Every finding on record at Pleasant View Center

Based on observation, interview, and record review, the facility failed to ensure that residents were assessed to self-administer medication for 1 of 4 residents reviewed for choices in a final sample of 30 residents. (Resident identifier is #1.)Findings include:Observation on 6/2/26 at approximately 8:30 a.m. of Resident #1's bedside table revealed a Phenylephrine HCL (hydrochloride) 1% (percent) nasal spray, expiration date 10/25.Interview on 6/2/26 at approximately 9:00 a.m. with Staff A (Registered Nurse) confirmed the above findings.Interview on 6/2/26 at approximately 8:30 a.m. with Resident #1 revealed that he/she used the nasal spray every night since purchasing the nasal spray months ago and Resident #1 had left the nasal spray on his/her bedside table.Review on 6/4/26 Resident #1's medical record revealed Resident #1 did not have a physician's order for the above medication and that Resident #1 had not been assessed to self-administer medication. Interview on 6/4/26 at approximately 8:00 a.m. with Staff E (Director of Nursing) confirmed Resident #1 was not assessed to self-administer medication and that Resident #1 did not have a physician's order for the Phenylephrine HCL 1% nasal spray.Review on 6/4/26 of the facility policy titled, Resident Self-Administration of Medication, Revision Date: 12/25 revealed . A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .4. The results of the interdisciplinary team assessment is recorded and placed in the resident's medical record .8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage .

Based on interview and record review, the facility failed to ensure that an alleged violation of abuse was reported timely to the State Survey Agency (SSA) for 1 of 5 resident reviewed for Abuse or Neglect. (Resident Identifier is #137.) Findings include:Interview on 6/2/26 at approximately 10:40 a.m. with Resident #137 revealed that he/she recalled an incident in the dining room when Resident #137 felt that a staff member was rude and condescending. Resident #137 further revealed that the incident occurred in front of other residents and family. Resident #137 stated that he/she did complain to staff. Observation on 6/2/26 at approximately 10:45 a.m. of Resident #137 revealed that while recounting the incident he/she became teary and emotional. Interview on 6/2/26 at approximately 11:43 a.m. with Resident #137's spouse revealed that he/she observed part of the incident. Resident #137's spouse further revealed that the staff member was standing over the resident and their voice was aggressive and escalating in tone. Interview on 6/4/26 at approximately 1:15 p.m. with Staff N (Licensed Practical Nurse) revealed that they reported the incident to Staff L immediately after it occured. Interview on 6/4/26 at approximately 1:28 p.m. with Staff L (Assistant Director of Nursing) revealed that they were made aware of the incident on 5/27/26 at approximately around 2:30 p.m. Staff L further revealed that he/she did not report the incident to the administrator. Review on 6/4/26 of the facility reported incident, initial report, submitted to the SSA revealed that it was submitted on 5/29/26.Interview on 6/4/26 at approximately 1:33 p.m. with Staff Q (Administrator) confirmed that the alleged violation was reported late to the SSA. Review of the facility's policy Abuse, Neglect and Exploitation, last reviewed 6/25, revealed, V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . VII. Reporting/Response A. 1. Reporting of alleged violations to the administrator, state agency, adult protective services and to all other required agencies .a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse . B. The administrator will follow up with government agencies, during business hours, to confirm the initial report was received .

Based on observation, interview, and record review, the facility failed to follow professional standard for medication administration via jejunostomy tube for 1 of 3 residents observed for medication administration. (Resident identifier is #14.)Findings include: Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 608 Because the nurse who administers the medication is responsible for any errors related to it, nurses administer only the medications they prepare. You cannot delegate preparation of medication to another person and then administer the medication to the patient. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Page 618-619, .Administering Medications Through an Enteral Tube (Nasogastric Tube, G-tube [gastrostomy tube], J-tube [jejunostomy tube], or Small-Bore Feeding Tube .Steps .Before administration of enteral medications, verify placement of feeding tube according to agency policy and determine that tube is placed in the stomach or small intestine correctly .Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents .Check for gastric residual volume . Observation on 6/3/26 at approximately 2:00 p.m. with Staff A (Registered Nurse) during Resident #14's medication administration revealed that Staff A prepared and crushed the following medications then placed it in individual medicine cups: Baclofen 20 milligram (mg), Oxycodone 5 mg, Tizanidine 2 mg, Ondansetron 4 mg, and Excedrin (250 mg acetaminophen, 250 mg aspirin, 65 mg caffeine). Staff A administered the medications via Resident #14's J-tube and did not verify the placement of the J-tube prior to administering the medications. Further observation revealed that after administering the medications to Resident #14, one of the medication cups had crushed white powder (medication) mixed with liquid (water) left in the cup. Observation also revealed that Staff A documented and saved the above mentioned medications as administered in the electronic Medication Administration Record (eMAR), except for Excedrin, using Staff O's (Medication Nursing Assistant (MNA)) eMAR login. Interview on 6/3/26 at approximately 2:00 p.m. with Staff A confirmed the above observation and that the medication cup that was thrown in the trash and had crushed white powder left was Resident #14's Tizanidine 2 mg medication. Staff A revealed that only the licensed nurses were to administer medications to Resident #14's J-tube and not MNAs. Review on 6/4/26 of Resident #14's June 2026 MAR revealed that on 6/1/26 the following medications were documented as administered via J-tube by Staff O: Ondansetron 4 mg, Excedrin, Baclofen 20 mg, and Tizanidine 2mg. Interview on 6/4/26 at approximately 12:00 p.m. with Staff O revealed that he/she did not administer medications to Resident #14's J-tube and that it was the licensed nurses that were responsible in administering Resident #14's J-tube medication. Staff O confirmed that he/she documented the above mentioned medications as administered to Resident #14 on 6/1/26; however, he/she did not administer those medications on that date. Interview on 6/4/26 at approximately 12:00 p.m. with Staff P (Registered Nurse) revealed that he/she administered Resident #14's above mentioned medications on 6/1/26, which had been prepared by Staff O. Staff P also revealed that the medications were already crushed before he/she was called to administer the medications to Resident #14's J-tube. Review on 6/4/26 of Resident #14's enteral feeding tube care plan, revision date 1/5/26, revealed an intervention to check patency and placement of the J-tube daily before administering feedings and medications. Review on 6/4/26 of the facility policy titled, Medication Administration via Enteral Tube, revision date 12/2025, revealed, .Enteral tube placement must be verified prior to administering any fluid or medication .

Based on observation, interview, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing for 1 of 1 resident reviewed for pressure ulcers in a final sample of 30 residents. (Resident identifier is #38).Findings include:Review on 6/3/26 of Resident #38's Admission/Re-Admission/Quarterly Screening (an assessment form) with an effective date of 5/19/26 revealed under Section K Skin Integrity that the resident readmitted to the facility with the following pressure areas:1. Right heel pressure area 2.5 cm (centimeters) length by 3 cm width by 0.3 depth; 2. Left heel pressure area 0.5 cm length by 0.5 cm width by 0.2 cm depth;3. Sacrum pressure 1.5 cm length by 1.5 cm width by 0.2 cm depth.Further review revealed that the pressure ulcers were not staged and there was no other description of the wounds or the surrounding tissue. Review on 6/3/26 of Resident #38's provider note for date of service 5/21/26 and signed by the provider on 6/3/26 revealed the following under Wound Care, . wounds [sic] are to the right heel measuring 2 cm x [by] 1.5 cm x 0.2 cm with moderate sanguinous drainage and no sign of infection, no pain or discomfort. Treatment at this time is to clean with warm cleanser, pat dry and apply Anasept get and AG silver and cover with for me [sic] dressing. Area of the sacrum measuring 2 cm x 1.5 cm x 0.4 cm with moderate sanguinous drainage 2 cm x2 cm and 0.2 cm moderate sanguinous drainage with no sign of infection [sic]. Treatment will clean with wound cleanser, pat dry and apply Anasept gel and calcium Ag to wound bed cover with foam dressing . Area to the left heel is closed but fragile skin, no drainage, no sign of infection and no complaint of pain or discomfort. Treatment cleanse with wound cleanser, pat dry, Skin-Prep and cover with foam dressing . Further review revealed that the pressure ulcers were not staged. Review on 6/3/26 of Resident #38's Treatment Administration Record for May 2026 and June 2026 and current physician's orders revealed that there were no physician's orders for treatments for the above pressure areas. Review on 6/3/26 of Resident #38's Weekly Skin Review Assessment revealed the following:On 5/23/26 and 5/26/26 revealed that under Section 1.1 Skin Intact was coded no. Further review revealed that if no, a wound assessment must be completed. Further review revealed under Section 3.1 Skin Observations that no pressure areas were documented. On 6/3/26 the right and left foot had pressure areas, the coccyx had redness. Further review revealed that the pressure ulcers were not staged, measured or described. Review on 6/3/26 of a Late Entry progress note, dated 5/27/26 and entered on 6/3/26, revealed, Area to L [left] heel closed but fragile skin. no drainage, no s/sx [signs or symptoms] of infection, no c/o [complaints of] pain or discomfort. Treatment: cleanse with wound cleanser, pat dry, skin prep and cover with foam dressing. Area to right heel measure 2cm x2 cm x0.2 cm, moderate sero sang [serosanguinous] drainage. no s/sx of infection, no c/o pain or discomfort. Treatment: clean with wound cleander [sic], pat dry, apply anasept gel and AG silver and cover with foam dressing. Area to sacrum measuring at 2cm x1.5 cm x 0.4 cm. moderate sero sang drainage 2cm x2 cmx0.2 cm, moderate sero sang drainage. no s/sx of infection, no co/o pain or discomfort. Treatment cleanse with wound cleanser, pat dry, apply anasept gel and calcium ag to wound bed cover with foam dressing . Further review revealed the pressure ulcers were not staged. Observation on 6/3/26 at 10:20 a.m. of Resident #38's dressing revealed an undated dressing on the right heel and a dressing to the sacral area dated 6/2/26 3-11 shift. There was no dressing on the left heel. Observation on 6/03/2026 at 1:41 p.m. of Staff U (Wound Care Nurse) and Staff G (Registered Nurse) providing wound care to Resident #38 revealed the following:1. The right heel had an open area with dry black flaky skin surrounding it. Staff U measured the wound as 2.5 cm length by 2 cm width by 0.3 cm depth. The area was cleansed, anasept gel and silver alginate applied and covered with foam dressing. 2. The left inner heel had dark red area, not open. There were no measurements taken. The area was cleansed, skin-prep applied and covered with foam dressing. 3. The sacral area had an open area with a crusty brown covering part of the wound. Staff U measured the wound as 2 cm length by 1 cm width by 0.2 cm depth. The area was cleansed, anasept gel and silver alginate applied and covered with foam dressing. Interview on 6/4/26 with Staff U and Staff E (Director of Nursing) confirmed that the wounds had not been staged and that there were no physician orders to treat the wounds. Review on 6/4/26 of the facility's policy titled Documentation of Wound Treatment revised on 12/2025 revealed, .1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment . b. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue pressure injury, unstageable pressure injury) . d. Description of wound characteristics: i Color of the wound bed ii Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium) iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated) iv. Presence, amount and characteristic of wound drainage/exudate v. Presence or absence of odor vi Presence of absence of pain 3. Wound treatments are documented at the time of each treatment .

