she stated she told Resident #30 in a little bit. Staff A explained Resident #30 had just gotten into her recliner. When asked how long a resident should wait to be assisted with a transfer, Staff A answered 5 or 10 minutes, if that. During an interview on 6/19/25 at 10:53 AM, Staff B, RN stated Resident #30 transfers with an assist of 2 with a non-mechanical lift. When asked if Resident #30 asked to be moved to her wheelchair, Staff B stated yes, just like Resident #30 did today. Staff B stated Resident #30 would stay in her wheelchair all day if Resident #30 could, but Resident #30 needed a position change. Staff B informed Resident #30 requested to be moved during water pass and Staff B stated staff just got Resident #30 in the recliner after breakfast. During an interview on 6/23/25 at 3:39 PM, the DON informed of the observation and the DON stated that was not right and when water pass was completed, Resident #30 should have been moved. The DON stated staff need to give the residents a time frame of when they will come back. The DON asked what if the Resident had just transferred to the recliner 10-15 minutes prior and the DON stated if the resident wanted moved, move them and it was always good to reposition. Review of the facilities Resident's [NAME] of Rights Policy, revised on 12/2023, revealed the following: a. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, facility policy review, resident and staff interview, the facility failed to offer the pneumococcal vaccine to 3 of 5 residents (Residents #23, #36, and #40) reviewed for immunizations. The facility reported a census of 49 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 4/24/25, revealed Resident #23 list of diagnoses included respiratory failure and lung cancer. The Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicated intact cognition. The MDS listed an admission date of 4/8/24, and over the age [AGE]. Review of the Vaccination Consent Form, signed 4/8/24 by Resident #23, documented the resident had never received the Pneumovax (PPSV23) vaccine or any of the pneumococcal conjugate vaccines, Prevnar 13 (PVC13), Prevnar 20 (PVC20), or Vaxneuvance (PVC15). The resident consented to receive the pneumococcal vaccination on 4/8/24. On 6/17/25, review of the clinical record revealed a lack of documentation that Resident #23 had received any form of the pneumococcal vaccine. On 6/18/25 at 2:40 PM, the Administrator sent an email response which identified the resident did not receive the pneumococcal vaccine. During an interview on 6/18/25 at 3:50 PM, the Administrator reported Resident# 23's family member had consented to the vaccine for the resident and staff had not followed through with getting an order for the pneumococcal vaccine. The family member still wanted the vaccine administered when they contacted them today (6/18/25). The Administrator reported facility staff got an order from the resident's physician to administer the vaccine. 2. Review of the MDS assessment, dated 4/15/25, revealed Resident #40 list of diagnoses included of acute and chronic respiratory failure, and chronic obstructive pulmonary disease. The BIMS score of 13 out of 15 indicated intact cognition. The MDS listed an admission date of 10/6/23, and over the age of 65. Review of Resident #40's immunization record revealed the resident had received Prevnar 13 (PVC13), dated 4/24/17 and Pneumovax (PPSV23), dated 8/28/18, and had not received one of the following immunizations 5 years after (since 8/28/23) Pneumovax (PPSV23): PCV15, or PCV20, or PCV21 (pneumococcal conjugate vaccine). Review of the Pneumococcal Immunization Informed Consent form, signed and dated 10/6/23 by Resident #40, documented the reason the resident refused the pneumococcal conjugate was due to already received. The clinical record lacked documentation the resident had received the PCV15, or PCV20, or PCV21 vaccine. The clinical record lacked documentation facility staff had offered the PCV15, or PCV20, or PCV21 vaccine in 2024 or 2025. On 6/18/25 at 6:28 PM, the Administrator sent an email with a signed and dated consent form, dated 6/18/25, for Resident #40 to receive the pneumococcal vaccine. During an interview on 06/19/25 at 8:55 AM, Resident #40 reported she had been offered the pneumococcal vaccine on admission to the facility, but had refused. Resident #40 thought she had been offered the vaccine last year. Resident #40 reported she was offered the pneumococcal vaccine today (6/19/25). 3. Review of the MDS assessment, dated 3/13/25, revealed Resident #36 list of diagnoses included iron deficiency anemia, moderate intellectual disability and history of venous thrombosis and embolism (blood clot). The BIMS score of 2 out of 15 indicated a severe cognitive impairment. The MDS listed an admission date of 7/13/22, and over the age of 65. Review of Resident #36's immunization record revealed the resident had received the Pneumovax (PPSV23) vaccine, dated 8/11/22, and had not received one of the following immunizations: PCV15, or PCV20, or PCV21 (pneumococcal conjugate vaccine) at least 1 year after the last PPSV23 dose. The clinical record lacked documentation facility staff had offered a pneumococcal conjugate vaccine once the resident became eligible on 8/11/23. Review of the Vaccination Consent Forms, signed 9/23/24 by Resident #36's guardian, documented the guardian consented to the resident to receive the Influenza, COVID and Respiratory Syncytial Virus (RSV) vaccinations. The record lacked documentation facility staff offered the resident's guardian the choice of consenting or refusing the pneumococcal conjugate vaccine for the resident. During an interview on 06/18/25 at 12:00 PM, the Director of Nursing (DON) reported she had been in her role as the Infection Preventionist about one year. The DON explained she was responsible for educating and offering residents vaccinations. The DON explained she tracked immunization through the electronic health record and ran a report to identify when residents were due for immunizations. During an interview on 06/19/25 at 8:33 AM, when asked about the knowledge the DON had about the pneumococcal vaccine schedule, she explained she just recently learned how to determine when the pneumococcal vaccines were due. The DON clarified that she just learned the pneumococcal vaccine schedule a couple weeks ago. The DON reported she followed the Center for Disease Control (CDC) chart for determining when residents were due for the pneumococcal vaccine, and used the chart to provide education to residents and their family. The DON explained that she had not had a chance to run the reports in the electronic health record (EHR) to determine who should have been offered the pneumococcal vaccine since learning when the vaccinations should be offered. The DON reported she did not run a report until yesterday (6/18/25) in the EHR on Resident #40 after the surveyor asked about the pneumococcal vaccine. The DON explained that she identified from the EHR report that Resident #40 was due to be offered the pneumococcal conjugate vaccine (PCV15, or PCV20, or PCV21) and obtained the consent from Resident #40 to administer the medication. The DON reported that Resident #36 was also due for the pneumococcal conjugate vaccine, and staff was calling the POA (Power of Attorney) right now to see if POA wants Resident #36 to have it. Review of the policy, titled Pneumococcal Vaccinations, dated 9/12/24, revealed facility staff would assess all persons, upon admission, for receiving a pneumococcal polysaccharide vaccine and/or pneumococcal conjugate vaccine and follow CDC recommendations. Staff would administer PCV15, PCV20, or PCV21 for all adults 65 years or older whether the resident had received PVC13 at any age and PPSV23 at or after the age of 65 years. Per CDC guidelines: if a person previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older, based on shared clinical decision-making, 1 dose of PCV20, or 1 dose of PCV21 administered at least 5 years after the last pneumococcal vaccine dose. If the person previously received only PPSV23: then 1 dose PCV15, or 1 dose PCV20, or 1 dose PCV21, at least 1 year after the last PPSV23 dose.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide monitoring, assessment and intervention services causing a pressure ulcer present on admission to worsen, and the development of new pressure ulcers. Resident #9 admitted on [DATE] with a Stage 2 pressure ulcer present on the right heel. The pressure ulcer deteriorated to a Stage 3 by 7/5/24. The clinical record revealed the resident experienced pain and a referral to the wound clinic. During the first wound clinic appointment on 6/11/24, the right heal pressure ulcer was not assessed or treated. The facility did not follow up with the clinic. On 6/25/24, the wound clinic assessed the right heel as a Stage 3 pressure ulcer with necrotic (dark, dead tissue) tissue and identified a new unstageable pressure area on the left heel, and Stage 3 Pressure ulcers on bilateral buttocks. On 7/5/24, both the right and left heels presented with necrotic tissue. The facility reported a census of 49 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/16/24 at 4:15 PM. The IJ began on 5/28/24. Facility staff removed the Immediate Jeopardy on 07/17/24 at 04:28 PM by implementing the following actions: 1. All nursing staff educated by the end of the day on 7/17/24. Education included: policies for pressure ulcer prevention, wound care-infection prevention, skin checks, and physician notification. 2. An audit of all skin assessments and ensured all wound assessments up to date as of 7/16/24. 3. Assistant Director of Nursing (ADON) named as person responsible for re-assessment of wounds weekly. The Director of Nursing (DON) will monitor for compliance. In the absence of the ADON, the DON will re-assess all wounds weekly. 4. A skin assessment will be completed by the admitting nurse on the day of admission. Any wound will be documented on the wound record. Skin will be observed by the bath aides at least weekly per the skin check policy. Any abnormalities will be reported to the charge nurse for assessment. Any new wound identified will be documented on the wound record. 5. Physician/provider will be notified of wounds present on admission, new wounds, and wounds not responding to treatment. Licensed nurse will call the provider if there is no response from the provider within 24 hours. DON and the ADON will monitor documentation to ensure compliance. 6. A copy of the facility's wound assessment will be sent with a resident for any wound clinic appointment. The scope lowered from J to G at the time of the survey. Findings include: The Admission Nursing Assessment, dated 5/28/24, revealed Resident #9 right heel noted to have an open area measuring 0.8 centimeters (cm) by 0.8cm. The Admission Assessment identified bruises on left hand, left lower leg, right lower leg, an open area on front of right lower leg, and intravenous infiltration site to the right antecubital (area on arm commonly used for IV insertion). Assessment lacked identification of pressure injuries. A Wound and Skin Healing Record, dated 5/28/24, identified a right heel Stage 2 pressure injury, measuring 0.8cm by 0.8cm with 0.1 cm depth. Assessment of the Stage 2 pressure injury revealed the wound bed had normal tissue, no drainage, no odor, no pain present, and surrounding skin had normal appearance. A Braden Assessment (used to identify risk of pressure ulcer development), completed 5/28/24, identified Resident #9 at moderate risk for development of pressure injuries due to occasionally moist skin, very limited mobility, inadequate nutrition, and problem with friction or skin shearing from moderate to maximal assistance required with movement. Additional Braden Assessments, completed on 6/25/24 and 7/05/24, continued to identify Resident #9 at risk for development of pressure injuries. A Nursing Progress Note on 5/28/24 at 3:57 PM, revealed Resident #9 had arrived to facility following a fall at home and left hip fracture that had an incision site with 15 staples in place and covered with foam dressing. Resident #9 noted to have aphasia (difficulty with speech) and right facial drop from past stroke. Nurse indicated skin assessment completed and Primary Care Provider (PCP) notified of skin issues. The Baseline Care Plan, completed on 5/29/24, identified skin break interventions that included pressure reducing mattress and skin/wound treatments to be found on the Medication/Treatment Administration Record. The Baseline Care plan lacked documentation of a pressure ulcer present on admission. A Nursing Progress Note, dated 5/31/24 at 9:27 PM, revealed Resident #9 right heel wound had a clean, dry dressing applied. Note lacked assessment, including measurements of the wound. The Minimum Data Set (MDS) assessment, dated 6/03/24, revealed Resident #9 required substantial to maximal staff assistance to transfer and partial to moderate staff assistance for bed mobility. The diagnoses listed for Resident #9 included: diabetes mellitus, cerebrovascular accident (CVA or Stroke), and heart failure, and an encounter for orthopedic aftercare. The assessment identified Resident #9 had a surgical wound and required a pressure reducing device for chair and bed, surgical wound care, the application of nonsurgical dressings, and ointment or medications applied (other than to feet). The Brief Interview for Mental Status (BIMS) result of 15 out of 15 indicated the resident had intact cognition. The MDS lacked identification of unhealed pressure injuries on admission, and did not identify the resident at risk for pressure ulcers. The Care Plan, revised on 7/03/24, indicated Resident #9 had been at risk for skin breakdown related to fractured hip, previous cerebrovascular accident, weakness, and pain, staff instructed to monitor and report signs of skin breakdown, and complete skin treatments as ordered. The Care Plan lacked identification of pressure injuries or unhealed skin impairments. The Medication Administration Record (MAR), dated May 2024, revealed the following orders: 1. Mepilex wound pad, started 5/29/24, to be placed to left leg topically every evening on Monday, Wednesday, and Friday, related to atherosclerotic heart disease of native coronary artery diagnosis. 2. Mupirocin Ointment 2%, started 5/29/24 and discontinued 6/11/24, to be applied to wound every evening shift on Monday, Wednesday, and Friday, for wound. A review of SNF (Skilled Nursing Facility) Documentation Fracture, from 5/29/24 to 6/18/24, lacked identification, assessment or monitoring of Resident #9's right heel Stage 2 pressure injury. A Nursing Progress Note, dated 6/05/24 at 4:10 AM, revealed Resident #9 called with complaint of pain to right heel, nurse noted an open area on right heel, and determined this area had been documented in the admission assessment. Nurse identified no treatment orders in place for right heel wound, faxed PCP for treatment orders, and floated Resident #9's heels. A Nursing Progress Note, dated 6/07/24 at 4:37 PM, revealed the PCP faxed back for Resident #9 to have a wound care consultation, appointment with Wound Clinic on 6/10/24. The Wound Office/Clinic Note, dated 6/11/24, lacked assessment or documentation of right heel Stage 2 pressure injury. Visit note revealed Resident #9 presented with Stage 3, bilateral pressure Injury to buttocks that measured 10cm by 6cm with 0.1cm depth. Discharge documentation included the following orders: 1. Treatment to buttocks to include an equal mixture of clotrimazole 1% cream, mupirocin 2% ointment, and triad barrier cream to buttocks twice per day. Do not scrub excess cream off, gently wipe away soiled cream and reapply. 