Every finding on record at Onyx Care of Natchitoches

Based on interview, observation, and record review, the facility failed to follow professional standards for food service safety by failing to:document food temperatures for each meal prior to tray assembly and store clean dishes appropriately.This deficient practice had the potential to affect residents who received meals prepared in the kitchen. The census was 72.Findings:Review of the facility's undated policy titled On-Tray Dietary Policies and Procedures-Food & Beverage Temperature Control revealed in part.Food temperatures are maintained during serving times.To ensure residents receive safe food served at acceptable temperatures.Food and beverage temperatures should be taken and logged upon being cooked and again prior to meal service. 1.In an interview on 08/24/2026 at 12:13 p.m. food temperature logs for the lunch meal served was requested. S8 [NAME] and S9 [NAME] revealed they did not have the temperature log for today's lunch meal. S8 [NAME] stated, we checked the temperature, but we don't have the production sheets to write the temperatures on. S8 [NAME] and S9 [NAME] confirmed they could not provide any evidence that food temperatures were logged and that they have not recorded food D2.Observation on 08/24/2026 at 12:13 p.m. revealed S11 Dietary Aide placed clean cups upward, not inverted in the drying rack on the shelf available for use. In an interview on 08/24/2026 at 4:10 p.m., S5 Regional DM confirmed the food temperatures were not recorded in the temperature log but should have been and the clean dishes were not stored appropriately.

Based on observations, interviews and record review, the facility failed to ensure dietary staff were competent to safely and effectively carry out the functions of the food and nutrition service. This deficient practice had the potential to affect all residents who received meals prepared from the kitchen. The census was 72.Findings:In a shared interview on 08/24/2026 at 12:13 p.m. with S8 [NAME] and S9 Cook, revealed both Cooks stated, nobody in this kitchen has been trained. Observation on 08/24/2026 at 12:13 p.m. of S11 Dietary Aide hand drying cups with a towel and not storing cups inverted in the drying racks. At the time of observation, S11 Dietary Aide stated she was unaware not to hand dry cups or store inverted. S11 Dietary Aide stated she was employed as a dietary aide for a couple of months. At the time of observation, S8 [NAME] and S9 [NAME] acknowledged that S11 Dietary Aide should not have been towel/hand drying the cups or storing cups upright. S8 [NAME] and S9 [NAME] stated again, nobody has been trained back here. S8 [NAME] stated, The dietary manager is out on sick leave and that the facility should have put somebody in charge of the kitchen. - idk if to add because this sounds like 835-admin tag. Review of employee personnel files revealed S8 [NAME] (date of hire 05/06/2025), S9 [NAME] (date of hire 05/06/2025), S10 Dietary Aide (date of hire 07/14/2026), S11 Dietary Aide (date of hire 05/08/2026), and S19 Dietary Aide (date of hire 06/01/2023) with no documentation of performed/completed dietary competencies upon hire or throughout employment. No other documentation found in the personnel files reviewed to ensure they could safely and effectively carry out the functions of the food and nutrition services. In an interview on 08/25/2026 at 10:54 a.m., S5 Regional DM confirmed there were no established or documented competencies to ensure dietary staff could safely and effectively carry out the functions of the food and nutrition service, but should have been.

Based on observations and interviews, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 2 designated smoking areas observed for environmental concerns. This deficient practice had the potential to affect all 19 residents identified as smokers who remained in the facility. Findings: Review of the facility's policy titled Safe Environment with a review date of 01/11/2026 read in part.Intent: It is the policy of the facility to provide a safe environment in accordance to State and Federal regulations. Procedure: 1. The facility will be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. 7. The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. Observation on 08/24/2026 at 8:30 a.m. of the front designated smoking area gazebo revealed a broken wooden board on the top of the roof and multiple broken wooden posts. Interview on 08/24/2026 at 10:09 a.m., S7 Maintenance revealed a maintenance log binder is kept at the nurse's station for staff to write down any maintenance issues. S7 Maintenance stated staff will also notify him verbally of any disrepairs needing to be done. Review of maintenance work order binder on 08/24/2026 at 10:13 a.m. revealed no maintenance documentation of front designated smoking area gazebo being completed or worked on. Observation and interview on 08/24/2026 at 12:11 p.m. of the front designated smoking area gazebo revealed 4 residents and 1 guest smoking, multiple broken wooden posts scattered on the ground, cigarette butts all over the ground, trash on the ground, 1 wasp nest, poison ivy stems growing around sitting benches, and 1 broken board on the roof. Residents #3 and R#6 stated this is where they come to smoke their cigarettes. Resident #3 stated it's nasty out here and this is what we have to deal with. R#6 stated they have no where to put their ashes or cigarette butts. R#6 stated the wood is dry-rotted and trash is always out here thrown on the ground while residents smoke. Interview on 08/24/2026 at 12:30 p.m. S18 CNA revealed there are 2 designated smoking areas in the facility, one in the front of the building at the gazebo and one at the back of the facility. S18 CNA revealed residents who smoke are able to go to either designated smoking areas to smoke. Interview on 08/24/2026 at 1:11 p.m., S1 DON revealed there are 2 designated smoking areas at the facility, which are located at the front of the building at the gazebo and the back of the building. S1 DON accompanied surveyor to the front designated smoking area gazebo and confirmed the above findings of disrepair. Interview on 08/25/2026 at 8:00 a.m., S7 Maintenance stated the front designated smoking area gazebo had been in disrepair for about a month. S7 Maintenance stated the rain came and messed up most of the wooden boards. S7 Maintenance confirmed he didn't conduct any repairs with that area because it's been so hot.

Based on record review and interview, the facility failed to use the services of a Registered Nurse (RN) at least 8 consecutive hours per day, 7 days a week for 2 days reviewed for RN hours.Findings: Review of the facility's 08/2026 Grievance log revealed in part.Resident R5 did not receive wound care on the weekend of 08/01/2026 and 08/02/2026. Immediate response: Admin staff discovered agency nurse was a no call no show for the entire weekend of 08/01/2026 and 08/02/2026. Grievance confirmed: Yes. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 08/01/2026-08/02/2026, 08/08/2026-08/09/2026, 08/15/2026-08/16/2026, and 08/22/2026-08/23/2026 and signed by S1 DON revealed the facility did not have a RN that worked 8 hours on 08/01/2026 and 08/02/2026. Further review of the form revealed the facility had a census of 64 residents on 08/01/2026 and 65 residents on 08/02/2026. Interview on 08/24/2026 at 1:03 p.m., S1 DON revealed the weekend RN didn't show up for her shift on 08/01/2026 and 08/02/2026. S1 DON revealed there was no other RN in the building and staff didn't call to notify her that the weekend RN didn't show up to work. S1 DON revealed she wasn't made aware until the following Monday. S1 DON confirmed the facility did not provide 8 consecutive RN hours on 08/01/2026 and 08/02/2026, but should have.

Based on observations, interviews and record reviews, the nursing staff failed to ensure the resident was treated with respect and dignity for 1 (#2) of 6 sampled residents by failing to allow the resident to retain his personal property (microwave). Findings: Review of the facility's policy dated 11/01/2026 titled, Resident Rights-Exercise of Rights revealed in part.The facility will protect and promote the rights of the resident. Review of Resident # 2's Electronic Health Record revealed an admit date of 06/10/2026. Resident #2 had the following diagnoses including in part Type 2 Diabetes Mellitus with Hyperglycemia, PVD, Schizophrenia, and Major Depressive Disorder. Review of Resident #2's Quarterly MDS with ARD of 06/16/2026 revealed in part .Resident had a BIMS of 15 (Cognitively intact). In an interview on 08/24/2026 at 9:17 a.m. Resident #2 complained about not having a microwave anymore in his room and stated he wanted it back. In an interview on 08/25/2026 at 10:44 a.m., S20 Clinical Operations revealed she was unsure if residents could or could not have microwaves in their rooms. She stated she thinks the facility had set up for the therapy department to do screenings on residents with microwaves. In an interview on 08/25/2026 at 11:04 a.m., S14 DOT stated they had not done evaluations on residents with microwaves since either last summer or summer before last. In an interview on 08/25/2026 at 11:10 a.m., S1 DON stated they had removed Resident #2's microwave because he would not allow staff to clean it. Review of therapy's evaluation on 08/25/2026 at 12:57 p.m. from S14 DOT revealed in part.eval performed on 07/25/2024 by OT stating Resident #2 was able to safely demonstrate the use of the microwave and his personal (dial) microwave. In an interview on 08/25/2026 at 3:27 p.m., S15 HSK Sup acknowledged she had entered Resident #2's room and asked him to clean his microwave. She stated Resident #2 agreed, she removed the microwave, cleaned it, and plugged it in to see if it still worked. She stated the microwave no longer worked after it was plugged in. S15 HSK Sup stated there were plates containing old food inside the microwave and indicated Resident #2 appeared to be using the microwave for storage because it was not functioning. She stated she informed Resident #2 that the microwave was not working, and he replied, ok. S15 HSK Sup stated Resident #2 did not request microwave after that date. In an interview on 08/25/2026 at 12:12 p.m., S1 DON stated the facility does not have a policy addressing residents having microwaves in their rooms. In an interview on 08/26/2026 at 2:49 p.m., S1 DON confirmed staff discarded Resident #2's microwave but should not have.

Based on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed: 1. to follow physician treatment orders for 3 (Resident #2, Resident #3, and Resident R5) of 6 sampled residents; and2. to ensure safe medication practices were followed by S16 LPN when Resident #2 self-administered his own medications. Findings: 1. Review of the facility's policy and procedure titled Physician Orders read in part .Policy: 1. Licensed Professional Nurses/Registered nurses will follow orders from physicians and document in a timely manner. Resident #3 Review of Resident #3's medical record revealed an admission date of 05/05/2026 with diagnoses that included in part, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Acquired Absence of Left Leg Below Knee and Muscle Weakness. Review of Resident #3's 08/2026 Physician Orders revealed .cleanse right ankle with wound cleanser, paint with betadine every other day and as needed (ordered date: 07/30/2026). Review of Resident #3's 08/2026 Treatment Administration Record (TAR) revealed no documentation that treatment was completed on 08/02/2026 of the above physician's order. Interview on 08/25/2026 at 10:27 a.m., Resident #3 stated he does have a wound, gets treatments every once in a while, and doesn't refuse care. Resident R5 Review of Resident R5's medical record revealed an admission date of 04/12/2024 with diagnoses that included in part, Type 2 Diabetes Mellitus with Foot Ulcer, Peripheral Vascular Disease, Non-Pressure Chronic Ulcer of Right Heel and Mid-foot, and Open Wound Left Foot. Review of Resident R5's 08/2026 Physician Orders revealed in part.06/24/2026 cleanse right heel with wound cleanser, apply Mesalt to wound bed cover with ABD (abdominal) pad wrap with rolled gauze, secure with tape daily and as needed; 06/24/2026 cleanse left foot planter with wound cleanser, apply Mesalt to wound bed cover with ABD pad wrap with rolling gauze secure with tape daily and as needed. Review of Resident R5's 08/2026 TAR revealed no documentation that treatments were completed of the above physician orders on 08/01/2026 and 08/02/2026. Review of Resident R5's Quarterly MDS with an ARD of 07/02/2026 revealed a BIMs score of 15 which indicated intact cognition. Resident R5 had diabetic foot ulcers and required application of dressings to his feet. Review of the facility's 08/2026 Grievance log revealed in part.Resident R5 filed a grievance on 08/12/2026 that he did not receive wound care on the weekend of 08/01/2026 and 08/02/2026. Immediate response: Admin staff discovered agency nurse was a no call no show for the entire weekend of 08/01/2026 and 08/02/2026. Grievance confirmed: Yes. Interview on 08/24/2026 at 1:03 p.m., S1 DON revealed the weekend RN didn't show up for her shift on 08/01/2026 and 08/02/2026. S1 DON revealed there was no other RN in the building and staff didn't call to notify her that the weekend RN didn't show up to work. S1 DON revealed she wasn't made aware until the following Monday. S1 DON revealed the weekend RN was responsible for performing wound care for the residents who required it. S1 DON stated it was the floor nurses responsibility to perform wound care since the weekend RN didn't show up for their shift. Interview on 08/25/2026 at 9:14 a.m., S16 LPN stated she worked on 08/01/2026 and 08/02/2026 from 6:00 a.m. to 6:00 p.m. S16 LPN stated if the treatment nurse didn't show up for their shift then the floor nurses were responsible for performing wound care. S16 LPN stated the weekend RN called the facility to say she'd be running late for work around 3:00 p.m. on 08/01/2026 and called back to say she'd be in around 5:00 p.m. S16 LPN stated she got off around 6:00 p.m. and the weekend RN still hadn't showed up to the facility. S16 LPN stated she's unsure if wound care was ever done on 08/01/2026 but knows they weren't done during her shift. Interview on 08/25/2026 at 9:22 a.m., S17 LPN stated she worked 6:00 a.m. to 6:00 p.m. on the weekend of 08/01/2026 and 08/02/2026. S17 LPN stated the weekend RN called her and stated she was running late for her shift. S17 LPN stated she called S4 SDC/LPN to inform her that the weekend RN hadn't made it to the facility and S4 SDC/LPN told her she'd try to figure something out. S17 LPN confirmed wound care wasn't performed for Residents #2, Resident #3, and R5 on 08/01/2026 and 08/02/2026. Resident #2 Review of Resident #2's medical record revealed an admission date of 06/10/2026 with diagnoses that included in part, Type 2 Diabetes Mellitus with Hyperglycemia, Schizophrenia, Peripheral Vascular Disease, and an Unspecified open wound, Right Foot. Review of Resident #2's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/16/2026 revealed the resident had a BIMS score of 15, indicating intact cognition. Review of Resident #2's 07/2026 Physician Orders revealed.cleanse right foot plantar with wound cleanser, apply mesalt to wound bed, cover with rolled gauze daily and PRN every day shift. Review of Resident #2's ETAR (electronic Treatment Administration Record) for 07/2026 revealed no documentation that the treatment was completed on July 5, 19, and 21 of the above physician's order. Review of Resident #2's 08/2026 Physician Orders revealed.cleanse right foot plantar with wound cleanser, apply mesalt to wound bed, cover with rolled gauze daily and PRN (as needed) every day shift. Review of Resident #2's ETAR (electronic Treatment Administration Record) for 08/2026 revealed no documentation that the treatment was completed on August 1, 2, and 16 of the above physician's order. Interview on 08/24/2026 at 9:17 a.m., Resident #2 stated the facility has trouble getting a treatment nurse on the weekends. Interview on 08/25/2026 at 9:29 a.m., Resident #2 stated he should receive wound care treatments daily. He stated that he does not receive wound care on some weekends and reported that the facility has difficulty getting a treatment nurse on the weekends. Interview on 08/25/2026 at 2:15 p.m., S1 DON acknowledged that if the required documentation was not present, indicating the ETARs were not signed, the treatments were not performed. S1 DON confirmed Resident #2's treatments for the dates of July 5, 19,21 and August 1, 2, and 16 were not performed but should have been. 2. Findings: Review of the facility's policy with a review date of 03/01/2026 titled Medication Administration revealed in part.Remain with the resident to ensure that the resident swallows the medication. In an interview and observation on 08/25/2026 at 2:45 p.m., Resident #2 had a clear, plastic cup of 5 pills (one yellow capsule, one blue capsule, 2 white circular tablets, and 1 purple caplet). Resident #2 stated the nurse had just given him his afternoon medicines. Resident #2 stated, I don't drink their water on them carts, I drink my own bottled water. Observation revealed Resident #2 in his room taking those medications alone with his bottled water. In an interview on 08/25/2026 at 2:48 p.m., S16 LPN confirmed she did give Resident #2 his medications, but he put them in his mouth. She stated Resident #2 must have spit the medicines back into his cup and went down the hall. Surveyor informed her of the medications being dry with no evidence of the medications being put in his mouth. S16 LPN confirmed Resident #2 was not allowed to administer his own medication. In an interview on 08/25/2026 at 2:52 p.m., S1 DON and S2 Unit Manager confirmed nurses are supposed to always stay with residents while they are taking their medications. S1 DON confirmed Resident #2 is not allowed to administer his own medication and should not have taken his medications without being in the presence of a nurse.

Based on interviews and observations the facility failed to ensure all mechanical and electrical equipment were maintained in safe operating conditions. The facility failed to ensure the kitchen walk-in refrigerator and walk-in freezer were functioning properly. This deficient practice had the potential to affect all residents who received meals from the kitchen. The facility census was 72.Findings:Kitchen observation on 08/24/2026 at 12:13 p.m., accompanied by S9 Cook, revealed the following:-Walk-in refrigerator and walk-in freezer temperature logs were incomplete. Walk-in freezer temperatures for the dates of 08/03/2026 to 08/22/2026 had multiple dates of abnormal temperatures. -Walk-in refrigerator had water puddles on the floor. S9 [NAME] revealed the water puddles were coming from the freezer. -Walk-in freezer revealed a large amount of ice built-up on the back of the motor attached to the walk-in freezer's ceiling. -Three thermometers in the walk-in freezer revealed in part.one digital thermometer had a reading of 34 degrees Fahrenheit; one analog thermometer was unreadable; and one analog thermometer showed a reading of 40 degrees Fahrenheit. Walk-in refrigerator revealed a temperature of 50 degrees Fahrenheit on an analog thermometer. Walk-in freezer revealed a temperature of 34 degrees Fahrenheit. -Walk-in freezer revealed. one half case (greater than 20) of thawed cinnamon rolls, less than one half case (less than 10) of thawed chicken breast, one case (greater than 10) of thawed vanilla ice cream, multiple bags of unfrozen vegetables which included broccoli, fried okra, fried zucchini, and one 10lb tube of ground meat. S8 [NAME] stated the 10lb tube of ground beef was thawed out yesterday (08/23/2026) and still available for use. -Walk-in refrigerator revealed.one unopened bag of wilted, brown lettuce; one case (greater than 20) of overripen, darkened peel, and very soft bananas. S9 [NAME] confirmed all the information above. S9 [NAME] acknowledged at time of observation the walk-in refrigerator and freezer temperature logs were incomplete and had abnormal temperature readings. S9 [NAME] confirmed the items listed above were thawed in the walk-in freezer; the freezer had ice build-up inside; walk-in refrigerator had puddles on the floor, and lettuce and bananas should have been disposed of properly. In an interview on 08/24/2026 at 4:10 p.m., S5 Regional DM confirmed the temperatures of the walk-in refrigerator were abnormal and had food stored for resident use. S5 Regional DM confirmed the walk-in freezer had unopened, thawed food available for use but should have not. S5 Regional DM confirmed the kitchen walk-in freezer and refrigerator were not cooling appropriately and needed repairs.

Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure staff refilled the dishwasher's sanitizer and monitored sanitizer levels on the kitchen's dishwasher. The facility census was 72.Findings:Review of the facility's policy dated 2026 Edition titled On Tray Dietary Policies and Procedures-Infection Control revealed in part.To prevent cross-contamination and the spread of infection.The Dietary Manager or designee should provide training for all new dietary employees on infection control.The Dietary Manager or designee should provide ongoing training on infection control and cross-contamination for employees.The Dietary Manager or designee should develop and monitor systems to ensure guidelines for infection control and cross-contamination are followed. Observation on 08/24/2026 at 12:13 p.m. revealed the August 2026 Low temp dish machine logs were incomplete, with a last recorded date of 08/15/2026. In an interview and observation on 08/24/2026 at 12:13 p.m., S19 Dietary performed the sanitizer check which revealed there was no sanitizer in the dishwasher. Observation of the sanitizer jug underneath and connected to the dishwasher revealed it was empty. S19 Dietary Aide stated he told S8 [NAME] about the sanitizer on the dishwasher being empty that morning (08/24/2026). S8 [NAME] stated she did not let anyone know. S8 [NAME] and S19 Dietary Aide stated they did not have any extra jugs of sanitizer on site to change the empty jug out. In an interview on 08/24/2026 at 4:10 p.m., S5 Regional DM confirmed the sanitizer had not been checked but should have been checked prior to washing dishes after each meal. S5 Regional DM confirmed the sanitizer in the dishwasher was empty but should not have been.

Based on record review, observations, and interviews, the facility failed to ensure activities of daily living (ADL) were performed for 1 (#3) of 6 sampled residents. The facility failed to ensure resident #3 received his scheduled showers and/or baths.Findings: Review of Resident #3's medical record revealed an admission date of 05/05/2026 with diagnoses that included in part, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Acquired Absence of Left Leg Below Knee and Muscle Weakness.Review of Resident #3's Quarterly MDS with an ARD of 08/12/2026 revealed a BIMs summary score of 15 which indicated intact cognition. Resident #3 required partial/moderate assistance with showers and baths. Review of Resident #3's facility progress notes revealed no documentation of Resident #3 refusing showers or baths on scheduled dates. Review of Resident #3's comprehensive care plan with a next review date of 08/31/2026 revealed in part.at risk for decline in ADL's and self-care deficit related to impaired mobility, absence of left leg below the knee amputation, and incontinence. Interventions included: Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Further review revealed no refusals of ADL care. Review of Resident #3's Task: ADL Shower on Dayshift on Tuesday, Thursday, and Saturday with a 30 day lookback period revealed the last documented shower for Resident #3 was completed on 07/28/2026 at 2:53 p.m. Interview on 08/25/2026 at 9:06 a.m., S18 CNA revealed Resident #3 gets a nightshift bath so when she comes on shift during the day she assumed he'd already received his bath. S18 CNA stated Resident #3 doesn't refuse nor is he resistant to ADL care. Interview on 08/25/2026 at 10:27 a.m. Resident #3 stated his showers are scheduled on Tuesdays, Thursdays, and Saturdays. Resident #3 stated he went a week without receiving a shower or bath recently. He stated he doesn't refuse his showers and the reason he doesn't get them is because staff is short-handed. Interview on 08/25/2026 at 2:26 p.m., S1 DON revealed there isn't a process for monitoring and ensuring staff are performing or documenting resident showers or baths. S1 DON revealed the floor nurses, S2 Unit Manager, and herself should be ensuring that ADL care is being performed by staff for residents that require it. S1 DON revealed Resident #3 received his showers during nightshift. S1 DON confirmed there was no other documentation she could provide that revealed Resident #3 received his showers or baths on nightshift. S1 DON reviewed Resident #3's Task: ADL Shower and confirmed the last documented date of him receiving a shower was on 07/28/2026.