Based on observation, interview, and record review, the facility failed to ensure that ordered devices were used to maintain mobility for 1 of 1 residents reviewed for range of motion in a final sample of 30 residents. (Resident identifier is #145.) Findings Include: Review on 6/3/26 of Resident #145's medical record revealed an order to Apply right palmar protector after breakfast until dinner always removing for meals, with a start date of 5/21/26. Observation on 6/2/26 at approximately 1:30 p.m. of Resident #145 revealed Resident #145 was in a sitting Broda chair near the nurses' station with his/her right hand closed tightly and no palm protector in place. Observation on 6/3/26 at 11:51 a.m. of Resident #145 revealed Resident #145 was sitting in Broda chair with right hand closed tightly and no palm protector in place. Interview on 6/3/26 at 12:06 p.m. with Staff I (Occupational Therapist) revealed that Resident #145 worked with occupational therapy for decreased range of motion on right hand with a discharge date of 5/29/26. Staff I further revealed that multiple palm protectors had been provided for Resident #145. Interview on 6/3/26 at approximately 12:30 p.m. with Staff J (Licensed Nursing Assistant), revealed that Staff J provided care to Resident #145 that morning and that Resident #145 does have a palm protector for their right hand. Staff J confirmed he/she did not apply the palm protector to Resident #145 after breakfast. Review on 6/3/26 of Resident #145's occupational therapy discharge note, dated 5/29/26, revealed Pt [patient] tolerating palmar protector well in order to avoid further contractions and skin breakdown.Review on 6/3/26 of Therapy to Nursing Communication Form, dated 5/20/26, and labeled with Resident #145's name revealed Pt to wear built up palm protector during day remove during meals .

Based on observation, interview and record review, the facility failed to ensure medications were labeled according to professional standards and that expired medications were not available for use for 2 of 2 medication rooms and 2 of 3 medication carts observed. Findings include: Observation on 6/2/26 at approximately 8:13 a.m. of the Second Floor North Medication Cart with Staff V (Licensed Practical Nurse (LPN)) revealed the following open and used medications with no open date or discard dates: Resident #11's Latanoprost Ophthalmic Solution 0.005% (percent), with a dispensed date of 5/14/26 and no open date or open expiration date. Resident #55's Ventolin 90 mcg (microgram) inhaler with a dispensed date of 1/7/25 and no open date or open expiration date. Resident #137's Olopatadine Hydrochloride Solution 0.2%, with a dispense date of 3/31/26 and no open date or open expiration date. Resident #137's Gentamicin Sulfate 0.3% Ophthalmic Solution with a dispensed date of 4/13/26 and no open date or open expiration date. Interview on 6/2/26 at approximately 8:36 a.m. with Staff V confirmed the above findings. Observation on 6/2/26 at approximately 8:41 a.m. with Staff P (RN) of the Second Floor Medication room revealed two open Tuberculin Purified Protein Derivative in the refrigerator with a dispensed date of 4/8/26 and no open date or open expiration date. Interview on 6/2/26 at approximately 8:45 a.m. with Staff P confirmed the above findings. Review on 6/2/26 of Resident #137's physician's orders revealed that Olopatadine Ophthalmic solution was discontinued on 4/27/26. Review on 6/2/26 of Resident #137's Medication Administration Record (MAR) revealed that Resident #137 stopped receiving the Gentamicin Ophthalmic solution on 4/20/26. Observation on 6/2/26 at approximately 8:10 a.m. of the fourth floor medication room with Staff B (Medication Nursing Assistant (MNA)) revealed an open vial of Tuberculin Purified Protein Derivative (PPD) with an open date of 4/8/26. Interview on 6/2/26 at approximately 8:15 a.m. with Staff B confirmed the above finding. Review on 6/2/26 of manufacturers' instructions for PPD revealed: Storage . Vials in use more than 30 days should be discarded . Interview on 6/3/26 at approximately 9:00 a.m. with Staff W (Regional Director of Staff Development and Infection Prevention) revealed that there were eight residents that received PPD's between 5/8/26 and 6/2/26. Review on 6/2/26 at approximately 8:45 a.m. of third floor south west cart with Staff T (MNA) revealed one bottle of Timolol Maleate 0.05% for Resident #54 revealed a manufacturer's expiration date of 4/2026. Further observation revealed a bottle of Latanoprost 0.005% eye drops with no open date and no open expiration date and a bottle of Dorzolamide Hydrochloride and Timolol Maleate 2%/0.5% for Resident #160 with no open date or open expiration date. Interview on 6/2/26 at approximately 8:50 a.m. with Staff T confirmed the above findings in the third floor south west medication cart. Review on 6/4/26 of the facility policy titled, Medication Storage, Revision Date 10/22 revealed: 8.whichever comes first. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, . These medications are destroyed in accordance with out Destruction of Unused Drugs Policy. 9. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Review on 6/2/26 of the Manufacturer's instructions for Gentamicin Ophthalmic Solution revealed, . Storage note: Once open, sterile eye drops lose effectiveness after about 4 weeks . Review on 6/4/26 of Manufacturer's instructions for Latanoprost Ophthalmic Solution 0.005% revealed, Once a bottle is opened for use, it may be stored at room temperature . for 6 weeks. Review on 6/4/26 of the Manufacturer's instructions for Ventolin 90 mcg revealed, The inhaler should be discarded when the counter reads 000 or 12 months after removal from the moisture protected foil pouch, which ever comes first.

Based on interview and record review, the facility failed to assist a resident to obtain dental care for 1 of 1 resident reviewed for dental in a final sample of 30 residents. (Resident identifier is #51.)Findings include: Interview on 6/2/26 at approximately 8:45 a.m. with Resident #51 revealed he/she has been complaining of dental pain. Resident #51 stated, My teeth are rotten and I have been asking to see the dentist for months. They hurt and no one is helping me see a dentist. Review on 6/3/26 of Resident #51's dental record revealed he/she was last seen by the dentist at the facility on 9/15/25 with a recall date of 9/1/26. Review on 6/3/26 of Resident #51's physician's progress note, dated 4/16/26, revealed, . [pronoun omitted] reports overall dental pain and would like to see the in house dentist. dental pain reported, . Dental care needs: Referral placed for in-house dental consult. Interview on 6/4/26 at approximately 10:45 a.m. with Staff E (Director of Nursing) revealed the facility dentist has been in the building on 5/11/26 and 6/1/26, and Resident #51 had not been seen by the dentist since 4/16/26. Review on 6/4/26 of Resident #51's current care plan revealed he/she did not have interventions for dental care. Interview on 6/4/26 at approximately 10:45 a.m. with Staff C (Staff Development Coordinator/Infection Preventionist) confirmed Resident #51 did not have a dental care plan.