2. Keep wounds out of shower water. 3. Reposition every 2 hours and place cushion in every chair. 4. Offer nutritional shake or protein ice cream with meals and at bedtime. A Wound and Skin Healing Record, dated 6/18/24, recorded an assessment of the Stage 2 pressure injury to right heel with measurements of 1.8cm by 2.4cm without depth, and a description of the wound bed as lacking educate (drainage), odor not assessed, wound bed normal, surrounding skin color and tissue normal. Response to treatment assessed as deteriorated. A handwritten note indicated fax sent to Dr. The Wound/Skin Healing Record, dated 6/18/24, revealed a Stage 2 pressure injury noted to left heel that measured 3.8cm by 3.4cm, had small amount of serosanguineous drainage, wound bed and surrounding skin documented as normal tissue. No Provider or family notification documented on healing record. No additional assessments or measurements documented for Stage 2 pressure injury of left heel. A Nursing Progress Note, dated 6/18/24 at 5:35 PM, revealed Resident #9 had an area of skin impairment to left heel that measured 3.8cm by 3.4cm and the right heel measured 1.8cm by 2.2cm. Nurse applied heel protector and faxed PCP with update and request for an order to apply Betadine twice a day to heels. A review of SNF Documentation Fracture from 6/19/24 through 6/26/24, revealed Resident #9 had open areas to right lower extremity and bilateral heels, no assessment of wounds or measurements documented. The Wound/Skin Healing Record, dated 6/19/24, revealed identification of a blood blister to top of right first toe, document lacked wound measurement or assessment of tissue, the surrounding skin, or drainage type. Document indicated Provider and family had been notified of wound on 6/19/24. No additional assessments or measurements documented for blood blister to top of right first toe. A Nursing Progress Note, dated 6/19/24 at 10:57 AM, revealed Resident #9 had new area of skin concern on top of first toe, appeared to be a blood blister, that measured 0.4cm by 0.6cm. Nurse informed PCP that a foam dressing had been applied to area for protection and requested order to change padded dressing daily. A Nursing Progress Note, dated 6/20/24 at 01:42 AM, revealed an order received from PCP for foam border dressing, to be replaced every other day, to top of first toe for two weeks time. A Nursing Progress Note, dated 6/25/24 at 4:56 PM, indicated Resident #9 went to a Wound Clinic appointment and received new orders. The Wound Office/Clinic Note, dated 6/25/24, revealed Resident #9's husband had requested for Provider to inspect resident's feet, and upon removal of socks, Resident #9 noted to have multiple pressure injuries to bilateral feet. Visit Note indicated that the Nursing Facility had been called to obtain further information regarding wounds. Facility informed Wound Clinic they were aware of the right heel ulceration and first noted it on 6/21/24, but were unaware of any ulcerations to Resident #9's left foot. Assessment of Resident #9's right foot, during Wound Clinic visit on 6/25/24, revealed a large, oval shaped ulceration noted to the lateral aspect (side) of the right heel, which measured 1.5cm by 2cm. Right heel wound bed covered with moderately adhered cream colored slough (non-viable) tissue. Wound Clinic performed an excisional (scalpel) debridement of wound. Wound Clinic identified wound as a Stage 3 pressure injury. Assessment of Resident #9's left foot, during Wound Clinic visit on 6/25/24, revealed a large circular shaped ulceration noted to the posterior aspect of left heel, which measured 3.1cm by 3cm with 0.1 cm depth. Left heel wound bed covered with black, dry, eschar (dead) tissue. Wound Clinic identified left heel wound as an unstageable pressure injury. Assessment of Resident #9's buttocks, during Wound Clinic visit on 6/25/24, revealed redness and excoriation over bilateral buttocks with scattered ulcerations and satellite macules (similar to that of yeast infection). Buttocks ulcerations had granulated tissue to wound beds. Wound Clinic identified buttocks wound as Stage 3 pressure injury to bilateral buttocks. The Medication Administration Record (MAR), dated June 2024, revealed the following treatment orders: 1. Mepilex foam border dressing, started 6/20/24, to be applied to right first metatarsal topically one time a day, changed every other day, for 14 days. 2. Foam dressing to right lateral foot boney prominence's, started 6/26/24, to be applied every evening shift, every 3 days, for wound care. 3. Betadine Solution 10%, started on 6/26/24, to be applied to left heel topically every evening shift, every other day, for wound care. 4. Mupirocin 2% ointment and prisma, started on 6/26/24, to be applied to wound bed and covered with foam border every evening shift, changed every other day for wound care. 5. Mupirocin 2% ointment, started on 6/26/24, to be applied to right medial foot and left plantar foot, to be covered with foam border dressing and changed every other day for wound care. In a Nursing Progress Note, dated 6/27/24 at 11:18 PM, revealed dressings to bilateral feet had fallen off, feet were redressed with foam border dressing. Nurse noted left heel had dried brown drainage on old dressing and Resident #9 had reported pain with dressing change. Nurse charted that Resident #9's feet supported in boots and elevated on pillows following wound care, no indication of Provider or family notification. In a Nursing Progress Note, dated 7/05/24 at 10:34 AM, nurse reported Resident #9 had increased pain and cracking sensation in left knee, call placed and message left for Orthopedic Provider with request for any new orders. A Nursing Progress Note, dated 7/05/24 at 1:56 PM, revealed Resident #9 left facility with family to a Wound Clinic appointment. A Nursing Progress Note, dated 7/05/24 at 4:07 PM, revealed the facility had been notified by Wound Clinic that Resident #9 was sent to the Emergency Department (ED) for suspected cellulitis. Note indicated the Wound Clinic reported to facility that Resident #9 had a lot of redness and warmth by right foot wound. A Wound Office/Clinic Note, dated 7/05/24, revealed that upon evaluation, it is noted Resident #9's wounds had deteriorated significantly. Redness noted to right foot and left knee, present for an unknown length of time due to lack of documentation of it from facility. Wound Clinic Provider indicated a concern related to infection of the right foot that required further workup. Wound Clinic Provider discussed transfer to Emergency Department with Resident #9 and family whom stated understanding and agreement to further evaluation. Assessment of Resident #9's right foot, completed by Wound Clinic on 7/5/24, revealed irregularly shaped non-pressure ulceration noted to right medial foot that measured 2cm by 3.1cm with 0.1cm depth, wound bed had yellow slough and macerated (damage from moisture) tissue, copious amounts of seropurulent (containing pus) drainage, malodor, and significant redness, warmth, and edema surrounding wound. The right heel continued to have oval shaped Stage 3 pressure ulceration, that measured, 1.5cm by 2.3cm with 0.1cm depth, covered with cream colored slough tissue, moderate amount of serosanguineous drainage, and maceration of skin surrounding ulcer. Assessment of Resident #9's left foot, completed by Wound Clinic on 7/5/24, revealed a large circular, Stage 3 pressure ulceration, noted to the left heel that measured, 4cm by 3.4cm with 0.1cm depth, wound bed covered with black, dry, eschar tissue. Assessment of Resident #9's buttocks/coccyx area, completed by Wound Clinic on 7/5/24, revealed redness and excoriation noted to the coccyx, that extended to the buttocks, and back of thighs with scattered ulcerations noted on bilateral buttocks, identified as a Stage 3 pressure injury of bilateral buttocks. A Nursing Progress Note, dated 7/05/24 at 5:27 PM, revealed a notification from the Hospital that Resident #9 had been admitted for sepsis related to left knee infection, a right foot infection, and poorly controlled Diabetes Mellitus. The Transfer Assessment, completed by facility on 7/05/24 at 8:14 PM, indicated Resident #9 had discharged to the hospital. Transfer Assessment lacked documentation of pressure injuries or unhealed skin impairments. The Hospital Emergency Department (ED) Note, dated 7/05/24 at 5:02 PM, revealed that Resident #9 had been sent from the Wound Clinic with bilateral foot redness and wounds. Resident #9 presented with left knee pain, small swelling of bilateral foot wounds, and poor control of diabetes. ED noted bilateral heel pressure sores with eschar in which debridement of tissue may be required. Redness and bruising noted over the right first toe, with possibility of cellulitis and indicated Resident #9 would need x-ray of bilateral feet, antibiotics, and possible admission for the same. ED Note revealed that Resident #9 had been given fluids, antibiotics, and insulin intravenously. The ED Note revealed the following assessment/plan: 1. Infection of left knee 2. Right foot infection 3. Poorly controlled type 2 Diabetes Mellitus 4. Sepsis On 7/16/24 at 10:42 AM, Staff C, Registered Nurse (RN) confirmed she completed the admission skin assessment for Resident #9 on 5/28/24. Staff C recalled an open area on Resident #9's right heel on admission, that had been covered with a foam dressing, unable to recall how wound appeared during admission assessment. Staff C informed that Resident #9 had no treatment orders for the open area on right heel, stated she assessed the wound, re-applied foam dressing, and then faxed the Primary Care Provider (PCP) regarding the skin impairments noted in the admission assessment. Staff C unable to recall if PCP responded to fax. Staff C reported that evening shift nurse had been responsible for weekly monitoring and assessment of Resident #9 wounds as well as completion of treatment for Resident #9's heels. Staff C informed she had thought the heels were getting better. Staff C revealed that in Skilled Nursing Facility assessment documentation, open areas would be mentioned if known, but the assessment and measurement documentation would be completed on Wound/Healing Record. Staff C denied having seen Resident #9's feet the week she went to the hospital and denied changes noted in Resident #9's condition. Staff C informed that she would fax PCP with any new wounds observed, denied having called Resident #9's PCP with updates on her wounds. On 7/16/24 at 11:22 AM, Staff D, Licensed Practical Nurse (LPN), confirmed she had completed multiple daily SNF assessments on Resident #9. Staff D stated that open areas or skin issues would be mentioned in the daily assessments, as well as in Nursing Progress Notes. When asked why SNF assessments completed by Staff D had lacked information related to Resident #9's wounds, Staff D revealed she had not known about any of Resident #9's pressure injuries until survey. When asked how nurses would be informed about wounds, Staff D claimed there would be information on the MAR or Admission Assessment, in Progress Notes, and through verbal communication with other nurses. Staff D revealed first and second shift nurses each had a list on Tuesdays and Wednesdays which notified the residents due for a weekly skin assessment. Staff D recalled Resident #9 had been non-ambulatory, but worked with therapy on transfers, also stated Resident #9 had poor eating habits and required Provider notification related to blood sugar levels. On 7/16/24 at 11:45 AM, Staff E, Agency Staff Registered Nurse (RN), recalled Resident #9 had a couple pressure injuries located on heels, stated she had competed wound treatment the week prior to hospitalization and remembered that wounds had some drainage, but did not recall any signs of infection. Staff E informed she would know about wounds when treatment orders showed up on the MAR to be completed. Staff E unaware of facility's schedule for weekly skin assessments. On 7/16/24 at 12:02 PM, Staff F, Licensed Practical Nurse (LPN) confirmed she had worked with Resident #9 on 07/05/24. Staff F denied changes in Resident #9's condition when she left for Wound Clinic appointment and stated she had not seen Resident #9's feet that day because dressings and booties had been placed on feet. On 7/16/24 at 2:33 PM, Staff G, Licensed Practical Nurse (LPN), worked overnight shifts and recalled Resident #9 was not very alert or oriented. Staff G stated Resident #9 required repositioning every 2 hours, due to wound on her bottom, did not recall any other wounds present on Resident #9. Staff G did not recall heel protectors worn by Resident #9 overnight. On 7/16/24 at 2:43 PM, Facility Administrator provided a For Your Information (FYI) sheet completed by Staff C, RN, that reported admission skin assessment findings on Resident #9 with an order request for open areas on right heel and shin. A stamp at the top of document indicated that fax had been sent to PCP on 5/28/24. Facility unable to produce additional documentation of confirmation that fax had been sent or Provider response to fax. Administrator denied any follow up documentation related to admission skin assessment fax and revealed the expectation of nurses to call Provider within 24-48 hours if no response is received. On 7/16/24 at 3:00 PM, Staff H, Registered Nurse (RN), revealed she had worked Wednesday evenings during the months of May and June 2024. Staff H stated Resident #9 had wounds to right upper arm and one on her heel. Staff H denied Resident #9 having any wounds on buttocks. Staff H reported Resident #9's right heel had been pretty red and looked sore just before she was hospitalized , Staff H denied notification to Provider. Staff H revealed that skin sheets would be completed on admission and monitored weekly. Staff H revealed that the nurse working when the weekly wound assessments were due would be responsible for completing wound measurements and assessment. Staff H revealed that a wound assessment included measurements, how the wound looked, and if the Provider had been notified. Staff H identified times in which the Provider should be notified about wounds would be on admission, changes in wound conditions such as worsening, abnormal tissue or drainage and stated notification is faxed to Provider or, if needed to addressed that day, to call the Provider's office. On 7/17/24 at 1:00 PM, Staff I, Registered Nurse and MDS Coordinator revealed when residents are admitted , she would review the Admission Assessment and Nursing Progress Notes to determine if wounds were present on admission. Staff I revealed wounds and pressure injuries should be included in the Care Plan with indication of wound type and interventions. Staff I confirmed Resident #9's Care Plan lacked identification of pressure injuries or unhealed wounds. The facility provided a document, titled Weekly Skin Measurements, not dated, that revealed Resident #9 had been scheduled for wound measurements every Wednesday evening shift. The facility provided documents, titled Bathing Documentation and Skin Assessment, completed on Resident #9, by Certified Nursing Assistant (CNA) staff on the following dates: a. 5/31/24- Shower given, no skin issues identified. b. 6/04/24- Resident refused. c. 6/07/24- Resident refused. d. 6/14/24- Bed bath given, no skin issues identified. e. 6/18/24- Resident refused. f. 6/21/24- Resident refused. g. 6/25/24- Bed bath given, no skin issues identified. h. 6/28/24- Bed bath given, no skin issues identified. i. 7/02/24- Bed bath given, no skin issues identified. j. 7/05/24- Bed bath given, no skin issues identified. The facility policy titled, Pressure Ulcer Prevention Policy, not dated, revealed the facility shall have a system in place that assures assessments are timely and appropriate; interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals as appropriate. The policy informed that the facility shall provide, care, treatment, and services to promote the prevention of pressure ulcer development, promote healing of pressure ulcers that are present, and to prevent the development of additional pressure ulcers. The policy additionally revealed the following procedures nursing staff shall perform: 1. Assess, reassess, and document the ulcer's characteristics weekly. 