Based on interview and record reviews the facility failed to ensure a resident's electronic Medication Administration Record (eMAR) was accurately documented for 4 (Resident #5, Resident #9, Resident #15, and Resident #34) residents. This deficient practice had the potential to effect all 62 residents in the facility.Findings: Review of the facility's policy titled Medication Administration with a review date of 03/01/2026 revealed in part.Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. Guideline: 14. Document as each medication is prepared on the MAR. Resident #5 Review of Resident #5's medical record revealed an admission date of 08/28/2024 with a re-entry date of 04/07/2025 with diagnoses that included in part, Peripheral Vascular Disease and Depression. Review of Resident #5's 02/2026 eMAR revealed no documentation on 02/13/2026, 02/13/2026, and 02/14/2026 of the following: -9:00 p.m.-Benadryl Allergy Oral Tablet 25 mg; -9:00 p.m.-Lexapro Oral Tablet 10 mg; -9:00 p.m.-Amoxicillin-Pot Clavulanate Tablet 875-125 mg along with a temperature check -Assist Rails x 2 to bed for bed mobility and repositioning every shift; -8:00 p.m.-Coreg Oral Tablet 6.25 mg; -Document Pain Scale Every Shift; -8:00 p.m.-Eliquis Oral Tablet 5 mg; -Enhanced Barrier Precautions every shift; -Keep Abdominal Binder on at all times every shift; -Monitor for signs and symptoms of Tardive Dyskinesia every shift; -Monitor for Target Behaviors every shift; -9:00 p.m.-Procardia Xl Oral Tablet Extended 24 Hour 30 mg; -9:00 p.m.-Pro-Stat Sugar Free Oral Liquid; -Smoking Checks; and no documentation for 26 of 28 days for the following: -Monitor for active bleeding and bruising due to resident on anticoagulant therapy. Review of Resident #5's facility progress notes revealed no documentation or evidence of refusals of medications or monitoring on those dates listed above. Resident #9 Review of Resident #9's medical record revealed an admission date of 03/10/2023 with a re-entry date of 02/16/2024 with diagnoses that included in part, Type 2 Diabetes Mellitus With Diabetic Neuropathy, Unspecified. Review of Resident #9's 03/2026 Electronic Medication Administration Record (eMAR) and Electronic Treatment Administration Record (eTAR) revealed no documentation of the following: - Atorvastatin Calcium Oral Tablet 10 (milligrams) MG at bedtime (HS) on 03/28/2026; - B12 Folate Oral Capsule 800-800 (micrograms) MCG at morning (AM) medication pass (MP) on 03/12/2026, 03/132026, and 03/24/2026; - Duloxetine HCl Capsule Delayed Release Particles 30 MG at AM MP on 03/12/2026 and 03/13/2026; - Ferrous Sulfate Tablet (Enteric Coated) EC 325 MG at AM MP on 03/12/2026 and 03/13/2026; - Melatonin Oral Tablet 10 MG at bedtime on 03/18/2026; - Metoprolol Tartrate Tablet 25 MG at AM MP on 03/12/2026 and 03/13/2026; - Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG no blood pressure or administration noted for AM MP on 03/12/2026, 03/13/2026, and 03/16/2026; - Renal Vitamin Oral Tablet 0.8 MG (B-Complex with C and Folic Acid) at AM MP on 03/12/2026 and 03/13/2026; - Trazodone HCl Oral Tablet 50 MG at 8:00 p.m. on 03/18/2026; - Vitamin C Oral Tablet (Ascorbic Acid) at AM MP on 3/12/2026 and 03/13/2026; - Vraylar Oral Capsule 1.5 MG (Cariprazine HCl) at AM MP on 3/12/2026 and 03/13/2026; - Weekly Skin Assessment Due every dayshift on Friday on 03/13/2026; - Zyrtec Allergy Oral Tablet 10 MG (Cetirizine HCl) at AM MP on 03/13/2026; - Clonazepam Tablet 1 MG at AM MP on 3/122026 and 03/13/2026 and HS on 03/18/2026; - Dialysis: Check Thrill and Bruit every shift on dayshift of 03/05/2026, 03/09/2026, 03/12/2026, 03/13/2026, 03/16/2026, 03/17/2026 and on nightshift of 03/18/2026; - Document Pain scale every shift on dayshift of 03/05/2026, 03/09/2026, 03/12/2026, 03/13/2026, 03/16/2026, 03/17/2026 and on nightshift of 03/18/2026; - Famotidine Tab 20 MG at AM MP on 3/12/2026 and 03/13/2026 and HS on 03/18/2026; - Gabapentin Capsule 400 MG at 8:00 p.m. on 03/18/2026; - Midodrine HCl Tablet 10 MG no blood pressure, pulse, or administration noted for AM MP on 03/12 and 13/2026 and HS on 03/18/2026; - Monitor BP (blood pressure) and Pulse Q (every) Shift for dayshift on 03/05/2026, 03/12/2026, 03/13/2026, 03/16/2026, 03/17/2026 and for nightshift on 03/18/2026; - Amino Acids Oral Liquid (Amino Acids) at 2:00 p.m. on 03/05/2026, 03/09/2026, 03/17/2026, and 03/19/2026 and at 8:00 p.m. on 03/18/2026; - Calcium Acetate Oral Tablet 667 MG at 2:00 p.m. on 03/05/2026, 03/09/2026, 03/17/2026, and 03/19/2026 and at 8:00 p.m. on 03/18/2026; - Tizanidine HCl Tablet 2 MG on AM MP on 03/12/2026 and 03/13/2026, on MID M (Midday Med Pass) on 03/05/2026, 03/09/2026, 03/17/2026, and 03/19/2026, and on PM MP on 03/01/2026, 03/05/2026, 03/09/2026, 03/12/2026, 03/13/2026, 03/17/2026, and 03/19/2026. Review of Resident #9's facility progress notes revealed no documentation or evidence of refusals of medications or monitoring on those dates listed above. Resident #15 Review of Resident #15's medical record revealed an admission date of 01/19/2024 with a re-entry date of 11/16/2024 with diagnoses that included in part, Chronic Atrial Fibrillation, Paranoid Schizophrenia, unspecified Dementia, Depression, and other Hypertension. Review of Resident #15's 03/2026 eMAR revealed no documentation of completing the following orders: Amiodarone HCL Oral Tablet 200mg; 7 out of 31 days during 03/2026 Atorvastatin Calcium Oral Tablet 20mg; 1 out of 31 days during 03/2026 Cholecalciferol Tablet 1000unit; 4 out of 31 days during 03/2026 Donepezil HCL Tablet 10mg; 1 day out of 31 days during 03/2026 Ferrous Sulfate Tablet 325mg; 4 out of 31 days during 03/2026 Fish Oil Capsule 1000mg; 4 out of 31 days during 03/2026 House Supplement; 2 out of 31 days during 03/2026 House Supplement; 4 out of 31 days during 03/2026 Lasix Oral Tablet 20 mg; 4 out of 31 days during 03/2026 Metoprolol Tartrate Tablet 75mg; 4 out of 31 days during 03/2026 Quetiapine Fumarate Tablet 25mg; 1 out of 31 days during 03/2026 Trazodone HCL Oral Tablet 50mg; 1 out of 31 days during 03/2026 Xarelto Oral Tablet 20mg; 7 out of 31 days during 03/2026 Assist Rails x 1 to bed for bed mobility and repositioning; 8 out of 31 days during 03/2026 Colace Oral Capsule 100mg; 8 out of 31 days during 03/2026 Divalproex Sodium Tablet Delayed Release 250 mg; 5 out of 31 days during 03/2026 Document Pain Scale every shift; 8 out of 31 days during 03/2026 Famotidine Oral Tablet 20 mg; 5 out of 31 days during 03/2026 Memantine HCL Oral Tablet 5mg; 5 out of 31 days during 03/2026 Monitor for Active Bleeding, and bruising d/t resident on Anticoagulant therapy; 8 out of 31 days during 03/2026 Monitor for Edema q Shift; 8 out of 31 days during 03/2026 Monitor for S/SX of Tardive Dyskinesia; 8 out of 31 days during 03/2026 Monitor for Targeted Behaviors such as attention seeking behaviors, refusals for meds, noncompliance with MD orders, etc.; 8 out of 31 days during 03/2026 Observe closely for side effects of Psychotropic Medication including dry mouth, constipation, blurred vision, disorientation, etc.; 9 out of 31 days during 03/2026 Was head of bed elevated due to episode of or to prevent shortness of breath when lying flat; 9 out of 31 days during 03/2026 Methadone HCL oral Tablet 10mg; 4 out of 31 days during 03/2026 Smoking checks must be done every smoke break, Check for smoking paraphernalia including snuffed out cigs; 7 out of 31 days during 03/2026 Q HR monitoring for elopement risk and to ensure safety every hour related to Paranoid Schizophrenia; 9 out of 31 days during 03/2026 Review of Resident #15's facility progress notes revealed no documentation or evidence of refusals of medications or monitoring on the dates listed above. Resident #34 Review of Resident #34's medical record revealed an admission date of 04/25/2024 with diagnoses which included in part . Type II Diabetes Mellitus with Diabetic Mononeuropathy, Major Depressive Disorder, Single Episode, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Venous Insufficiency (Chronic) (Peripheral). Review of Resident #34's 03/2026 EMAR/ETAR (electronic medication administration record/electronic treatment administration record) revealed the following dates with no documented evidence of order administration for the following orders: -03/05/2026: Duloxetine HCl Enteric Coated Pellets Capsule 60 MG (Base Eq) Give 1 capsule orally one time a day related to Major depressive disorder, single episode; -03/05/2026 and 03/09/2026: Flomax Oral Capsule 0.4 MG (Tamsulosin HCl) Give 0.4 mg by mouth one time a day; -03/05/2026: Folic Acid Tablet 1 MG Give 1 tablet orally one time a day related to Venous insufficiency (chronic) (peripheral); -03/05/2026: Linzess Oral Capsule 72 MCG (Linaclotide) Give 1 capsule by mouth one time a day for Constipation; -03/05/2026: Methadone HCl Oral Tablet 10 MG (Methadone HCl) Give 10 mg by mouth one time a day for Pain; -03/05/2026 and 03/09/2026: MiraLax Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day related to constipation- mix in 4oz- 8oz of water daily; -03/05/2026 and 03/09/2026: Potassium Chloride Microencapsulated [NAME] ER Tab 20 mEq Give 2 tablet orally one time a day for hypokalemia; -03/05/2026 and 03/09/2026: Pravastatin Sodium Tablet 40 MG Give 1 tablet by mouth one time a day for Hyperlipidemia; -03/05/2026, 03/09/2026, 03/16/2026: air mattress to bed every shift; -03/04/2026, 03/05/2026, 03/09/2026, 03/12/2026, 03/17/2026: Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth two times a day related to non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026: Assist Rails times 2 to bed for bed mobility and repositioning. (Non-restraint) Monitor for safety every shift for bed mobility and transfer; -03/05/2026 and 03/09/2026: Desmopressin Acetate Oral Tablet 0.1 MG (Desmopressin Acetate) Give 1 tablet by mouth two times a day related to Diabetes Insipidus; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026: document pain scale every shift 0= none 1-3 = mild pain 4-5 = moderate pain 6-7= severe pain 8-10= very severe pain every shift; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026: enhanced barrier precautions every shift; -03/04/2026, 03/05/2026, 03/09/2026, 03/12/2026, 03/16/2026, and 03/17/2026: Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) Give 1 tablet orally two times a day related to Iron deficiency anemia; -03/04/2026, 03/05/2026, 03/09/2026, 03/12/2026, and 03/17/2026: Fluticasone Propionate Aerosol 220 MCG/ACT 1 puff inhale orally two times a day for Prophylaxis rinse mouth after use; -03/04/2026, 03/05/2026, 03/09/2026, 03/12/2026, and 03/17/2026, Furosemide Tablet 40 MG Give 40 mg orally two times a day for edema; -03/05/2026 and 03/09/2026: House Supplement Sugar Free two times a day related to Type II diabetes mellitus with diabetic mononeuropathy; -03/04/2026, 03/05/2026, 03/09/2026, 03/17/2026, and 03/19/2026: Insulin Aspart Solution 100 UNIT/ML Inject as per sliding scale: if 70 - 150 = 0 units notify md for fasting blood glucose less than 60; 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 7 units; 301 - 350 = 9 units; 351 - 400 = 11 units notify md for fasting blood glucose greater than 400, subcutaneously two times a day for diabetes related to type 2 diabetes mellitus with diabetic mononeuropathy before breakfast; -03/04/2026, 03/05/2026, 03/09/2026, 03/12/2026, and 03/17/2026: Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day related to Type 2 diabetes mellitus with diabetic mononeuropathy; -03/09/202, 03/12/2026, and 03/17/2026: Methadone HCl Oral Tablet 10 MG (Methadone HCl) Give 1 tablet by mouth two times a day for pain; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026 monitor edema every shift: 0, 1+, 2+, 3+, 4+ notify md if 3+ or greater every shift; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026: monitor for signs/symptoms of tardive dyskinesia; notify md of involuntary movements of tongue, face, mouth, jaw, or trunk. Notify medical director (MD) of motor restlessness which may consist of anxiety, pacing, inability to sit still, or foot tapping. (Document + if any noted and notify MD) every shift; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2025: Monitor for signs of impairment related to substance abuse q shift. Notify MD immediately if noted. Y= Yes signs of impairment N= No signs not observed S/S: Slurred speech, slow movements, decreased alertness, quick, slow fluctuation of speech, bloodshot eyes, pupils larger or smaller than usual, changes in appetite, sleep patterns, physical appearance, unusual smells on breath, body, or clothing, unsteady gait, unable to arouse, breathing slow; -03/05/2026, 03/09/2026, 03/16/2026, 03/18/2026, and 03/19/2026: Monitor odor every shift 0-no odor 1-ordor noted every shift; -03/05/2026, 03/09/2026, 03/16/2026, 03/18/2026, and 03/19/2026: Monitor resident for opioid overdose i.e.: unconsciousness, shallow breathing, unresponsiveness, limpness, blue gums, lips or fingertips, slow or irregular pulse, small pupils. Document N if none noted. Document Y if s/s are noted, administer PRN Narcan as ordered and document in Progress Notes. every shift; -03/05/2026, 03/09/2026, 03/16/2026 03/18/2026, and 03/19/2026: monitor urine color q shift 0-yellow 1-straw 2-amber 3-blood tinged; -03/05/2026, 03/09/2026, 03/16/2026, 03/18/2026, and 03/19/2026: Observe closely for side effects of Psychotropic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above was observed, select chart code Other/See Nurses Notes and progress note findings; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026: pressure reducing cushion to wheelchair every shift related to other chronic pain; -03/05/2026, 03/09/2026, 03/16/2026, and 03/18/2026: Supra pubic catheter care with soap and water q shift every shift; -03/05/2026, 03/09/2026, 03/16/2026, 03/18/2026, and 03/19/2026: Was head of bed Elevated due to episode of or to prevent shortness of breath when lying flat related to COPD, Asthma, Emphysema every shift; -03/04/2026, 03/05/2026, 03/09/2026, 03/17/2026, and 03/18/2026: Cyproheptadine HCl Tablet 4 MG Give 1 tablet by mouth three times a day for poor appetite related to vitamin deficiency; -03/04/2026, 03/05/2026, 03/09/2026, 03/17/2026, and 03/18/2026: Robaxin-750 Oral Tablet (Methocarbamol) Give 500 mg by mouth three times a day related to other muscle spasm; In an interview on 03/24/2026 at 3:20 p.m., S2 QI Nurse revealed the floor nurses are expected to chart on in the medical record in real time. S2 QI Nurse acknowledged if the nurses did not chart the information in the EMAR/ETAR, then it did not happen. A shared interview on 03/24/2026 at 3:39 p.m. with S3 Regional VP, S8 DON, S1 Admin, and S2 QI Nurse was conducted. S3 Regional VP revealed the facility had a big turnover rate in leadership and administration since 01/2026, including 4 DONs, 2 Unit Managers, and 2 Treatment Nurses. S3 Regional VP revealed she contributed the poor nursing documentation, including narcotic documentation, due to the increased turnover of the administrative team and administrative nurses. S3 Regional VP revealed she cannot defend a nurse who did not chart in the EMAR/ETAR, and stated the nurses should always chart in real time or document refused if the order was refused. In a record review, at the time of interview, S3 Regional VP reviewed the 03/2026 EMAR/ETAR for Resident #34 and confirmed all the above findings and missing documentation, stating the nurses should have documented every shift, but did not. S3 Regional VP revealed she expected all nurses to chart in the EMAR in real time or document refused when it applied for all residents. All present in the shared interview, agreed to the above.

Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings.Findings:Review of the Resident Council meeting minutes held on 01/19/2026 revealed, in part .New Business: Agency nurse not giving meds timely.Review of the Resident Council meeting minutes held on 02/26/2026 revealed, in part .Old Business: Was the issue resolved to your satisfaction? No, agency nurse not giving meds timely and New Business: Agency nurses not giving meds timely on night shift.Review of the Resident Council meeting minutes held on 03/11/2026 revealed, in part .Old Business: Was the issue resolved to your satisfaction? No, agency nurses not giving meds timely at night.During the Resident Council meeting on 03/23/2026 at 1:50 p.m., residents complained that an agency nurse continues to give medications late on the weekends and/or at night. The residents stated this issue had been discussed at multiple Resident Council meetings but had not been resolved by the facility.Interview on 03/24/2026 at 11:50 a.m., S1 Admin confirmed that she had signed the minutes of the resident council meetings on 01/19/2026, 02/26/2026, and 03/23/2026 to verify her review of those minutes. S1 Admin stated that she was aware of the residents' complaints of not receiving medications timely. S1 Admin stated she did not have any documentation to show that the residents' concern had been addressed. S1 Admin confirmed that there had not been an effective resolution of the residents' complaints.