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and procedures for 1 of 4 Residents reviewed for Enhanced Barrier Precautions (EBP). (Resident identifier is #35).Findings include:Observation on 6/2/26 of Resident #35's door to his/her room revealed signage for EBP.Review on 6/2/26 of Resident #35's physician orders revealed that he/she had an order dated 3/9/26, Maintain Enhanced Barrier Precautions for Indwelling Medical Device(s). Specify device: suprapubic catheter.Observation on 6/2/26 at approximately 10:54 a.m. revealed Staff H (Licensed Nursing Aide (LNA)) opened Resident #35's door from the inside and Staff H was wearing gloves and no gown.Interview on 6/2/26 at approximately 11:15 a.m. with Staff H revealed that Staff H was providing bathing, dressing, and personal care assistance for Resident #35 while not wearing a gown. Staff H further revealed that they would wear a gown when working directly with the resident's catheter. Observation on 6/2/26 at approximately 11:00 a.m. revealed Staff K (LNA) entering Resident #35's room without donning gloves and a gown.Interview on 6/2/26 at approximately 11:15 a.m. with Staff K revealed that Staff K was assisting with transferring Resident #35 wearing gloves and no gown.Review on 6/4/26 of the facility's policy Enhanced Barrier Precautions, reviewed 9/25, revealed . Implementation of Enhanced Barrier Precautions .b. PPE for enhanced barrier precautions is only necessary when performing high-contact activities . 4. High-contact resident activities include a. Dressing b. Bathing c. Transferring d. Providing hygiene e, Changing linens f. Changing briefs or assisting with toileting g. Device care or use: .urinary catheters .

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 3 of 5 residents reviewed for resident assessment and 1 of 1 resident reviewed for pressure ulcer in a final sample of 30 residents. (Resident Identifier are #23, #38, #109, and #129.)Findings include:Resident #23 Review on 6/2/26 of Resident #23's Entry Tracking Record with an entry date of 3/11/26 revealed that under item A0810 - Sex was coded Male. Review on 6/2/26 of Resident #23's admission Record revealed that Resident #23 was admitted to the facility in March 2026 and had the assigned sex of female. Interview on 6/4/26 at 1:02 p.m. with Staff M (MDS Coordinator) confirmed that Resident #23's sex was incorrectly coded. Resident #38 Review on 6/4/26 of Resident #38's 5-Day MDS with an Assessment Reference Date of 5/25/26 revealed under Section M - Skin Conditions item M0210 Unhealed Pressure Ulcers/Injuries was coded No. Further review revealed under items M0300 no pressure ulcers were coded. Review on 6/3/26 of Resident #38's Admission/Re-Admission/Quarterly Screening with an effective date of 5/19/26 revealed under Section K Skin Integrity identified right heel, left heel and sacral pressure ulcers. Interview on 6/03/2026 at 9:32 a.m. with Staff U (Wound Care Nurse) revealed that Resident #38 confirmed the above pressure ulcers for Resident #38. Interview on 6/4/26 at 1:02 p.m. with Staff M confirmed that Resident #38's above 5-Day MDS for the above sections was incorrectly coded. Resident #109 Review on 6/4/26 of Resident #109's Quarterly MDS, with an Assessment Reference Date 2/17/26, revealed that hospice services was coded No indicating that Resident #109 did not receive hospice services. Review on 6/4/26 of Resident #109's physician's order revealed an order to admit to hospice on 6/7/25. Interview on 6/4/26 at approximately 1:02 p.m. with Staff M confirmed that hospice services was coded No on the above mentioned Quarterly MDS. Interview on 6/4/26 at approximately 1:30 p.m. with Staff C (Staff Development Coordinator/Infection Preventionist) revealed Resident #109 was receiving hospice services on 2/17/26. Resident #129 Review on 6/3/26 of Resident #129's Quarterly MDS, with an Assessment Reference Date (ARD) of 5/11/26 revealed under section N0415 Medications: High-Risk Drug Classes: Use and Indication E. Anticoagulant was coded taking, indicating that Resident #129 had received an anticoagulant medication during the last 7 days. Review on 6/2/26 of Resident #129's Medication Administration Record for May 2026 revealed that no anticoagulant medication was ordered or administered between 5/4/26 to 5/11/26. Review on 6/4/26 of the facility's policy MDS 3.0 Completion last revised 12/2025 revealed, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . 4. Care Plan Team Responsibility for Assessment Completion: b. Coding of Assessment: i. All disciplines shall follow the guidelines in Chapter 3 of the current RAI [Resident Assessment Instrument] Manual for coding each assessment .

Based on interview and record review, the facility failed to ensure that resident's medical records were accurate and complete for 3 of 4 residents reviewed for closed records and 2 residents in a final sample of 30 residents. (Resident Identifiers are #9, #18, #30, #146, and #164.)Findings include: Resident #9 Interview on 6/2/26 at approximately 10:00 a.m. with Resident #9 revealed that Resident #9 had a foley catheter and no concerns. Review on 6/2/26 of Resident #9's physician's orders revealed and order dated 4/10/26 that stated, Foley catheter__ FR with __ balloon to bedside straight drainage for diagnosis/Hx (History) of need____. Further review revealed that the order audit for the foley catheter was reviewed and confirmed by Staff X (Registered Nurse Supervisor), Staff L (Assistant Director of Nurses (ADON)) and Staff R (Doctor of Medicine). Interview on 6/3/26 at approximately 1:14 p.m. with Staff L revealed that Staff L had placed the foley catheter order on 4/10/26 and confirmed the order information was incomplete. Staff L further revealed that there was no other active order that contained the complete information. Review on 6/4/26 of the facility's policy Appropriate Use of Indwelling Catheters, Revised 12/25, revealed, .4. The use of an indwelling catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable). Resident #18 Review on 6/3/26 of Resident #18's medical record revealed a physician's order dated 5/25/26, OK to Discharge home on 5/26/26 . Review on 6/3/26 of Resident #18's Discharge summary, dated [DATE], revealed that Resident #18's anticipated discharge was on 5/26/26. Review on 6/3/26 of Resident #18's progress note, dated 5/28/26 at 5:07 p.m., revealed that, Resident discharged home with family member in stable condition. Interview on 6/4/26 at approximately 6/4/26 with Staff L confirmed the above findings for Resident #18. Staff L revealed that there was no order from the provider for discharge on [DATE]. Review on 6/4/26 of the facility's policy titled, Transfer and Discharge (including Against Medical Advice (AMA)), reviewed on 6/25, revealed .12. Anticipated Discharge to the community a. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care . Resident #164 Review on 6/3/26 of Resident #164's a progress noted. dated 3/6/26, revealed that Resident #164 was having terminal secretions. Further review revealed that the Resident 164's body was released to the funeral home on 3/6/26. There was no documentation of Resident #164 assessment of death and pronouncement. Interview on 6/3/26 at approximately 2:46 p.m. with Staff G (RN) revealed that Staff G pronounced Resident #164 on 3/6/26 and confirmed that he/she did not document it the medical record. Staff G further revealed that the pronouncement order and pronouncement documentation was not in Resident #164's medical record. Resident #146 Review on 6/3/26 of Resident #146's progress note, dated 3/30/26 at 4:49 a.m., revealed [First name omitted] passed at approximately 445am. Further review revealed no documentation of clinical signs of death. Interview on 1/8/25 at 12:30 p.m. with Staff W (Regional Director of Staff Development/Infection Prevention) confirmed the above findings. Resident #30 Interview on 6/2/26 at approximately 12:10 p.m. with Resident #30 revealed he/she could not recall the last time he/she has seen a podiatrist. Review on 6/3/26 of Resident #30's medical record revealed there was no documentation of a podiatrist visit. Interview on 6/3/26 at approximately 9:30 a.m. with Staff F (Social Worker) revealed Resident #30 was seen by an outside podiatrist on 2/9/26 and there was no documentation in Resident #30's medical record of the visit. Review on 6/4/26 of the facility policy titled, Documentation in Medical Record, Revision Date 12/25, revealed, .Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through, complete, accurate, and timely documentation . Review on 6/4/26 of the facility policy titled, Maintenance of Electronic Clinical Records, Revision Date 6/25, revealed, . 1. A complete and accurate electronic clinical record will be maintained on each resident . Review on 6/4/26 of the facility's Post Mortem Care policy, reviewed 12/25 revealed, 1. Upon expiration of resident within the facility, the resident shall be pronounced by the physician or other designated entity as per state and local regulations 4. The family will be contacted and follow-up and/or confirmation of the disposition of the body will be determined 25. Document in the medical record: a. Date and time resident was pronounced and by whom. b. Notifications to the physician or designee, family, funeral home, or other designated disposition location, coroner, and/or authorities (if indicated). c. Post mortem care and disposition of belongings. d. Date and time body was transported to the funeral home or other designated location.