2. Observe for infection. 3. Follow physician's orders for treatment of the pressure ulcer, including cleansing and dressing. 4. Monitor the healing process. 5. Assess, reassess, and manage the resident's pain. 6. Avoid positioning residents on a pressure ulcer. 7. Continue preventive measures to prevent other pressure ulcers from developing. 8. Observe and change dressings as ordered and needed. The Pressure Ulcer Prevention Policy further instructed that interventions shall be incorporated into the resident's plan of care, evaluated, and revised as the condition of the resident indicates. The facility policy titled, Skin Checks, dated 7/12/18, revealed that bath aides are to observe all resident's skin for abnormalities during each bath or shower, and report abnormalities to the charge nurse. The Skin Check policy instructed for charge nurse to complete an assessment of the skin and document on the appropriate skin assessment form. Policy further instructed charge nurse to notify physician and resident representative of any new or worsening area, obtain a treatment order as needed, and reassess skin impairments weekly. The facility policy titled, Physician Notification, dated 10/10/19, revealed that physician will be notified promptly for a significant change in resident condition which has potential for clinical complication with open skin listed in this category.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure the Care Plan revisions to indicate; a resident use of prophylactic antibiotics, resident wandering, and the presence of pressure ulcers for 3 of 13 residents reviewed for Care Plans (Resident #29, Resident #45, and Resident #9). The facility reported a census of 49 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #45, dated 6/13/24, revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident had an indwelling catheter and took an antibiotic. Review of the Physician Order dated 4/19/24 revealed, cephalexin (an antibiotic) oral tablet 250 MG give 1 tablet by mouth one time a day for prophylactic (medication used to prevent infection.) Review of the Office/Clinic Notes for Resident #45, dated 6/20/24, revealed, a Chronic Foley due to failed void trial and continues on cephalexin 250 mg (milligram) daily for prophylaxis. Review of the Care Plan for Resident #45 did not address use of a prophylactic antibiotic for the resident. On 7/12/24 at 12:09 PM, the MDS Coordinator acknowledged prophylactic antibiotics should be on the care plan. Review of the Facility Policy titled Comprehensive Care Plan, dated 8/30/21 and revised 7/18/22, revealed, the facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals. 48374 2. The MDS assessment, dated 5/23/2024, for Resident #29 listed diagnoses included: progressive supranuclear ophthalmoplegia (neurodegenerative disease), adjustment disorder with anxiety, and obsessive-compulsive disorder. The assessment indicated the resident walks independently with a walker. The BIMS score of 11 out of 15 indicating moderately impaired cognition. A Progress Note dated 5/3/2024 at 10:10 PM, revealed Resident (Resident #29) requested to go outside to sit this evening due to increased agitation. Resident ambulated further than anticipated and an LPN staff member escorted the resident back to the building. Resident was educated on the safety risks of ambulating outside without a staff members assistance. Wander guard placed on residents left ankle for safety reasons A review of the clinical record revealed a Physician's Order, dated 5/6/24, for Wanderguard for every shift. The Care Plan, dated 6/14/24, included a Focus Area for wandering. Interventions included: a. Avoid overstimulation. (Noise, crowding, other physically aggressive residents). b. Convey an attitude of acceptance toward the resident. c. Develop a pathway for resident to follow. Keep pathway free from obstacles. d. If resident looks for family/significant other, reassure that others know where to find him/her. e. Maintain a calm environment and approach to the resident. f. Redirect resident from exit doors as needed. g. Wander guard. On 07/08/24 at 10:45 AM Resident #29 was interviewed. Resident #29 shared she likes to go outside but they won't let her go out by herself anymore. Resident indicated she left the building on several occasions but did not leave the property. The resident shared she likes to walk around and used to walk all around on her parent's land. Resident advised she had gotten 4 wander guards off and now she is watched all the time so she doesn't go out different doors. Resident shared the staff keep a close eye on her now. Resident shared she does not feel there is enough staff to take her outside when she wants to go out On 07/10/24 at 09:05 AM The Facility Nurse Consultant was queried. She advised the resident is very mobile and likes to walk around all the time. She had gotten the door code and went outside so she has a wander guard now. Resident has a wander guard on her wrist and one on her walker. The resident has never eloped but has tested the boundaries a bit and it started to make staff uncomfortable so she can't go outside by herself anymore. For awhile she could go out on her own. Activity staff take her outside. On 07/11/24 at 12:22 PM The Administrator was interviewed regarding Resident #29 and wandering concerns. On 5/3/24 Resident #29 was outside with staff and she walked beyond a point the staff member was comfortable with so the staff member brought her back in the building. The Resident did not go off the property and was never out of sight. The wander guard was placed on the resident for safety measures. We have several interventions for her. The Administrator advised the staff member responsible for completing Care Plans is new to that position and when the facility conducted a care plan audit they discovered the wandering concerns and interventions with Resident #29, in error, had not been added to the resident's care plan. 48888 3. The MDS assessment for Resident #9, dated 6/03/24, lacked identification of unhealed pressure injuries and indicated no risk for the development of pressure injuries. The MDS identified Resident #9 had a surgical wound and required a pressure reducing device for chair and bed, surgical wound care, the application of nonsurgical dressings, and ointment or medications applied (other than to feet). The MDS revealed Resident #9 required substantial to maximal staff assistance to transfer and partial to moderate staff assistance for bed mobility. The diagnoses listed for Resident #9 included: diabetes mellitus, cerebrovascular accident (CVA or Stroke), heart failure, and an encounter for orthopedic aftercare. The Care Plan, revised on 7/03/24, indicated Resident #9 at risk for skin breakdown related to fractured hip, previous cerebrovascular accident, weakness, and pain. Interventions included: monitor and report signs of skin breakdown, and complete skin treatments as ordered. The Care Plan lacked identification of pressure injuries or unhealed skin impairments. The Admission Nursing Assessment, dated 5/28/24, revealed Resident #9 right heel noted to have an open area that measured 0.8 centimeters (cm) by 0.8 cm. The Admission Assessment identified bruises on left hand, left lower leg, right lower leg, an open area on front of right lower leg, and intravenous infiltration site to the right antecubital (common area on arm for IV insertion). Assessment lacked identification of pressure injuries. A document titled, Wound and Skin Healing Record, dated 5/28/24, identified a right heel Stage 2 pressure injury that measured 0.8 cm by 0.8 cm with 0.1 cm depth. The Wound/Skin Healing Record, dated 6/18/24, revealed a Stage 2 pressure injury noted to left heel that measured 3.8 cm by 3.4 cm, had small amount of serosanguineous drainage, wound bed and surrounding skin documented as normal tissue. The Wound/Skin Healing Record, dated 6/19/24, revealed identification of a blood blister to top of right first toe, document lacked wound measurement or assessment of tissue, the surrounding skin, or drainage type. On 7/17/24 at 1:00 PM, Staff I, Registered Nurse and MDS Coordinator revealed when residents are admitted , she would review the Admission Assessment and Nursing Progress Notes to determine if wounds were present on admission. Staff I revealed wounds and pressure injuries should be included in the Care Plan with indication of wound type and interventions. Staff I confirmed Resident #9's Care Plan lacked identification of pressure injuries or unhealed wounds. The facility policy titled, Pressure Ulcer Prevention Policy, not dated, revealed that pressure injury interventions shall be incorporated into the resident's plan of care, evaluated, and revised as the condition of the resident indicates.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure use of antiplatelet medication and seizures were included on the resident's comprehensive plan of care for two of thirteen residents reviewed for care plans (Resident #16, Resident #20). The facility reported a census of 49 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #16 dated 6/20/24 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) assessment, which indicated moderately impaired cognition. Per this assessment, the resident took antiplatelet medication. The Physician Order dated 6/14/24 revealed, Clopidogrel Bisulfate (generic Plavix, an antiplatelet medication) Oral Tablet 75 MG (milligram) with direction to give 1 tablet by mouth one time a day. The Physician Order dated 6/14/24 revealed, Aspirin EC (enteric coated) Tablet Delayed Release 81 MG with directions to give 1 tablet by mouth one time a day. Review of the resident's Medication Administration Record (MAR) dated June 2024 and July 2024 revealed the resident received both medications on 6/14/24 to 6/30/24, and also on 7/1/24 to 7/11/24. On 7/11/24 at 12:07 PM during an interview with the MDS Coordinator, the MDS Coordinator acknowledged antiplatelet medication should be on the care plan. 2. Review of the MDS assessment for Resident #20 dated 6/15/24 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Review of the Physician Order dated 6/14/24 revealed, Phenytoin Sodium (generic Dilantin, an antiseizure medication) Extended Capsule 100 MG (milligram) with directions to give 1 capsule by mouth three times a day related to altered mental status. Review of the Office/Clinic Notes by the Advanced Registered Nurse Practitioner (ARNP) dated 6/20/24 revealed, Medications were adjusted in the hospital and Dilantin was added for possible observed seizure activity. Review of the Assessment/Plan section of the note documented the following per the 3.Seizure section: Started on phenytoin 100 mg 3 times daily. She is follow-up with neurology per discharge summary, June 24. Review of the Neurology Note dated 6/25/24 revealed, in part, [Resident #20] is on Dilantin 3 times daily for subclinical seizures mainly for level to be checked to make sure is in a therapeutic range. On 7/10/24 at 10:02 AM, review of the resident's care plan did not address seizures. On 7/11/24 at 12:09 PM, the MDS Coordinator acknowledged seizure disorder/medications for seizures should be on the care plan. Review of the Facility Policy titled Comprehensive Care Plan, dated 8/30/21 revised on 7/18/22, revealed, Care, treatment and services shall be planned to ensure that they are individualized to the resident's needs.

Based on clinical record review, policy review, and staff interviews the facility failed to administer medications as directed for one of one residents (Resident #254) reviewed. The facility reported a census of 49 residents. Findings Include: The Admission Minimum Data Set (MDS) assessment, dated 6/27/2024, list of diagnoses included: hypokalemia (low potassium), paroxysmal atria fibrillation (irregular heartbeat), hypotension, and adult failure to thrive. The MDS listed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating a moderate cognitive impairment. A review of the clinical record revealed Resident #254 admitted to the facility on [DATE] at 3:00 PM. The Physician Order dated 6/21/2024 documented, Metoprolol Tartrate Oral Tablet 50 mg related to Essential (Primary) Hypertension. Give 2 tablet by mouth two times a day. The Physician Order dated 6/21/2024 documented, Levetiracetam Oral Tablet 500 mg related to Alcohol use, unspecified, uncomplicated. Give 1 tablet by mouth two times a day. The Physician Order dated 6/21/2024 documented, Potassium Chloride ER Tablet Extended Release 10 MEQ (milliequivalent). Give 1 tablet via PEG-Tube two times a day related to hypokalemia. The June 2024 Medication Administration Record (MAR) documented on 6/21/24 Resident #254 had not received the prescribed levetiracetam 500 mg, metroprolol tartrate 50 mg, and potassium chloride 10 MEQ. A review of the (EHR) revealed the following Orders-Administration Notes: a. At 12:26 AM Metoprolol Tartrate Oral Tablet 50 MG Give 2 tablet by mouth two times a day .NA (not available) not sent from pharmacy. b. At 12:26 AM levETIRAcetam Oral Tablet 500 MG Give 1 tablet by mouth two times a day .NA not sent with pharmacy c. At 12:27 AM Potassium Chloride ER Tablet Extended Release 10 MEQ Give 1 tablet via PEG-Tube two times a day .NA not sent from pharmacy During an interview on 07/11/24 at 3:40 PM, the Nurse Consultant stated Resident #254 may have admitted to the facility past the cut off time for the day when they pharmacy does not get the medications to the facility. During an interview on 07/11/2024 at 4:10 PM, the Nurse Consultant provided the Packing Slip from the pharmacy documenting all of the prescribed medications were delivered to the facility together. The nurse that omitted the three medications did so in error. The facility policy, revised on 4/1/23, titled Medication Administration revealed the Policy statement included: Medications shall be administered per physician order.