Based on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to:ensure scheduled medications were administered timely for 1(Resident #14) resident; andfollow physician orders for Resident #40. Findings: Review of the facility's policy and procedure titled Medication Administration with a review date of 03/01/2026 read in part.Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve, and prevent symptoms and help in diagnosis. Level of responsibility: RN, LPN. Guideline: 19. If the medication is given at a time different from the scheduled time, update the MAR to reflect administration time. Scheduled medications will be given within an hour window before and after it's scheduled and as preferred by resident.). Review of Resident #14's medical record revealed an admission date of 11/19/2025 with diagnoses that included in part, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Quadriplegia, and Major Depressive Disorder. Review of Resident #14's Quarterly MDS with an ARD of 02/11/2026 revealed a BIMs summary score of 15, indicating intact cognition. Review of Resident #14's 03/2026 Physician Orders revealed in part. Trazodone HCl (Hydrochloride) Oral Tablet 50 mg: give 50 mg by mouth at bedtime for Insomnia – start date 01/07/2026 Baclofen Oral Tablet 10 mg: give 15 mg by mouth three times a day for Muscle Spasm – start date 03/12/2026 Protonix Oral Tablet Delayed Release 40 mg: give 40 mg by mouth two times a day for GERD – start date 11/19/2025 Sucralfate Tablet 1 gram: give 1 tablet by mouth two times a day for Gastric Protection – start date 02/01/2026 Rosuvastatin Calcium Tablet 10 mg: give 1 tablet by mouth one time a day for Lipid Control Review of Resident #14's 03/2026 eMAR revealed in part. Rosuvastatin Calcium Tablet 10 mg scheduled administration time 08:00 p.m. (2000 hours); Trazodone HCl Oral Tablet 50 mg scheduled administration time 08:00 p.m.; Protonix Oral Tablet Delayed Release 40 mg scheduled administration time 08:00 p.m.; Sucralfate Tablet 1 gram scheduled administration time 08:00 p.m.; and Baclofen Oral Tablet 10 mg scheduled administration time 08:00 p.m. Review Resident #14's Medication Administration Audit Report revealed in part. -Rosuvastatin Calcium Tablet 10mg scheduled administration time at 8:00 p.m., and administered on 03/04/2026 at 11:28 p.m., 03/07/2026 at 12:02 a.m., 03/11/2026 at 12:33 a.m., 03/13/2026 at 10:19 p.m., 03/14/2026 at 11:50 p.m., 03/17/2026 at 11:35 p.m., 03/18/2026 at 11:30 p.m., 03/20/2026 at 12:20 a.m., 03/21/2026 at 03:26 a.m., and 03/23/2026 at 11:02 p.m. -Sucralfate Tablet 1 gram scheduled administration time at 8:00 p.m., and administered on 03/05/2026 at 11:25 p.m., 03/07/2026 at 12:02 a.m., 03/11/2026 at 12:33 a.m., 03/13/2026 at 10:19 p.m., 03/14/2026 at 11:51 p.m., 03/17/2026 at 11:36 p.m., 03/18/2026 at 11:30 p.m., 03/20/2026 at 12:20 a.m., 03/20/2026 at 03:26 a.m., and 03/23/2026 at 11:02 p.m. -Protonix Oral Tablet Delayed Release 40 mg scheduled administration time at 8:00 p.m., and administered on 03/05/2026 at 11:10 p.m., 03/07/2026 at 12:02 a.m., 03/11/2026 at 12:33 a.m., 03/13/2026 at 10:19 p.m., 03/14/2026 at 11:50 p.m., 03/17/2026 at 11:35 p.m., 03/18/2026 at 11:30 p.m., at 03/20/2026 at 12:20 a.m., 03/21/2026 at 03:26 a.m., and 03/23/2026 at 11:02 p.m. -Trazodone HCl Oral Tablet 50 mg scheduled administration time at 8:00 p.m., and administered on 03/05/2026 at 11:27 p.m., 03/07/2026 at 12:02 a.m., 03/11/2026 at 12:33 a.m., 03/13/2026 at 10:19 p.m., 03/14/2026 at 11:50 p.m., 03/17/2026 at 11:36 p.m., 03/18/2026 at 11:30 p.m., at 03/20/2026 at 12:20 a.m., 03/21/2026 at 03:26 a.m., and 03/23/2026 at 11:02 p.m. -Baclofen Oral Tablet 10mg scheduled administration time at 9:00 p.m., and administered on 03/05/2026 at 11:10 p.m., 03/07/2026 at 12:02 a.m., 03/11/2026 at 12:33 a.m., 03/14/2026 at 11:50 p.m., 03/17/2026 at 11:36 p.m., 03/18/2026 at 11:30 p.m., at 03/20/2026 at 12:20 a.m., 03/21/2026 at 03:26 a.m., 03/21/2026 at 11:13 p.m., and 03/23/2026 at 11:02 p.m. In an interview on 03/23/2026 at 9:22 a.m., Resident #14 revealed that earlier this month she didn't receive her bedtime medications at their scheduled time. Resident #14 stated she had been complaining to staff about getting her bedtime medications late at night. Resident #14 revealed one night she didn't get her bedtime medications until after 12:30 a.m. and revealed she did not refuse any of her medications. In an interview on 03/24/2026 at 11:20 a.m., S2 QI Nurse revealed that all nursing staff have an hour before the scheduled administration time and an hour after the scheduled administration time to administer a medication to all residents. S2 QI Nurse reviewed Medication Administration Audit report for Resident #14 along with this surveyor and acknowledged Resident #14's medications were not administered within the required timeframe. In an interview on 03/24/2026 at 11:50 a.m., S3 Regional VP stated all nursing staff were aware to administer scheduled medications within an hour before and an hour after. S3 Regional VP stated she was made aware of Resident #14's Medication Administration Audit report by S2 QI Nurse and stated we can't even defend the deficient practice. S3 Regional VP confirmed Resident #14 was not receiving her scheduled medications timely but should have. In an interview on 03/24/2026 at 11:59 a.m., S8 DON stated all nursing staff are required to administer scheduled medications within the required timeframe of 1 hour before the scheduled time and 1 hour after the scheduled time. S8 DON reviewed Resident #14's Medication Administration Audit report and stated this is out of compliance. S8 DON confirmed Resident #14's scheduled medications were not administered timely, but should have been. Resident # 40 Findings: Review of the clinical record revealed Resident #40 admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus due to underlying condition with Diabetic Neuropathy, Peripheral Vascular Disease, and Chronic Kidney Disease, Stage 3. Review of Resident #40's March Physician's Orders revealed an order for Novolog Injection Solution 100unit/ml (Insulin Aspart) Infect as per sliding scale: if 200-250=2 units, if less than 70 give 4 oz juice. Recheck in 15 minutes. If 300=4 unit; 301-350=6 units; 351-400=9 units; 401-600=12 units. If greater than 400 notify NP. Further review of the order had a start date of 03/04/2026. Observation of March eMAR (electronic medication administration record) on 03/24/2026 at 3:00p.m. revealed documentation of recorded blood sugars for 3 days out of 31 days for the following dates: 03/06/2026 of 457, 03/10/2026-441, and 03/21/2026-451. Observation of nurses' notes for 03/06/2026, 03/10/2026, and 03/21/2026 revealed no documentation of the nurse practitioner (NP) being notified of blood sugars greater than 400. In an interview on 03/24/2026 at 3:10 p.m. with S8 DON revealed the nursing staff did not notify the NP for the blood sugars greater than 400, but should have.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate disposition and/or administration of medications to meet the needs of each resident. The facility failed to: Ensure an accurate account for controlled medications was completed at the start of shift and time of administering narcotics on 1 (Cart A) of 4 medication/treatment carts for Resident #62; and Ensure proper nursing procedures for wasting of controlled substances were completed when Resident #46 and Resident #64's controlled medications were not administered.Findings: Review of a facility policy on 03/25/2026 at 2:30 p.m. titled, Facility Protocol on Controlled Substances with a review date of 01/26/2025 revealed the following in part .Complete documentation in the narcotic book prior to administering control substances to the resident. Check the count with each administration to ensure accuracy. Initial the MAR after administering the medication. Wasting: When breakage or wasting of all or partial dose of a controlled substance not in its original package and/or not administered to a patient occurs, the amount administered and the amount wasted shall be recorded by the licensed person who wasted the controlled substance and verified by the signature of another licensed person who observed the wastage and how it was wasted. Controlled substances shall be wasted in such a manner that such substances are render unusable. All controlled substance, including the ER narcotic kit and medications in the refrigerator, must be counted at each shift change. Both the oncoming and outgoing nurse should look at the card and the narcotic book to ensure accuracy. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. Observation, interview and record review on 03/23/2026 at 2:51 p.m. of Cart A, accompanied with S9 LPN, revealed the following during the narcotic medication reconciliation:1.-Resident #62's blister packaging for an order of Diphenoxylate/atropine 2.5mg/0.025mcg one tablet by mouth four times a day was observed. The blister packaging revealed tablet #10 was popped, opened and unaccounted for. S9 LPN revealed she was unaware that tablet #10 was missing; therefore, the narcotic count was off by one tablet. Resident #62's Controlled Drug Record form for the above medication revealed 25 tablets documented; however, with tablet #10 missing and unaccounted for, the actual count on hand was 24 tablets left in the blister packaging. S9 LPN revealed she counted the tablets at the start of her shift, both herself and off-going nurse mistakenly overlooked the missing tablet #10 and did not document this, but should have. 2.-Resident #46's blister packaging for an order of Lorazepam 0.5 mg one tablet by mouth twice a day was observed. The blister packing revealed tablet #58 was popped, placed back into the packaging with the back of the card taped. -Resident #64's blister packaging for an order of Butalbital/acetaminophen/caffeine 50mg/325mg/40mg one tablet by mouth every six hours as needed was observed. The blister packaging revealed tablet #2 and tablet #14 were popped and placed back into the packaging with the back of the card taped. S9 LPN confirmed all the above findings at the time of observation of Cart A. S9 LPN revealed that putting the tablets back into the packaging and taping the back was allowed in the facility. S9 LPN revealed the nurses do not waste the pill if the nurse accidentally popped the packaging or if a resident refused the medications; the nurses just tape the pill back into the blister package. In an interview on 03/23/2026 at 4:15 p.m., S8 DON revealed she expected the nurses to count narcotics at the beginning of each shift with the off-going nurse, they are expected to count and document the narcotic count into the narcotic binder with their initials. S8 DON expected all nurses to verify the actual narcotics on hand and verify what is documented in the record. Nurses are to notify S8 DON of discrepancies in the narcotic count, if found. S8 DON revealed she expected all nurses to destroy narcotics appropriately with a second nurse present and document this in the medical record/narcotic book. S8 DON explained if a resident refused a medication, a nurse dropped a medication on the floor, or a medication was popped from the blister package accidentally, S8 DON expected all nurses to waste the medication appropriately and not tape the tablet back into the narcotic packaging. At the time of interview, S8 DON confirmed the above findings. S8 DON confirmed Resident #62's incorrect narcotic count should have been addressed upon beginning of the shift and Resident # 46's and Resident #64's narcotics which were taped should have been destroyed appropriately, but were not.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. This deficient practice has the potential to affect all 62 residents residing in the facility. The facility failed to ensure expired treatment supplies were not available for administration to residents in 1 (Cart C) of 3 medication/treatment carts.Findings:Review of a facility policy on 03/25/2026 at 2:30 p.m. titled, Medication Storage with a review date of 03/20/2022 revealed in part .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. All expired medication and supplies will be removed from the active supply and destroyed in the facility, regardless the amount remaining. Observation and review on 03/25/2026 at 2:23 p.m. of Cart C, accompanied with S10 TX LPN revealed the following expired items:14 individually wrapped Reinforced Gelling Fiber .75inches X 18inches rope dressing with an expiration date of 08/12/2025S10 TX LPN confirmed the above findings in Cart C at the time of observation. S10 TX LPN confirmed she used the expired treatment supplies to treat resident's wounds today during treatments, but should not have. S10 TX LPN revealed all expired medications and supplies should be discarded of and not available for resident use. S10 TX LPN confirmed the rope dressings should have been disposed of properly and not available for use, but were not.

Based on observation, interview and record review, the facility failed to administer its resources efficiently and effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to effect all 62 residents who resided in the facility. The facility failed to ensure the monthly Pharmacy Consultant Reports were utilized, reviewed, and/or addressed as it related narcotic medication reconciliation and documentation.Findings: Cross Reference F755. Review of a facility policy on 03/25/2026 at 2:30 p.m. titled, Facility Protocol on Controlled Substances with a review date of 01/26/2025 revealed the following in part .The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. 1. The director of nursing documents irreconcilable discrepancies in a report to the administrator. 2. If a major discrepancy or pattern of discrepancies occurs or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. 3. The administrator, the consultant pharmacist, and/or the director of nursing determine whether other action(s) are needed notification of police or other enforcement personnel, notification of family, etc. Any suspected loss, theft and/or diversion of any controlled substance shall be reported immediately to Pharmacy Services and complete a risk Management report. Review of a facility report prepared by S11 Pharmacist titled, PRN Documentation Audit- 12/2025 revealed the following in part . A total of 160 narcotic order administrations were reviewed for 12/2025 medical record, with only 96 narcotic order administrations documented in the medical record. The results included only 60% of these doses correctly documented in the medical record. Notes: Please see audit for the medication audited and follow up with the nursing staff on documenting the MAR with the administration of the PRN doses. Signed and dated by S11 Pharmacist on 12/31/2025. A shared interview on 03/24/2026 at 3:39 p.m. with S3 Regional VP, S8 DON, S1 Admin, and S2 QI Nurse was conducted. S3 Regional VP revealed the facility had a big turnover rate in leadership and administrative since 01/2026, including 4 DONs, 2 Unit Managers, and 2 Treatment Nurses. S3 Regional VP revealed she contributed the poor nursing documentation, including narcotic documentation, due to the increased turnover of the administrative team and administrative nurses. S3 Regional VP revealed she expected all nurses to chart in the EMAR in real time or document refused when it applies. All present in the shared interview, agreed to the above. In a telephone interview on 03/25/2026 at 8:37 a.m., S11 Pharmacist revealed he rounds at the facility monthly and reconciles narcotics randomly. S11 Pharmacist stated the 12/2025 narcotic audit revealed only 60% of narcotic documentation completed. S11 Pharmacist stated these findings were very alarming, due to 80% being the average rate. S11 Pharmacist revealed due to this alarmingly low percentage, he also spoke to the DON and notified her of his findings. S11 Pharmacist revealed he emails his monthly reports to the Administrator and DON once completed. In a shared interview with S1 Admin and S2 QI Nurse on 03/25/2026 at 11:36 a.m., S1 Admin revealed she was the facility administrator from 12/2025 to current. S1 Admin revealed she was unaware of the findings during S11 Pharmacist rounding for 12/2025; however S4 Former DON was made aware and received the email from S11 Pharmacist with the 12/2025 results, as it related to narcotic reconciliation and documentation. S1 Admin revealed she requested the audit report from S11 Pharmacist on 03/24/2025 via email. S2 QI Nurse revealed normally the DON should collaborate with the nursing team and the Administrator to correct any findings related to the monthly Pharmacy Reports. During an interview on 03/25/2026 at 12:56 p.m., S3 Regional VP telephoned S4 Former DON. S4 Former DON revealed S11 Pharmacist did alert her of the poor narcotic documentation and discrepancies found during his narcotic audit. S4 Former DON stated she began a nursing in-service to address the poor narcotic documentation and asked the Unit Manager to audit medication carts randomly. S4 Former DON stated she normally communicated with S1 Admin about different nursing issues or need for monitoring/in-services, however S4 Former DON did not communicate the 12/2025 narcotic findings or monitoring/in-services implemented to S1 Admin, but should have. In an interview on 03/25/2026 at 1:02 p.m., S1 Admin revealed reports from S11 Pharmacist continued to be emailed to S4 Former DON after she resigned. S1 Admin stated she nor any other facility staff received or addressed the pharmacist report for 01/2026. In an interview on 03/25/2026 at 1:02 p.m., S1 Admin revealed she should have made a better effort to communicate with the S11 Pharmacist to alert him that S1 Admin should be the point of contact due to the changing of leadership to ensure issues related to medications were addressed timely, but she did not.

Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #71) of 1 resident reviewed for transfer/discharge. The total sample size was 30.Findings:Review of Resident #71's medical record revealed an admission date of 02/09/2026 and a discharge date of 02/18/2026. Resident #71 had diagnoses of Acute Respiratory Failure with Hypoxia, End Stage Renal Disease, Type 2 Diabetes Mellitus with Unspecified Complications, and Chronic Obstructive Pulmonary Disease. Review of Resident #71's Discharge-Return Not Anticipated MDS with an ARD of 02/18/2026 revealed in part.discharge date of 02/18/2026. Type of discharge: unplanned. In an interview on 03/25/2026 at 3:20 p.m., the facility's Emergency Transfer Log was requested from S2 QI Nurse. At 3:29 p.m. S2 QI Nurse revealed that they only report hospitalizations to the Louisiana Ombudsman Program. In an interview on 03/25/2026 at 3:54 p.m., S7 SSD revealed she was responsible for notification to the Louisiana Ombudsman Program of resident transfers. S7 SSD revealed she was only aware to report hospitalizations to the Ombudsman Program and had not reported any unplanned or planned discharges from the facility. S7 SSD confirmed she did not report Resident #71's unplanned discharge on [DATE] to the Louisiana Ombudsman Program.

Based on record review and interview, the facility failed to complete an annual performance review at least once every 12 months for 2 (S12 CNA and S13 CNA) of 5 CNA personnel records reviewed. Findings: Review of CNA personnel records revealed the following: Review of S12 CNA's personnel record revealed a date of hire of 07/30/2024. Further review revealed no evidence of an annual performance review being completed in the past 12 months. Review of S13 CNA's personnel record revealed a date of hire of 10/17/2024. Further review revealed no evidence of an annual performance review being completed in the past 12 months. In an interview on 03/25/2026 at 10:55 a.m., S14 HR revealed S13 CNA did not have a completed annual performance review. In an interview on 03/25/2026 at 11:50 a.m., S14 HR revealed S12 CNA did not have a completed annual performance review. Interview on 03/25/2026 at 12:00 p.m., S1 Admin confirmed both S13 CNA and S12 CNA should have had an annual, completed performance review, but did not.

Based on observation and interview, the facility failed to ensure infection control measures were practiced providing a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by failing to ensure medical equipment was cleaned in between uses with multiple residents during medication administration. This had to potential to affect all 62 residents. Findings: Review of the facility's policy dated 09/2019 titled Standard Precautions revealed in part Policy Statement-Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infections (HAI) agents among patients and healthcare personnel. Observation of medication administration on 03/24/2026 at 8:31a.m., revealed S18 LPN used a blood pressure cuff between multiple residents without sanitizing or disinfecting it in between resident use. In an interview on 03/24/2026 at 9:54 a.m., S8 DON confirmed S18 LPN did not clean the blood pressure cuff in between uses with multiple residents but should have.

Based on observations, interviews, and record reviews, the facility failed to provide a diet/supplements to meet the resident's needs for 3 (Resident #R1, Resident #R2 and Resident #2) of 9 sampled residents. The facility failed to:Provide supplements and providing feeding assistance with meals for Resident #R1; Provide feeding assistance for meals for Resident #R2; and Provide a meal tray and feeding assistance for Resident #2. Findings:Review of the facility's undated policy titled Food & Nutrition- Diet and Diet Orders read in part.Policy: Clients are served their diets as ordered. Resident #R1Review of Resident #R1's medical records revealed an admit to the facility on [DATE] with the following diagnoses in part.Quadriplegia, Chronic Kidney Disease, Neuromuscular Dysfunction, Pressure ulcer to Sacral Region, Stage 3, Pressure Ulcer of Sacral Region and Left Hip, Unspecified Mood Disorder, and Anxiety Disorder. Review of Resident #R1's Care plan with a review date of 03/18/2026 read in part. Resident is at risk for weight loss (resident is below ideal body weight). Diagnoses: Anorexia, Malnutrition, and Unable to feed self. Staff to feed all meals. Give supplements as prescribed. Review of Resident #R1's Quarterly MDS with ARD of 12/02/2025 revealed a BIMS score of 15 indicating resident has intact cognition. Resident #R1 is dependent on staff for all activities of daily living. During an interview on 02/19/2026 at 11:25 a.m., Resident #R1 stated that he usually only gets to eat 1 meal a day and that staff just won't come feed him at times. Resident #R1 stated if he is asleep, staff will not wake him up to feed him at times. An interview on 02/24/2026 at 11:35 a.m., Resident #R1 stated he did receive his supplements this morning, but does not get them very often or every day. Resident #R1 denies refusing any supplement. Resident #R1 denies any recent weight loss. Resident #R2Review of Resident #R2's medical record revealed an admission to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Quadriplegia, Body Mass Index 19 or less, Adult, Depression, and Pressure Ulcer to Sacral Region, Stage 4. Review of Resident #R2's 02/2026 Physician Orders read in part.02/12/2025- admitted to Heart of Hospice with diagnosis of Severe Protein Calorie Malnutrition. Review of Resident #R2's admission MDS with ARD of 01/06/2026 revealed a BIMS score of 13 indicating intact cognition. Resident #R2 has impairment on both left and right side and is dependent on staff for all activities of daily living. Review of Resident #R2's Care plan with a review date of 04/29/2026 read in part.The resident has nutritional problems related to diet restrictions. Interventions: Provide and serve diet as ordered. Review of Resident #R2's medical record revealed the following weights:12/31/2025-82.3 lbs01/05/2026-77.6 lbs01/13/2026-79.6 lbs01/23/2026-79.2 lbs01/30/2026-79.6 lbs02/03/2026-78.4 lbs During an observation and interview on 02/19/2026 at 11:35 a.m., Resident #R2 stated that he sleeps a lot and that staff do not always wake him to up to feed him if he is asleep. Resident #R2 stated that he has lost weight since admitting into the facility in 12/2025. In an interview on 02/23/2026 at 8:50 a.m., Resident #R2 stated 2 of the 6 meals over the weekend of 02/21/2026-02/22/2026 were missed because he was sleeping and no one came back to feed him. Resident #R2 stated he feels as though he is rushed when he is fed and it causes him to get full too fast. Resident #2 Review or Resident #2's medical record revealed an admit to the facility on [DATE] with the following Diagnoses in part.Type 2 Diabetes Mellitus, Quadriplegia, Essential HTN, Major Depressive Disorder, Cognitive Communication Deficit, and Osteoporosis.Review of Resident #2's admission MDS with ARD of 11/26/2026 revealed a BIMS score of 15 indicating intact cognition. Resident #2's is dependent on staff for all activities of daily living. An interview on 02/23/2026 at 11:45 a.m., Resident #2 stated she depends on staff to feed her and that she usually gets fed after all trays are passed out on the hall. Resident #2 stated there were 2 times in the last couple weeks where she did not receive her tray because it stayed on cart and was brought back to the kitchen. Resident #2 stated on 1 of the occasions she asked the CNA and agency nurse at the time to go get it from the kitchen. They returned and told her the kitchen was shut down and they were cleaning up, so she did not get anything to eat. An interview on 02/23/2026 at 1:22 p.m., S4 CNA stated there has been issues with staff feeding residents dinner on the evening shift because the meal carts were coming at same time as shift change, which caused some confusion. An interview on 02/24/2026 at 9:26 a.m., S3 LPN stated there had been a problem with residents not receiving their meal trays from dietary after coming back from hospital. S3 LPN stated she would have to go to kitchen to get their tray and that there had been instances where residents had notified her they hadn't received trays. S3 LPN stated Resident #R1 and Resident #R2 have complained to her that someone didn't feed them or they didn't eat about 3-4 weeks ago. An interview on 02/23/2026 at 3:00 p.m., S5 DM stated when a resident leaves out the facility, she is provided a departmental communication form notifying her that the resident is not in the facility. She stated she then removes the resident from the dining system so that their meal tickets are not printed for the meal service until they are added back. S5 DM confirmed there have been some issues receiving the communication form to add the residents back into the dining system upon returning to the facility; Therefore those residents were not being provided a meal because their meals tickets weren't printed. S5 DM stated she had not notified the Administrator of the issues of not receiving the departmental communication form once residents return back to facility.

Based on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs for 1 (#R2) of 9 sampled residents. The facility failed to ensure Resident #R2 had an appropriate call light within reach to call for assistance.Findings:Review of Resident #R2's medical record revealed an admission to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Quadriplegia, Body Mass Index 19/9 or less, Adult, Depression, and Pressure Ulcer to Sacral Region, Stage 4. Review of Resident #R2's admission MDS with ARD of 01/06/2026 revealed a BIMS score of 13, indicating intact cognition. Resident #R2 has impairment on both the left and right side and requires assistance with all ADL's. An observation on 02/19/2026 at 11:35 a.m. Resident #R2 is observed lying in bed. The call bell is observed situated between the bed and side rail, out of reach to resident. Resident #R2 stated that he is unable to utilize the call bell system, and at times has to ask his roommate to call for help. An interview on 02/19/2026 at 11:23 a.m. with Resident #R2's Hospice Registered Nurse stated visited with Resident #R2 today and the call bell was within reach, but she does not think he can use it. An observation on 02/23/2026 at 8:50 a.m., Resident #R2 observed lying in bed with the call bell on the 2 drawer dresser out of reach of the resident. Resident #R2 stated that he would not have been able to call for help over the weekend if he would have needed to. An interview on 02/24/2026 at 11:45 a.m., S5 Admin confirmed that the call bell was not within reach of the resident at this time. Resident #R2 notified S5 Admin that he has difficulty due to his mobility issues and is unable to utilize the current call bell system device if it is not appropriately placed at all times. S5 Admin stated that she will make other accommodations so that he can utilize the call bell system.