Based on interview and record review, it was determined that the facility failed to facilitate the inclusion of the resident and/or representative in quarterly care plan meetings for 5 of 5 residents reviewed for care plan meetings in a final sample of 30 residents. (Resident identifiers are #6, #13, #16, #37, and #68). Findings include: Resident #13 Interview on 1/9/26 at 12:44 p.m. with Resident #13 revealed that he/she had not attended a care plan meeting in over a year. Review on 1/9/26 of Resident #13's medical record revealed that there was a care plan meeting note, dated 10/29/24. Further review revealed that there was no documentation of a care plan meeting for Resident #13 after 10/29/24. Resident #16 Interview on 1/9/26 at 12:47 p.m. with Resident #16 revealed that Resident #16 had never attended a care plan meeting. Review on 1/9/26 of Resident #16's medical record revealed that there was no documentation of a care plan meeting since Resident #16's admission in 2024. Resident #37 Interview on 1/9/26 at 12:38 p.m. with Resident #37 revealed that he/she had not attended a care plan meeting since 2024. Review on 1/9/26 of Resident #37's medical record revealed that there was a care plan meeting note dated 2/15/24. Further review revealed that there was no documentation of a care plan meeting for Resident #37 after 2/15/24. Resident #6 Review of on 1/7/26 of Resident #6's medical record revealed that there was no documentation of a care plan meeting for Resident #6 after 5/27/25. Interview on 1/9/26 at approximately 1:30 p.m. with Resident #6 confirmed that he/she did not remember the last time they had a care plan meeting. Resident #68 Review on 1/9/26 of Resident #68's medical record revealed that there was no documentation of a care plan meeting for Resident #68 since readmission in June 2025. Interview on 1/9/26 at approximately 1:15 p.m. with Resident #68 confirmed that he/she does not remember the last time they had a care plan meeting. Interview on 1/9/26 at 9:35 a.m. with Staff E (Social Worker) confirmed that were no quarterly care plan meetings for Resident #6, #13, #16, #37, and #68. Review on 1/9/26 of facility policy titled Care Planning-Resident Participation, revised 6/25, revealed .10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion of viewing of the care plan .

Based on interview and record review, it was determined that the facility failed to document that the resident and/or the resident's representative was fully informed of the risk and benefits of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 30 residents. (Resident identifier is #66). Findings include:Review on 1/9/26 of Resident #66's provider progress note, dated 12/5/25, revealed the following: Depression currently treated with Sertraline 25 mg daily; decision made to change regimen, discontinue Sertraline 25 mg [milligram] daily. Prescribed Duloxetine 30 mg daily. Interview on 1/9/26 at approximately 9:00 a.m. with Staff F (Nurse Practitioner) revealed that he/she did not explain the risks and benefits of the medication with Resident #66 and/or their representatives before starting the duloxetine. Review on 1/9/26 of Resident #66's December Medication Administration Record revealed that Resident #66 was administered Duloxetine HCI (Hydrochloride) Capsule Delayed Release Particles 30 MG (Antidepressant) 1 time daily since 12/5/25. Review 1/8/26 of Resident #66's medical record revealed that there was no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medication. Interview on 1/9/26 at 1:55 p.m. with Staff L (Director of Nursing) confirmed the above findings. Review on 1/12/26 of facility policy titled Use of Psychotropic Medication(s), revised 12/25, revealed .9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase .

Based on interview and record review, it was determined that the facility failed to provide resident choice regarding meal times for 2 out of 3 residents reviewed for choices in a final sample of 30 residents (Resident identifiers are #48 and #64). Findings include:Resident #64Interview on 1/7/2026 at approximately 10:15 a.m. with Resident #64 revealed that the he/she has dialysis three times a week and usually returns to the facility during lunchtime. His/her meal tray is usually delivered and waiting for them when they return from dialysis and the food is cold. Resident #64 has requested the meal be reheated and staff stated they could not. Resident #64 has to eat the meal cold.Resident #48Interview on 1/6/2026 at approximately 9:20 a.m. with Resident #48 revealed that he/she was not always ready to eat when the meal tray was served. When Resident #48 requested the meal be reheated, staff stated they could not due to germs. Resident #48 said they had to eat the meal cold.Interview on 1/6/2026 at approximately 12:30 p.m. with Staff P (Licensed Nursing Assistant) revealed the staff used to heat food for residents, but are not allowed anymore due to cross contamination.Interview on 1/6/2026 at approximately 12:40 p.m. with Staff Q (Registered Nurse) revealed they reheat food unless the resident has eaten already due to germs on their plate/food.

Based on observation, interview and record review, it was determined that the facility failed to ensure admission medications and supplements were administered for 1 of 2 newly admitted residents reviewed. (Resident Identifier is #163).Findings include:Interview on 1/9/26 at 1:42 p.m. with Resident #163 revealed that he/she was admitted to the facility on [DATE] and was not given all of their medications that evening. Review on 1/9/26 of Resident #163's Progress Notes, dated 1/5/26 at 1:20 p.m., revealed a Social History and Initial Assessment was completed by Social Services. Review on 1/9/26 of Resident #163's January 2026 Medication Administration Record revealed the following medications and supplements ordered by the physician was not documented as administered:On 1/5/26:Melatonin Tablet 3 milligrams (mg) fat, scheduled for 8:00 p.m.,MiraLAX Powder 17 grams, scheduled for 7:00 p.m. to 11:00 p.m.,Olanzapine Tablet 2.5 mg, scheduled for 8:00 p.m.,Phenytoin Sodium Extended Oral Capsule 30 mg eight tablets (240 milligrams), scheduled at bedtime (8:00 p.m.),Sennosides-Docusate Sodium tablet 8.6-50 mg give 2 tablets twice daily scheduled for 7:00 p.m. to 11:00 p.m.,Tamiflu Oral Capsule 75 mg twice daily for positive flu, scheduled for 7:00 p.m. to 11:00 p.m., andTuberculin Solution 5 units administer 0.1 milliliters scheduled for 3:00 p.m. to 11:00 p.m. On 1/6/26:Phenytoin Sodium Extended Capsule 100 mg scheduled for 6:00 a.m., Coenzyme Q10 Oral Capsule 100 mg scheduled for 7:00 a.m. to 12:00 p.m.,andTamiflu Oral Capsule 75 mg twice daily scheduled for 7:00 a.m. to 12:00 p.m. Review on 1/9/26 of Resident #163's Progress Notes revealed the following notes:On 1/5/26 at 8:14 p.m., medication on order waiting for arrival. There was no documentation that Resident #163's provider was notified.On 1/6/26 at 5:18 a.m., a note indicated Phenytoin Sodium Extended Capsule was not administered due to waiting to receive stock. On 1/6/26 at 7:55 a.m., a note indicated Coenzyme Q10 Oral Capsule was not administered due to waiting to receive from pharmacy.On 1/6/26 at 7:56 a.m., a note indicated Tamiflu Oral Capsule was not administered due to waiting to receive from pharmacy. There was no documentation that Resident #163's provider was notified. Interview on 1/9/26 at 1:55 p.m. with Staff F (Nurse Practitioner) revealed that he/she was not notified of the above missed doses.Review on 1/9/26 of the facility's Active Inventory List for medications revealed that Olanzapine 2.5mg tabs and Phenytoin Sodium extended 100 mg would be available in the facility's automated medication dispenser (a machine set up by pharmacy to keep prescription medications). Observation on 1/09/2026 at 2:23 p.m. of the Second Floor Medication Room with Staff H (Registered Nurse) and Staff G (Nursing Supervisor) revealed that melatonin, MiraLAX, Tamiflu, Sennosides-Docusate Sodium, Coenzyme Q10 and Tuberculin were available in the house stock. Further review revealed the facility kept active inventory of Olanzapine 2.5 mg and Phenytoin Sodium extended 100 mg in the automated medication dispenser. Interview on 1/9/26 at 2:38 p.m. with Staff I (Licensed Practical Nurse) confirmed that he/she had worked the evening shift on 1/5/26 and did not administer the above medications. Staff I revealed that he/she did not have a code to access the facility's automated medication dispenser on that day.