Based on observation, staff interview, and clinical record review the facility failed to ensure an antibiotic was initiated timely for treatment of a urinary tract infection (UTI) and failed to ensure clear process for frequency of urinary catheter change for one of one resident reviewed for catheters (Resident #45). The facility reported a census of 49 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #45, dated 6/13/24, revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident had an indwelling catheter and took an antibiotic. Review of the Care Plan for Resident #45, dated 4/11/24, revealed a Focus Area related to the Resident requiring an indwelling urinary catheter due to neurogenic bladder (lack of bladder control.). Interventions, all dated 4/11/24, included: a. Assess for continued need for catheter at least quarterly. b. Keep catheter system a closed system as much as possible. c. Obtain labs as ordered. d. Provide catheter care BID (twice a day) and PRN (as needed) e. Report UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, n/v (nausea/vomiting), chills, fever, foul odor, concentrated urine, blood in urine). f. Use a catheter strap. Assure enough slack is left in the catheter between the meatus and the strap. Review of Physician Orders for Resident #45 revealed the following: a. (Order Start date 12/5/23, discontinued 5/21/24): Change catheter drainage bag every 2 weeks; once with entire system change. every day shift every 14 day(s) for infection prevention-catheter care. b. (Order start date 6/11/24, current order): Change catheter drainage bag every 2 weeks; once with entire system change. Every night shift starting on the 15th and ending on the 27th every month for infection prevention-catheter care Review of the clinical record for Resident #45 revealed the resident's catheter changed on the following dates, as documented per clinical record review below: 1/15/24, 1/30/24, 2/4/24, 3/13/24, 3/29/24, 4/18/24, 5/5/24, and 6/28/24. Review of the Health Status Note dated 1/26/24 at 3:58 PM revealed, Sediment noted in tubing of Foley catheter. Sediment is pink tinged and thick. Urine is cloudy and dark in color. Draining as expected. Catheter was last changed on 1/15/2024. Sending this note to Dr. [Name Redacted], PCP (Primary Care Physician) to update on Foley. Handwritten under the note was the following: May we have an order for acetic acid flushes daily? Would you like a UA (urinalysis) collected? Resident is asymptomatic with stable vital signs. The following response written by an ARNP, and dated 1/30/24: order sent (change symbol) Foley [illegible word redacted] insert new Foley send clean urine for UA and C&S (culture and sensitivity) if indicated may need ID (infectious disease) if repeat UTIs. Review of the Physician Order dated 1/30/24 by an ARNP revealed, change Foley catheter. Obtaining urine sample from clean catheter drainage. Send for urinalysis with culture and sensitivity if indicated. Report to PCP abnormal vital signs, fever, or abdominal pain/pelvic pain or bloody urine. Review of the Orders-Administration Note dated 1/30/24 at 10:51 AM revealed, Change catheter and get a Cath ua with C&S w/reflux one time only for possible UTI until 01/30/2024 23:59 changed catheter via sterile technique, also collected a ua sent to [abbreviation for hospital name redacted]. Review of the Health Status Note dated 2/3/24 at 8:28 PM revealed, Res (resident) noted to have pink tinged urine in catheter tubing and bag. Did not change catheter due to irritation. Resident denies pain or discomfort coming from catheter. Will attempt to change catheter tomorrow. Review of the Health Status Note dated 2/4/24 at 7:17 AM revealed, Foley cath changed, 16 FR [16 french - catheter size] inserted times 1 attempt, clear yellow urine returned. Resident tolerated well. Review of the Orders-Administration Note dated 3/12/24 at 1:35 PM revealed, Change catheter drainage bag every 2 weeks; once with entire system change. Every day shift every 14 day(s) for infection prevention-catheter care will replace on 3/13/24 resident didn't want to lay down after lunch. Review of the Orders-Administration Note dated 3/13/24 at 2:04 PM revealed, in part, Changed this catheter and bag via sterile technique. Resident tolerated well. Review of the Communication with Physician Note dated 3/28/24 at 11:48 PM revealed, Res has been having increased confusion, Urine in Catheter bag is dark yellow, cloudy, and has a slight odor, She has been complaining of not feeling well, Staff is currently trying to push fluids. May we have an order for UA (urinalysis) with C&S (culture and sensitivity if needed. Further down on the note, a response of yes was given and signed by an Advanced Registered Nurse Practitioner (ARNP). The Health Status Note dated 3/29/24 at 9:30 PM revealed, The res urine was obtained per her order for UA C&S c (with) reflex. The urine has been delivered to the ER (emergency room ) Lab at [name redacted] located nearest the facility. The res also had a catheter and urinary bag change, the catheter was changed to a 16 FR with 10cc (cubic centimeter) inserted. It is patent and the res tolerated well. Review of the Orders-Administration Note dated 4/18/24 at 1:14 PM revealed, in part, changed catheter and bag via sterile technique. Review of the Orders-Administration Note dated 4/23/24 at 11:53 AM revealed, in part, The entire system was change on 4/18/24, next time to change the bag would be two weeks and that would be 5/2/24. Review of the Health Status Note 5/5/24 at 7:13 AM revealed, Due to be changed,Catheter was changed via sterile technique w/16 FR catheter and bag. Review of the clinical record regarding initiation of antibiotics for UTI revealed, in part, the following: The Health Status Note dated 3/29/24 at 9:30 PM revealed, The res urine was obtained per her order for UA C&S c (with) reflex. The urine has been delivered to the ER (emergency room ) Lab at [name redacted] located nearest the facility. The Physician Order present in the resident's paper chart electronically signed by an ARNP on 4/2/24 at 12:26 PM revealed, Levofloxacin 500 mg (milligram) PO (per oral) x1 dose on day 1; then decrease dose to 250mg (milligram) PO daily on day 2 through 5. The Physician Order further revealed the following: dose and abx (antibiotics) per C&S results and renal function, 80-90,000 cfu/ml (colony forming unit per milliliter) Pseudomonas aeruginosa, 60-70,000 cfu/ml Enterobacter cloacae complex, 80-90,000 cfu/ml Enterococcus faecalis, and 80-90,000 cfu/ml Lactobacillus species. Review of the resident's Medication Administration Record (MAR) dated 4/4/24 revealed Levofloxacin 500 mg (milligram), an antibiotic medication, administered to the resident on 4/4/24, and 250mg of the medication administered 5/5/4 through 5/8/24. On 7/11/24 at 8:13 AM, Resident #45 observed present in the dining room at the table. Resident #45 seated in a wheelchair at the table, and the resident had catheter tubing to dignity bag under the resident's wheelchair. On 7/11/24 at 12:12 PM, the MDS Coordinator explained would be in their orders, and changed monthly unless the doctor wanted more frequently for a Foley, and then PRN (as needed). During an interview on 7/11/24 at 1:34 PM, the Corporate Nurse explained the facility would use the physician order for frequency of changes, and further explained policy did not address how frequently to change. The Corporate Nurse explained they would have to see order in the resident's chart. When shown the order and queried how frequently the catheter would be changed, the Corporate Nurse acknowledged it was confusing.

Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure medications including a diuretic, antibiotic, and blood pressure medication were available from the pharmacy to administer to a resident for one of three resident reviewed for medication availability (Resident #45). The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #45, dated 6/13/24, revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Review of Orders-Administration Notes dated 7/1/24 at 8:39 AM revealed the following medications documented as meds not delivered from pharmacy: Furosemide Oral Tablet 20 MG (milligram), a diuretic medication, with directions to give 0.5 tablet one time a day, Lisinopril Oral Tablet 40 MG with directions to give 1 tablet by mouth one time a day, Cephalexin Oral Tablet 250 MG, an antibiotic medication, with directions to give 1 tablet by mouth one time a day for prophylactic, Amlodipine Besylate Oral Tablet 10 MG with directions to give 1 tablet one time a day, and Alendronate Sodium Oral Tablet 10 mg with directions to give 1 tablet by mouth one time a day. Review of the Heatlh Status Note dated 7/1/24 at 11:03 AM revealed, Resident did not have any medications today d/t (due to) not arriving from [Pharmacy Name Redacted] at [Hospital Name Redacted] Call placed to pharmacy spoke with a [name redacted] she said we will send those out today. This note sent to PCP (Primary Care Physician). Review of the resident's Medication Administration Record (MAR) dated July 2024 revealed the resident's medications for 7/1/24 marked with a code of 9, which indicated other/see progress notes. On 7/11/24 at 12:10 PM during an interview with the MDS Coordinator, the MDS Coordinator acknowledged a concern with getting medications promptly for a new admission. On 7/11/24 at 1:35 PM during an interview with the Administrator and the Corporate Nurse, the following was explained: Typically what done was placed call to Resident #45's family or to the pharmacy directly to put in order to resend (medications). Review of the Facility Policy titled Medication Administration, dated 10/10/19 and revised 4/1/23, revealed the following: Medications shall be administered per physician order.

Based on observation, record review, interviews, and the facility policy, the facility failed to document food temperatures and dishwasher temperatures on multiple occasions between October 2023 and January 2024. Failure to check food and dishwasher temperatures can lead to food borne illness and serving food that are not palpability to the residents if the food and dishwasher did not meet or exceed the required temperatures to prevent illness or infection. The facility reported a census of 50 residents. Findings include: During the initial walk through of the kitchen on 1/25/24 at 8:52 AM, observed the dishwasher and sanitizer log papers attached to the clipboard hung on the wall near the dishwasher. The paperwork revealed many blank areas for the breakfast, lunch, and dinner on multiple occasions. The food temperature log papers hung on a clipboard above the countertop near the food preparation area and the oven also revealed multiple dates/times left blank. The Review of the Dish Machine Temperature and Sanitizer Logs revealed the following dates and times the dish wash temperatures and sanitizer log lacked documentation: a. 10/2/23 at breakfast, lunch, and dinner b. 10/5/23 at lunch and dinner c. 10/6/23 at lunch and dinner d. 10/8/23 at lunch and dinner e. 10/9/23 at dinner f. 10/10/23 at dinner g. 10/11/23 at lunch and dinner h. 10/12/23 at breakfast, lunch, and dinner i. 10/13/23 at breakfast and dinner j. 10/14/23 at breakfast, lunch, and dinner k. 10/15/23 at breakfast, lunch, and dinner l. 10/16/23 at dinner m. 10/17/23 at lunch and dinner n. 10/18/23 at breakfast and dinner o. 10/19/23 at breakfast, lunch, and dinner p. 10/20/23 at lunch and dinner q. 10/21/23 at lunch and dinner r. 10/22/23 at lunch and dinner s. 10/23/23 at lunch and dinner t. 10/2423 through 11/18/23 at breakfast, lunch, and dinner u. 11/19/23 at dinner v. 11/20/23 at breakfast, lunch, and dinner w. 11/21/23 at lunch and dinner x. 11/22/23 through 11/23/23 at breakfast, lunch, and dinner y. 11/24/23 at breakfast and dinner z. 11/25/23 through 11/27/23 at breakfast, lunch, and dinner aa. 11/28/23 at lunch and dinner bb. 11/29/23 at breakfast, lunch, and dinner cc. 11/30/23 at lunch and dinner dd. 12/1/23 at dinner ee. 12/2/23 at lunch and dinner ff. 12/3/23 to 12/30/23 (no paperwork provided for the temperature dishwasher logs/ gg. 1/1/24 at lunch and dinner hh. 1/3/24 at dinner ii. 1/4/24 at dinner jj. 1/6/24 at dinner kk. 1/7/24 at dinner ll. 1/8/24 at breakfast, lunch, and dinner mm. 1/9/24 at dinner nn. 1/10/24 at lunch oo. 1/11/24 at dinner pp. 1/12/24 at dinner qq. 1/13/24 at breakfast, lunch, and dinner The Review of the Daily Temperature Logs sheet for food temperature revealed the following dates the temperatures for food lacked documentation: a. 10/9/23 at lunch and dinner b. 10/12/23 at lunch c. 10/14/23 at breakfast and lunch d .10/15/23 at breakfast and lunch e. 10/17/23 at dinner f. 10/21/23 at dinner g. 10/30/23 at lunch h. 11/3/23 at dinner i. 11/5/23 to 11/12/23- no temperature log sheet provided j. 11/13/23 at dinner k. 11/14/23 at dinner l. 11/15/23 at dinner m. 11/17/23 at breakfast and lunch n. 11/18/23 at dinner o. 11/19/23 at breakfast, lunch, and dinner p. 11/20/23 to 11/25/23 no temperature log sheet provided q. 11/27/23 at lunch and dinner r. 12/1/23 at breakfast and lunch s. 12/3/23 at dinner t. 12/9/23 at breakfast u. 12/11/23 at lunch v. 12/23/23 at dinner w. 12/26/23 at dinner x. 12/30/23 at lunch y. 1/8/24 at dinner z. 1/10/24 at lunch and diner aa. 1/21/24 at dinner bb. 1/23/24 at dinner The Resident Council Meeting Notes dated 10/23/23 revealed the following information: a. recent concerns from the last council meeting b. cold food c. Temperature of the food and fluids: food- cold except for lunch The Resident Council Meeting Notes dated 11/30/23 revealed the following information: a. potatoes not completed cooked in vegetable soup The Resident Council Meeting Notes dated 12/28/23 revealed the following information: a. watery soup, cold food (all meals), and crunchy potatoes b. hot foods not hot. During an interview on 1/25/24 at 1:49 PM, Staff I, Dietary Aide queried on when she conducted food temperatures and she stated they logged them prior to service and she checked them more than once and would put back in the oven if the temperature not high enough. Staff I asked when the dishwasher checked for the temperature and chemical level and she stated she checked as soon as they used it and again after breakfast, lunch. Staff I queried if expectation of the dishwasher log being filled out and she stated they were expected to log it. During an interview on 1/25/24 at 3:16 PM, Staff M, Dietary Aide queried on the expectation of logging food temperatures and she stated that they log the temperatures prior to service. Staff M asked if she noticed the food temperature log not filled out and she stated yes, they had a problem with a night cook not filling it out. Staff M asked if she conducted the dishwasher checks for temperature and chemical levels and she stated she wasn't told who done them and they showed her once where they charted it and then walked away from her. She stated she thought the 10 am to 2 pm staff member conducted the dishwasher checks. Staff M asked if the residents ever complained about the food or the food temperatures and she stated it depended on the person cooking. She stated the residents complained about the raw potatoes in the soup. Staff M stated the cook put the potatoes in the soup too late and didn't check to see if they cooked properly. During an interview on 1/25/24 at 3:45 PM, the Dietary Manager queried on the expectation of staff recording the food temperatures and she stated right before they serve the meal. The Dietary Manager asked the expectation of documenting the dishwasher temperature and the chemical level and she stated they need charted prior to start up in the morning, lunch and supper dishes. The Dietary Manager queried if the staff trained on how to check the dishwasher temperatures and chemical level and she stated yes, all the aides were trained on how to do it. The Dietary Manager asked if she ever received complaints about the food from the residents and she stated no. The Dietary Manager asked if she heard complaints about potatoes not cooked and stated no. She stated one time they served soup and the potatoes not completely cooked but the soup was the correct temperature. During an interview on 1/25/24 at 4:46 PM, the Administrator queried on the expectations for the kitchen staff to document the food temperatures and the dishwasher temps and she stated her expectation was the temperatures be done per the policy and procedure. The Administrator asked if she ever heard complaints from residents for the food being cold and she stated they complained in the resident council and the situation got better and the Dietary Manager spoke to the resident personally and talked with her staff on the expectation for the food temperatures. The Administrator stated the only other food complaint was about watery soup. The Facility Dietary Food Temperature Policy and Procedure dated 4/2017 revealed the following information: a. The cook's responsibility was to make sure the temperature of the food at the proper temperature. b. Temperature taken and recorded for all items at the meals. Temperatures recorded on the temperature log sheet. The Facility Dietary Dishwasher Procedures dated 4/2017 revealed the following information: a. Dish Machine Sanitizer Log 1. To ensure dishes, glasses, and flatware were properly sanitized, a log must be completed by those directly involved in the dishwashing process. Entries must be made for each meal. 2. Post the log in the immediate vicinity of the dishwashing area.