Based on observations, interviews, and record reviews, the facility failed to implement, monitor, and modify interventions, consistent with the resident's assessed needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for 2 (Resident #3, and Resident #36) of 3 (Resident #3, Resident #14, and Resident #36) residents sampled for nutrition. The facility failed to ensure: 1. Meal intake was recorded for every meal for Resident #3 as care planned; 2. Resident #3 was assisted with all meals as care planned; 3. The MD/NP was notified when Resident #3 refused to eat, as care planned; 4. The MD/NP was notified of a severe weight loss for Resident #3; and 5. Failing to ensure a resident was provided a meal tray during lunchtime. This deficient practice resulted in an actual harm for Resident #3 on 03/05/2025 at 11:35 a.m., when S12 RD identified that Resident #3 had experienced a 7.7% severe weight loss that occurred from 12/04/2025 through 03/03/2025. Review of Resident #3's medical record revealed from 01/21/2025 through 03/03/2025, Resident #3 was not assisted with all meals, meal intake had not been recorded for every meal, and the MD/NP had not been notified when Resident #3 refused to eat and had exhibited severe weight loss. Findings: Review of an undated facility policy on 03/12/2025 at 11:15 a.m. titled, Meal Time Observation for Food Acceptance and Food Replacement revealed the following in part .Guideline: Residents will be observed during meal times to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy. Resident #3 Review of Resident #3's medical record revealed an admitted [DATE], with diagnoses that included, in part .Dementia and Alzheimer's disease. Review of Resident #3's Quarterly MDS with ARD of 12/19/2024 revealed a BIMS score of 99, indicating Resident #3 was unable to complete the interview. Resident #3 required partial to moderate assistance with eating. Review of an untitled form for Resident #3 dated 03/12/2025 revealed, in part: Eating/Nutrition: Assist resident with feeding at all meals Assist x1 staff for eating Provide and serve diet as ordered Set up assist and feed assist with all meals Review of Resident #3's weight records revealed on 12/04/2024, the resident weighed 141.0 lbs. On 03/03/2025, the resident weighed 130.2 pounds, a 7.7 % weight loss over the previous 3 months. Review of Resident #3's Care Plan revealed the resident had a nutritional problem or a potential nutritional problem related to Anorexia and Alzheimer's disease, with a problem onset date of 01/21/2025. The goal revealed the resident will maintain weight and consume at least 75% of most meals daily through review date. Interventions included, in part .monitor, document, and report if resident refuses to eat; feed resident all meals; and record intake every meal. Review of Resident #3's EHR revealed the CNA Plan of Care Response History for the following tasks from 12/04/2025 through 03/12/2025: ADL - Eating: 1. Resident #3's meal intake was not recorded on 12/18/2024, 12/20/2024, 12/23/20254, 12/25/2024, 12/27/2024, 12/28/2024, 01/01/2025, 01/06/2025, 01/12/205, 01/13/2025, 01/21/2025 - 01/30/2025, 02/03/2025 - 02/09/2025, 02/12/2025 - 02/15/2025, 02/17/2025, 02/19/2025, 02/20/2025, 02/23/2025, 02/26/2025, 02/27/2025, 03/01/2025, 03/03/2025, 03/04/2025, 03/07/2025, 03/08/2025, 03/09/2025 and 03/12/2025, as indicated on the plan of care. 2. Resident #3 refused 1 of 3 meals on 01/14/2025, and 1 of 3 meals on 01/17/2025. There was no documentation that Resident #3's meal refusals were reported as indicated on the care plan. 3. Resident #3 was documented as independent - no help or staff oversight at any time for 80 meals. Nutrition - Amount Eaten dated 12/04/2024 through 03/12/2025 revealed intake had not been recorded for 58% of meals served. She refused to eat 1 meal on 01/14/2025 and 1 meal on 01/17/2025. Review of Resident #3's RD Nutrition Assessment noted by S12 RD on 03/05/2025 revealed, in part . resident has had a decline. Gradual weight loss over the last 180 days with significant weight loss of 7.7% over the past 90 days. No new recommendations. Review of Resident #3's medical record revealed no documentation of MD or NP notification of meal refusal on 01/14/2025 or 01/17/2025. Review of Resident #3's medical record revealed no documentation of MD or NP notification of the 7.7% severe weight loss. Interview with S7 LPN on 03/11/2025 at 2:58 p.m. revealed she did not check Resident #3's medical record to monitor daily meal intake. She stated the CNA would notify her verbally if the resident had not eaten well, but had not received any such notification. Interview with S14 CNA on 03/12/2025 at 12:38 p.m. revealed she did not document Resident #3's meal intake in the medical record or report it to the nurse. She stated if Resident #3 consumed 5-25% of the meal, she wrote that information on the resident's meal ticket, placed the ticket on the tray, and returned the tray to the dietary department for review. S14 CNA stated she had worked in the facility for [AGE] years and this had always been the process for documenting meal intake. Interview with S15 Dietary Staff member on 03/12/2025 at 12:44 p.m., revealed she discarded meal tickets that were returned with resident meal trays. She stated dietary staff were not responsible for documenting or recording meal intake for residents. She stated she did not collect any information from the ticket, or monitor/record intake of the meal. Interview with S2 DON on 03/12/25 at 2:44 p.m. revealed the CNA was to notify the nurse if a resident consumed 50% or less of any meal. She stated the amount consumed was to be documented in the EHR after each meal, but that is something we are working on. S2 DON stated she was aware the CNAs had not been documenting meal intake. S2 DON stated the Registered Dietician (RD) reviewed the resident's weights, entered them into the electronic medical record, and gave the facility a list of her recommendations at each visit. S2 DON stated nursing staff, typically S2 DON or S6 Unit Manager, would notify the MD/NP of the RD's recommendations and of any weight loss identified. Interview with S12 RD on 03/12/2025 at 3:40 p.m. revealed the resident's weights and her recommendations were given to the nursing staff at each visit. The information was stored in a binder in S2 DON's office. S12 RD stated the resident's meal intake was not always documented in the electronic medical records, and the information was not reliable. Interview with S2 DON on 03/12/2025 at 4:23 p.m. confirmed Resident #3's meal intake had not been documented as ordered, but should have been. S2 DON confirmed the MD/NP were not notified of Resident #3's severe weight loss on 03/05/2025, but should have been. S2 DON could not explain why MD/NP had not been notified of Resident #3's severe weight loss. On 03/12/2025 at 4:34 p.m. S2 DON stated she had notified S13 NP of Resident #3's severe weight loss, and S13 NP would be entering orders. Telephone interview with S13 NP on 03/14/2025 at 11:25 a.m. confirmed she had not been notified of Resident #3's severe weight loss until 03/12/2025. She stated she ordered an appetite stimulant, and would have ordered the appetite stimulant on 03/05/2025 had she been notified of the severe weight loss. S13 NP confirmed there had been a delay in treatment for Resident #3's significant weight loss. S13 NP confirmed the appetite stimulant would have decreased, or even stopped, Resident #3's weight loss. 51503 Resident #36 Review of an undated facility policy on 03/12/2025 at 11:15 a.m. titled, Meal Time Observation for Food Acceptance and Food Replacement revealed the following in part .Guideline: Residents will be observed during meal times to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy. Review of Resident #36's medical record revealed an admitted [DATE] and diagnoses included in part .Type 2 Diabetes Mellitus with Diabetic Mononeuropathy, Morbid Severe Obesity due to Excess Calories, Major Depressive Disorder, Single Episode, Anxiety Disorder, Neuromuscular Dysfunction of Bladder, and Essential Primary Hypertension. Review of Resident #36's Quarterly and State Optional MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/23/2025 revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. The resident was independent with eating. Review of Resident #36's care plan with an initial date of 11/12/2024 revealed the following in part .Focus: the resident has an ADL self-care performance deficit related to activity intolerance. Interventions: Eating-the resident is able to feed self with tray set up. Diet is pureed texture with nectar thickened consistency. Focus: the resident has a nutritional problem or potential for a nutritional problem related to dietary restriction, Diabetes Type II, swallowing issues, and dysphagia. Interventions: provide and serve diet as ordered. On 03/10/2025 at 12:13 p.m., Resident #36 was observed sitting in his wheelchair in the day area at a table alone. Resident #36 stated he had not received his lunch tray and he was hungry. Observation on 03/10/2025 at 12:18 p.m., revealed lunch carts being pushed out the kitchen for meal service and staff members serving lunch in the day area. Observed other residents eating in the day area and Resident #36 seated at a table alone in the day area with no lunch tray. Observation on 03/10/2025 at 12:21 p.m., revealed S5 CNA perform meal services which included handing out lunch trays and assisting residents with opening their beverages. Observed S5 CNA push her lunch cart out of the day area. Observed Resident #36 still seated at the table in the day area with no lunch tray. In an interview on 03/10/2025 at 12:28 p.m., S5 CNA revealed she had completed meal services in the day area. S5 CNA stated her lunch cart did not have Resident #36's lunch tray that his lunch tray was on the other lunch cart. In an interview on 03/10/2025 at 12:37 p.m., S4 CNA stated she was assigned to Resident #36 today and responsible for his meal services. S4 CNA stated she had asked Resident #36 if he was eating lunch and he refused and she did not offer an alternate meal. S4 CNA stated she put his original lunch tray in his room. S4 CNA confirmed she had thrown Resident #36's lunch tray in the garbage. In an interview on 03/10/2025 at 12:38 p.m., Resident #36 stated he did not refuse his lunch meal and he was hungry. Surveyor observed Resident #36 still seated in the day area at a table alone with no lunch tray. In an interview on 03/10/2025 at 12:44 p.m., Resident #36 stated that he normally eats in the day area with the other residents. Resident #36 confirmed he was not offered his lunch tray earlier and he did not refuse his lunch tray. In an interview on 03/10/2025 at 1:40 p.m., S10 LPN revealed she was assigned Resident #36 today and often cared for him. S10 LPN stated Resident #36 does not refuse his meals and has a good appetite. S10 LPN confirmed that Resident #36 should have been served his lunch tray in the day area with the other residents and S4 CNA should not have put his lunch tray in his room. S10 LPN confirmed that if Resident #36 did refuse his lunch tray, S4 CNA should have been offered his meal again or offered an alternate meal. In an interview on 03/10/2025 at 2:06 p.m., S2 DON confirmed that S4 CNA should have offered Resident #36 his lunch tray in the day area with the other residents and should not have left his lunch tray in the room.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and residents' person centered care plans for 6 (#3, #4, #5, #9, #10 and #12) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) sampled Residents. The facility failed to have a system in place to: 1. Notify the physician of a low critical Hemoglobin level for Resident #5 and failed to document bleeding monitoring for Resident #5 and Resident #12; 2. Obtain ordered weekly PT/INR levels for 2 (Resident #5 and Resident #12) of 2 residents receiving Coumadin, (an anticoagulant) therapy; 3. Ensure medications that included anticoagulant, analgesics, and antidiuretics were administered for Residents #5 and #9; 4. Obtain and/or monitor blood glucose levels as ordered for Resident #9; 5. Obtain and/or monitor blood pressure and pulses with medication administration for Resident #9; 6. Obtain routine laboratory draws as ordered for Residents #3 and #10; and 7. Ensure physician orders were followed regarding changing Resident #4's suprapubic catheter. This deficient practice resulted in an Immediate Jeopardy situation for Resident #5, who had a history of Coumadin toxicity and GI bleed, on 05/20/2024 when the facility failed to obtain an ordered PT/INR level and then failed to notify Resident #5's PCP of a critically low Hemoglobin of 7.5 g/dL and continued to administer Coumadin 7.5mg, an anticoagulant/ blood thinner, to Resident #5 on 05/22/2024, 05/24/2024, and 05/28/2024. Resident #5's PCP discovered the low critical laboratory results during a routine visit on 05/29/2024 and ordered STAT CBC and PT/INR. Resident #5 was subsequently transferred to the hospital on 05/29/2024 diagnosed with Coumadin Toxicity, received a blood transfusion and an injection of Vitamin K, and remained hospitalized through 06/01/2024. The deficient practice continued at a potential for more than minimal harm for any resident in the facility who required lab monitoring and notification of changes to their PCP. S1 Administrator was notified of the Immediate Jeopardy situation on 10/24/2024 at 3:36 p.m. Findings: Review of Facility's policy, dated 11/2017, reviewed on 10/08/2024, titled Laboratory Tests read in part . Lab tests are completed as ordered by the physician or physician extender. PT/INR: Initially completed weekly for residents receiving warfarin. If stable and long term may complete monthly. Review of the facility's policy titled Notification of a Change in a Resident's Status, dated 11/2017, revealed in part . The attending physician/physician extender and the resident's representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Guideline for notification of physician/responsible party . f. Abnormal lab findings. Resident #5 Resident #5 admitted to the facility on [DATE] with diagnoses that included: Presence of Prostatic Heart Valve, Chronic Atrial Fibrillation, Cerebrovascular Disease, Persistent Mood Disorder, Liver Disease, Chronic Kidney Disease, COPD, Heart Failure, End Stage Renal Disease, and Dependence of Renal Dialysis. Review of Resident #5's 05/2024 Physician orders revealed an order to obtain PT/INR every Monday dated Friday, 05/17/2024. Review also revealed an order, dated 05/20/2024, to administer Coumadin 7.5mg every other day. There was no order for bleeding monitoring or bleeding monitoring completed for 05/2024 and 06/2024. Review of Resident #5's clinical record revealed there was no evidence a PT/INR had been drawn on Monday, 05/20/2024. Review revealed Resident #5 had a CBC drawn on 05/22/2024 with resulted low critical Hemoglobin of 7.5 which was reported by the laboratory to S6LPN at 2:22 p.m. on 05/22/2024. Review of Resident #5's medical record revealed no documentation Resident #5's PCP had been notified of the low critical Hemoglobin on 05/22/2024 or that Resident #5's PT/INR had not been drawn on 05/20/2024. Review of Resident #5's 05/2024 EMAR revealed Resident #5 received doses of Coumadin 7.5mg on 05/22/2024, 05/24/2024, and 05/28/2024. Review of a progress note for Resident #5, dated 05/29/2024, by S3NP read in part During this evaluation resident told S3NP that she felt like she was bleeding and that she had blood in her stool and has had to have multiple transfusions in the past. She had a critical Hemoglobin on 5/22/2024 of 7.5. S3NP nor MD was notified. S3NP gave orders to obtain PT/INR weekly, however PT/INR has been cancelled in the computer. Stat orders for CBC, PT/INR and fecal occult blood. Results are as follows 05/29/2024 HGB 4.8, HCT 16.6, PT 84.5, and INR 11.02. Orders were given to send patient to ER stat. A review off Resident #5's hospital record revealed Resident #5 was hospitalized [DATE] through 06/01/2024 with a diagnosis of Coumadin toxicity, received Vitamin K, and required 1 unit of packed red blood cells to be transfused. In an interview on 10/08/2024 at 9:30 a.m., S6 LPN revealed that when she received a critical lab, she would notify the NP by call or fax. S6 LPN stated with a critical lab like Resident #5's hemoglobin of 7.5, she probably would have texted S3 NP to notify her of the critical lab, and put it in the folder for the NP to sign off on. S6 LPN stated she could not recall the critical lab from 05/22/24, but it was not uncommon for her (Resident #5) to have a critical lab, because Resident #5 had some issues with bleeding but denied observing blood in her stool. S6 LPN stated she couldn't remember receiving the critical lab value from the lab on 05/22/2024. In a telephone interview on 10/08/2024 at 9:41 a.m., S3 NP stated her standard practice was for all PT/INRs to be drawn weekly on Monday, and Resident #5's PT/INR should have been drawn on Monday, no matter what was going on. S3 NP stated she was not notified of the critical lab on the day the labs were drawn (05/22/2024), and discovered the lab on 05/29/2024. During an interview on 10/09/2024 at 11:45 a.m., S2 DON and S4 Unit Manager revealed they were unsure why Resident #5's PT/INR wasn't drawn on 05/20/2024 but believed the requisition was not put in place after Resident #5 returned from the hospital on 05/16/2024. Review of Resident #5's 02/2024 EMAR revealed Coumadin 5mg dose was not documented as given on 02/03/2024. Review of Resident #5's EMAR/ETAR revealed monitoring for bleeding was not being done for 05/2024 and 06/2024 Review of Resident #5's 05/2024 EMAR revealed Coumadin 7.5mg dose was not documented as given on 05/26/2024. In an interview on 10/09/2024 at 10:14 a.m., S2 DON revealed the facility received Resident #5's critical H&H lab results on 05/22/2024, and failed to notify the MD or NP of the results, but should have. S2 DON stated the facility failed to ensure Resident #5's ordered PT/INR lab work was completed on 05/20/2024, 05/27/2024 and 06/03/2024, should have been followed up on and ensured that they were completed. S2 DON acknowledged Resident #5 was not being monitored for bleeding/bruising while on Coumadin therapy, but should have been. During an interview on 10/24/2024 at 9:15 a.m., S1 Administrator revealed the issue with the labs not being done and the PCP not being notified of critical labs for Resident #5 was not discovered until it was brought to her attention by the surveyors on 10/08/2024 as she, S2 DON and S4 Unit manager were not working at the facility in 05/2024. In an interview on 10/24/2024 at 11:48 a.m. with S8 Clinical Operations Nurse revealed after reviewing the Resident #5's 02/2024 and 05/2024 EMAR the 02/03/2024 and 05/26/2024 dose of prescribed Coumadin was missed and she believe agency staff worked the shifts and there is no documentation in nurses notes as to why the Coumadin wasn't given. Resident #12 Review of Resident #12's medical record revealed an admitted [DATE], with diagnoses that included in part .Aortic Valve Replacement, Cerebral Infarction due to Thrombosis, and Schizoaffective Disorder - Bipolar type. Review of Resident #12's current physician orders revealed the following, in part . 01/18/2024: Warfarin Sodium (Coumadin) 4mg, Give 2 tabs (8mg) by mouth every evening; and 11/03/2021: PT/INR every Monday. Review of Resident #12's Annual MDS with an ARD of 08/08/2024, revealed a BIMS score of 14, which indicated intact cognition. Review of the MDS revealed the resident required set up or clean up assistance with eating, and resident was independent with rolling left and right, lying to sitting on bed side, sitting to standing, and chair/bed to chair transferring. Review of Resident #12's Care Plan with a target date of 11/08/2024 revealed a problem of At risk for abnormal bleeding related to use of anticoagulant medications - related to presence of artificial heart valve, with a target date of 11/08/2024. Interventions included: administer medications as ordered, obtain lab work as ordered, and notify physician of results when available, nurse to monitor for active bleeding and bruising .if noted, notify MD, monitor for signs and symptoms of bleeding IE: bruising, black tarry stools, bright red vomit, coffee ground brown vomit, and red/pink/tea colored urine. Coumadin 8mg by mouth every evening. Review of Resident #12's 09/2024 EMAR revealed Resident #12 received 8mg of Coumadin every evening at 4:00 p.m. Review of the 09/2024 MAR revealed nurses were to monitor for active bleeding and bruising every shift, and notify MD if noted, due to Resident #12 on daily Coumadin therapy. The 09/2024 MAR revealed monitoring for active bleeding, was not documented on the 6:00 a.m. - 6:00 p.m. shift on 09/15/2024 and 09/19/2024 or on the 6:00 p.m. - 6:00 a.m. shift on 09/24/2024 and 09/25/2024. Review of Resident #12's 10/2024 EMAR revealed Resident #12 received Coumadin daily, and monitoring for bleeding and bruising was not documented on the 6:00 a.m. - 6:00 p.m. shift on 10/03/2024. Interview with S1 Administrator on 10/08/2024 at 10:00 a.m., and review of Resident #12's medical record revealed Resident #12's PT/INR was last obtained on Tuesday, 09/03/2024, although it was ordered to be checked every Monday. Review of a Progress Note for Resident #12 dated 09/23/2024, by S3 NP, revealed in part . History of present illness: He continues to refuse PT/INR due to him not liking the phlebotomist. Education provided on the importance of this lab .contacted unit managers for further assistance. In a telephone interview on 10/08/2024 at 10:30 a.m., S3 NP stated a PT/INR was supposed to be drawn every week for Resident #12. S3 NP stated after about two weeks of refusals, she went to talk to the resident, who told her he didn't like the phlebotomist, and refused to let her (the phlebotomist) draw it. S3 NP stated the resident agreed to let staff draw it. S3 NP reported she then talked to staff and asked them to draw it, and they agreed, but stated she hasn't received any results yet. In a telephone interview on 10/08/2024 at 11:05 a.m., S4 Unit Manager stated she couldn't recall if, or when she and S3 NP discussed staff drawing Resident #12's lab. S4 Unit Manager said she did recall having a conversation with S3 NP about Resident #12 refusing lab draws, but couldn't remember when it was. S4 Unit Manager stated she called the lab and asked them if they could send a different phlebotomist, and was told they could try. S4 Unit Manager stated she couldn't remember if she had followed up to see if Resident #12's blood was drawn, and didn't know if it had been. In a telephone interview on 10/08/2024 at 12:20 p.m., the Supervisor at the lab confirmed Resident #12 had refused to have his lab work drawn on 10/07/2024, 09/30/2024, 09/24/2024, 09/23/2024, 09/18/2024, and 09/17/2024 and said it was reported to S5 LPN. The lab Supervisor stated she did not see any documentation of anyone from the facility calling to request a different phlebotomist for Resident #12, but said they could change the time for his lab draw, and it would be a different phlebotomist. In a telephone interview on 10/08/2024 at 12:24 p.m., S5 LPN revealed she worked from 6:00 p.m. to 6:00 a.m. shift, and confirmed Resident #12 refused to let the lab draw his blood. S5 LPN stated Resident #12 doesn't want to be woken up in the middle of the night. S5 LPN stated she knew S4 Unit Manager was aware; however, no one had ever asked her to draw it. In an interview on 10/09/2024 at 1:00 p.m., S2 DON confirmed Resident #12 had not had a PT/INR level drawn since 09/03/2024, and stated no staff had attempted to draw it because they weren't aware they needed to draw it until yesterday. S2 DON stated she was unaware S3 NP had asked anyone in the facility to draw the resident's blood. S2 DON confirmed Resident #12 had orders to receive Coumadin 8 mg daily, and an order to have his PT/INR drawn weekly. S2 DON acknowledged the facility had continued to give Resident #12 Coumadin every day, although they were aware his lab had not been drawn in over a month. S2 DON acknowledged there was no documentation of Resident #12 being monitored consistently on each shift for bleeding or bruising. Resident #9 Review of Resident #9's medical record revealed an admitted [DATE] with diagnoses that included: Hemiplegia, Cerebral Infarction, Type 2 DM, Bladder Disorder, and Nocturia. Review of Resident #9's current physicians' orders revealed the following: 09/12/2023: Novolog 100 unit/ml vial bid- 60-199=0 units 200-250=2 units 251-300=4 units 301-350=6 units 351-400=9 units 401-give 12 units, recheck in 15 minutes, if still greater than 400, call me. 08/28/2024: Lidocaine 4% patch-apply one patch at HS and note remove in am 09/18/2024: Desmopressin Acetate 0.2mg PO at bedtime Review of Resident #9's 09/2024 EMAR revealed the following: Resident #9 did not receive his Lidocaine 4% patch on 09/05/2024. Resident #9 did not receive his Desmopressin Acetate 0.2mg by mouth on 09/25/2024 and 09/26/2024. Resident #9's accucheck/blood glucose levels were not documented 13 times in 09/2024, as ordered. Resident #9's blood pressure and pulse were not documented bid with blood pressure medication administration on 34 occasions during the month. In an interview on 10/09/2024 at 10:25 a.m., S2 DON acknowledged Resident #9's 09/2024 EMAR had missed documentation of vital signs, blood glucose levels, a Lidocaine patch application, and two doses of Desmopressin, as ordered, and shouldn't have. Resident #10 Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses that included in part .Type 2 DM, Chronic Kidney Disease, and End Stage Renal Disease. Review of the current physician's orders revealed the following orders: 05/20/2024: Vitamin D3 1000 unit tablet every day 09/19/2024: Vitamin D level on 9/20/2024. Review of Resident #10's medical record revealed no documented evidence of a Vitamin D level being drawn on 09/20/2024. In an interview on 10/09/2024 at 1:14 p.m., S2 DON and S3 Unit Manager confirmed the Vitamin D level for Resident #10 was not drawn on 09/20/2024, as ordered, but should have been. S2 DON and S3 Unit Manager both stated they didn't know why it was not drawn, as ordered. Resident #3 Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses that included: Anoxic brain damage, Cerebral Infarction, Type 2 DM, Neuromuscular dysfunction of bladder, Persistent Atrial fibrillation, and Schizoaffective disorder. Review of Resident #3's Physician's orders revealed the following: 06/07/2024: CBC, CMP, TSH, Mag (Magnesium) level every 6 months (Jan/July) Review of Resident #3's medical record revealed no magnesium level was completed as ordered. In an interview on 10/09/2024 at 11:19 a.m., S2 DON revealed the magnesium level for Resident #3 was not drawn in July 2024 as ordered by the physician, but should have been. In an interview on 10/09/2024 at 1:16 p.m., S2 DON and S4 Unit Manager revealed that they did not know why the magnesium lab was cancelled for 07/2024. Resident #4 Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses that included Multiple Sclerosis, Neuromuscular Dysfunction, Schizophrenia, Major Depressive Disorder, Specified Anxiety Disorder, Type 2 DM, and Pressure ulcer to left heel. Review of Resident #4's Physician Orders revealed the following: 06/28/2024 Irrigate suprapubic catheter with 60 ml sterile water as needed 06/26/2024 May change Suprapubic catheter if needed 05/20/2024 Suprapubic catheter care with soap and water every shift Review of Resident #4's Care plan, with a review date of 11/20/2024, revealed Alteration in Elimination related to resident has suprapubic catheter. An intervention included on 08/12/2024 to change Suprapubic catheter every 2 weeks and PRN. Urology to follow up. Review of Resident #4's medical records revealed a physician order dated 08/12/2024 to change resident's suprapubic catheter every two weeks and prn. Review of Resident #4's medical records revealed documentation that Resident #4's suprapubic catheter had not been changed on 08/12/2024, 09/09/2024 or 09/23/2024, as scheduled. S2 DON confirmed the suprapubic catheter had not been changed as ordered, but should have been. The Immediate Jeopardy was removed on 10/25/2024 at 10:47 a.m., when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews, and observations that the Plan of Removal had been initiated and/or implemented. Corrective action 1. On 10/09/2024 at 5:00 p.m., an in-service was initiated for licensed nurses on ensuring critical labs are immediately communicated to the MD/NP for proper treatment and that ordered labs are obtained; in-servicing completed 10/12/2024. 2. On 10/17/2024 Clinical Operation Consultants initiated 100% audit of all labs from 09/2024 and 10/17/2024 to ensure compliance with lab orders. Any concerns were immediately addressed. Continue to monitor daily x4 weeks. 3. On 10/21/2024, Clinical Operations Consultant completed 100% lab verification with Nurse Practitioner to ensure facility had correct lab ordered. 4. On 10/08/2024, Clinical Operations Consultant started lab audit to ensure any critical labs were communicated to MD/NP as warranted as well to ensure ordered labs obtained. This continues as an ongoing audit with lab orders/routine labs follow up with Nurse Practitioner. 5. Executive Director, Director of Nurses and Clinical Operations Nurse's employment was separated 05/24/2024 prior to facility gaining knowledge of alleged deficient practice. 6. On 10/09/2024, Charge Nurse received corrective counseling by Executive Director regarding not communicating critical labs to the physician/nurse practitioner. 7. On 10/24/2024, Staff Development Coordinator initiated educational in-servicing of all nurses regarding following physician orders. All agency nurses to be trained prior to next shift 8. Daily morning meetings with interim Director of Nurses and Unit Manager initiated 10/24/2024 where all physician orders from the day before are reviewed to ensure all properly followed up on. 9. On 10/24/2024 reviewed general medication administration policy and initiated in-servicing of all nurses regarding administering ordered medication. All agency nurses and staff nurses to be trainer prior to next shift. 10. On 10/24/2024 reviewed insulin administration policy and initiated in-servicing of all nurses regarding properly documenting all blood sugar results. All agency nurses and staff nurses to be trained prior to next shift. 11. On 10/24/2024 reviewed lab policy and initiated in-servicing of all nurses regarding obtaining all ordered lab and notifying MD/NP of critical labs. All agency nurses and staff nurses to be trained prior to next shift. 12. Clinical Operations Nurse or designee will monitor morning meeting with Director of Nurses and Unit Manager to ensure all orders are properly completed and followed up on five days a week x 4 weeks. 13. The facility asserts that their will be no further likelihood for any serious harm to any residents. The likelihood for serious harm to residents no longer exists. Facility Completion date: 10/25/2024.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 (#3, #5, #4, #9, #10 and #12) of 13 sampled residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13). The Facility failed to: 1. Ensure there was a system in place to monitor the completion of laboratory draws and timely communication of abnormal lab results to the provider; and 2. Follow and implement physician's orders for residents who required bleeding and glucose monitoring, routine labs, medication administration and catheterization. This deficient practice resulted in an Immediate Jeopardy situation for Resident #5, who had a history of Coumadin toxicity and GI (gastrointestinal) bleed, on 05/20/2024 when the facility failed to obtain an ordered PT/INR level, failed to notify #5's PCP (primary care physician) of a critically low Hemoglobin of 7.5 g/dL and continued to administer Coumadin 7.5mg, an anticoagulant/ blood thinner, to Resident #5 on 05/22/2024, 05/24/2024, and 05/28/2024. Resident #5's PCP noticed the low critical laboratory results during a routine visit on 05/29/2024 and ordered STAT CBC and PT/INR. Resident #5 was subsequently transferred to the hospital where she received a blood transfusion and injection of Vitamin K. The deficient practice continued at a potential for more than minimal harm for any resident in the facility who required lab monitoring and notification of changes to their PCP. S1 Administrator was notified of the Immediate Jeopardy on 10/24/2024 at 3:36 p.m. Findings: Cross Reference F684 Review of the facility's policy revised 11/2017 titled Laboratory Tests revealed in part . Lab tests are completed as ordered by the physician or physician extender . Responsibility: All Licensed Nursing Personnel monitored by Director of Nursing or Designee. 7. Any labs not obtained as indicated will be rescheduled by the Licensed Nurse. 9. The Licensed Nurse, or designee, will forward the lab results to the appropriate IDT nursing and dietary staff for review. The physician/physician extender will be promptly notified of abnormal results according to facility policy. Resident #5 In an interview on 10/09/2024 at 10:14 a.m., S2 DON revealed the facility received Resident #5's critically low Hemoglobin lab results on 05/22/2024 at 2:22 p.m., and failed to notify the MD or NP of the results, but should have. S2 DON confirmed the facility failed to ensure Resident #5's ordered PT/INR lab work was completed on 05/20/2024, 05/27/2024 and 06/03/2024, and should have been followed up on but was not. S2 DON acknowledged Resident #5 was not being monitored for bleeding/bruising while on Coumadin therapy, but should have been. In an interview on 10/24/2024 at 9:15 a.m., S1 Administrator acknowledged the facility's multiple quality of care issues being cited. S1 Administrator reported the facility has had a high turnover rate in administrative leadership positions, such as the Administrator, DON, and Clinical Operations Nurse positions, which may have attributed to many of these care issues. An interview on 10/24/2024 at 11:48 a.m. with S8 Clinical Operations Nurse revealed after reviewing Resident #5's 02/2024 and 05/2024 EMAR, the 02/03/2024 and 05/26/2024 dose of prescribed Coumadin was missed. S8 Clinical Operations Nurse believed agency staff worked the shifts and there was no documentation in nurses' notes as to why the Coumadin wasn't given. Resident #12 In an interview on 10/09/2024 at 1:00 p.m., S2 DON confirmed Resident #12 had not had a PT/INR level drawn since 09/03/2024, and stated no staff had attempted to draw it because they weren't aware they needed to draw it until yesterday. S2 DON stated she was unaware S3 NP had asked anyone in the facility to draw the resident's blood. S2 DON confirmed Resident #12 had orders to receive Coumadin 8 mg daily, and an order to have his PT/INR drawn weekly. S2 DON acknowledged the facility had continued to give Resident #12 Coumadin every day, although they were aware his lab had not been drawn in over a month. S2 DON acknowledged there was no documentation of Resident #12 being monitored consistently on each shift for bleeding or bruising. Resident #9 In an interview on 10/09/2024 at 10:25 a.m., S2 DON acknowledged Resident #9's 09/2024 EMAR had missed documentation of vital signs, blood glucose levels, a Lidocaine patch application, and two doses of Desmopressin, as ordered, and shouldn't have. Resident #10 In an interview on 10/09/2024 at 1:14 p.m., S2 DON and S3 Unit Manager confirmed the Vitamin D level for Resident #10 was not drawn on 09/20/2024, as ordered, but should have been. S2 DON and S3 Unit Manager both stated they didn't know why it was not drawn, as ordered. Resident #3 In an interview on 10/09/2024 at 11:19 a.m., S2 DON revealed the magnesium level for Resident #3 was not drawn in 07/2024 as ordered by the physician, but should have been. In an interview on 10/09/2024 1:16 p.m., S2 DON and S4 Unit Manager revealed that they did not know why the magnesium lab was cancelled for 07/2024. Resident #4 Review of Resident #4's medical records revealed a physician order dated 08/12/2024 to change resident's suprapubic catheter every two weeks and prn. Review of Resident #4's medical records revealed documentation that Resident #4's suprapubic catheter had not been changed on 08/12/2024, 09/09/2024 or 09/23/2024, as scheduled. S2 DON confirmed the suprapubic catheter had not been changed as ordered, but should have been. The Immediate Jeopardy was removed on 10/25/2024 at 10:47 a.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews, and observations that the Plan of Removal had been initiated and/or implemented. Corrective action l. On 10/09/2024 at 5:00 p.m., an in-service was initiated for licensed nurses on ensuring critical labs are immediately communicated to the MD/NP for proper treatment and that ordered labs are obtained: in-servicing completed 10/12/2024. 2. On 10/17/2024 Clinical Operation Consultants initiated 100% audit of all labs from 09/2024 and 10/17/2024 to ensure compliance with lab orders. Any concerns were immediately addressed. Continue to monitor daily x4 weeks. 3. On 10/21/2024, Clinical Operations Consultant completed 100% lab verification with Nurse Practitioner to ensure facility had correct lab ordered. 4. On 10/08/2024, Clinical Operations Consultant started lab audit to ensure any critical labs were communicated to MD/NP as warranted as well to ensure ordered labs obtained. This continues as an ongoing audit with lab orders/routine labs follow up with Nurse Practitioner. 5. Executive Director, Director of Nurses and Clinical Operations Nurse's employment was separated 05/24/2024 prior to facility gaining knowledge of alleged deficient practice. 6. On 10/09/2024, Charge Nurse received corrective counseling by Executive Director regarding not communicating critical labs to the physician/nurse practitioner. 7. On 10/24/2024, Staff Development Coordinator initiated educational in-servicing of all nurses regarding following physician orders. All agency nurses and staff nurses to be trained prior to next shift. 8. Daily morning meetings with interim Director of Nurses and Unit Manager initiated 10/24/2024 where all physician orders from the day before are reviewed to ensure all properly followed up. 9. On 10/24/2024 reviewed general medication administration policy and initiated in-servicing of all nurses regarding administering ordered medication. All agency nurses and staff nurses to be trained prior to next shift. 10. On 10/24/2024 reviewed insulin administration policy and initiated in-servicing of all nurses regarding properly documenting all blood sugar results. All agency nurses and staff nurses to be trained prior to next shift. 11. On 10/24/2024 reviewed lab policy and initiated in-servicing of all nurses regarding obtaining all ordered lab and notifying MD/NP of critical labs. All agency nurses and staff nurses to be trained prior to next shift. 12. Clinical Operations Nurse or designee will monitor morning meeting with Director of Nurses and Unit Manager to ensure all orders are properly five days a week x 4 weeks. 13. Executive Director and Director of Nurses in-serviced on 10/24/2024 by [NAME] President regarding ensuring the facility is administered in a manner that uses resources to effectively and efficiently meets the needs of the residents by ensuring there is a system in place to monitor the completion of laboratory draws and timely communication of abnormal lab results to the provider. 14. [NAME] President of Operations to monitor Executive Director and Director of Nursing weekly x 4 weeks to ensure compliance of corrective action. 15. The facility asserts that there will be no further likelihood for any serious harm to any resident. The likelihood for serious harm to residents no longer exists. Facility Completion date: 10/25/2024.