Based on record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for 2 of 3 residents reviewed for smoking, and 1 of 1 residents reviewed for dementia care in a final sample of 30 residents (Resident Identifiers are #38, #66 and #113). Findings include:Resident #66 Review on 1/9/26 of Resident #66's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/25 under section F0400 - Interview for Activity Preferences revealed that while Resident #66 was in the facility, very important was coded for the following: to have books, newspapers, and magazines to read; listen to music; be around animals; keep up with the news; do things with groups of people; do you favorite activities; do your favorite activities, and participate in religious services or practices. Review on 1/9/26 of Resident #66's care plan revealed there was no care plan interventions for activities. Interview on 1/9/26 at 9:35 a.m. with Staff D (Director of Social Services) confirmed the above findings. Resident #38 Interview on 1/6/26 at approximately 10:00 a.m. with Resident #38 revealed that Resident #38 would smoke occasionally and was supervised by staff while smoking. Review on 1/6/26 of Resident #38's smoking/vaping screening assessment, dated 1/5/26, revealed that Resident #38 required supervision while smoking. Review on 1/9/26 of Resident #38's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/25 revealed that section J1300 - Current Tobacco Use was coded Yes, indicating that at the time of the assessment, Resident #38 was using tobacco. Review on 1/8/26 of Resident #38's care plans revealed that there was no care plan for smoking. Resident #113Interview on 1/7/26 at 10:54 a.m. with Resident #113 revealed that he/she was a smoker. He/she stated that he/she was able to go outside to the designated smoking area anytime that he/she wanted. Review on 1/9/26 of Resident #113's smoking/vaping screening assessment, dated 1/6/26, revealed that Resident #113 was an unsupervised smoker. Review on 1/9/26 of Resident #113's care plans revealed that there was no care plan interventions for smoking. Interview on 1/9/26 at approximately 10:30 a.m. with Staff J (Registered Nurse Supervisor) confirmed that there was no care plan in place for smoking for Resident #38 and Resident #113. Review on 1/9/25 of the facility's policy, Resident Smoking/Vaping, revised 1/25, revealed .10. All safe smoking/vaping measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking/vaping. Supervision will be provided as indicated on each resident's care plan .

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for 1 of 2 residents reviewed for insulin, for 1 of 4 residents observed for medication administration, and for 1 of 3 residents reviewed for smoking in a final sample of 30 residents (Resident Identifiers are #4, #38, and #47). Findings include: Resident #4 Standard: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Interview on 1/7/2026 at approximately 11:40 a.m. with Resident #4 revealed he/she sometimes doesn't get his/her insulin. Review on 1/9/2026 of Resident #4's physician orders revealed Insulin Lispro inject per sliding scale [based on blood sugar]: if 0-150 = 0 units, 151-200 = 3 units,201-250 = 7 units, 301-350 = 9 units, 351-499 = 12 units, if greater than 500 call provider, subcutaneously before meals and at bedtime for diabetes. Review on 1/9/2026 of Resident #4's December 2025 Medication Administration Record (MAR) revealed no documentation for blood sugars or insulin administered on 12/9/25, 12/15/25, 12/28/25, and 12/29/25 at 6:00 a.m. Review on 1/9/2026 of Resident #4's January 2026 MAR revealed no documentation for blood sugars or insulin administered on 1/5/26 at 5:30 p.m. Interview on 1/9/2026 at approximately 3:00 p.m. with Staff F (Nurse Practitioner) confirmed the above missed blood sugars and insulin. Review on 1/9/2026 of facility policy titled Medication Administration revised 12/25 revealed .Policy Explanation and Compliance Guidelines:.10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation Resident #38 Standard: Department of Health and Human Services, Food and Drug Administration [Docket No. FDA-2013-N-0341} Federal Register :: Modifications To Labeling of Nicotine Replacement Therapy Products for Over-the-Counter Human Use II. Proposed Revisions to the Labeling of OTC NRT Products A. Concomitant Use of OTC NRT Products With Cigarettes or Other Nicotine-Containing Products, Including Other NRT. The Drug Facts section of the label for OTC NRT products currently contains two statements relating to the use of these products with other nicotine-containing products. The first statement is found under the Do not use subheading of the Warnings section. It instructs consumers not to use the OTC NRT product if they continue to smoke, chew tobacco, use snuff, or use [a different NRT product] or other nicotine containing products. Review on 1/8/26 of Resident #38's physician orders revealed the following order, dated 12/24/25, Nicotine Patch 24 hour, Apply 14 mg [milligram] trans dermally every 24 hours for smoking cessation for 6 weeks. Rotate patch sites daily. Do not leave on for more than 24 hours and be sure to remove old patch before applying new patch. Interview on 1/8/26 at approximately 9:45 a.m. with Resident #38 revealed that Resident #38 was a smoker and would go out to smoke in the afternoon with staff. Interview further revealed that he/she went out to smoke on 1/7/26 at 6:30 p.m. and that a staff member removed the nicotine patch prior to him/her smoking. Interview on 1/08/26 at approximately 11:30 a.m. with Staff F (Nurse Practitioner) revealed that Resident #38 had a long history of smoking prior to coming to the facility. In December, Resident #38 wanted to quit smoking cold turkey. He/she placed an order for the nicotine patch for Resident #38. Interview further revealed that Staff F was not aware that Resident #38 was occasionally smoking. Review on 1/12/26 of the facility's policy Resident Smoking/Vaping, revised 1/25, revealed .14. The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking.vaping by: a. Including the resident, family, and/or resident representative in discussions regarding the risks associated with smoking/vaping. b. Offering pharmacological and/or behavioral interventions to assist with smoking/vaping cessation, c. Providing educational materials regarding smoking/vaping and smoking/vaping cessation. d. Developing a safe smoking/vaping plan, or an individualized plan to quit smoking/vaping . Resident #47 Standard:[NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021, Chapter 31, Medication Administration, Page 618-619, .Administering Medications Through an Enteral Tube (Nasogastric Tube, G-tube [gastrostomy tube], J-tube [jejunostomy tube], or Small-Bore Feeding Tube .Steps .Before administration of enteral medications, verify placement of feeding tube according to agency policy and determine that tube is placed in the stomach or small intestine correctly .Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents .Check for gastric residual volume . Observation on 1/6/26 at approximately 10:25 a.m. with Staff M (Licensed Practical Nurse) during Resident #47's medication administration revealed Staff M was preparing Resident #47's scheduled morning medication at the medication cart and crushed one tablet of Lamotrigine (anticonvulsant) 100 milligram (mg). Resident #47's Lamotrigine 100 mg bingo card had a pharmacy warning label that indicated to DO NOT CRUSH. Staff M flushed Resident #47's J-tube with water using a 60 milliliter syringe, administered crushed medications that included the crushed Lamotrigine 100 mg tablet through the J-tube, and then flushed the J-tube again with water. Staff M did not verify J-tube placement prior to administering the medications. Interview on 1/6/26 at approximately 11:00 a.m. with Staff M confirmed the above findings and that he/she did not check for the J-tube placement prior to administering medications to Resident #47. Review on 1/6/26 of the Lamotrigine manufacturer's instruction revealed .Warning Labels: Swallow Tablet Whole. Do Not Chew, Break, Or Crush . Review on 1/6/26 of the facility's policy titled, Medication Administration, review date of 12/2025, revealed .Administer medication as ordered in accordance with manufacturer's specifications .Do not crush medications with do not crush instructions. Review on 1/6/26 of Resident #47's enteral feeding care plan, revision date of 1/5/26, revealed an intervention, dated 9/24/24, to check patency and placement of tube daily before administering feedings and medications. Review on 1/6/26 of the facility's policy titled, Care and Treatment of Feeding Tubes, review date of 6/2025, revealed .The resident's plan of care will address the use of feeding tube, including strategies to prevent complications .In accordance with facility protocol. licensed nurses will monitor and check that the feeding tube is in the right locations (e.g. stomach of small intestine, depending on the tube): 1. Tube placement will be verified before beginning a feeding and before administering medications .

Based on interview, observation, and record review it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for 1 of 1 residents reviewed for skin conditions in a final sample of 30 residents. (Resident identifier is #125). Findings include:Observation on 1/6/26 at approximately 9:30 a.m. of Resident #125 sitting in the hallway with his/her button shirt open at the top; and resident itching his/her chest area that was bright red and raised with bumps.Interview on 1/6/26 at approximately 9:45 a.m. with Resident #125 revealed I'm always itchy.Review of Resident #125's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/21/25 revealed in Section C Cognitive Patterns C0200 BIMS (Brief Interview for Mental Status) a score of 03 which indicates severe impairment.Review on 1/8/26 of Resident #125's medical record revealed a diagnosis of seborrheic dermatitis. Further review of Resident #125's MAR (Medication Administration Record) revealed a physician's order for CeraVe itch relief, apply to arms/back topically two times a day for dry skin, and an order for HydrOXYzine Tablet 25 MG (Milligrams) every six hours as needed for itching with a start date of 11/24/25. Review on 1/8/26 of Resident #125's Weekly Skin Review-V5 dated 12/27/25 revealed Section 4. Comments and Orders 1. Right breast redness, groins pinkend, scratches all over upper body r/t c/o itch. Lotion applied, this has been ongoing Staff F (Nurse Practitioner) aware.Interview on 1/8/26 at approximately 12:30 p.m. with Staff F (Nurse Practitioner) confirmed that this is ongoing for Resident #125 and that he/she was aware of the 12/27/25 Weekly Skin Review. Further interview with Staff F revealed that he/she did not give any new orders.Review on 1/8/26 of Resident #125's MAR for January 2026 revealed that Resident #125 had not received any HydrOXYzine in January.