Based on observation, interview, and record review, the facility failed to consistently assess, monitor, and document change in condition for a resident's urinary catheter site for one of three residents reviewed for catheters (Resident #1). The facility reported a census of 50 residents. Findings include: 1. The Admission Minimum Data Set (MDS) assessment for Resident #1 dated 1/21/24 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The assessment revealed both an indwelling and external catheter had been selected on the assessment for Resident #1, and the resident marked as always incontinent of urine. Review of the Profile section of the electronic health record for Resident #1 revealed the resident admitted to the facility on [DATE], and went to the hospital on 1/21/24. Medical Diagnoses for Resident #1 included metabolic encephalopathy, retention of urine, and enterocolitis due to Colstridium Difficile (C-Diff). The Baseline Care Plan for the admitted [DATE] documented the bladder appliance of foley with size 14 french 10 ml (milliliter) balloon. The bowel bladder goal documented, no complications, and the bowel and bladder interventions documented ,Scheduled check and change before/after meals, @ (at) HS, PRN (as needed). The Physician Order dated 1/17/24 at 8:03 PM documented, Foley Catheter French Size: 14fr Balloon: 10mL (milliliters) every day shift every 30 day(s) for catheter care per directions received from Dr. [Name Redacted] 1/17/24; follow-up with urology for further orders. AND as needed for Clogged. The Admission Nursing Assessment for Resident #1 dated 1/15/24 at 6:27 PM revealed the resident had a non-distended bladder, had a foley catheter, and did not have pain. The Admission Note dated 1/15/24 at 6:23 PM and the Admission Summary dated 1/15/24 at 6:27 PM did not address appearance of the resident's urine. Review of SNF (Skilled Nursing Facility) Documentation Observation/Assessment-V 2 forms for Resident #1 revealed the following per the GI (gastointestinal)/Bowel Assessment portion of the form, noted to include the following prompt: GI/Bowel Assessment-bowel sounds, distention, N/V (nausea, vomiting), diarrhea and Urinary Assessment-color, odor, sediment: a. Assessment Date 1/16/24 at 10:41 AM: Narrative: Bowel sounds active, denies nausea/vomiting, diarrhea continues due to positive for C-Diff. The narrative section lacked description of urinary assessment for Resident #1. b. Assessment Date 1/17/24 at 10:24 AM: Narrative: Bowel sounds active x 4. noted soft stool this AM. Urine is a dark yellow. NO N/V or diarrhea. c. Assessment Date: 1/18/24 at 10:53 AM: Narrative: bowel sounds active x 4. no ABD (abdominal) distention. no c/o (complaints of) N/V. Foley cath draining yellow urine. d. The Skilled Visit Note by the Nurse Practitioner (NP) dated 1/19/24 at 9:28 AM documented, in part, 2. Retention of urine Foley catheter in place. On finasteride and terazosin. Foley catheter present with dark thick urine. Assessment Date: 1/19/24 at 1:47 PM: bowel sounds active x 4. No c/o N/V or diarrhea. foley catheter patent draining. The narrative section lacked documentation of the color of the resident's urine, and lacked the presence or absence of odor or sediment per the prompt. e. Assessment Date: 1/20/24 at 1:11 PM: bowel sounds active x4. No c/o N/V or diarrhea. foley catheter patent draining. The narrative section lacked documentation of the color of the resident's urine, and lacked the presence or absence of odor or sediment per the prompt. The Health Status Note dated 1/21/24 at 11:04 AM documented, resident observed with lg (large) amount of pus coming from foley penis red in color no urine in bag unable to change 14fr (french) not available my self and another nurse checked cage called on call nurse 2x and sent text no response text don (Director of Nursing) she responded and awaiting a return call [Family Member] at bedside The Health Status Note dated 1/21/24 at 11:34 AM documented, Don responded and catheters being sent stat today awaiting their arrival The Health Status Note dated 1/21/24 at 12:22 PM documented, arnp (Advanced Registered Nurse Practitioner) [Name Redacted] called back and stated to change foley with 18fr (french) resident [family member] refused want him to go to hospital per [family member's] request not the resident tried to explain to him i can change the foley and he refused ambulance called and told him they are on the way he stated no i am not paying this is on you i stated do you want him to go out or not and he stated yes awaiting their arrival. The Nursing Home to Hospital Transfer Form dated 1/21/24 at 12:01 PM revealed Resident #1 sent to [Hospital Name Redacted] for the following reason: Other-penile discharge, pus in foley cath line. The Transfer Form included the following vital signs: Blood pressure 102/62, Heart Rate 98, Respiration Rate 18, Temperature 98.7, and Oxygen Saturation 97%. The Ambulance Record for Resident #1 dated 1/21/24 documented onset time and last known well as 1/20/24 at 12:00:00, and Chief Complaint revealed, R/O (Rule Out) infection. Signs and symptoms documented, Other skin changes (Primary). The Assessment Time for the resident documented 1/21/24 at 12:45 PM, and documented, in part, the following per the Narrative section: On arrival pt (patient) found aox3 (alert and oriented times three), and in no apparent distress laying semi-Fowler's in a nursing home bed. Staff reports green penile discharge and swelling x 24 hours and they want to r/o a foley site infection. They add no further symptoms and pt himself is complaint free. He is bed confined due to CVA deficits. Assessment finds no other trauma/deficit/distress. Review of the ED (Emergency Department) Note-Physician dated 1/21/24 at 12:57 PM documented the following per Chief Complaint: Patient presents via ambulance from nursing home with c/o (complaints of) green discharge. The History of Present Illness section documented the following: a. Presents with: Infected Foley catheter b. Onset: Unknown, abrupt c. Course/Duration: Worsening The Narrative section documented, in part, [age redacted]-year-old male, presents to the emergency department via EMS (Emergency Medical Services) from [Facility Name] secondary to infection in his urinary catheter. The [Family Member] states that for several days, the patient has had pus coming from the end of his penis and around his catheter. The urine in the catheter bag appears to be a greenish purulent drainage. [Family Member] states the patient has been less responsive that he had previous .[Family Member] had been asked about changing the catheter and they stated they did not have any of the correct size catheter to change to a new urinary catheter. It is unknown if the patient has had any fevers. Patient has continued to feel like he had the urge to urinate although he had a catheter in. His abdomen has appeared to be getting more swollen. The Review of Systems documented the following per the Genitourinary Section: Catheter in place, patient has greenish thick exudate in the catheter bag. There is thick yellowish foul-smelling exudate along the catheter at the penis. The Physical Exam section documented, in part, The skin in the groin and the scrotum appears to be extremely erythemic, denuded and moist with exudate. The GU section documented, GU: The scrotum and penis area appear to be denuded, erythemic, and moist, there is a Foley catheter in place there is a thick yellowish foul-smelling purulent drainage along the side of the Foley catheter and extending onto the skin of the scrotum. The Assessment/Plan section documented the following: 1. Acute Kidney Injury (AKI), 2. Urinary retention, 3. Urinary tract infection in male, 4. Hyperkalemia, 5. Pyelonephritis. The Urinalysis (UA) results dated 1/21/24 at 2:06 PM included in the resident's hospital records noted, in part, the following: UA color: orange abnormal, urine clarity: ex. turbid, Urine hemoglobin (Hgb): 2+ abnormal, Urine protein: 2+ abnormal, Leuk esterase: 3+ abnormal. The UA Microscopic results dated 1/21/24 at 2:06 PM included in the resident's hospital records noted, in part, the following: Urine [NAME] Blood Cells (WBC): (greater than) > 50, Urine Red Blood Cells (RBC): 21-50 Abnormal, Bacteria 4+ Abnormal, and UA Amorphous Sediment 4+ Abnormal. On 1/25/24 at 12:57 PM, review of Task Documentation, specifically a 30 day lookback for Catheter Output, revealed documentation for the following dates: 1/21/24 at 9:46 PM, 1/22/24 at 2:28 AM, and 1/23/24 at 9:59 PM. For all three entries, Resident Not Available was selected. The record lacked documentation of Resident #1's catheter output prior to 1/21/24, and was noted the resident was sent to the hospital prior to the date and time of the three entries for Catheter Output previously mentioned. The SNF Documentation Observation/Assessment-V 2 forms for Resident #1 dated 1/21/24 at 1:48 PM documented, bowel sounds active x4. No c/o (complaints of) N/V or diarrhea. foley intact with mucous in tubing and draining a scant amount of cloudy urine to gravity. On 1/29/24 at approximately 7:50 AM when queried about charting output for residents with a catheter, Staff A, Licensed Practical Nurse (LPN) indicated it would charted, and showed on the electronic health record (EHR) where it would be documented. When queried if documented in anywhere other than tasks, Staff A responded it shouldn't be, and they might write it on their daily sheet if go in and empty it, and when got back and chart at the end of the shift it's right here (EHR). On 1/29/24 at 10:43 AM when queried about charting catheter output, Staff B, Registered Nurse (RN) responded she thought it would be done if the doctor wanted it, and did not know if the aides would do it on their end. On 1/29/24 at 10:53 AM when queried about charting catheter output, Staff C, Certified Nurse Assistant (CNA) explained in the EHR there was a catheter tab in the profile section, and when she logged in and selected her pod and shift up at the top there were different icons to click. When queried if output charted per shift, CNA C responded yes. When queried if catheter care was charted, Staff C, CNA, responded not on the CNA end. When queried about Resident #1, Staff C, CNA, explained she drained it and it was yellow/normal. Staff C queried when this had occurred, and responded very shortly before the resident left the facility, and she could not remember the exact day. Per Staff C, she was assisting the resident with transfer. On 1/29/24 at 10:55 AM, Staff D, Registered Nurse (RN) explained for residents with a catheter, input and output done if the doctor wanted to do so, and it was not done as a facility protocol to her knowledge. Per Staff D, she would communicate to staff if need to know how much output, and this would be reported to her. When queried if catheter care was documented somewhere, Staff D responded, not that I'm aware of. Per Staff D, if the catheter was changed, it would be in the MAR (Medication Administration Record) or TAR (Treatment Administration Record), and only the nurse could document in that. When queried if she, Staff D, RN cared for Resident #1, Staff D responded the resident came in the afternoon, she was off the next day, and then she had the resident for a few days. Per Staff D, the resident's catheter was patent, draining darker yellow, and had some sediment. Per Staff D, it was like that the first day she cared for the resident until the last day she had him. Per Staff D, for all three days it was draining, not a clear yellow and not a super dark. When queried if there was anything with the insertion site, Staff D responded not that I noticed personally. When queried about frequency of catheter care, Staff D responded any time clean the resident up would need to do that also. On 1/29/24 at 11:04 AM, Staff E, CNA acknowledged no current residents with catheter, then mentioned Resident #1 by first name and room number. Staff E explained for output, in the times taken care of him he did not have area to chart in their charting system, and she did not know if the nurses had (place) to chart it in. Staff E explained she did not know if supposed to report to the nurse to chart it, but she knew there was not one in the system to chart. Staff E explained she did not take care of the resident's catheter, and pretty much checked and changed the resident, and had gotten the resident up once. When queried about the resident's skin/catheter area, Staff E explained when she went in to change the resident she reported to the nurse discharge out of the catheter, greenish in color. When queried as to the amount, Staff E explained probably a nickel size around the catheter, described as enough to cover the tip of the penis. When queried as to which day she was referring to, Staff E could not provide the date. When queried if the resident went that day to the hospital, Staff E responded no. When queried if this had occurred on a 6A to 2P shift, Staff E acknowledged yes. On 1/29/24 at 12:17 PM, Staff A, LPN, explained they had cared for Resident #1 once on the resident's second day at the facility. Staff A acknowledged the resident had a catheter, and was having some drainage. Staff A queried as to when this occurred, and explained it was the 16th (1/16/24). Per Staff A, it was very slight, nothing like when he left per Staff A. Staff A further explained from what they remembered it was kind of clear and mucousy. When queried as to the amount, Staff A responded, not much. When queried if she cared for the resident again, Staff A said no. On 1/29/24 at 2:26 PM, Staff F queried about catheter output. Per Staff F, when the catheter emptied out, supposed to say how much was in there. Per Staff F, she would tell the staff that had been at the facility the longest, and Staff F thought it was supposed to be put in the computer. Staff F explained she thought she worked with Resident #1 one time, the resident's first day. Per Staff F, the urine was cloudy and did not look right to her. Staff F reported she knew something was wrong with it by looking at it, and explained it did not look good. Per Staff F, nurses and the Director of Nursing (DON) were present. When queried about catheter care, Staff F explained she thought catheter care was supposed to be done every shift, and explained if she took care of someone with it, she would empty at the end of the night unless it needed to be emptied before that. Staff F explained most of the time it did not need emptied until cares on the person at the end of the shift, and at the end of the shift it was emptied and swabbed with alcohol wipe. When queried about cleaning of the tubing, Staff F explained she did not know about cleaning the tubing, and further explained no one taught her to do that. When queried if she had seen others doing that, Staff F responded she had not seen anyone do it (clean the tubing) . On 1/29/24 at 2:37 PM, Staff G, LPN explained the following about Resident #1: Per Staff G, the resident had a foley catheter. Staff G explained they had been on vacation, and came back Wednesday and Thursday and worked with the resident. Staff G explained the resident's urine as slightly cloudy those days. Staff G explained the resident came up for catheter change one of those days, Staff G went to the DON, and it was explained the resident did not need the catheter changed due to being changed at the hospital on a certain date. Staff G explained she did not change it and pushed fluids on the resident. Per Staff G, the first day she noticed drainage was the day the resident's [Family Member] came in on Sunday, and Staff G sent the resident out on Sunday. Staff G explained it looked mucousy, and could tell looked like some type of infection going on. Staff G explained there was a moderate amount of drainage. Per