Based on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The Administration failed to have an effective system in place to ensure Resident #1, who was assessed as being at risk for elopement, was adequately supervised to prevent him from exiting the front door of the facility unattended. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 05/13/2024 at 11:30 a.m., when Resident #1, (a moderately cognitively impaired resident who was identified as an elopement risk), asked S5 Agency Nurse to unlock the facility's front door so he could go see his wife, while holding a clear trash bag containing clothing items. S5 Agency Nurse did not notify any other staff of Resident #1's exit seeking behavior. Resident #1, who was last seen at the nurses' station by S3 LPN Unit Manager at 12:45 p.m., and was found at 1:00 p.m., 0.4 miles away, down a busy four-lane roadway, by staff from Resident #1's IOP (Intensive Outpatient Program). The IOP staff notified S4 LPN SDC and S2 DON of Resident #1's whereabouts, and S4 LPN SDC drove to Resident #1's location to assist the IOP staff with returning Resident #1 back to the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 05/23/2024 at 5:25 p.m. The Immediate Jeopardy was removed on 05/24/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The likelihood of elopement exists for all newly admitted residents with a history of wandering/elopement due to failure to retrain all facility staff. Findings: Cross Refer to F689 Review of a facility policy titled Missing Resident/Elopements, and dated 05/2022, revealed in part . Policy: The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participants. Procedure: l. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Interview on 05/22/2024 at 12:19 p.m. with S2 DON revealed she received a telephone call at approximately 1:00 p.m., from an IOP Program employee, informing her Resident #1 was at a business down the busy four-lane roadway. Interview on 05/22/2024 at 3:58 p.m. with S1 ADM revealed a resident's family was moving her belongings out of the facility on 05/13/2024, around the time that Resident #1 eloped from the facility. S1 ADM reported she assumed staff opened the door to let the family members in and out. S1 ADM stated the staff must have left the open door unattended in order for Resident #1 to have been able to leave the facility without being seen by staff. S1 ADM stated staff were at the nurses' station and corridor, it would have only taken a split second, and with a lot going on in a little space, no one noticed Resident #1 leave. S1 ADM stated they determined Resident #1 only required every one hour monitoring for elopement, and did not require a higher level of supervision, through nursing staff assessment, speaking with his wife, and watching him get acclimated to the facility. Interview on 05/23/2024 at 2:31 p.m. with S1 ADM confirmed supervision should have been increased at 11:30 a.m. on 05/13/2024, when Resident #1 asked S5 Agency Nurse to unlock the front door to leave to go see his wife. S1 ADM reported staff know what residents are at risk for elopement by an elopement binder that is maintained at the nurses' station. S1 ADM confirmed Resident #1 was at risk for elopement at the time of the incident on 05/13/2024 when he eloped, but he was not placed in the elopement binder until after he eloped from the facility. S1 SDM stated the off going nurse should in-service oncoming agency nurses on who is at risk for elopement. Interview on 05/23/2024 at 4:48 p.m. with S1 ADM revealed the facility did not have a policy on training all staff including agency staff on risk for elopement.