Based on observation, interview, and record review, it was determined that the facility failed to implement established infection prevention policies for transmission-based precautions (TBP) for 1 of 6 residents reviewed for droplet precautions. (Resident identifier is #136.)Findings include:Observation on 1/6/2026 at approximately 10:15 a.m. of Resident #136's room revealed signage for Droplet Precautions. Further observation revealed two housekeepers don personal protective equipment (PPE) to include mask, gown and gloves. After performing some cleaning tasks, Staff A (Housekeeper) wore all PPE out of the room to access the housekeeping cart and speak with other staff. Staff A walked down the hall and accessed another room with all the same PPE from Resident #136's room and Staff A had not performed hand hygiene.Interview on 1/6/2026 at approximately 10:15 a.m. with Staff A confirmed that he/she left PPE on after exiting Resident #136's room and entering the hallway and another resident's room.Review on 1/7/2026 of facility outbreak line list revealed Resident #136 was on Droplet Precautions for suspected Influenza.Interview on 1/9/2026 at approximately 8:45 a.m. with Staff C (Infection Preventionist) confirmed if PPE is worn for Droplet Precautions, it is their policy to remove PPE and perform hand hygiene prior to leaving the room.Review on 1/12/25 of facility policy titled Personal Protective Equipment revised 6/25 revealed .Policy Explanation and Compliance Guidelines: 1. All Staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate.2. PPE will be utilized as part pf standard precautions regardless of resident's suspected or confirmed infection status.4. Indications/considerations for PPE use: a. Gloves: i. Wear gloves when direct contact with potentially contaminated surfaces or equipment. Ii. Perform hand hygiene.after removal.vi. The outside of gloves are contaminated.vii. Dispose of gloves in appropriate waste receptacle.b. Gowns: i. Wear gowns to protect.from contamination with.potentially infectious material.iv.Remove gown to prevent contamination.v. Dispose of gown into appropriate waste receptacle.

Based on interview, record review, and observation it was determined that the facility failed to care plan according to their smoking assessment for 1 of 3 residents reviewed for smoking in a final sample of 30 residents. (Resident identifier is #68.)Resident #68Review on 1/6/26 of Resident #68's smoking assessment, dated 11/6/25, revealed that Resident #68 is a supervised smoker. Review on 1/6/26 of Resident #68's smoking care plan, revised 1/6/26, revealed that Resident #68 may smoke without supervision per smoking assessment. Interview on 1/7/26 at approximately 9:30 a.m. with Resident #68 revealed that he/she smokes independently. Interview on 1/8/26 at approximately 11:00 a.m. with Staff J (Nurse Supervisor) confirmed Resident #68 smokes independently.Review on 1/9/26 of the facility policy titled Resident Smoking implemented on 7/1/21 revealed .Policy Explanation and Compliance Guidelines: #7. Residents who smoke will be further assessed, using the Smoking Evaluation, to determine whether or not supervision is required for smoking , orif resident is safe to smoke at all .#10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.

Based on interview, record review, and policy review, it was determined that the facility failed to implement the facility's antibiotic stewardship program and antibiotic use protocols for 1 of 1 month of antibiotic line list reviewed. (Resident identifier is #41.)Findings include:Review on 7/1/25 of the facility policy title, Antibiotic Stewardship Program, review date of 6/2025, revealed the following: .Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' effort by working with the following partners: a. Infection Preventionist - utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms .3. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. 4. The program included antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols:I. Nursing staff shall assess residents who are suspected to have an infection and notify the physician.ii. Laboratory testing shall be in accordance with current standards of practice .iv. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics .vi. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized.b. Monitoring antibiotic use:I. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g. antibiotic time-out) .12. Data obtained from antibiotic stewardship monitoring activities is discussed in the facility's QAPI [Quality Assurance Performance Improvement] .Review on 7/1/25 of the facility's June 2025 antibiotic line list revealed that there were 25 residents on antibiotics. Further review of the June 2025 antibiotic line list revealed that the list included the resident's name, infection, antibiotic, antibiotic start date, and antibiotic end date. The June 2025 antibiotic line list did not indicate if the antibiotics were appropriate for use nor the antibiotic use protocol (i.e. Loeb Minimum Criteria) was utilized. Review of the June 2025 antibiotic line list also revealed that Resident #41 was on Bactrim DS (antibiotic) on 6/1/25 to 6/8/25 and Nitrofurantoin (antibiotic) 50 milligrams (mg) for Urinary Tract Infection (UTI) prophylaxis (prevention). Review on 7/2/25 of Resident #41's medical record revealed no documentation of the Loeb's minimum criteria evaluation for the initiation of antibiotic on 6/1/25. Interview on 7/1/25 at approximately 1:00 p.m. with Staff S (Infection Preventionist) revealed that the facility uses the Loeb's minimum criteria for the initiation of antibiotics. Staff S was unable to explain or to provide documentation if the Loeb's criteria was used for the antibiotic use for the month of June 2025.Interview on 7/2/25 at approximately 2:30 p.m. with Staff S confirmed the above findings for the June 2025 antibiotic line list. Staff S also confirmed that the Loeb's minimum criteria was not initiated during the initiation of antibiotics for Resident #41. Staff S revealed that QAPI was held twice a month and that he/she has not discussed any data regarding resident infections and antibiotic use in QAPI since he/she started on February 2025. Interview on 7/3/25 at approximately 8:37 a.m. with Staff W (Administrator) confirmed that there was no discussion about resident infections and antibiotic use by Staff S in their recent QAPI meetings.

Based on interview and record review, it was determined that the facility failed to ensure residents remained free from significant medication errors which resulted in a resident requiring interventions and hospitalization for multiple nights for 1 of 1 residents reviewed for medication errors. (Resident identifiers is #5.) Findings include: Review on 2/26/25 of Resident #5's medical record revealed the following nursing note written by Staff E (Registered Nurse), dated 2/23/25 at 4:17 p.m.: During morning medication round I inadvertently administered the incorrect medication to the patient. While verifying the medication administration record (MAR) I recognized that the following medications were given. Ativan oral tab [tablet] 0.5 mg [milligrams] Zyprexa oral tab 7.5 mg Tramadol HCL [hydrochloric acid] 50 mg half tab Amantadine 100 mg tab Amlodipine 10 mg tab Cymbalta oral cap [capsule] delayed release particles 20 mg Gabapentin 300 mg capsule Protonix oral tab delayed release 40 mg tab Instead of the following prescribed medication Atenolol oral tab 25 mg Lactobacillus capsule Omeprazole oral capsule delayed release 20 mg RN [Registered Nurse] assessed Patient immediately and notified attending physician. RN continued to assess the patient. Family notified. No allergic reaction noted. MD [Physician] states to call back if any changes and ordered PRN [as needed] Naloxone spray. Interview on 2/26/25 at approximately 10:00 a.m. with Staff E confirmed that they administered another resident's medications to Resident #5 a little before noon on 2/23/25. Review on 2/26/25 of Resident #5's medical record revealed the following physician's note dated 2/23/25 3:01 p.m.: Primary Chief Complaint: Clinical Concern: Medication Given in Error, . Vital Signs . BP [Blood Pressure] 98/57 .Orders: q [every] 15 min [minutes] vitals for 2 hrs [hours] after the 2 hrs q 1 hr vitals update me if any changes, but update me again in 2 hrs regardless . Review on 2/26/25 of Resident #5's medical record revealed the following nursing note, dated 2/23/25 10:46 p.m.: Resident lethargic at beginning of shift. Previous staff reported a med [medication] error. [Telehealth name omitted] provider contacted. Provider asked this nurse to monitor vitals and report back. This nurse contacted provider with vitals, which were trending down. Provider ordered Narcan. Narcan administered. Resident still lethargic. Resident sent out 911 [Emergency Medical Services] per facility police [sic]. Family contact 1 notified. DON [Director of Nursing] also notified Interview on 2/26/25 at approximately 11:30 a.m. with Staff A (Director of Nursing) confirmed that Resident #5 had been admitted to the hospital on 2/23/25. Staff A revealed that Resident #5 was currently an inpatient at the hospital. Review on 2/28/25 of Resident #5's Hospital's History and Physical, dated 2/23/25 at 7:01 p.m. revealed: Chief Complaint .given incorrect medication intended for other patient. now responsive to painful stimuli . History of Present Illness Patient is a [AGE] year-old female with past medical history including hypertension, hyperlipidemia, bladder cancer, chronic hypoxemic respiratory failure in the setting of intersititial lung disease requiring 3 L [liters] nasal canula at baseline and chronic kidney disease stage IV. [Pronoun omitted] presented via EMS [Emergency Medical Services] from nursing home after she accidentally received several medications in error . Patient's mental status was altered. [Pronoun Omitted] responded to stimulation but has required brief bag mask ventilation .Hospitalist team was asked to admit the patient for observation and medical management . Additional Information . blood pressure was 70s over 30s . Review on 2/28/25 of Patient's #5's hospital's progress note dated 2/24/25 at 1:50 p.m. revealed , Chief complaint accidental ingestion of medications. Patient still requires Levophed [used to treat threatening low blood pressure] .Vital Signs Blood Pressure 101/45 [decreased] .Assessment/Plan .11. Hypotension due to medication Patient still hypotensive. May take another few hours for medication to get out of [pronoun omitted] system completely .