Staff G, they called the NP (Nurse Practitioner) to see if needed to change the catheter, and let the NP know it looked infected. Staff G explained the facility did not have the size catheter that Resident #1 had, and an order was given for an 18 french. Staff G explained they were not comfortable with the amount of swelling, and the [Family Member] refused the (catheter) replacement. Staff G explained the resident sent to the hospital after talked to the DON and NP. Per Staff G, there was redness in the penis area and inflamed, which Staff G described as not present on Wednesday or Thursday. Staff G described urine as cloudy but not mucous, and further explained she, Staff G, had not seen that presentation the previous days or Saturday. Staff G further explained she noticed when the resident came to the facility that the facility had no 14 catheter (size used by Resident #1), and when she noticed they did not have any she told the DON. Staff G reported at the time the catheters ordered, the resident's catheter did not need to be changed because Resident #1 just had it changed in the hospital. When queried about output, Staff G explained supposed to have been done, and she didn't think he (Resident #1) had one in there. Staff G explained when the [Family Member] started to ask to know how output going, Staff G could not find anything, and there was not a place for output. Staff G explained she thought/assumed the CNAs were charting it and it wasn't anywhere. On 1/29/2 at 3:08 PM, the Director of Nursing (DON) explained output with catheters were done every shift, and the expectation is done every shift. Per the Nurse Consultant, if there was a Physician Order then output would have to be documented. The DON explained the facility did not do Intake and Output (I and O) like a hospital. When queried about catheter output in the tasks section, the Nurse Consultant explained it did not hurt to do that, and would not be absolutely necessary to do that unless there was an order. The Nurse Consultant explained if the doctor wanted it then would put in a Physician Order, and process generally not done. Per the DON, she did not believe anyone had an order, and had to look. On 1/29/24 at 3:21 PM, the DON explained catheter care at least daily, and the Nurse Consultant explained done on AM, PM, and PRN (as needed). When queried if this would be charted, the Nurse Consultant said no, and was part of ADLs (activities of daily living). Per the Nurse Consultant, they did not have a spot to sign out completed peri-care/completed catheter care specifically. On 1/29/24 at 3:44 PM, the Nurse Consultant explained various persons had assigned the task (catheter output) but it ws not necessary to assign it and would not hurt if done. Per the Nurse Consultant, intakes were recorded from dietary, but not output. On 1/30/24 at 10:58 AM, Staff K, CNA explained she had been on Resident #1's hall twice. Staff K explained the first time she worked at the facility she was assigned with Resident #1, later clarified as on 1/18/24, and the second time the resident was already at the hospital. Per Staff K, when she went in the resident's room the resident was sweating. Staff K explained another staff emptied the resident's foley bag and gave the output to the nurse. Per Staff K, she went to see if the other staff needed any help, and did see the catheter area for the resident was a little red at the tip where inserted into catheter, and explained there was some clear irritation going on. On 1/30/24 at 12:10 PM, Staff L, CNA explained they cared for Resident #1 three or four times. When queried if the resident had a catheter, Staff L responded he did. Per Staff L, the first day she took care of Resident #1, one of the previous CNAs from first shift said there was drainage coming out of it which she said was normal for him. Staff L explained later that night, Staff L went in and changed Resident #1, and Staff L described an abundant amount of drainage that was colorful. Per Staff L, it was like a yellow, not a deep yellow, kind of like a tinge of yellow, and it was from under Resident #1's urethra surrounding the catheter. Per Staff L, even when cleaning doing per cares it kept coming out, and a wash cloth was under there because drainage kept coming out so much. Per Staff L, they did tell their nurse on the floor that night he was having drainage, and said got in report this was normal for him. Per Staff L, the next times Staff L cared for the resident, same amount of drainage per Staff L. Staff L explained drainage was around the outside of the tubing coming out of the urethra. When queried further about the drainage, Staff L explained it got on linens because when first went in there had a chux tucked under him so if leaked it was not on Resident #1's skin. Per Staff L, she could see drainage on there and it wasn't a puddle or anything. When queried if the color of drainage changed over observations, Staff L responded it was the same, the color did not change. When queried about the frequency of catheter care, Staff L responded once a shift minimum and at every scene of incontinence. On 1/30/24 at 3:20 PM, observation of storage with the Director of Nursing (DON) revealed size 14 catheter present. On 1/31/24 at 8:27 AM, the DON queried about the process if staff noticed redness or drainage for a foley catheter. The DON explained if it was a CNA, should alert the nurse. When queried what the nurse would do, the DON responded she would have the nurse assess. When queried if redness or drainage would be documented, the DON responded yes. When queried where that would be, the DON responded several places in the chart. Review of the Facility Policy titled, Catheter Care, dated 10/1/18, did not address how staff were to address drainage or redness at a catheter site. The Facility Policy titled, Comprehensive Assessment and Reassessment dated [DATE] documented, The assessment of care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's stay, with the assessment process individualized to meet the needs of the resident population.

Based on clinical record review, policy review, hospital record review, and staff interview, the facility failed to document wound care treatment, assess wounds, and report signs of infection timely for a surgical wound in 1 of 5 sampled (Resident #5) with wounds. This resulted in Resident #5 being hospitalized for surgical debridement of the wound. The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #5 admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had surgical wounds receiving surgical wound care by the facility. The Care Plan documented Resident #5 had surgical incisions/wounds to the abdomen, right thigh, and left foot. The Care Plan dated 7/17/20 directed the staff to: a. Administer antibiotic as ordered. b. Assess the surgical wounds weekly for progress with healing. c. Monitor and drain Jackson [NAME] (JP) drain as ordered. d. Monitor for signs and symptoms of infection: pain, redness, swelling, warmth, loss of function. Notify provider if present. e. Treatment as ordered. Hospital Discharge Summary Notes dated 7/8/20 directed wound care: a. Abdominal incision: keep incision clean, dry and intact b. Right abdominal JP drain: keep in place until follow-up c. Left ankle: to remain covered in xeroform gauze In addition, it directed Resident #5 to take [MEDICATION(S)] (an oral antibiotic) for 7 days. It did not address treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A Progress Note dated 7/8/20 documented Resident #5 had the following surgical incisions/wounds: a. Midline surgical incision measured 31centimeters (cm) by 0.3 cm. b. Hardened area right of midline incision measured 10 cm in diameter. c. Unable to assess the top left foot. d. Skin graft to right thigh measured 15 cm by 9 cm. e. Hardened area around Jackson [NAME] drain measured 5 cm by 7 cm. Review of the Skin Condition Record sheets revealed the facility failed to measure the surgical sites/wounds from July 8, 2020 to July 20, 2020. The sheets revealed the following measurements: a. The midline abdomen on 7/20/20 measured 27 cm by 5 cm (increased in width since admit). b. The hardened right midline abdomen surgical incision on 7/8/20 measured 10 cm in diameter. On 7/20/20 measured 17 cm by 12 cm (increased in size since admit). c. The top left foot surgical site on 7/8/20 unable to assess. d. The right thigh skin graft on 7/8/20 measured 15 cm by 9 cm. e. The hardened area around the Jackson [NAME] drain site measured 5 cm by 7 cm on 7/8/20. On 7/20/20 the area measured 5 cm by x 3 cm with epithelial tissue and serosanguineous drainage The facility's Order Summary Report indicated orders dated: On 7/8/20 for [MEDICATION(S)] (generic [MEDICATION(S)]) until 7/15/20. a. On 7/8/20, [MEDICATION(S)] (generic [MEDICATION(S)]) until 7/15/20. b. On 7/15/20, Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) on 7/20/20. c. On 7/17/20, remove the JP drain on 7/20/20 if drainage remained less than 25 milliliters (mL) per day. A Nursing Home Documentation Sheet revealed Resident #5's Primary Care Provider saw her for a routine visit on 7/15/20. The provider noted a midline (abdominal) dressing with a drain, a compression dressing on the left ankle, and healing graft. The provider ordered a CBC and BMP for the following week and did not note any reports of, or concerns for, infection. The facility's Order Summary Report failed to document any treatment orders for the right thigh skin graft. It also failed to address the abdominal incision treatment until 7/20/20 when orders were added: a. Gauze pad over JP removal site twice daily b. Abdominal (gauze) pad twice daily to midline abdominal incision c. [MEDICATION(S)] cream (topical antibiotic) to abdominal incision twice daily The Treatment Administration Record (TAR) showed no treatment orders for the right thigh skin graft site and no treatment orders for the abdominal incision until 7/20/20. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Note entries revealed nurse documentation: a. On 7/15/20 at 9:57 PM: Firm red, non-warm area mid right side of abdominal dressing. Distal end of dressing loose with foul smell. Reinforced with opsite (adhesive) dressing. Resident complaining of intermittent right lower abdominal discomfort b. On 7/16/20 at 5:15 AM: Resident complained of intermittent right lower abdominal discomfort. Pain medication given with good results c. On 7/17/20 at 5:42 AM: Resident complained of intermittent right lower abdominal discomfort. Pain medication given with good results d. On 7/17/20 at 10:32 PM: Has abdominal incision that is covered, a skin graft site- changed dressing on it, and changed dressing to left foot. Emptied 5 mL of putrid smelling brown liquid drainage from JP drain in abdomen. e. On 7/18/20 at 9:30 PM: Abdominal dressing changed. Had foul smelling drainage. Area cleansed with sterile water, [MEDICATION(S)] (not adherent) and abdominal (absorbent) dressings applied. f. On 7/19/20 at 9:28 PM: Abdominal dressing changed using [MEDICATION(S)] and abdominal dressings. Slightly foul odor. Scant amount of brownish yellow drainage. g. On 7/20/20 at 2:37 PM: JP drain removed with a 5 x 3 cm incision underneath and mucous-like drainage. Midline abdominal incision measuring 27 x 5 cm with surrounding skin a deep red color. Area oozing with a very foul odor. The bottom of the incision looks at if dehiscing and becoming necrotic (tissue death). The hardened area seems to be spreading, measuring 17 x 12 cm. Specialty physician and local nurse practitioner updated. h. On 7/20/20 at 3:14 PM: New orders received for abdominal pads over the abdominal incision. i. On 7/20/20 at 3:51 PM: New orders received for [MEDICATION(S)] cream to the abdominal incision and an appointment on 7/21/20 at the clinic. j. On 7/20/20 at 5:33 PM: Facility set up ambulance transfer as ordered by Advanced Registered Nurse Practitioner (ARNP) as medically necessary for transport to 7/21/20 appointment. The Clinical Record lacked documentation of the appearance of the abdominal incision from 7/8/20 until 7/20/20 and a lack of Physician notification of the odorous drainage from the abdominal incision from 7/15/20 until 7/20/20. A Phone Message/Call document dated 7/21/20 from Advanced Registered Nurse Practitioner (ARNP) to local Physician stated the facility called her (ARNP) on 7/20/20 about the resident's wound having a small open area with green, foul-smelling, [MEDICATION(S)] present when removing the JP drain. The resident's labs showed a white blood cell (WBC) of 14.9, likely from the wound infection. A Plastic Surgery Note dated 7/21/20 documented Resident #5 presented to the clinic for post-operative follow up. Resident #5 had a status of post left lower extremity reconstruction with free retus abdominis flap and split thickness skin graft on 6/2/9/20. Plastic Surgery Nurse spoke to facility on 7/17/20 to discuss Jackson [NAME] drainage outputs. A follow up call placed to the facility on [DATE], at which time a Nurse reported areas of necrosis to Resident #5's midline abdominal incision. Resident #5 presented to clinic today with large area of tissue necrosis to the midline abdomen. A Discharge Summary from the hospital noted an admitted ,d+[DATE] 20 and a discharge date of [DATE]. Resident #5 admitted from the clinic for abdominal wound dehiscence and infection. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment included a wound vac (negative pressure wound treatment) and intravenous (IV) and oral antibiotics. The Protocol for Skin Care policy dated 9/05 directed the following: a. Visual assessment with every dressing change, documented assessment at least weekly. b. Documented assessment includes: size in centimeters, depth, condition of surrounding skin, presence of drainage, odor, amount, condition of wound bed, current treatment and response, watching for symptoms of wound infection (foul-smelling drainage, inflammation of tissue around wound, fever), and medical intervention if the wound is infected (notification of doctor, progress note by physician and treatment order from physician). On 8/9/21 at 1:55 p.m., Staff A (Registered Nurse) stated the nurses' measure and assess the wounds on Tuesdays or Wednesdays, half each day split up between the morning and evening shifts. On 8/10/21 at 11:05 a.m., the MDS Coordinator reported wound treatment orders are normally on the TAR, occasionally on the MAR. Signs of infection include redness, drainage, smell, and an increase in size of a wound. Staff should report any of these symptoms to the provider and follow-up within a day if no response. On 8/10/21 at 12:20 p.m., Staff B (Licensed Practical Nurse) reported wound treatment orders are in the electronic health record on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff should report these symptoms to a provider right away so the wound does not get worse. On 8/11/21 at 4:30 p.m., The Director of Nursing (DON) stated nurses are expected to measure wounds and document the assessment every 7 days. If the wounds worsen, staff should notify the doctor and request new orders. Review of the In-Service Attendance Sheets dated 7/22/20 at 1:00 p.m., 2:00 p.m., and 3:00 p.m. revealed the Director of Nurses Provided staff education on the facility protocol for skin assessments which included continuous skin observations by direct care staff, reporting areas to the nurse, addressing skin areas with daily skilled charting, what to do if a new skin area develops, what to do if an area worsens, when to notify the Physician and Dietitian, what to do when an area heals, and not to apply a bandage without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was considered past non-compliance as the facility took the above actions prior to the visit and no new concerns were identified.