Based on interview and record review, the facility failed to ensure Resident #1, who had been assessed to be at risk for elopement, received adequate supervision to prevent him from exiting the facility without staff knowledge, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 05/13/2024 at 11:30 a.m., when Resident #1, (a moderately cognitively impaired resident who was identified as an elopement risk), asked S5 Agency Nurse to unlock the facility's front door so he could go see his wife, while holding a clear trash bag containing clothing items. S5 Agency nurse did not notify any other staff of Resident #1's exit seeking behavior. Resident #1, who was last seen at the nurses' station by S3 LPN Unit Manager at 12:45 p.m., was found at 1:00 p.m., 0.4 miles away from the facility, down a busy four-lane roadway, by staff from Resident #1's IOP (Intensive Outpatient Program). The IOP staff notified S4 LPN SDC and S2 DON of Resident #1's whereabouts. S4 LPN SDC drove to Resident #1's location to assist the IOP staff with returning Resident #1 back to the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 05/23/2024 at 5:25 p.m. The Immediate Jeopardy was removed on 05/24/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility had implemented an acceptable Plan of Removal (POR) prior to the survey exit. The likelihood of elopement exists for all newly admitted residents with a history of wandering/elopement due to failure to retrain all facility staff. Findings: Review of a facility policy titled Missing Resident/Elopements, and dated 05/2022, revealed in part . Policy: The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participants. Procedure: l. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Review of Resident #1's medical records from a local hospital revealed in part . admitted : 03/27/2024 Has been admitted to behavioral unit for worsening confusion. Apparently, he and his spouse live out in woods and he wandered off and had to be located by police. She brought him to primary care clinic where he was evaluated and sent here for further treatment. Reason for Admission: Neurocognitive Disorder with behavioral disturbances Review of Resident #1's clinical record revealed an admitted [DATE], with diagnoses that included: Major Depressive Disorder, Neurocognitive Disorder due to known physiological condition with Behavioral Disturbance, Unspecified Dementia, and Alzheimer's Disease. Review of Resident #1's Risk of Elopement Evaluation dated 04/15/2024, revealed he exhibited wandering behavior in the last 60 days, wandered aimlessly, ambulated independently, and was at risk for elopement with an intervention of door alarms. Review of Resident #1's Admission MDS with an ARD of 04/24/2024 revealed a BIMS score of 9, indicating moderate cognitive impairment. Review of Resident #1's care plan revealed a problem of at risk for elopement related to diagnoses of Dementia and Alzheimer's disease, and a history of wandering, with an onset date of 04/15/2024. Interventions included in part . alert staff to resident wandering/elopement behavior, provide reality orientation during routine care daily, monitor resident's whereabouts every 1 hour, and redirect when exhibit behaviors of elopement/wandering, such as going to doors, following staff to exit doors. Review of Resident #1's Admission/Readmission Evaluation dated 04/15/2024, revealed Resident #1 had a history of wandering, ambulated independently, and was at risk for elopement, with a care plan intervention of location monitoring. Review of Resident #1's Physician Progress note dated 04/29/2024 revealed in part . Seen today for admission visit . Recently hospitalized at a local Behavioral Hospital from 03/27/2024 through 04/15/2024. According to hospital paperwork, patient admitted due to worsening confusion. Patient was sent from walk-in clinic under PEC .He also wanders off at night and recently got lost in woods, law enforcement had to locate the patient .Attending IOP. Review of Resident #1's 05/2024 Flow Sheet revealed in part . -Start Date 04/18/2024 - Monitor resident location every hour. -05/13/2024 - S5 Agency Nurse initialed that Resident #1's location was monitored at 12:00 p.m. and 1:00 p.m. Interview on 05/21/2024 at 3:26 p.m. with S3 LPN Unit Manager, revealed she last saw Resident #1 on 05/13/2024 at 12:45 p.m. at the nurses' station. S3 LPN Unit Manager reported another resident was being discharged from the facility at that time, and the other resident's family was back and forth, and in and out the facility's front door moving her things out. S3 LPN Unit Manager reported the other resident's family might have thought Resident #1 was a visitor because he was very ambulatory. Interview on 05/21/2024 at 3:42 p.m. with S4 LPN SDC, revealed on 05/13/2024, an employee (did not remember the name of the employee) from Resident #1's IOP program called the facility around 1:00 p.m. to report that one of their drivers saw Resident #1 walking down a busy four-lane roadway. S4 LPN SDC stated she found Resident #1 on the busy four-lane roadway approximately 0.4 miles away, sitting on the side of a business with 3 employees (could not remember their names) from the IOP Program. S4 LPN SDC stated when she asked Resident #1 why he left the facility, Resident #1 told her he wanted to go home. S4 LPN SDC stated Resident #1 got on the IOP Program van to go back to the facility, and she followed them. S4 LPN/SDC stated they arrived at the facility together around 1:05 p.m. Interview on 05/22/2024 at 12:19 p.m. with S2 DON revealed she received a telephone call at approximately 1:00 p.m., from an IOP Program employee, informing her Resident #1 was at a business down the busy four-lane roadway. Interview on 05/22/2024 at 3:19 p.m. with S6 Transportation, revealed she last saw Resident #1 walking towards his room around 12:00 p.m. on 05/13/2024. S6 Transportation stated she told Resident #1 it was time for lunch, and to go up front. S6 Transportation reported Resident #1 had been confused lately, and she told S5 Agency Nurse to keep an eye on him because he could not leave the facility. S6 Transportation reported around 12:00 p.m., Resident #1 was observed walking around the front near the nurses' station, and S5 Agency Nurse redirected him towards the dining room. Interview on 05/22/2024 at 3:58 p.m. with S1 ADM revealed a resident's family was moving belongings out of the facility on 05/13/2024, around the time that Resident #1 eloped from the facility. S1 ADM reported she assumed staff opened the door to let family members in and out. S1 ADM stated staff were at the nurses' station and corridor, and the staff must have left the open door unattended in order for Resident #1 to have been able to leave the facility without being seen by staff. S1 ADM stated it would have only taken a split second, and with a lot going on in a little space, no one noticed Resident #1 leave. Interview on 05/23/2024 at 11:21 a.m. with S3 LPN Unit Manager, revealed she did not think to monitor Resident #1 when another resident's family was moving belongings and holding the door open, because she did not think Resident #1 was at risk for elopement at that time. S3 LPN Unit Manager stated he was not at risk for elopement until he came back. Telephone interview on 05/23/2024 at 11:52 a.m. with two IOP Program LPNs revealed they received a telephone call from their PRN van driver around 12:30 p.m., to report he had observed Resident #1 walking alone on a busy four-lane roadway. One LPN stated the van driver came to the office and she, along with a Senior Care Therapist, got into the van with the driver to go check on Resident #1, while the second LPN reported she called the facility to notify them. The first LPN stated it took them approximately 5 minutes from the van driver's telephone call to get to Resident #1, who was found standing by a business located on the busy four-lane roadway. The LPN stated Resident #1 was irritated, and said he did not want to go back to the nursing home because he wanted to go see his wife. The LPN stated Resident #1 was wearing a cowboy hat, jeans, and boots, and he was carrying an office sized trash bag with a few pieces of clothing in it. She stated S4 LPN SDC arrived about 5 minutes later and tried to get him to go with her in her vehicle; however, he refused. She stated Resident #1 finally agreed to go back, and got in their van and went back to the facility. Telephone interview on 05/23/2024 at 2:11 p.m. with S5 Agency Nurse revealed she was Resident #1's nurse on 05/13/2024 when he eloped from the facility. S5 Agency Nurse stated Resident #1 came to her at the nurses' station at around 11:30 a.m. asking her to unlock the front door so he could leave to see wife. S5 Agency Nurse stated Resident #1 was carrying a clear trash bag with clothes. S5 Agency Nurse reported S6 Transportation told her Resident #1 did that frequently, so she redirected him to the dining room. S5 Agency Nurse reported Resident #1 sat down at the table and when she asked if she could put his clothes up, he got agitated and said no to leave them with him. S5 Agency Nurse stated she left the bag with him and went back to the nurses' station. S5 Agency Nurse reported she was asked to go the dining room at 12:15 p.m. to go monitor a resident at risk for choking. S5 Agency Nurse stated she could not recall if Resident #1 was in the dining room at that time. S5 Agency Nurse reported that was the second shift she had worked at the facility, and she did not receive an official orientation to the facility. S5 Agency Nurse stated she was only oriented on where and what to chart. S5 Agency Nurse stated she was not told who was risk for elopement, and she was not aware Resident #1 was at risk for elopement, and he did not have a wander guard on. S5 Agency Nurse stated people are in and out of the front door and residents have the code. S5 Agency Nurse reported she was unsure of the last time she saw Resident #1 before he eloped from the facility. S5 Agency Nurse stated she did not feel Resident #1 needed increased supervision when he asked to leave while carrying a bag of clothes. She reported she did not notify the S3 Unit Manager, S2 DON or S1 ADM of Resident #1's behavior. S5 Agency Nurse reported she signed off on Resident #1's every hour location monitoring at 12:00 p.m. and 1:00 p.m., because she saw him at 11:30 a.m. and after 1:00 p.m. Interview on 05/23/2024 at 2:31 p.m. with S1 ADM confirmed supervision should have been increased at 11:30 a.m. on 05/13/2024, when Resident #1 asked S5 Agency Nurse to unlock the front door to leave to go see his wife. S1 ADM reported staff know what residents are at risk for elopement by an elopement binder that is maintained at the nurses' station. S1 ADM confirmed Resident #1 was at risk for elopement at the time of the incident on 05/13/2024, but he was not placed in the elopement binder until after he eloped from the facility. S1 SDM stated the off going nurse should in-service oncoming agency nurses on who is at risk for elopement. Interview on 05/23/2024 at 4:48 p.m. with S1 ADM revealed the facility did not have a policy on training all staff including agency staff on risk for elopement. Telephone interview on 05/24/2024 at 1:32 p.m. with another resident's grandson, revealed he and his fiancee went to the facility around lunchtime on 05/13/2024, to help his grandmother move out. He stated when they first arrived, a couple that looked like visitors entered the code to the front door, to let them into the facility, and they gave him the code. He reported when he went to go out, the code did not work, so he got staff to let him out. He stated when he was coming back in the front door of the facility from moving his truck, he saw a man wearing a cowboy hat, a button up shirt, a vest, jeans, and boots, go out the door as he was coming in. He reported there were no staff by the front door at that time. He stated he could not recall who opened the door for him to come in after moving his truck. He reported when they were wheeling his grandmother out of the facility, the man was back inside. He stated he did not know the timeframe between the man leaving the facility, and seeing him back inside.

Based on record review, observation, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans. The facility failed to ensure physician orders to obtain lab work was followed (#11, #16, #17, #43 and #59), failed to ensure medication was administered in a timely manner (#59), and failed to ensure medication was administered as ordered by the physician (#11), for 5 (#11, #16, #17, #43, and #59) of 24 sampled residents. This deficient practice resulted in an Actual Harm for Resident #17. On 12/27/2023, S10 NP ordered to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023. According to interview with S2 DON, S10 NP, and review of Resident #17's medical record, the orders were never carried out. On 01/02/2024 at approximately 12:50 p.m., Resident #17 was transferred to the emergency department of a local hospital for a temperature of 103.1, and audible wheezing. Resident #17 was diagnosed with UTI (Urinary Tract Infection), and was admitted to the hospital for treatment of the UTI on 01/02/2024 through 01/04/2024. Findings: Review of the facility's policy titled Laboratory Tests read in part . Lab tests are completed as ordered by the physician or physician extender. Licensed Nurse, or designee shall obtain the labs ordered by the physician or physician extender. The licensed nurse will complete all lab requisitions for all routine lab work needing to be done on the day they are due. This will be done using the information on the Lab Scheduling/Tracking form. The licensed nurse, or designee, will complete the appropriate Lab Requisition Form. This will be completed prior to each lab day, using the information on the Scheduling/Lab Tracking form. Any newly ordered labs needing immediate attention will be added to the Lab Scheduling/Tracking form on each unit. The lab will be obtained as ordered. Review of the facility's policy titled Medication Administration-General Guidelines revealed in part . 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 5. All current medications and dosage schedules are listed on the resident's medication administration record eMAR/eTAR and administered timely according to facility policy. Resident #17 Review of Resident #17's medical record revealed an admitted [DATE], with diagnoses that included in part . Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, Atherosclerotic Heart Disease, Diverticulitis, Osteoarthritis, Urinary Tract Infection, Epilepsy, and Chronic Obstructive Pulmonary Disorder. Review of Resident #17's Quarterly MDS with an ARD of 11/30/2023, revealed a BIMS score of 10 (Moderate Cognitive Impairment). Resident #17 had functional limitations due to impairment on one side. Resident #17 required Substantial/Maximal assistance with eating, oral hygiene, toileting, showering/bathing, dressing, and transfers. Resident #17 was always incontinent of bowel and bladder. Review of Resident #17's Care Plan with a target date of 02/22/2024, revealed she was at risk for infection related to history of UTI, and was incontinent of bowel and bladder. Interventions included in part . Provide peri-care after each incontinent episode, monitor for signs and symptoms of UTI and contact MD if noted, and toilet every 2 hours, and as needed. Review of Resident #17's Physicians Orders dated 12/27/2023, revealed an order was written to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023. Review of Resident #17's medical record including completed lab results revealed there was no documentation that the above order was implemented. Review of Resident #17's Departmental Note dated 01/02/2024 at 1:45 p.m. by S35 LPN revealed the following in part .During routine med pass, this nurse and S5 LPN noticed resident was hot to the touch, temp 103.1. Resident also had audible wheezing. Resident sent to the ER, and left the facility to ED at 12:50 p.m. Review of Resident #17's medical record revealed Resident #17 was sent out to theER on [DATE], and admitted with diagnoses of UTI, Dehydration, and Sepsis. Interview on 01/11/2024 at 9:32 a.m. with S10 NP revealed she did not receive lab or UA results from her 12/27/2023 order. S10 NP stated she had trouble with the facility carrying out orders. S10 NP stated she would have treated Resident #17 in-house with antibiotics if the labs and UA had been collected at the time she ordered. S10 NP stated this would have prevented Resident #17 from being admitted to the hospital on 01/02/2024 with a diagnosis of UTI. Interview on 01/11/2024 at 10:38 a.m. with S2 DON revealed the orders to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023 were not carried out. S2 DON confirmed the lab work and UA had not been collected. Interview on 01/11/2024 at 11:08 a.m. with S2 DON revealed she and S8 Unit Manager were responsible for reviewing new written orders when NP makes rounds. S2 DON stated the order should be placed in the computer, a call should be made to notify the lab of the order, and staff should carry out the orders. S2 DON stated when labs are ordered, the labs are expected to be collected the following day, and when an UA is ordered, it is expected to be collected on the day it was ordered. S2 DON stated lab came to the facility to collect labs Monday- Friday, and as needed for stat orders. S2 DON stated she was ultimately responsible for ensuring the orders were carried out, and had failed to do so. Resident #16 Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE], and had diagnoses that included in part . Dementia, Primary Generalized Osteoarthritis, Type 2 DM, Major Depressive Disorder, Abnormal weight loss, and Alzheimer's Disease. Review of Resident #16's Quarterly MDS with an ARD of 11/09/2023, revealed Resident #16 had a BIMS of 99 (Unable to assess cognition). Resident #16 required supervision/setup assistance for eating; moderate assistance for oral hygiene, and dressing; and maximal assistance for toileting, showering/bathing, and personal hygiene. Resident #16 was always incontinent of Bowel and Bladder. Review of Resident #16's physician's orders revealed the following: 12/21/2023: UA (Urinalysis) with Reflex. Review of Resident #16's medical record revealed lab results for the Urinalysis with an order date of 12/21/2023 was not carried out, and there were no results within the medical record. Interview on 01/11/2024 at 4:30 p.m. with S2 DON revealed she could not find results for the UA ordered on 12/21/2023, and confirmed the lab had not been completed for Resident #16. Interview on 01/11/2024 at 9:32 a.m. with S10 NP revealed she ordered a UA on 12/21/2023, because Resident #16 had a decline, and she needed to rule out a UTI. S10 NP confirmed there was a delay in care, and the UA should have been collected. Interview on 01/11/2024 at 11:08 a.m. with S2 DON, revealed she and S8 Unit Manager were responsible for reviewing new written orders when a provider made rounds. S2 DON stated the order should have been placed in the computer, a call should have been made to notify lab of the order, and staff should have collected the UA on the day of order. S2 DON stated she was ultimately responsible for ensuring the orders were carried out, and had failed to do so. Resident #59 Review of Resident #59's medical record revealed an admitted [DATE]. Resident #59 had the following diagnoses that included in part . Schizoaffective Disorder, Bipolar Type; and Unspecified Dementia, unspecified severity with other behavioral disturbances. Review of Resident #59's Annual MDS with an ARD of 11/10/2023 revealed Resident #59 had a BIMS of 8 (Moderate Cognitive Impairment). Resident #59 had wandering behaviors which occurred 1-3 days. Resident required Partial/Moderate assistance for toileting, showering/bathing, and dressing. Resident #59 had occasional incontinence of urine and was always incontinent of bowel. Review of Resident #59's physician's orders revealed the following: 01/06/2024: CBC, CMP, and UA. 01/08/2024: Macrobid 100mg twice daily for 10 days, diagnosis- UTI. Review of Resident #59's medical record revealed a UA was ordered on 01/06/2024. The medical record revealed the UA was not collected until 01/09/2024, and revealed the presence of bacteria in the urine. Interview on 01/11/2024 at 9:32 a.m. with S10 NP revealed she ordered UA on 01/06/2024, as Resident #59 had presented with UTI symptoms. S10 NP confirmed she ordered Macrobid 100mg twice daily for 10 days on 01/08/2024. Review of Resident #59's 01/2024 MAR revealed the resident had not received Macrobid 100mg twice daily starting 01/08/2024. Interview on 01/11/2024 at 12:25 p.m. with S7 LPN revealed she was unaware Resident #59 had recently been diagnosed with UTI, and was unaware Resident #59 had an order for Macrobid 100mg BID X10 days. S7 LPN confirmed she had not administered Macrobid to Resident #59, and confirmed this medication was not listed on Resident #59's MAR, and was not available on her medication cart. S7 LPN stated the nurse who received the order for Macrobid on 01/08/2024 was responsible for entering the medication on the MAR, and obtaining the medication from pharmacy. Interview on 01/11/2024 at 12:39 p.m. with S2 DON revealed S8 Unit Manager received the order to begin Macrobid 100mg BID X 10 days for Resident #59 on 01/08/2024. S2 DON confirmed there was a delay in care. S2 DON confirmed S8 Unit Manager should have entered the order into the computer, called pharmacy to get the medication, and had the medication added to Resident #59's MAR, but failed to do so. Resident #11 Review of the medical record for Resident #11 revealed an admitted [DATE], with diagnoses that included: Dementia, Respiratory Syncytial Virus, Pruritus and Dermatitis, and Encounter for Attention to Gastrostomy Tube. Review of Resident #11's Quarterly MDS with an ARD of 11/17/2023 revealed a BIMS score of 14, indicating intact cognition. Review of the MDS revealed Resident #11 required substantial or maximal assistance with personal hygiene, and extensive assistance by two persons with bed mobility and toilet use. Review of Resident #11's physician's orders revealed the following orders: 12/14/2023: Ivermectin per pharmacy dosing x 1 dose, and repeat in one week. 12/28/2023: Medrol 4 mg dose pack (Methylprednisolone-a steroid). Review of Resident #11's December 2023 MAR revealed the resident received the first dose of Ivermectin on 12/14/2023, but never received the second dose, as scheduled one week later. Review of Resident #11's January 2024 MAR revealed the resident never received the final dose of Methylprednisolone 4mg on the sixth day (01/03/2024), as scheduled. Interview at 01/10/2024 at 10:05 a.m. with S11 Corporate RN, confirmed Resident #11 did not receive the second dose of Ivermectin, and did not receive the last dose of the Methylprednisolone dose pack on 01/03/2024. Review of Resident #11's nurses' notes revealed the following: 01/04/2024 at 2:16 p.m. - The Nurse Practitioner made rounds and ordered a chest x-ray, CBC, BMP, and a Urinalysis with reflex. Documented by S8 Unit Manager. 01/07/2024 at 10:26 p.m. - UA collected in and out cath. Awaiting lab tech in a.m. Documented by S9 LPN. Review of Resident #11's medical record revealed lab results for the CBC, BMP, and Urinalysis, with a collection date of 01/08/2024. In an interview on 01/11/2024 at 9:40 a.m., S10 NP stated she ordered the two doses of Ivermectin because Resident #11 had a constant itch. S10 NP stated she was not notified the resident didn't receive the second Ivermectin dose, or the final dose of Methylprednisolone. S10 NP confirmed she ordered the chest x-ray, CBC, BMP, and Urinalysis on 01/04/2024 because she didn't think the resident had improved enough since her recent hospital stay. S10 NP confirmed there was a delay in obtaining the blood work and urinalysis. In an interview on 01/11/24 at 10:27 a.m., S8 Unit Manager stated the NP or MD puts orders on a certain rack and she makes copies and gives them to the floor nurse to transcribe and carry out the orders. S8 Unit Manager said the floor nurse should fill out a form for lab work and place it in the binder behind the day it is to be done. S8 Unit Manager stated if a UA was ordered, the floor nurses are supposed to collect the urine and put it in the fridge to be picked up. S8 Unit Manager said the floor nurses should collect the urine as soon as possible, but said it should be done in less than 24 hours. S8 Unit Manager stated the lab comes to the facility every day except Saturday and Sunday, unless the lab was ordered stat. In an interview on 01/11/2024 at 11:21 a.m., S2 DON reviewed Resident #11's medical record and confirmed Resident #11's blood work and urinalysis were ordered on 01/04/2024, the urinalysis was not collected until 01/07/2024, and the blood work was not collected until 01/08/2024. S2 DON confirmed there was a delay in care because the lab work should have been drawn the next morning, and the urinalysis the same day it was ordered. In an interview on 01/11/24 at 10:27 a.m., S8 Unit Manager stated the NP or MD puts orders on a certain rack and she makes copies and gives them to the floor nurse to transcribe and carry out the orders. S8 Unit Manager said the floor nurse should fill out a form for lab work and place it in the binder behind the day it is to be done. S8 Unit Manager stated if a UA was ordered, the floor nurses are supposed to collect the urine and put it in the fridge to be picked up. S8 Unit Manager said the floor nurses should collect the urine as soon as possible, but said it should be done in less than 24 hours. S8 Unit Manager stated the lab comes to the facility every day except Saturday and Sunday, unless the lab was ordered stat. In an interview on 01/11/2024 at 11:21 a.m., S2 DON reviewed Resident #11's medical record and confirmed Resident #11's blood work and urinalysis were ordered on 01/04/2024, the urinalysis was not collected until 01/07/2024, and the blood work was not collected until 01/08/2024. S2 DON confirmed there was a delay in care because the lab work should have been drawn the next morning, and the urinalysis the same day it was ordered. Resident #43 Review of Resident #43's medical record revealed an admitted [DATE], with diagnoses that included: Hemiplegia, Type 2 Diabetes Mellitus, Dementia, and Adjustment Disorder. Review of Resident #43's Quarterly MDS with an ARD of 11/21/2023 revealed a BIMS score of 9, which indicated moderately impaired cognition. Review of the MDS revealed the resident required substantial/maximal assistance with toilet hygiene, and set up or clean up assistance with eating; Review of Resident #43's nurses' notes revealed the following: 01/04/2024 at 2:12 p.m.: 8:00 a.m. S10 NP made rounds with new orders noted: Obtain UA (urinalysis) with reflex. Documented by S8 Unit Manager. Review of Resident #43's lab results revealed the urine was collected on 01/08/2024 at 4:11 a.m., and revealed the resident had a urinary tract infection. In an interview on 01/11/2024 at 9:36 a.m., S10 NP confirmed she ordered a UA on Resident #43 on 01/04/2024, because the resident had increased behaviors and was angry with staff. S10 NP stated the UA was not done until 01/08/2024, and was positive for a UTI. S10 NP confirmed there was a delay in care, and the UA should have been done sooner. In an interview on 01/11/2024 at 11:21 a.m., S2 DON confirmed there was a delay in care, and staff took too long to collect his urine. S2 DON stated a urinalysis should be done the same day it was ordered.