Potter, [NAME] A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page ,[DATE]-Vital Signs .Vital signs are a quick and efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention. When you learn the physiological variables influencing vital signs and recognize the relationship of vital sign changes to other physical assessment findings, you can make precise determinations of the clients health problems .the health care provider will order a minimum frequency of vital sign measurements for each client .As a clients physical condition worsens, it is often necessary to monitor vital signs as often as every ,[DATE] minutes. The nurse is responsible for judging whether more frequent assessments are necessary . Resident #647 Interview on [DATE] at 3:06 p.m. with Staff J (Nurse Practitioner) revealed that when ever a resident sustains a fall the facility's fall protocol is indicated, which would include neurological and vitals. Staff J stated that each unit has a sheet of paper that shows which steps are to be started and an order is not needed, it is expected to be provided by staff. Interview on [DATE] at 3:15 p.m. with Staff N (Medical Director) which was conducted by phone confirmed that the facility would follow the falls protocol but did not know the specifics of the policy because it was not right in front of them. Staff N was asked if they would expect the facility to do neurological and vitals on a resident who fell hit there head, Staff N responded Yes. Review of the facility's FALLS CARE DELIVERY PR[NAME]ESS with a revision date of [DATE] page 3 under RESPONSE TO A PATIENT FALL 1. Evaluate and monitor patient for 72 hours after the falls. Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. Review of facility policy titled NSG204 Assessment: Neurological states .When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: * every 30 minutes x two hours, then * every one hour x four hours, then * every four hours x 24 hours. Review on [DATE] of a nurses note dated [DATE] revealed 1630 Resident found sitting on floor, Resident stated that (they) fell and hit (their) head on foot of bed .Res (Resident) had lump on back of head d/t (due to) fall .Neuros started 1635 BP (Blood Pressure) ,[DATE] p (Pulse) 67, 1640 called NP (Nurse Practitioner) .1700 checked on resident asked if (they) would like a cold compress for head, (resident) stated yes. 1725 check on res asked if (he/she) wanted Tylenol res declined pain medication. 1800 resident sitting in wheel chair watching TV. 1845 LNA stated that (resident) needs help, found resident on bed non responsive with eyes opened and moving side to side .Called NP (Nurse Practitioner) and than called 911 . On (MONTH) 15, 2019 a clarification note was written that was completed by Staff B (Director of Nurses) after contacting Staff O (Licensed Nursing Assistant). Staff O was the person who was caring for Resident #647 at the time of the event. The facility's investigation revealed .Staff O stated that (they) entered the room of Resident #647 at around 4:30 p.m., and Resident #647 was on the floor. Staff O obtained vitals immediately and got the nurse to assess (resident) .Staff O went back to the room a little while later to see if (he/she) wanted to go to the dining room, and Resident #647 told Staff O Resident #647 wanted to eat in (their) room. Staff O states that when (they) went back into Resident #647 room after dinner to collect trays, that Resident #647 was 'not looking good', 'lying across the bed' Resident #647 arm was deep purple, and Resident #647 told Staff O 'I have a horrible headache. Staff O stated she got Resident #647 vital sings right away and 'I will never forget that her blood pressure was over 200'. 'I got the nurse right away and we sent Resident #647 by 911. Review of the NEUROLOGICAL ASSESSMENT FLOW SHEET for instructions states Document the date and time of each assessment, then proceed as follows: LEVEL OF CONSCIOUSNESS - check the appropriate response PUPIL RESPONSE - check PERL if applicable or enter the appropriate code for each eye. MOTOR FUNCTIONS-HAND GRASPS - Enter the appropriate code EXTREMITIES - Check the appropriate column(s) PAIN RESPONSE - Check the appropriate column VITALS - Record blood pressure, temperature, pulse and respiration in the appropriate columns. Use the OBSERVATION column to note the presence or absence of specific resident conditions . Review of the NEUROLOGICAL ASSESSMENT FLOW SHEET revealed on [DATE] at 4:30 p.m. Resident #647 vitals showed BP (blood pressure) ,[DATE], TEMP (temperature) 97.7 P (pulse) 67 R (respirations) 16 and none of the other assessments were completed as written above. The next documented entry on the neurological assessment flow sheet was at 5 p.m. with just the word dinner with no assessments completed. Then the next entry which was document at 6 p.m. showed vitals of BP ,[DATE] TEMP 97.7, P71, R 16. Review of the hospital notes dated [DATE] revealed that when Resident #647 was emergently brought to have CT (CAT scan) performed which revealed a large right-sided subdural hematoma with midline shift. On [DATE] at around 2:38 p.m. Resident #647's family decided to terminally extubate Resident #647 and Resident #647 expired rapidly. Based on all the clinical information written above, it was determined that the facility failed to perform neurological assessments and vitals to monitor Resident #647's condition from 4:30 p.m. to approximately 6:15 p.m. at which time Resident #647 was found on their bed non responsive with eyes opened moving side to side and assessed by Nurse Practioner. Based on medical record review and interview, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 residents out of a final survey sample of 41 residents. (Resident identifier is #17, #112, and #647) Findings include: Potter, [NAME] A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page ,[DATE]-Vital Signs .Vital signs are a quick and efficient way of monitoring a client's condition or identifying problems and evaluating the client's response to intervention. When you learn the physiological variables influencing vital signs and recognize the relationship of vital sign changes to other physical assessment findings, you can make precise determinations of the clients health problems .the health care provider will order a minimum frequency of vital sign measurements for each client .As a clients physical condition worsens, it is often necessary to monitor vital signs as often as every ,[DATE] minutes. The nurse is responsible for judging whether more frequent assessments are necessary . Review on [DATE] of the the facility's falls protocol titled, Falls Care Delivery Process with a revision date of [DATE], page 3, Response to a Patient Fall 1. Evaluate and monitor patient for 72 hours after the fall. Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. Review of facility policy titled NSG204 Assessment: Neurological reveals .When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: * every 30 minutes x two hours, then * every one hour x four hours, then * every four hours x 24 hours. Review of the Neurological Assessment Flow Sheet for instructions reveals Document the date and time of each assessment, then proceed as follows: LEVEL OF CONSCIOUSNESS - check the appropriate response PUPIL RESPONSE - check PERL (Pupil Equal and Reactive to Light) if applicable or enter the appropriate code for each eye. MOTOR FUNCTIONS-HAND GRASPS - Enter the appropriate code EXTREMITIES - Check the appropriate column(s) PAIN RESPONSE - Check the appropriate column VITALS - Record blood pressure, temperature, pulse and respiration in the appropriate columns. Use the OBSERVATION column to note the presence or absence of specific resident conditions . Resident #17 Review of Resident #17's falls documentation of unwitnessed falls in the facility revealed the following: [DATE] and [DATE]. The Neurological Assessment Flow Sheet was started for each of these falls but none of them were complete based on the facility's falls protocol as listed below. Each of the above listed falls either was not completed for 3 full days or was missing vital sign assessments during the 3 day required assessment period or was missing the neurological part of the assessment or a combination of the above. Interview on [DATE] at approximately 2:10 p.m. with Staff E (Unit Manager/RN) confirmed there were missing entries on each of the falls listed above which means the falls protocol was not followed correctly. Resident #112 Review on [DATE] of Resident #112's falls documentation unwitnessed falls in the facility are as follows: [DATE], [DATE], [DATE], [DATE], and [DATE]. The Neurological Assessment Flow Sheet was started for each of these falls but none of them were complete based on the facility's falls protocol as listed below. Each of the above listed falls either was not completed for 3 full days or was missing vital sign assessments during the 3 day required assessment period or was missing the neurological part of the assessment or a combination of the above. Interview on [DATE] at approximately 2:15 p.m. with Staff E confirmed there were missing entries on each of the falls listed above which means the falls protocol was not followed correctly. Interview on [DATE] at 3:06 p.m. with Staff J (Nurse Practitioner) revealed that when a resident sustains a fall the facility's fall protocol is implemented, which consists of vital signs and a neurological assessment. Staff J stated that each unit has the protocol at each nurses station for reference which lists the steps required for all unwitnessed falls and Staff J stated that a doctors order is not required to implement this process but that it is expected staff will carry out the steps of the protocol. Interview on [DATE] at 3:15 p.m. with Staff N (Medical Director) was conducted over the phone, confirmed that the facility would follow the falls protocol.