Based on record review and staff interviews, the facility failed to provide adequate supervision for a cognitively impaired resident (Resident #1) served a hot beverage, which resulted in severe burn for 1 of 8 sampled. The facility reported a census 42. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 1 indicating a severe cognitive impairments. Resident #1 required extensive assistance from others with transfers, mobility, dressing, toilet use, personal hygiene needs and required extensive physical assistance with eating. Resident #1 had an age of [AGE] years. The Care Plan dated revealed Resident #1 required assistance with activities of daily living and directed the staff to: a. Provide diet as ordered, supervise and assist as needed at meals. Resident #1 likes bread/sandwiches/finger foods; breakfast is her favorite meal. b. Provide one finger food item available per meal to increase oral intake per speech therapy. c. Provide adaptive equipment as needed, currently two handled cups with lids. The Care Plan History printed on 5/14/20 revealed a revision dated 3/10/20 to provide adaptive equipment as needed, currently two handled cups with lids and a brown coffee cup. According to the Incident Report dated 4/3/20 at 5:30 p.m., Resident #1 spilled a cup of hot cocoa on her lap while sitting in a dining room chair. Resident #1 sustained a 32 centimeter (cm) by 6 cm reddened area with four blisters. The staff applied a cool rag over the burn. The Care Plan revised on 5/14/20 directed the staff to provide adaptive equipment as needed; currently two handled cups with lids, allow hot liquids to cool before placing in front of Resident #1due to spills, likes hot cocoa, and place ice in hot drinks as needed. During an interview on 5/13/20 at 3:46 p.m. Staff A (Nurse Aide) stated she turned to walk to the steam table and heard something. Staff A turned and observed Resident #1 knocked over her hot chocolate onto her lap. Staff A immediately left the pod to inform the nurse while Staff B placed a cold damp washcloth under her clothing on her left thigh. Staff A stated she did not place a lid over the cup of hot chocolate, as she was not aware she needed to. Staff A stated Resident #1 recently been moved to Pod C from Pod A and she was not familiar with her care. During an interview on 5/13/20 at 4:10 p.m. Staff B (Nurse Aide) while pouring drinks for the residents she had her back to Resident #1 and heard something hit the floor. Staff B turned and observed Resident #1 spilled her hot chocolate onto her lap. Staff B applied a cold damp washcloth under Resident #1's pants, while Staff A left the Pod to find the nurse. Staff B stated the dietary department provides a paper, which lets staff, know about resident diets and adaptive equipment, including cups to use and whether to use lids. Staff B stated she was unaware whether Resident #1 required a lid on her cup or not, but given what had happened she assumed Resident #1 probably did. Staff B stated Resident #1 had recently moved to Pod C and she was not familiar with her. During an interview on 5/13/20 at 4:24 p.m., the Dietary Supervisor (DS) stated the dietary department provided a list of residents and their specific dietary needs such as supplements and adaptive equipment. The adaptive equipment list included the type of cups and whether a lid is needed for the resident. The DS stated Resident #1 required a lid on her cups since the burn, but was uncertain of the lid status when she spilled her hot chocolate on 4/3/20. The DS did not have an adaptive equipment list dating back to 4/3/20. During an interview on 5/14/20 at 10:40 a.m., the DS described the process of delivering hot coffee and hot water to the pods. The DS stated every morning hot coffee and hot water are delivered in carafes to each pod. The hot liquids come from a BUNN coffee maker located in the kitchen. The DS stated the hot liquids are not temperature checked. The DS stated since the burn incident the dietary department has not changed the way hot beverages are delivered to the pods. During an observation on 5/14/20 at 10:44 a.m., the hot water from the BUNN coffee maker temped at 185 degrees Fahrenheit. During an observation on 5/13/20 at 5:40 p.m., revealed Resident #1 sitting at the dining room table with three 2 handled cups with lids/straws sitting in front of her on the table. During an observation on 5/14/20 at 12:15 p.m., revealed Resident #1 sitting at the dining room table eating lunch. A staff member assisted Resident #1 with eating her lunch. Resident #1 had two 2 handled cups with lids and straws were on the table. During an interview on 5/14/20 at 10:10 a.m., the Director of Nursing (DON) stated there are no protocols or policies related to hot liquids. The DON knew of no related safety assessments required for the serving of hot beverages. The DON stated residents who require feeding assistance are not to receive their meal until staff are present. Drinks are provided on a case-by-case basis. The DON stated speech therapy and nursing judgment determine whether lids are used and for what purpose. The DON stated Resident #1 was care planned for lids on her cups, most likely related to functional use of drinking her beverages and not spilling, but the DON stated she was unsure whether the lids were added as a safety intervention. The DON stated following the incident in which Resident #1 scalded herself on 4/3/20, the two aides and nurse responsible for the pod were written up and educated on where to access care plan information on residents. The DON stated over the next three days following the incident, the remaining staff were educated on ensuring care plans were followed and proper adaptive equipment was used. The DON stated she reminded staff to allow hot beverages to cool before serving and specifically to add ice to Resident #1's not liquids. During an interview on 5/14/20 at 10:35 a.m., the Administrator stated the facility has no policy related to serving hot beverages or safety assessments. During an interview on 5/14/20 at 2:04 p.m., the Dietician stated all residents get a brown thermos cup for their hot beverages. The Dietician stated Resident #1always used a brown thermos cup and the change on the care plan to add a brown thermos cup on 3/10/20 was because the brown cup had never been put on the care plan to begin with. During an interview on 5/14/20 at 3:05 p.m., the Advanced Registered Nurse Practitioner (ARNP) stated initially the burn was blistered and intact over her left thigh. However, the blisters opened and Resident #1 required a topical antibiotic. Over the following weeks, the wound area had irritation from moisture related to incontinence. Resident #1 had a Foley catheter inserted on 4/28/20 to reduce the moisture and irritation to the wounds. The ARNP stated Resident #1 continued with a catheter to date and the wound showed exceptional healing. The ARNP classified the wound as a second degree burn. The State Agency informed the facility of the Immediate Jeopardy on 5/14/20. On May 14, 2020, the facility abated the Immediate Jeopardy. The facility implemented a plan to complete restorative assessments on each resident to evaluate the need for assistance with hot beverages. The facility provided education to the Nursing Staff to not serve hot liquids until nursing staff present to supervise and provide assistance. The facility provided education to the Dietary Staff on a new policy for safely serving hot beverages.

Based on record review, and resident and staff interviews, the facility failed to provide accurate assessments and timely intervention for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 51 residents. Resident #3 voiced complaints of increased pain in her lower extremity and displayed a decreased ability to independently ambulate. The facility reported a census of 51 residents. Findings include: Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of 10/13/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) indicated the resident had a score of 13 out of 15. A score of 13 identified the resident had no cognitive impairment. When admitted on [DATE] for skilled care including physical/occupational therapy, the resident required limited assistance of 1 staff member for mobility, activities and hygiene cares Review of the Care Plan identified the resident needed assistance with ADLs (activities of daily living) initially but was deemed able to independently ambulate in the facility pod (neighborhood) with a wheeled walker by the physical therapy department on 10/17/17. The resident's goal was to be discharged from the facility to return to home after strengthening. Record review of a document titled Confidential Incident Report dated 11/4/17. The document revealed the staff found the resident on the bathroom floor, in a sitting position, with regular socks on her feet. Nursing documentation noted the resident could move all extremities without difficulty, had pain with range of motion (ROM), and reported she had continuous pain to the right hip area. The nurse notified the physician and routine neurological assessments were initiated because the resident reported she hit her head. A Care Plan intervention directed staff to ensure the resident wore proper foot ware when ambulating. Review of a Confidential Incident Report dated 11/7/17 identified the staff found the resident on the floor next to the chair. The resident reported pain in the mid right upper arm and she requested to go to the emergency room (ER) for x-rays. The physician was called and the resident sent to the ER. Nursing documentation noted an abrasion on the right hand- 3rd, 4th, 5th knuckle and pain in the mid upper right arm. The nurse completed the incident report did not document ROM was performed. Record review of a Diagnostic Radiology report dated 11/7/17 identified Resident #3 had a possible periprosthetic fracture (a broken bone that occurs around the components or implants of a total hip replacement) at the level of the right greater trochanter (bony prominence located at the end of the thigh bone). A second Radiology Report dated 11/17/17 revealed the resident also had a severely displaced fracture at the proximal to mid humeral diaphysis (upper arm). A computed tomography (CT) radiology exams performed on 11/7/17, revealed a mildly displaced periprosthetic [MEDICAL CONDITION] right femur with possible extension to the trochanter and a displaced fracture through the proximal right humerus. The Progress Notes (nurse's notes) documented the following entries of assessing the resident's complaints of pain and location of pain. Additional documentation noted the resident's complaints were treated with [MEDICATION NAME] (pain medication Tylenol and [MEDICATION NAME]) with good relief. 10/8/17- Resident had complaints of (c/o) pain. 10/9/17- c/o R shoulder pain and low back pain. 10/10/17- c/o back pain 10/11/17- c/o back pain 10/12/17- c/o headache. 10/13/17- c/o back pain with good relief. 10/14/17- c/o back pain. 10/15/17- c/o back pain and headache 10/17/17- c/o back pain 10/30/17- c/o of pain all over 11/3/17- c/o of abdominal pain 11/4/17- (Staff J, RN) Resident found on the floor of the bathroom. Assessment revealed the resident was able to move all extremities. Resident does report hip pain (usual constant, not new). Resident able to walk with no problem. 11/5/17- (Staff G, RN) Resident declined coming to breakfast this AM with complaint of pain in bilateral lower extremities and reported she has hurt since her fall (previous day). Ambulation using wheeled walker and self-care unchanged this AM. Resident states she will have her son take her to ER (emergency room ) later today for pain management. The resident unable to rate pain with non-verbal signs/symptoms non-existent. 11/5/17-(Staff G, RN) Resident remained in room for lunch, eating fair meal. The resident complains of pain in right lower extremity. 11/6/17- (Staff K, LPN) Continues to complain of pain in right hip. Asked for assist to use restroom, this nurse offered assist but resident initially made no effort to attempt to sit or stand on own, explained that resident had to assist and step by step directions were required. The resident eventually made it to the restroom and back with (SBA) stand by assist. 11/6/17- (Staff G, RN) Continues neuro checks with normal findings. Reports worsened lower extremity pain than usual. Requests to remain in room and reports she cannot walk to meals. However, resident up in room with steady gait and more pain than usual. Resident requests to stay in room and reports she cannot walk to meals. PCP (primary care physician) aware of fall with no new orders. 11/7/17- (Staff K, LPN) Resident continues to complain that she is in pain and requires pain meds and assistance with all cares. Resident again unwilling to attempt to even sit up but did after being walked through it. Noted that resident walked to restroom, with staff present, with a limp in the right leg, but on return to bed she walked with a limp on the left side. Later, this writer observed resident ambulated self around bed and to restroom independently with good gait and without limp. 11/7/17- Resident found seated on floor beside chair. Resident complained of discomfort in right upper arm. Able to move all other extremities. Small amount redness to right mid back, tiny abrasions to 3rd, 4th, 5th fingers on right hand. Stood with assist of two and gait belt and returned to bed. 11/7/17- (Nurse) Called physician and informed of fall and resident's request for x-rays. 11/7/17- Called son who agreed to have resident's friend transport to ER. 11/17/17- local hospital called and said resident is being admitted for fracture of right arm and right [MEDICAL CONDITION]. Record review of the PRN Medication Sheet for identified Resident #3 received Tylenol ([MEDICATION NAME]) and [MEDICATION NAME] ([MEDICATION NAME]) doses between 9/30/17 and 11/4/17. Documentation identified the resident received 17 doses of Tylenol and 17 doses of [MEDICATION NAME]. The reasons given for the administration of the pain medications were generalized pain 11 times, foot and back pain 2 times, back pain15 times, low back pain 1 time, shoulder pain 1 time and abdominal pain 1 time. On 11/13/17 at 1:45 PM, Staff I, Licensed Practical Nurse (LPN) was interviewed and stated she found Resident #3 sitting on the floor by the recliner on 11/7/17. The LPN stated occasionally the resident would eat breakfast in her room while seated in the chair with the over-the-bed table in front of her. It appeared to the LPN the resident had stood up from the chair, pivoted to the side to reach the wheeled walker, and sat down on the floor. The LPN stated the resident had a prior rotator cuff injury in her right arm and she complained of pain in the shoulder. The resident also complained of right leg pain at this time. The physician was notified and the resident was sent for evaluation in the ER. The LPN stated prior to the falls on 11/4/17 and 11/7/17 the resident typically would keep track of the time her next pain pill was due and ask for it routinely, usually complaining of back pain. The LPN stated the resident had arthritis all over. On 11/14/17 at 1:30 PM Staff H, CNA/Shower Aide was interviewed and stated Mondays/Thursdays were the resident's scheduled shower days. Staff H worked on Monday 11/6 and asked the resident if she wanted a shower. She vaguely recalled the resident said something about hurting her foot and she could not stand and refused to have a bath. On 11/14/17 at 1:00 PM Staff C, CNA, was interviewed and he stated he worked frequently with the resident. He stated the resident would frequently complain specifically of back pain and shoulder pain, and occasionally pain all over. On 11/14/17 at 2:30 PM Staff G, RN, was interviewed and stated Resident #3 would usually complain about pain all over, all day long, all the time. The resident would keep track of when the Tylenol and [MEDICATION NAME] could be given and would ask for it. Staff G stated the resident was whiny and had pain complaints when her body language and ambulation ability contradicted her complaints. Staff G confirmed her nurse's notes entry on 11/5/17 at 10:00 AM and stated the complaints of increased pain did not concern her as the resident always complained of pain. Staff G stated she saw the resident ambulate that morning without difficulty. She stated at lunch the resident remained in the room and c/o of right lower extremity pain. Staff G confirmed her entry on 11/6/17 regarding PCP (physician) aware and no new orders. The RN explained she was referring to the initial fax sent 11/4/17 telling the physician of the residents fall on 11/4/17. Staff G stated the physician had replied to that fax writing no new orders. Staff G did not call or fax the physician with information of the resident's increased pain or decreased mobility on 11/6/17. On 11/14/17 at 8:45 AM the Director of Nursing (DON) was interviewed and stated the resident's fall on 11/4/17 occurred when the resident was attempting to clean some water on the bathroom floor. The DON stated the resident was independent with ambulation with a wheeled walker at the time. It was noted she had regular socks on her feet so staff was instructed to ensure she had appropriate foot ware on while up walking. When asked if the DON thought the nursing documentation from 11/4/17 through 11/7/17 reflected the resident had some level of injury/decreased function after the 11/4/17 fall the DON was non-committal in her response. When asked if an injury had resulted from the fall on 11/4/17, did she think it was possible the injury might have contributed to the resident's fall on 11/7/17 and she stated it was possible. On 11/14/17 at 9:45 AM Resident #3 was interviewed and she initially answered simple questions appropriately. When discussing her recent falls, the resident became quite confused. Resident #3 was insistent that she broke her arm and hip months ago and her most recent fall was when she was trying to clean water up in the bathroom. She stated she had shoulder pain before her falls but cannot recall if she had back or hip pain in the past.