Based on record review, observation, and interview the facility failed to use a two-person transfer as outlined in the resident's care plan, during a lift transfer from the bed to the recliner for 1 (#3) of 5 (#1, #2, #3, #4, #5) residents reviewed for accidents. This deficient practice resulted in an actual harm on 06/22/2022 at 7:00 p.m. when Resident #3 was transferred with a mechanical lift from the bed to the recliner by S4 TNA, without the assistance of another staff member. During the transfer, the lift tilted over, dropped the resident in the recliner, and hit the resident in the head causing a laceration to the resident's scalp. Resident #3 complained of pain to her head and was sent to the ER where she received sutures and was diagnosed with a laceration and a head injury. Findings: Review of the facility's Competency Evaluation and Assessment form for the total lift revealed, in part, the following Precautionary measures: Never leave the resident unattended during lift/transfer. Follow individual resident transfer/lift instructions per care plan. Use number of staff indicated for lift/transfer. In an interview on 07/25/2022 at 11:00 a.m., Resident #3 reported an aide, S4 TNA, attempted to transfer her alone with the lift from the bed to the recliner. Resident #3 reported S4 TNA was standing on the lift and when she stepped off the lift, it toppled over with her. Resident #3 reported the lift hit her on the head causing her to go the emergency room and get about 10 stitches to her scalp. Resident #3 reported she was still in pain from that fall. Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses that included, in part, spondylosis with [CONDITION(S)] in cervicothoracic region, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], neuromuscular dysfunction of the bladder, [CONDITION(S)], and pain. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed Resident #3 required extensive assistance by two person physical assist with bed mobility, transferring, and toilet use. Further record review revealed Resident #3 was care planned for being at risk for falls related to impaired mobility, medication, and diagnosis of [CONDITION(S)]. Approaches to this problem included, in part: Hoyer lift for transfers with 2+ staff members, motorized wheelchair per self, bed low and locked at all times unless providing care, use shower stretcher when showering with 2 person assist, and do not keep bedrails up unless necessary. Review of the nurses' notes for Resident #3 revealed the following entry: 06/23/2022 at 6:31 a.m.: This nurse standing at nurses' station and called to the side per S4 TNA. She reported that she couldn't find anyone to help her transfer resident from motorized wheelchair to recliner with lift so she did it herself. The lift tilted causing top of lift to hit resident in head causing laceration to right side of scalp. Neuro checks within normal limits. Area cleaned with normal saline and gauze. Director of Nursing Services notified. CNA is to write a detailed statement of incident. CNA is to go home until investigation is completed. Report given to _______at the ER. EMS notified. Resident left facility in alert and stable condition via stretcher to ER. Resident notified her sister. Message left for brother. 104/65, 96, 97.4, 20. 11:15 p.m.: Resident returned to facility via EMS alert and oriented X 3 in stable condition noted with stitches to scalp. No new orders. Keep area clean and follow up with Primary Care Physician in 2 days. By S5 LPN. In an interview on 07/26/2022 at 8:15 a.m., S5 LPN. Reported she was working the night of the lift incident. She explained she was at the nurses' station at 7:00 p.m. and S4 TNA came and got her needing assistance. S5 LPN explained S4 TNA told her she was moving Resident #3 with the lift without any assistance from anyone. S5 LPN reported when she went in the room, the resident was still in the sling in the air and she helped S4 TNA get the resident down. S5 LPN reported Resident #3 had hit her head on the lift. S5 LPN reported the laceration to the right side of her hair line was deep and bleeding a lot. S5 LPN reported she cleaned the laceration and sent the resident out to the ER after calling the NP. S5 LPN reported she fussed at the CNA for not getting help with the lift stating she and the other nurse were standing right there at the nurses' station. S5 LPN reported S4 TNA told her she had been standing on the lift. Review of S4 TNA's signed, written statement dated 06/22/2022 revealed, in part, I ended up using the lift by myself making it safely to her bed, I got her changed, and put her nightgown on. I took the lift and bring it to her recliner, she made it safely in her recliner but as I was taking the lift rings out, it hit her head causing it to bleed. Review of the hospital's ER Practitioner Record dated 06/22/2022 revealed Resident #3 had a 3 cm laceration noted to the scalp area and received sutures in the ER. Differential diagnoses included head injury and laceration. Further review revealed Resident #3 was discharged with instruction for a concussion and a laceration. Review of the personnel file revealed S4 TNA was trained on using the total lift on 01/05/2022 and was signed off on the Competency Evaluation and Assessment by S6 SDC. Included in this form, signed by S4 TNA were instructions that included follow individual resident transfer/lift instructions per care plan and use number of staff indicated for lift/transfer. In an interview on 07/27/2022 at 10:45 a.m., S6 SDC confirmed she trained S4 TNA on using the lift with two people each time. S6 SDC confirmed S4 TNA should not have used the lift alone to transfer Resident #3. In an interview on 07/27/2022 at 11:10 a.m., S2 DON acknowledged S4 TNA used the lift to transfer Resident #3 without any assistance and should not have.

Based on observation, interview and record review the facility failed to ensure the resident environment remains as free from accident hazards as is possible with adequate supervision by failing to ensure: 1. a temporary nursing assistant transferred a resident with assistance of another staff member with the use of a mechanical lift for 1 sampled resident (#5) out of a total of 21 residents that required 2 person staff assistance with the use of a mechanical lift for transfers; 2. that a system was in place that identified residents as unsafe smokers needing supervision when smoking for 1 sampled Resident (#1) and 2 random sampled residents (R1, R4) out of a total of 5 unsafe smokers in the facility. An immediate jeopardy situation occurred on 11/19/2020 at 11:45 a.m. for Resident #5, who required two person assist during transfer with a mechanical lift, fell to the floor while being transferred from her bed to a chair by a temporary nursing assistant. During the transfer one of the wheels on the lift became lodged in the wheel of the resident's wheelchair causing the resident's weight to shift and the resident to fall to the floor. The lift's frame fell sideways onto the floor with the resident still in the sling, which remained attached to the swivel hooks. The resident was taken to a local hospital after a portable x-ray showed she sustained fractures to her right ankle and right femur. An immediate jeopardy situation occurred on 12/11/2020 at 11:15 a.m., when a partially smoked cigarette was found beneath R4's bed pillow after a strong odor of cigarette smoke was detected to be coming out of his room. R4 was also found in possession of a cigarette lighter. S1 Administrator was informed of the Immediate Jeopardy situations on 12/11/2020 at 4:00 p.m. The Immediate Jeopardy situations were removed on 12/12/2020 at 2:15 p.m. after it was determined through observation, interview, and record review that the facility submitted and implemented a plan of removal that included the following: Mechanical Lift 1. The mechanical lift was removed from use immediately after the incident on 11/19/2020, was evaluated by maintenance and determined to have a malfunction involving the hydraulic arm. It was sent out for repair on 11/23/2020. 2. On 11/19/2020, 100% of residents were screened by the facility's EZ move screening, which determined the transfer status, type of assistance required, and weight of each resident screened. EZ move screening was repeated on 12/11/2020 at 5:50 p.m. 3. On 11/19/2020, pocket care guides utilized by staff were reviewed for residents' transfer status and compared to residents' care plans to verify accuracy. All residents who required the use of mechanical lifts for transfers were listed as requiring 2 person assistance. 4. In-servicing of nursing staff was initiated on 12/11/2020 at 5:50 p.m. for following residents' plans of care for transfers and for utilizing mechanical lifts. Training completion date projected for 12/15/2020. 5. Return demonstration of proper use of the Mechanical Total Lift by all nursing staff was initiated on 12/11/2020 at 5:00 p.m. No nursing staff will be allowed to work until in-service and return demonstration is completed. Training completion date projected for 12/15/2020. 6. On 11/19/2020, Maintenance or designee began assessing each lift weekly to ensure all were safely operable. 7. On 11/19/2020, Director of Nursing or designee began monitoring by observing mechanical lift use weekly, until 01/05/2021, to ensure all were safely operable and proper staff assistance was utilized, as specified in plans of care. Smoking Supervision 1. On 12/11/2020 at 5:00 p.m., an Emergency Council meeting was held with all residents who smoked. They were informed that the facility had put a smoking schedule in place for all smokers, safe and unsafe, and all smokers were to be supervised by CNA, LPN, RN or administrative staff. Smokers were issued a copy of the smoking schedule. 2. A smoking evaluation and care plan update was performed on R1 and R4. On 12/11/2020 R1 was reassessed by DON and determined to be an independent smoker and was identified as being incorrectly listed as an unsafe smoker on the list at the nurse's station. On 12/11/2020 at 11:45 a.m., R4 was placed on one-to-one monitoring after he refused to give his cigarette lighter to the facility administrator. 3. Initiated on 12/11/2020: Under facility policy, no residents are to have lighters, regardless of independent or supervised smokers. Any lighters obtained at the store or by family members are to be given to the nurse for safe keeping. All residents and RPs were notified and informed of the new protocol. 4. On 12/11/2020 at 5:30 p.m., an in-service for staff was conducted to inform them that both independent and supervised smokers are to comply with the facility smoking schedule. All staff are to be in-serviced on this information by 12/15/2020. 5. On 12/11/2020, 100% audit of smoking assessments were completed by the DON. In-servicing of nurses initiated on 12/11/2020 at 6:15 p.m. informing them they are to check smokers for possession of lighters every 6 hours, and document checks on MAR. DON or designee to monitor MAR indicated [REDACTED]. Executive Director, DON, or designee will perform daily checks on two separate smoking times to ensure that staff are providing assistance and appropriate supervision to residents during smoke breaks. This monitoring will be conducted five days a week for 6 weeks. 6. Door codes changed on 12/09/20 by Executive Director/Administrator. 7. On 12/12/2020, initiation of staff education regarding updated smoking safety status on pocket care guides. All staff to be educated by projected date of 12/15/2020. 8. Training compliance completion date listed as 12/15/2020 and monitoring completion date listed as 01/05/2021. Findings: 1. Review of the facility's Policy and Procedure titled Invacare Total Lift (policy used by the facility for all mechanical lifts) revealed it did not state that 2 person assistance was required to perform mechanical lift transfers. Review of the Pocket Care Guide dated 11/18/2020 and used by CNAs as a resident care guide failed to reveal that 2 person assistance was required for mechanical lift transfers for resident #5. Review of resident #5's medical record revealed an admitted [DATE], and a re-admitted [DATE], with [DIAGNOSES REDACTED]. Review of resident #5's Quarterly MDS with an ARD of 10/09/2020 revealed a BIMS score of 15, indicating the resident was cognitively intact. The resident's Functional Status revealed she required extensive assistance of 2 or more persons with bed mobility, transfers, and toileting. Review of resident #5's Care Plan with a target date of 01/30/2021 revealed a problem of impaired mobility related to a [DIAGNOSES REDACTED]. Interventions included: 2 persons needed during use of mechanical lift and ensure Hoyer (mechanical) lift is in proper placement prior to lifting resident. Observation of resident #5 on 12/07/2020 at 11:00 a.m. revealed her lying in bed with her right leg elevated on a pillow. A soft dressing was in place to her RLE from mid-calf to just below her toes. Interview with the resident on 12/07/2020 at 11:05 a.m. revealed she was being transferred from her bed to her wheelchair via a mechanical lift on 11/19/2020 when the lift began coming down, and before she knew it, she was on the floor. Resident #5 stated she suspected right away that her leg was broken. She further stated S8 TNA performed the transfer alone and had not assisted her with a transfer prior to that day. The resident stated after she fell seated on the floor, she was assessed by 2 nurses and had pain to her right leg. She further stated she was transferred back into her bed by 2 CNAs with the same lift, and had an x-ray done in the facility later that day. She stated an x-ray done at the facility revealed her right leg was broken in two places, and she was transferred to a local hospital for evaluation. She stated she was told by the emergency room physician that her bones were brittle, she was not a candidate for surgery, and she would be fitted for a brace instead. She returned to the facility the following day. Interview with S8 TNA on 12/07/2020 at 9:00 a.m. revealed she was hired as a temp aide at the facility in September 2020. She stated her orientation included use of mechanical lifts; but, she was not instructed that all lift transfers required the assistance of 2 staff members. She stated prior to the incident with resident #5, she had never performed a lift transfer on the resident. She stated nurse aides were provided with pocket care guides daily, which informed them of the specifics of care for each resident, including the type of transfers required. She stated resident #5 was not listed as a 2 person assist on the pocket care guide. S8 TNA stated that 11/19/2020 was a very busy day, so she decided to perform the transfer alone. She stated she placed the lift pad beneath resident #5, placed the lift pad loops securely on the lift hooks, and proceeded to lift her and move her toward her wheelchair, which she had positioned to the left side of the resident's bed. She stated the wheels did not move freely, and when she moved the legs of the lift to straddle the wheelchair, one of the wheels did not move, and one leg of the lift was stuck in place. She stated this caused the lift to fall over from the imbalance of weight on the upper part of the lift. S8 TNA stated the resident fell approximately 4 feet, to a seated position on the floor, with her legs straight in front of her. She further stated the frame of the lift fell on its side to the floor, with the lift pad and resident still attached to the lift hooks. S8 TNA stated she called for help, and S9 CNA, S10 CNA, S11 LPN, and S2 DON arrived. She stated resident #5 moaned and complained of pain to her right leg and foot when she was transferred back into bed. She further stated the resident commented, I'll bet my leg is broken again. Review of resident #5 Departmental Notes documented by S2 DON dated 11/20/2020 at 12:56 p.m. - Late entry for 11/19/2020 at 11:45 a.m., revealed she was called to the resident's room per CNA. Upon entering, resident was noted on the floor in a supine position with lift sling still attached to Hoyer lift. The CNA voiced that as she was transferring the resident from the bed to wheelchair, the lift began to lean to the left side. The CNA voiced she was unable to keep the lift upright and she held onto the resident in the sling as she eased her to the floor. The resident voiced complaint of pain to RLE with movement. This nurse with attempts to send the resident to the ER for evaluation, but resident declined. The physician was notified and a telephone order was received to obtain stat x-ray of right and left hip, tib (tibia), fib (fibula), ankle, feet and femur. Review the resident's Departmental Notes dated 11/19/2020 at 7:45 p.m. revealed an LPN received x-ray results conducted by a mobile x-ray service. The results revealed: [MEDICAL CONDITION] femur and ankle, and an old fracture with callous formation to her right tibia. The MD was notified and ordered the resident be transferred to the ER. Review of the facility's Investigative Report dated 11/23/2020 revealed that on 11/19/2020 at 11:45 a.m. S2 DON was called to the resident's room by S8 TNA. Upon entering, the resident #5 was found lying on the floor in a supine position with the lift sling still attached to the Hoyer Lift. S8 TNA stated during a transfer of the resident with the lift from her bed to chair, the lift started going down on its own. The lift started tilting and the resident started falling. S8 TNA stated she was unable to maneuver the lift back to the upright position and she held onto the resident in the sling as she eased her to the floor. The resident complained of pain to the RLE with movement. Review of the hospital's ED Practitioner Record dated 11/19/2020 at 8:14 p.m. revealed the following: Chief Complaint of Lower Extremity Injury. The Stated Complaint revealed: Fall - RLL Fx. The Extremity Exam revealed: Quadriplegic. Contusion and swelling noted to the right ankle. The Course Narrative revealed a hx of [MEDICAL CONDITION], presents to the ED s/p right femur and tib/fib fx after a lift machine at the NH fell on her leg. Review of a hospital Consultation Report dated 11/20/2020 at 1:38 p.m. revealed the patient was being transferred from the bed to a chair with a lift on yesterday, when the lift fell over dropping her on the floor and then landing on her right leg. She states she felt a pop and had some pain. Review of the Assessment and Plan revealed: Assessment - Right supracondylar femur, proximal tibia, and tibial pilon fractures in a C6 Quadriplegic patient. Plan: Due to disuse Osteopenia, the bone is often very soft and often will not adequately hold screws for the course of treatment. The implants should pull out of the bone they could create worse damage. A common way of treating these fractures is through bracing and allow them to heal. Interview with S2 DON on 12/07/2020 at 1:20 p.m. revealed there were 21 residents in the facility who required Hoyer lift transfers. S2 DON stated S13 MDS Nurse printed patient care guides daily and placed several copies at the nurse's station for use by the CNAs. S2 DON further stated she entered the resident information included in the care guides herself. She stated the care guide dated 11/17/2020 revealed resident #5 required Hoyer lift for transfers; however, it did not indicate whether she required 1 or 2 person assistance. S2 DON stated she felt that all nursing staff were aware that mechanical lift transfers should be performed by 2 persons. She confirmed that prior to the incident involving resident #5, the care guides did not specify 2 person assistance for any of the 21 residents who required use of a mechanical lift. 2. Review of the facility's Smoking Policy revealed in part . A. All Residents who smoke will be assessed for his/her ability to smoke safely, the ability to handle smoking material and the need for supervision while smoking. The Smoking Safety Evaluation will be completed upon admission, re-admission, quarterly, annually, and as needed. B. Residents found to have modified independence with smoking may be subject to smoking limitations. Limitation may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products, assistance to hold cigarette, supervised smoking by staff, and/or other protective/safety measures as determined appropriate by the individualized plan of care based on the smoking evaluation. C. Violation of smoking policy may result in discharge from facility. R4 Review of R4's Comprehensive Care Plan revealed he was care planned for being an unsafe smoker due to risk for injury and had a history of [REDACTED]. Review of the resident's Smoking Safety Evaluation dated 01/24/2020, with a review date of 10/09/2020 revealed the resident had a history of [REDACTED]. Review of the facility's pocket care guide dated 12/10/2020 failed to reveal R4 was a smoker. Observation on 12/11/2020 at 11:15 a.m. revealed a strong odor of cigarette smoke in the hall just outside R4's room and inside his room. Further observation revealed R4 was seated on his bed and S17 LPN/UM and S18 Housekeeper standing at the resident's bedside. S17 LPN/UM was observed holding a partially smoked cigarette that she stated she just found beneath the resident's pillow. She asked the resident if he had anymore cigarettes, and he removed one from his jacket pocket. She asked if he had a cigarette lighter, and he stated he did not. When she asked him a second time, he pulled one out of his jacket pocket. She asked that he give it to her to hold, and he refused. She stated she would have to notify the Administrator and exited the room. Interview with S18 Housekeeper on 12/11/2020 at 11:20 a.m. revealed she was cleaning another room near R4's room when she heard R4 call out for someone to let him outside to smoke. She stated she told him she could not let him out because she didn't know the code, and he needed someone to go outside with him. She stated he walked back to his room, and she re-entered the room she was cleaning. Shortly after, she began to smell cigarette smoke. She stated she went into the hall and followed the smoke smell into R4's room. She stated he denied that he was smoking, but she had not smelled cigarette smoke when he asked her to open the door for him a few minutes earlier. Observation on 12/11/2020 at 11:22 a.m. revealed S1 Administrator entered R4's room on 12/11/2020 and asked the resident to relinquish his cigarette lighter. The resident refused. S1 Administrator then escorted the resident to a large dining table in the facility day room and assigned S19 Activity Director to sit with him one-on-one, as he was in possession of a cigarette lighter. Interview with S19 Activity Director on 12/10/2020 at 10:40 a.m. revealed only she, the nurses, or S20 SSD were allowed to give cigarettes to the residents. She stated a CNA or staff member was supposed to go outside with an unsafe smoker and light the cigarette for him/her, but she thought some unsafe smokers snuck out with the safe smokers and bummed cigarettes from them to smoke. She stated the safe smokers were allowed to keep a pack of cigarettes and a lighter on their person for the day, then return them at 6 p.m. in the evening. She stated there was no log book at the nurse's station so there was no way for staff to know who had returned their cigarettes and lighters and who had not. Interview with S5 RN/UM on 12/10/2020 at 11:20 a.m. revealed smoking evaluations were completed upon admission and updated quarterly. She stated she or S2 DON updated the pocket care guides as needed. She confirmed that the pocket care guides dated 12/10/2020 did not address that resident #1 and R4 were smokers and should have. She stated some safe smokers knew the door codes and allowed unsafe smokers to exit with them without staff supervision. She stated she was not aware of any monitoring being done to ensure that unsafe smokers were being supervised by staff. Interview with S1 Administrator on 12/11/2020 at 11:30 a.m. revealed the facility had no measures in place to monitor the number of cigarettes issued to a resident, to whom cigarettes were issued during the day, and whether safe smokers had returned their cigarettes and lighters at the end of the day. He stated it was possible that residents kept lighters in their rooms without the knowledge of staff. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Annual MDS Assessment with an ARD of 09/04/2020 revealed a BIMS score of 11 (Moderately Impaired Cognitively). Review of Resident #1's Smoking Safety Evaluation form dated 08/28/2020 revealed he had decreased fine motor control, was diagnosed with [REDACTED]. Review of a Smoking Safety Evaluation form with a review date of 11/30/2020 revealed the resident had a history of [REDACTED]. Further review revealed interventions that included facility storage of tobacco products and fire materials, and supervised smoking by staff. Review of the facility's list of smokers posted at the nurse's station revealed Resident #1 was an unsafe smoker. Review of the facility's pocket care guide dated 12/09/2020 failed to reveal Resident #1 was a smoker. Review of Resident #1's Comprehensive Care Plan with a target date of 11/30/2020 revealed a problem of Potential for injury due to cigarette smoking. Approaches included observe resident for unsafe smoking behaviors, assess resident for need of assistance to smoke due to inability to hold own cigarette, dropping ashes on clothing, and to supervise smoking per policy and assessment. Observation of Resident #1 on 12/10/2020 at 8:45 a.m. revealed the resident was seated in his wheelchair smoking a cigarette, alone on the back patio. He was not wearing a smoke apron. No staff were observed on the patio. Interview with S4 CNA on 12/10/2020 at 10:10 a.m. revealed she worked on the hall the resident resided on, and was unsure if Resident #1 required smoking supervision. S4 CNA looked at her pocket care guide and stated it did not indicate that Resident #1 was a smoker. Interview with S14 Treatment Nurse on 12/10/2020 at 10:12 a.m. revealed she did not know if Resident #1 required smoking supervision. Interviews with S15 CNA and S16 CNA on 12/10/2020 at 10:30 a.m. revealed both CNAs worked on the hall the resident resided on and neither CNA was able to state the smoking status of Resident #1. S15 CNA and S16 CNA stated their pocket care guides did not indicate that he was a smoker. Observation of Resident #1's closet on 12/10/2020 at 10:15 a.m. revealed a camouflage t-shirt and a black t-shirt, both of which had over 5 cigarette burn holes on the front of each of them. Interview with Resident #1 on 12/10/2020 at 10:20 a.m. revealed he had gone to smoke on the back patio at around 8:30 a.m. He stated he sat outside alone for 45 minutes that morning, until a housekeeper opened the door and let him inside. He stated he knew that staff were supposed to be with him outside, but many times they weren't. Further interview revealed he had gotten 2 cigarettes from a staff member at the nurse's station, whose name he did not know. He stated another resident had entered the code to open the back door for him to exit and then lit his cigarette for him. He further stated he was unable to propel his wheelchair on the incline that led from the patio to the door and could not press the door code buttons to re-enter the facility, because he did not have the strength in his fingers and hands. R1 Review of R1's quarterly MDS with an ARD of 10/02/2020 revealed a BIMS of 7 (Severe Impairment Cognitively). Review of the facility's list of residents who smoked revealed R1 was an unsafe smoker. Review of the Pocket Care Guide dated 12/10/2020 revealed R1 was an Independent Smoker. Review of R1's Comprehensive Care Plan with a target date of 01/01/2021 revealed the resident was not care planned for smoking. Review of R1's Smoking Evaluation Form dated 10/02/2020 failed to reveal whether the resident was an independent smoker, whether she required supervision, a smoker's apron, or assistance with lighting or holding a cigarette. Observation on 12/10/2020 at 10:15 a.m. of R1 revealed she was seated on the facility's back patio smoking with R2. There were no staff members present on the patio. Interview with R1 at the time of observation revealed that R2 had given her a cigarette and lit it for her. R1 stated that she was not required to be supervised when she smoked. Interview with R2 on 12/20/2020 at 10:15 a.m. revealed he provided R1 with a cigarette and lit the cigarette for her. He stated he was a safe smoker and did not require staff with him when he went out to smoke. He stated he knew the door code and would let himself out to smoke and let himself back inside when he was done. He stated he got his cigarettes and his lighter from the nurse's station in the morning and was allowed to keep them until the evening. He stated some of the residents bummed cigarettes from him when they didn't have any. Further interview with R2 revealed he often lit cigarettes for Resident #1. He stated Resident #1 often went outside with him to smoke. He stated staff were not always present when Resident #1 smoked. He stated Resident #1 was unable to light his own cigarettes and sometimes dropped his cigarettes on the ground or on his clothes, because his hands were crippled. R2 stated he has had to pick up Resident #1's cigarette from his lap and put it back into his mouth so that it would not burn him. He further stated he has seen ashes fall onto Resident #1's clothes and burn a hole in them.