Based on medical record review, observation, and interview it was determined that the facility failed to provide appropriate supervision which resulted in harm for 2 out of a final survey sample of 41 residents. (Resident identifiers are #7 and #92.) Findings include: Resident #7 Review on 4/3/19 of a facility reported incident revealed that on 3/20/19 Resident #7 fell from a shower chair after receiving a tub bath. Review of the facility's reportable form revealed Resident #7 needed Supervised for ambulation and for ADL (Activities of Daily Living) status also to be Supervised. Also under the care plan for ADL's under Interventions it states total care with bathing, grooming, bed mobility, incontinence, Assist with sitting her up during meal time. Resident #7 has a Focus care plan stating (Resident #7) requires assistance/is dependent of ADL care in bathing, grooming, personal hygiene, dressing, related to: cognitive loss. Review on 4/3/19 of the RMS (Risk Management System) Event Summary Report dated 3/20/19, it states Pt (patient) was observed in a shower mechanical lift after being given a shower. This nurse was called to examine pt's (patient's) right toe nails in which it was reported that LNA (Licensed Nursing Assistant) had cleaned feet and then a toenail came off of the 3rd digit. Instructed LNA's to place pt in bed and then this nurse would treat it. About 15 mins (minutes) later, this nurse was passing by room and observed pt on the floor at the same time LNA's were walking in. Pt was alert and breathing even/unlabored. Observed left foot bent under the bed in awkward position. Repositioned pt and placed back in hoyer lift to place in bed. Bilat ankles shows purplish - blue discoloration and [MEDICAL CONDITION]. Pt admitted that (he/she) had also hit her head with (they) fell , but no apparent injuries noted to skull or face. Pain level is 8/10. Ambulance called and pt transported to hospital for further eval. Review on 4/3/19 of the Hospital discharge notes dated 3/25/19, revealed Discharge Diagnosis: [REDACTED]. Interview on 4/3/19 at 8:20 a.m. with Resident #7 confirmed that he/she was left alone for a period of time in the shower chair and fell out of it have excruciating pain in both ankles. Resident #7 stated that he/she does not know why they left him/her there. Interview on 4/3/19 with Staff B (Director of Nurses) at 9:15 a.m. confirmed that staff had left Resident #7 alone due to lack of communication for a period of time and Resident #7 fell from the tub chair fracturing both ankles. Staff B was asked to show the tub chair Resident #7 was in when they fell . When observing the chair Staff B stated that a seat belt has been added to the chair so resident will not fall out. Resident #92 Review on 4/3/19 of a facility reported incident states that on 3/14/19 Resident #92 attended an activity in the mid morning on 3/14/19. As the activity concluded, (Resident #92) told the activities aide that they preferred to stay in the solarium/sun room .Shortly after that, (Resident #92) got up from wheelchair and was found on the floor in the hallway, and was sent out due to a question of a fracture . On review of the current care plan under Focus reveals (Resident #92) is at risk of elopement related to: (Resident #92) has made one or more attempts to leave the facility during this stay or previous stays in this or other facilities. Believes (his/her) mother is waiting for (him/her) downstairs . and under Interventions (Resident #92) is to be in a supervised area when up in w/c (wheelchair). Under Describe the circumstances of the event .(Resident #92) was found laying on the floor in the doorway of RM (room number omitted). It appeared (he/she) had walked from the sun lounge and left (his/her) w/c (wheelchair) in the sun lounge . (Resident #92) remained on the floor unmoved until 911 arrived Under the root cause/conclusion of the RMS (Risk Management System) Event Summary Report it states (Resident #92) was found on the floor inside the doorway of RM (room number omitted). (He/She) had been attending an activity in the sun lounge. It appeared (he/she) ambulated independently resulting in a fall. On the return to the facility on [DATE] the hospital discharge [DIAGNOSES REDACTED].Closed Fracture of left proximal humerus, closed fracture of left distal radius, Fracture of right iliac wing . Interview at 4/3/19 with the Staff B (Director of Nurses) confirmed that Resident #92 was left unattended and the activites director is new and did not know that Resident #92 could not be left alone.

Based upon an observations, staff interviews, a review of resident's records and through reviewing the facility's pressure ulcer prevention protocol the facility failed to prevent two pressure sores; an unstageable pressure sore and a stage 3 pressure sore from developing causing harm for 1 of 10 residents with pressure sores in a survey sample of 25 residents (Resident identifier #3). Findings include: Review of the Genesis Skin Integrity Care Delivery Process on 10/22/13, dated 10/1/2010 revealed the following: "Review of the National Pressure Ulcer Advisory Panel (NPUAP) guideline for the definition of a pressure ulcer and the stages of pressure ulcers, included the original 4 stages and added 2 stages for deep tissue injury and unstageable pressure ulcers." The guideline reads in part: "Pressure Ulcer Definition: localized injury to the skin and/or underlying tissue usually as a result of pressure or pressure in combination with shear and/or friction." Pressure Ulcer Stages (partial list) Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. These ulcers often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location....Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] possible. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Wound Documentation Guidelines Documentation will be completed for all new admissions/re-admissions that have skin impairment and weekly for any patient who has skin impairment, Documentation will also be completed daily and with dressing changes for all patients who have wounds." "Pressure Ulcer Prevention Guideline Perform daily observation of the skin. Promote adequate nutrition and hydration. Notify dietitian or designee, if indicated. Apply moisturizer daily. Apply moisture barrier to high risk areas such as heels, elbows, etc... Employ method to "float" heels. Refer to Rehab for assistance in seating selection, if indicated." "Evaluation 1. Identify Risk Completing risk tool investigation on admission/re-admission, weekly for the first month, quarterly, and with any significant change in condition... 2. Skin Inspection Observe all skin surfaces for tissue tolerance and signs of alternations in skin integrity on admissions/re-admission and weekly. Document licensed nurse skin check on Treatment Administration Record (TAR) 3. Daily Skin Observation Check skin integrity and tissue tolerance after pressure to that area has been removed or redistributed. Check for pressure related to positioning, shoes, contractures, deformities, or medical devices (e.g. O2 tubing, casts, prosthesis, orthotics, pommel, cushions, splints, etc.)." Resident #3 Resident #3 was admitted to the facility for skilled services on 7/25/13 following the fracture of her left humerus. On 8/9/13 at approximately 1:15 p.m. Resident #3 was observed, according to the nurses notes, to have developed "a new onset/change in skin integrity" a "Blister-serous filled to the back of her left heel LLE"(lower left extremity) . Resident #3's "slippers" were "noted to be tight and rubbing on" her "heel while putting it on/off" she was "experiencing pain." The nursing notes of 8/9/13 continued by stating that Resident #3 complained of "tenderness on back of" her "heel." The physician was notified on 8/9/13 and ordered a "dry dressing" to Resident #3's "left heel" with additional instructions to "elevate" Resident #3's "legs when sitting." A review of Resident #3's treatment records revealed that there was no documentation from 8/9/13 through 8/14/13 that Resident #3's legs had been elevated as ordered by the physician following the 8/9/13 appearance of Resident #3's left heel blister. The physician's orders [REDACTED].#3's "legs when sitting" was reiterated on 8/13/13 ordering facility staff to "Elevate" Resident #3's "legs as much as possible while sitting" and to "Initiate" the "Heelz-up program" for Resident #3. A review of Resident #3's treatment record documentation revealed that the Heelz-up program wasn't initiated until 8/15/13 six days after the initial physician's orders [REDACTED]. A 10/24/13 interview with Staff G (Unit Manager R.N.) revealed that after the 8/9/13 discovery by the facility of Resident #3's blister on her left heel Resident #3 no longer wore the slippers which had caused her discomfort. Staff G stated that Resident #3 was instead wearing a "slipper sock." On 8/9, 8/11,8/12, 8/13 and 8/14/13 Resident #3, according to the physical therapy notes was ambulated by physical therapy staff walking with a blister on the left medial heel without wearing any offloading pressure relieving footwear. Staff I (Physical Therapist) confirmed that no pressure relieving footwear had been provided for Resident #3 during those dates . Physical therapy documentation revealed that staff I noted Resident #3 developed a heel blister on 8/14/13. On 8/11/13 nursing notes stated that Resident #3's "Blister" to her "Left heel" had become "open and draining moderate amount of serous drainage." There was no documentation that the facility, after the 8/9/13 development of a blister on Resident #3's left heel, implemented the physician's orders [REDACTED].#3 with pressure relieving footwear to prevent the left heel blister from opening. On 9/1/13 Resident #3, according to the history and physical examination a fever of 101" degrees "and was provided with some tylenol." The report continued that "At this point, the patient's foot ulcer was seen to have a concerning effect for an infection and because of the foul odor, a wound culture was obtained." According to the report the "wound culture showed pansensitive MSSA([MEDICAL CONDITION]-Sensitive Staphylococcus Aureus) and Keflex 500mg BID was started at the nursing home." On 9/7/13, according to the 9/11/13 hospital discharge summary report Resident #3 was admitted to the hospital with [REDACTED]." Resident #3 was "started on antibiotics and orthopedics consult was obtained a surgical debridement of the left heel ulcer was performed" 9/8/13. On 9/20/13 a wounds consults note was written describing Resident #3's left heel area as a stage 3 pressure sore. On 10/24/13 Resident #3's pressure ulcer on the left heel was observed to be partially granulated with slough 4.0 cm in length and 3.2 cm wide while the depth could not be determined.