Based on observation, record review, and resident, family and staff interviews, the facility failed to provide adequate supervision and appropriate interventions to ensure safety for 1 of 3 residents (Resident #4). Resident #4 fell and suffered a hip dislocation. The facility knew the resident self transferred but failed to provide additional interventions to prevent the resident from falling and to keep the resident safe. The facility reported a census of 51 residents. Findings include: Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/28/17. The MDS identified the resident had [DIAGNOSES REDACTED]. and scored 3/15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment which indicated a severely impaired cognitive status. The resident required extensive assistance of 1 staff member for bed mobility, transfers to and from bed and chair, ambulation, toileting, and personal hygiene. The resident's balance was unsteady for all activities and could stabilize during transfers only with staff assistance. The resident did not need assistance for locomotion and self-propelled a wheelchair throughout the facility. A Fall Risk assessment completed upon admission and revised 9/23/17 noted the resident had a prior history of falls and was considered to be a fall risk. The Care Plan, initiated on 3/31/17, identified the resident's impaired mobility status and directed staff to assist the resident to transfer using a wheeled walker and 1 staff member. An additional intervention was added to the Care Plan after the resident experienced a fall while attempting to self-transfer from the wheelchair while alone in the room (on 8/15/17) and suffered an abrasion on the right elbow. The new intervention directed staff not to leave Resident #4 in his wheelchair in the bedroom unsupervised. Record review of a Confidential Incident Report dated 9/17/17 revealed the resident was found on the floor by staff and did not have any injuries. The Care Plan did not reflect any new interventions placed for the resident. Record review of a Confidential Incident Report dated 10/17/17 revealed the resident was found on the bathroom floor in front of the toilet after he apparently tried to self-transfer off the toilet. The resident was sent to the local emergency room after staff assessment due to left hip pain and shortening/rotation of the left lower extremity. The resident was diagnosed with [REDACTED]. The resident did not have a head injury and returned to the facility on [DATE] with a brace for the left hip. A new intervention was initiated and staff were directed to remain with the resident while he was on the toilet. Record review of a Confidential Incident Report dated 11/12/17 revealed the resident was found sitting on the bathroom floor in front of the toilet after he had self-propelled into the room without staff knowledge, self-transferred onto the toilet, had a bowel movement, and attempted to self-transfer off the toilet. The resident complained of back pain but staff did not identify any injuries during post-fall assessment. During an interview on 11/13/17 at 12:45 PM with Staff A, Registered Nurse (RN) she stated she worked on 10/17/17 when the resident dislocated the left hip. The RN assessed the resident, notified the physician, and sent the resident to the emergency room . The RN stated the resident would frequently attempt to self-transfer on to and off the toilet and staff tried to keep the resident busy and within eye sight to prevent this. On 11/13/17 at 2:30 PM Staff B, Certified Nurse Aide (CNA) was interviewed and stated the resident's compliance with staff requests and use of the call light varied. Prior to 10/17/17, staff had been told not to leave the resident in the wheelchair alone in his room because of frequent attempts to self-transfer. On 10/17/17 Staff B found the resident seated on the toilet and realized the resident had self-transferred onto the toilet. Staff B told the resident to put on the call light when he was finished because he needed help to transfer. Staff B went on break and told Staff F the resident was in the bathroom and would call when finished. The resident did not use the call light and tried to transfer off the toilet without help. The resident fell and dislocated his left hip. Staff B stated since the resident could self-propel the wheelchair with ease it was difficult to watch the resident all the time. She stated they tried to keep the resident's door closed but he was able to open the door and would even close it behind him sometimes. On 11/14/17 at 1:00 PM Staff C, CNA, was interviewed and stated Resident #4 could self-propel his wheelchair and open the bedroom door. The CNA stated staff were told to keep a close eye on him but was not instructed to monitor the resident 1:1. The CNA stated the resident could be non-compliant with using the call light for help and would attempt self-transfer when he needed to use the bathroom. On 11/14/17 at 1:45 PM Staff E, housekeeping, was interviewed and stated she observed Resident #4 self-propel into his/her room alone while she was cleaning the dining room. She stated it was common knowledge the resident was not to go in the room alone so she told one of the CNAs immediately. She stated the CNA headed towards the room. During an interview on 11/14/17 at 12:30 PM with Staff F, CNA, the CNA stated staff tried to keep the door closed and tried to keep Resident #4 busy but it was difficult to watch the resident all the time because he/she could easily self-propel the wheelchair. On 11/14/17 at 8:45 AM the Director of Nursing (DON) was interviewed and stated prior to 10/12/17, Resident #4 could be alone in his room when in bed or in the recliner. The resident was not to be alone in the wheelchair in the room because of his attempts to self-transfer. The DON agreed it was difficult for staff to monitor him constantly because the resident was able to self-propel in the wheelchair. After the 10/12/17 fall, the intervention was to have staff stay with the resident while seated in the bathroom to prevent self-transfers. Since the 11/12/17 fall the resident is to be transferred into a recliner in the day room so staff can more easily see him. On 11/13/17 at 1:00 PM Resident #4's spouse was interviewed and stated the resident had multiple falls at home prior to coming to the facility. The spouse stated she has witnessed him attempt to self-transfer into the bathroom but has never seen the resident self-transfer off the toilet. The spouse stated though he/she had doubts as to whether the resident really understood how to use the call light and she has entered the room before and had seen the resident alone in the wheelchair in his room. On 11/13/17 at 1:00 PM Resident #4 was interviewed and stated it is hard for him to ask others for help. Resident #4 stated he would forget he needs help and forgets to use the call light because he is used to getting up on his own. The resident stated he is getting better about asking for help now.

Based on record review and staff interview, the facility failed to provide adequate nursing supervision for one of eight residents reviewed who required assistance with transfers. (Resident #12). Staff interviews and the facility investigation revealed staff failed to transfer Resident #12 to a safe position before leaving the room to get assistance. The facility reported a census of 45 residents. Findings include: 1. Resident #12's Minimum Data Set quarterly assessment completed [DATE] had documentation of the following Diagnoses: [REDACTED]. It also identified the resident to be cognitive impaired and required extensive staff assistance with most activities of daily living. The care plan with the target date of [DATE] identified the resident with impaired mobility. The care plan directed staff to assist with toileting before and after meals, at bedtime and as needed. The care plan directed staff to transfer Resident #12 with the assist of one staff member using a walker. Resident #12 received Coumadin as ordered and staff were directed to monitor for abnormal bleeding or bruising. A review of the incident report revealed on [DATE] at 5:45 a.m., the CNA placed a gait belt on the resident who used a walker to attempt to walk to the bathroom. The resident stated his/her left knee gave out and the CNA lowered the resident to the floor and the resident hit his/her head on the CNA's stomach. The resident developed an 11 centimeter hematoma to the back of the head. An ice pack had been applied to the back of the head. A review of the neurological assessment flow sheet had documentation that assessments began on [DATE] at 5:50 a.m The resident's level of consciousness at 8:00 a.m., became stuporous and his/her pupil responses were pinpoint and sluggish. The resident was not able to follow commands. Staff sent the resident to the hospital. A review of the witness statement dated [DATE] and written by Staff C, CNA who assisted the resident during the above incident revealed she placed a gait belt around the resident, placed the walker in front of the resident. Staff C assisted the resident to stand when the resident's knees buckled, she lowered the resident to the floor. Staff C left the resident to get help to assist the resident back to bed. A review of the nurse's notes revealed the following entries: On [DATE] at 7:01 a.m. the CNA reported she assisted the resident to ambulate. The resident had a gait belt and had been using a wheeled walker when the resident's knees became weak. The CNA lowered the resident to the floor. Upon arrival to the room, the resident sat on the floor beside the lower half of the bed. The resident reported he/she hit head. The nurse completed a neurological assessment (Neuro checks) and initialed vital signs. When the day nurse arrived to check on the resident she found an 11 centimeter sized hematoma. On [DATE] at 9:00 a.m. at approximately 8:00 a.m. the resident stated I don't feel well, what am I supposed to be doing; I don't know. The resident then became very drowsy then stuporous, pupils sluggish and pinpoint. Vital signs were stable. The nurse called the physician and received orders to send the resident to the hospital and notified the family. On [DATE] at 1:09 p.m. the resident returned from the hospital via ambulance. Four staff transferred the resident to bed. Resident #12 was unresponsive and hospice would be attending to the resident. On [DATE] at 11:23 p.m. time of death 10:25 p.m. assessment showed absence of blood pressure, apical pulse and respirations. According to the ED (emergency department) Note Physician summary dated [DATE] at 9:40 a.m. the resident present with a head injury with onset prior to arrival. The resident fell at the nursing home with loss of consciousness and still unconscious. The occipital (bottom back part of the brain) was identified as the location with the course of the symptoms was constant (no change). The resident was at the nursing home when his/her knees gave out and the aide lowered him/her to the floor. The head CT dated [DATE] at 10:36 a.m. showed and intracranial bleeding with closed head injury. A review of a facsimile from the physician dated [DATE] had documentation the resident had an intracranial hemorrhage due to head trauma. A typed summary by the Director of Nursing dated [DATE] revealed she investigated the incident and conducted a demonstration with Staff C, another nurse and the DON. The summary included the following information: Staff C allowed Resident #12 to get his/her bearing by sitting on the side of the bed as they conversed, which was the usual routine. Resident #12 stood at bedside with gait belt and wheeled walker, CNA demonstrated that she put her foot in front of the resident's left foot to support his/her leg as it would often slip/give out. Once Resident #12 stood he/she then turned towards the bathroom (to the right) then his/her left knee gave out. Staff C attempted to support resident. Staff C stated the resident Hold on a minute as the resident was trying to regain a standing position. Staff C stated resident was not able to regain standing position therefore CNA began to step backwards to lower resident to the floor. As CNA stepped back she came in contact with the 3 drawer bedside stand therefore she braced herself to assist in lowering resident since resident was heavy (body weight was 219 pounds). While lowering resident, the resident fell back into Staff C's body (torso area) causing Staff C to push back against bedside table. Staff C continued to lower resident to floor. Staff C was seated on the floor next to bed. Staff C reports the resident leaned his/her head on the mattress holding onto bedframe, remaining in a seated position. CNA reports she then exited the room to get assistance. Staff J stated Staff C came to find her for assistance and when they returned Resident #12 was sitting on his/her buttocks toward lower half of bed holding onto the bed frame. Staff J then instructed Staff C to stay with resident left to get the nurse. After demonstration completed, the DON took the placement of how the resident was sitting in the positon that Staff C stated resident was left in, the DON let go of the bed frame and fell backwards sticking the right posterior side of her head on the bed frame/bed rail (where the two meet). The DON re-educated Staff C that when a resident is lowered or had fallen to ensure safety, as in this instance, Staff C should have assisted Resident #12 to lie down and placed a pillow under his/her head if she needed to exit the room. Staff C was also instructed to not leave the area but to use the phone to call other areas or page for assistance. The nurses were re-educated of when to inform a physician of a change in condition. In an interview on [DATE] at 12:31 p.m., Staff C reported on [DATE] at the end of working 3rd shift, she helped the resident sit at the edge of the bed. Staff C placed a gait belt around the resident and placed the walker in front of him/her and began to help the resident stand beside the bed. When the resident stated his/her knees started to give out, Staff C lowered the resident to sit on the floor next to the bed without any support behind the resident's back. Staff gave the resident the call light and left the room to get the nurse. Staff B, LPN helped Staff C transfer the resident back to bed and both filled out the incident report and turned over care to the day shift staff. During an interview on [DATE] at 10:52 a.m., Staff A, Registered Nurse (RN) reported she came to work (day shift) at 6:00 a.m. and overheard Staff C, CNA reported to day shift Staff I, CNA that she had assisted the resident to stand when the resident's knees buckled, and she lowered the resident to the floor. Staff A did not witness the incident. Staff I later asked Staff A to check the resident as she felt a bump on the back of the resident's head. Staff A assessed the resident and discovered an 11 centimeter hematoma to the back of the resident's head. The resident became unresponsive later and sent to the hospital. She also reported she would have expected Staff C to stay in the room with the resident and pull the emergency call light for help. In an interview on [DATE] at 11:14 a.m., Staff I, CNA reported on [DATE] she received report from Staff C, CNA of Resident #12 being lowered to the floor at 5:45 a.m. At 7:45 a.m., when Staff I checked the resident she found a bump in the back of the resident's head and asked the nurse to assess the resident. After the resident had been taking to the dining room and became responsive, paramedics took the resident to the hospital. The resident returned to the facility that same day and expired 2 days later. During an interview on [DATE] at 11:44 a.m., Staff B, License Practical Nurse (LPN) reported she had been the only nurse on duty during third shift on [DATE] before 6:00 a.m. when Staff A asked for her assistance. Upon arrival to the resident's room, Resident #12 sat on the floor beside the bed and stated he/she hit his/her head. Staff B completed an assessment and did not find a hematoma to the back of the resident's head at that time. She completed the incident report and turned the care over to the day shift staff. During an interview on [DATE] at 12:08 p.m., the Director of Nursing reported she would have expected the CNA to use the emergency call light and stay with the resident until help arrived.