Based on record review, observation and interview, the facility failed to ensure 1 (#1) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents received adequate assistance devices to prevent accidents. This failed practice resulted in an Actual Harm for Resident #1 on 8/5/19 at approximately 3:30 a.m. when the resident was assisted to transfer by one CNA (S5) using a standing lift instead of a Hoyer lift with two person assistance as care planned. S6 LPN Charge Nurse was called to the resident's room by S5 CNA on the above date and time, and observed the resident in a standing lift instead of the Hoyer lift upon entrance to the resident's room. S6 LPN and S5 CNA unsuccessfully attempted to place the resident in his wheelchair from the standing lift, and had to lower the resident to the floor. Prior to being lowered to the floor, while still in the standing lift, the resident yelled ouch, but then said he was alright. At 8:30 a.m. the resident complained of pain to his right leg and stat portable x-rays of the resident's right tibia, fibula and foot were ordered. The x-ray reports revealed the resident had acute fractures of the right distal tibia and fibula with mild medial displacement. At 4:00 p.m. the resident was transferred to the hospital and an x-ray of the resident's right leg was ordered. However, the resident's left leg was inadvertently x-rayed instead of the right leg. Review of the x-ray report revealed the resident had an oblique oriented acute to subacute mildly displaced [MEDICAL CONDITION] left tibial metaphysis, with fracture extension into the articular surface of the lateral tibial plateau. The resident was transferred to another hospital and while at the hospital, an X-ray of the resident's left leg revealed the resident had a subacute [MEDICATION NAME] fracture through the proximal metaphysis of the tibia. Thus, the resident sustained [REDACTED]. Findings: Review of resident #1's Accumulative [DIAGNOSES REDACTED]. Disease. Observation of the resident on 12/10/19 at 10:00 a.m. revealed the resident was lying in bed with HOB elevated. Further observation revealed the resident had wound dressings on both lower extremities and a full length knee immobilizer on the right lower extremity secured by 6 Velcro straps. Review of the Annual MDS assessment dated [DATE] (ARD) revealed a Cognitive BIMS score of 12 (moderate cognitive impairment). Review of the resident's care plan with an onset date of 10/3/14 revealed the resident had a problem of self-care deficit r/t requires extensive assist with ADLs, mobile via wheelchair, and Hoyer lift for transfers. Approaches included: use Hoyer lift for transfers. Review of the Daily Care Guide dated 8/2/19 revealed the resident required transfer with a Hoyer mechanical lift, with 2 person assistance. Review of the Departmental Notes dated 8/5/19 at 8:39 a.m. revealed resident #1 complained of pain to the right lower extremity, repositioning ineffective and [MEDICATION NAME] (pain medication) was given and a stat order for the right tib/fib and right foot were obtained. At 9:30 p.m., the resident's daughter came to the facility and reported that the resident had been transferred to another hospital with acute fractures to the resident's right tibia and fibula with mild displacement. The resident was transferred to the hospital and was ordered another x-ray of the right leg. However, resident #1's left leg was inadvertently x-rayed, and it was discovered that the resident also had an acute mildly displaced oblique [MEDICAL CONDITION] left tibia metaphysics. Further review of the Departmental Notes revealed a late entry for 8/5/19 at approximately 3:30 a.m., S6 LPN/Charge Nurse was called to the resident's room by S5 CNA, and when she entered the resident's room S5 CNA reported to S6 LPN that she was having difficulty transferring the resident using the stand-up lift. The resident was suspended in the air by the sit to stand lift, neither of the resident's feet were on the foot plate properly. S5 CNA stated to S6 LPN his legs keep bending and I don't know why and we always use this lift on him. S5 CNA and S6 LPN attempted to place the resident in his wheelchair with the Hoyer lift pad that was in his wheelchair, but were unsuccessful. S6 LPN made the decision to lower the resident to the floor, then used the Hoyer lift to transfer the resident from the floor to the wheelchair. S6 LPN had reported that during the event the resident yelled out ouch, but then voiced he was alright. S6 LPN performed a head to toe assessment on the resident and noted no abnormalities. S6 LPN then educated the staff to only use the Hoyer lift for transfers on this resident. On 8/5/19 at 8:30 a.m., stat portable x-rays of the resident's right tibia, fibula and foot were ordered due to the resident's complaint of pain to his right leg. Review of the x-ray reports revealed the resident had acute fractures of the right distal tibia and fibula with mild medial displacement. The resident was transferred to the hospital on [DATE] at 4:00 p.m. and an x-ray of the resident's right leg was ordered. However, the resident's left leg was inadvertently x-rayed instead of the right leg. Review of the x-ray report revealed the resident had an oblique oriented acute to subacute mildly displaced [MEDICAL CONDITION] left tibial metaphysis, with fracture extension into the articular surface of the lateral tibial plateau. The hospital transferred resident #1 to another hospital on [DATE] at 9:30 p.m. for treatment of [REDACTED]. X-rays of the right and left leg were ordered. Review of the x-ray reports dated 8/6/19 at 1:52 a.m. revealed a two-view of the right tibia and fibula that indicated there was a comminuted fracture through the distal tibia and fibula. The [MEDICAL CONDITION] and fibula demonstrate minimal periosteal reaction. The findings suggest subacute fracture with incomplete healing. Impression: Fractures as described above involved the distal fibula and tibia. Continued review of the reports revealed on 8/6/19 at 1:52 a two-view of the left leg was also obtained that indicated: Subacute [MEDICATION NAME] fracture through the proximal metaphysis of the tibia. Interview with S2 DON on 12/12/19 at 10:30 a.m. revealed that through her investigation, it was determined that S5 CNA had not followed the resident's plan of care and attempted to transfer resident #1 with an incorrect lift, and attempted to perform the lift with only a 1 person assist, and the resident sustained [REDACTED]. The surveyor requested the facility's Policy and Procedure for use of the Hoyer and Standing Lift, and was given the Invacare Total Lift Policy and Procedure for the Hoyer Lift. Review of the Invacare Total Lift Policy and Procedure for the Hoyer Lift revealed no documentation of how many staff members were required when the lift was used. However, interview of the DON on 12/12/19 at 1:30 p.m. revealed that 2 person physical assistance by staff was required while using any lift at the facility. Interview with S2 DON on 12/12/19 at 1:30 p.m. revealed the facility used the Invacare Total Lift Policy and Procedure for Hoyer Lift as the facility's written Policy and Procedure for use of a Lift. S2 DON confirmed that she had not reviewed the written policy and procedure, and was not aware the policy/procedure did not include the number of staff needed to perform a safe lift transfer, but should have.

Based on observation, record review and interview the facility failed to ensure that a resident with an indwelling catheter received the appropriate care and services to prevent urinary tract infection to the highest extent possible for 1 (#1) of 2 (#1 and #4) residents with an indwelling catheter out of a sample of 5 residents reviewed. The facility failed to: 1.) Ensure adequate assessment and monitoring of the resident's urine status following the placement of a Foley catheter, and; 2.) Ensure the resident's urinary status was properly assessed and care planned for, including the appropriate interventions. This failed practice resulted in an actual harm on 9/4/18 for Resident #1, who had history of Urinary Tract Infections, when the resident was found with an elevated temperature. Upon transfer to a local hospital, the results of the resident's Urinalysis revealed dark red, cloudy urine with greater than 200+white blood cells, 200+ red blood cells, and 4+ bacteria with 2+ leukocyte esterase, 3+ protein , 1+ [MEDICATION NAME], and positive [MEDICATION NAME]. The resident was admitted into the hospital with the Physician Clinical Impressions of Altered Mental Status, Dehydration, Fever, Right Lobe Pneumonia,[MEDICAL CONDITION], and UTI. The resident remained hospitalized from [DATE] to 9/17/18. Findings: Observation on 9/18/18 at 8:20 a.m. revealed the resident was asleep in her room. She was easily aroused, but she was nonverbal. Her catheter was draining clear yellow urine. Review of resident #1's clinical records revealed the resident was hospitalized from [DATE] to 9/17/18 with [DIAGNOSES REDACTED]. Review of the resident's [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. 8/29/18 - 14 French/5 milliliter indwelling catheter, change every month on the 29th and as needed for leakage or obstruction. 8/29/18 - Catheter care every shift and as needed with soap and water. Review of a late entry nurses' note dated 9/5/18 at 10:27 a.m. revealed the nurse documented that on 8/30/18 (no time recorded), 14 fr/5 cc Foley catheter was put in place without difficulty per MD order, with yellow urine returned. Review of the nurses' notes from 8/31/18 to 9/4/18 revealed there was no subsequent re-assessment or monitoring of the resident's urinary status from the date of catheter insertion (8/30/18) to the date the resident was hosptalized on [DATE]. Review of the resident's current care plan from the admission date of [DATE] revealed there was no care plan to monitor the resident's urine for infection and monitor the status of the resident's indwelling catheter. Review of a nurses' note dated 9/3/18 at 9:28 p.m. revealed the resident had a blood pressure (BP) of 154/69, pulse of 78, RR 20 and temp of 100.3 Fahrenheit. There was no documentation of an assessment of the resident's urine color and quality at that time. Review of a nurse's note dated 9/4/18 revealed there was no further documentation of an assessment of the quality of the resident's urine and/or signs and symptoms. Interview on 9/19/18 at 12:05 p.m. with S2 DON confirmed there was no care plan for the resident's indwelling catheter since the catheter insertion date on 8/30/18. She confirmed there was no assessment in the nurses' notes regarding the resident's catheter or the appearance of the resident's urine from 8/30/18 until the resident was hosptalized on [DATE]. Further interview on 9/19/18 at 2:10 p.m. with S2 DON confirmed the resident had a temperature of 102.1 on 9/3/18 at 8:00 p.m. and 102.3 on 9/4/18 at 6:20 p.m., and there was no documentation of an assessment of the resident's urinary status. Interview on 9/19/18 at 3:27 p.m. with S3 LPN revealed she was on duty the evening of 9/3/18, and confirmed that she did not assess the resident's urine status. Review of resident #1's hospital records revealed the resident was hospitalized from [DATE] - 9/17/18 with [DIAGNOSES REDACTED]. Review of the ER record dated 9/4/18 and timed 7:01 p.m. revealed the resident was seen at the ER by the practitioner with c/o fever. The resident had altered mental status, weak and sick, mucous membranes dry, multiple stage 2 wounds to buttocks, right heel, Stage III to left heel, and positive eschar to left foot plantar region. Continued review of the ER record dated 9/4/18 revealed the resident's vital signs on 9/4/18 at 6:55 p.m. was 100.8, Pulse 110, Respirations 31, BP 137/53 and O2 sat at 95%. Review of the Laboratory report revealed urine was collected on 9/4/18 at 10:37 p.m. The results revealed the urine was dark red in color, cloudy in appearance, urine blood 3+ (normal =negative), urine WBC 200+ (normal= 0-6), Urine bacteria, 4+, urine ph 7 (normal 5-9), Urine [MEDICATION NAME] 1+. Further review of the ER record revealed the Clinical Impression of Dehydration,[MEDICAL CONDITION] type due to Unspecified Organism, Lobar Pneumonia, Altered Mental Status, Fever Unspecified. Review of the physician's History and Physical on hospital admitted d 9/4/18 revealed the resident was brought to the ER with fever and weakness, high temperature, lethargic, aroused with difficulty, and was found to have evidence of UTI, probable Pneumonia, [MEDICAL CONDITION] and was admitted for further evaluation and treatment. The admitting physician treatment plan included IV Fluid Resuscitation, and Broad Spectrum Antibiotics.

Based on observation, interview, and record review the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 (#57) of 18 sampled residents. According to the Resident Census and Conditions of Residents form provided by the facility and dated 2/5/18, the facility's total census was 74 residents. This failed practice resulted in an actual harm situation for resident #57 on 2/3/18 when he was sent to the ER and diagnosed with [REDACTED].#57 who was bed/chair bound, unable to make his needs known, and required assistance with all ADL including being given fluids, was hospitalized from [DATE] to 12/26/17 with [DIAGNOSES REDACTED]. Findings: Review of Resident #57's clinical record revealed he was admitted to the nursing facility on 7/24/13. Review of the resident's Face Sheet revealed the resident had [DIAGNOSES REDACTED]. Review of the resident's return admission assessment dated [DATE] and the resident's Quarterly MDS assessment dated [DATE] revealed his BIMS score was blank, indicating he was cognitively impaired. The above dated MDS assessment further revealed the resident required extensive assistance of 2 or more persons for Bed Mobility, Transfers, and Toileting; extensive assistance of 1 person for dressing, eating and hygiene; and totally dependent for bathing. The above dated MDS also revealed the resident had no ROM limitations to upper and lower extremities. Review of the Departmental Notes dated 12/22/17 revealed the nurse call the physician and reported the resident had been not eating and was drowsy/napping frequently during the day. The physician ordered labs - CBC, CMP TSH/T4 and UA with C&S. The resident was started [MEDICATION NAME] mg one BID X 10 days after the UA results were received. The facility received a call from lab with a critically high lab value of Sodium- 164 (Normal range - 135 to 148 mEq/L). The physician was notified and orders were received to send the resident to the emergency room . Further review of the Departmental Notes revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Dehydration Risk assessment dated [DATE] revealed the resident was assessed for being at a low risk for dehydration. Review of resident #57's Comprehensive Plan of Care revealed the resident had not been care planned for Dehydration Risk Potential until 1/30/18. Review of the RD Dietary assessment dated [DATE] revealed the resident's recommended fluid requirement was 1882 cc/day for a normal resident who was not diagnosed with [REDACTED]. requirement remained at 1882 cc/day for a normal resident who was not diagnosed with [REDACTED]. Review of the Departmental Notes dated 2/3/18 revealed the resident was transferred to the hospital with a [DIAGNOSES REDACTED]. Review of the hospital ED Practitioner Record dated 2/3/18 revealed the resident was admitted to the emergency room with [DIAGNOSES REDACTED]. Observation on 2/07/18 at 11:25 a.m. revealed the resident was in a reclined Geri-chair with no water pitcher or cup in his room. Interview with S5 LPN/Unit Manager on 2/7/18 at 11:40 a.m. who was standing outside the resident's room, revealed she was monitoring the resident while waiting for the CNA to get to the resident's room. She stated the resident was able to feed himself and get his own fluids if they were within reach; however, staff would assist him if they saw that he needed help or was not eating. She stated that the resident's care plan was to assist with meals, if needed. Interview with S6 CNA on 2/7/18 at 11:45 a.m. revealed she was going to put resident #57 to bed to change him. S6 CNA stated the resident required total assistance with all meals and had to be given all fluids to drink because he was cognitively impaired and did not know to ask for them. Interview with S5 LPN/Unit Manager on 2/7/18 at 12:00 p.m. revealed the CNAs were responsible for reporting to the nurses if a resident did not eat or drink well. S5 LPN/Unit Manager was asked who monitored the Meal Intake report to ensure residents received enough fluids and adequate meal intake, and she stated she thought it was the CNA's responsibility. She further stated the facility monitored the resident's CMP labs weekly. Interview with S7 Regional RD and S8 DM on 2/7/18 at 12:20 p.m. revealed all water pitchers with ice were passed at 8:00 a.m. and refilled at 2:00 p.m. daily. S8 DM stated that at 8:00 a.m. each resident was given a new 20 oz. container of ice and water. The residents who were on thicken liquids were given a container with thickened liquids. Interview with S9 CNA on 2/7/18 at 12:22 p.m. confirmed she worked with resident #57 and revealed the resident had a decline in his condition about a month ago and now required total assistance with feeding and receiving his fluids. Interview with S10 LPN on 2/7/18 at 12:30 p.m. confirmed she was the resident's floor nurse. She revealed that S13 MDS/LPN was the one who monitored the Meal Report sheets, and the CNAs were to report and document how much each resident ate and drank at each meal. S10 LPN confirmed the resident required full assistance with meals and fluids for over a month now. Interview with the resident's wife on 2/7/18 at 1:00 p.m. revealed she felt the facility staff were not monitoring or giving the resident fluids between meals. She stated there was a cup on his night stand, but was sure it wasn't his because it had ice and water in it and there was no thickener in it. She stated the resident's roommate was pleasantly confused and used the whole room as his own. She stated she had a meeting with S1 Administrator and S2 DON on Monday, 2/5/18 along with her daughter regarding him not getting enough fluids and the resident having to be hospitalized twice since the end of December, 2017 for a UTI and dehydration. She stated S1 Administrator and S2 DON told her that they were going to put a sheet in the resident's room, so staff could write down each time they gave him fluids. The resident's wife stated that as of today 2/7/18, the staff still had not done that. Interview with S1 Administrator and S2 DON on 2/7/18 at 1:30 p.m. confirmed the resident's family had come Monday (2/5/18) with their concerns. S2 DON confirmed she had not put anything in place to ensure the resident was getting his fluids. She stated she had looked on the computer system and was unable to find a form to monitor the resident's intake. Further interview with S2 DON on 2/7/18 at 2:00 p.m. revealed S13 MDS/LPN was the staff person who monitored the Meal Report weekly for the residents who were on weight loss prevention. S2 DON revealed the facility had not put any measures in place after the resident returned from the hospital on [DATE] with the [DIAGNOSES REDACTED]. She revealed she had updated the resident's care plan on 1/30/18, but had no documentation of any measures to ensure the resident was receiving the fluids he needed. She also confirmed there had been no new or additional measures put in place to ensure the resident was receiving adequate hydration since the resident's return from an ER visit on 2/3/18 with [DIAGNOSES REDACTED]. Interview S2 DON on 2/7/18 at 2:00 p.m. confirmed there should have been measures put in place after the resident's 12/26/17 hospital discharge, his 2/3/18 emergency room visit, and the family's voiced grievance. Review of the resident's labs dated 1/10/18 revealed the resident's sodium was within normal range, but his BUN was 27 (high) - normal range 6 -20. The labs for 1/16/18 revealed the resident's sodium level was 146 (high) - normal range 136 - 145, BUN was 26 (high). The labs for 1/23/18 revealed the resident's sodium level was 154 (high) and his BUN was 35 (high). The labs for 1/30/18 revealed the resident's sodium level was 148 (high), Potassium was 5.24 (high) - normal range 3.5 - 5.10 and his BUN was 37 (high). Interview with S13 MDS/LPN and S15 MDS/LPN on 2/7/18 at 4:15 p.m. confirmed S13 MDS/LPN monitored the Meal Intake reports weekly for residents on weight loss precautions and confirmed resident #57 was on the list. S13 MDS/LPN confirmed she should have evaluated the resident as being at high risk for dehydration on 1/8/18, but that she failed to see that the resident was admitted with [MEDICAL CONDITION] and UTI on his hospitalization on [DATE] - 12/26/17. She confirmed that she had also not care planned the resident for the resident's UTIs. S13 MDS/LPN confirmed the resident should have been care planned for UTI and Dehydration after his hospital stay in December 2017, which would have ensured the nurses were monitoring his intake more closely. Observation of the resident's room on 2/7/18 at 4:56 p.m. revealed a full 20 oz. container of thickened liquids and a full 8 oz. glass of a red colored thickened liquid with a straw on the table. Observation revealed neither of the fluids had been opened. The last hydration pass was done at 2:00 p.m. on that day. Interview with S3 Regional Administrator on 2/8/18 at 9:05 a.m. confirmed the resident not being assessed for being a dehydration risk after just returning from a hospital stay from 12/22/17 to 12/26/17 with the [DIAGNOSES REDACTED]. She also confirmed that the resident not receiving his supper meal on 2/6/18, not being served thickened liquids as ordered, and no measures to ensure the resident received adequate hydration between meals to prevent a reoccurrence of dehydration and UTI, was unacceptable.