Every finding on record at Regency at Troy

This citation pertains to intake 3069088. Based on interview and record review, the facility failed to ensure a dental evaluation was completed in a timely manner for one resident (R901) of two residents reviewed for Nutrition, resulting in continued oral pain, facial swelling, delay in starting speech/language pathology therapy (SLP) and subsequently being kept on a pureed diet. Findings include:On 7/22/26 a concern submitted to the State Agency was reviewed which alleged R901 was unable to eat properly and did not receive the appropriate treatment for mouth pain. On 7/22/26 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and was discharged to the hospital on 6/27/26 and did not return. R901 had diagnoses that included Type 2 Diabetes with foot ulcer and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 5/28/26 revealed R901 needed assistance from staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was 11 which indicated moderately impaired cognition. A review of R901's care plan revealed the following: Focus-[R901] has alteration in nutritional and/or hydration status r/t (related to) PMH (previous medical history): HTN (Hypertension), DM (Diabetes Mellitus), CVA (stroke) with aphasia, HLD (Hyperlipidemia), Depression, learning disorder, seizure disorder. Recent weight loss during hospital stay with N/V (nausea/vomiting). BMI (body mass index)in the obese range. Hx (history) of being treated for oral thrush. Per nutrition risk screen resident is at risk for malnutrition. 3/10 . c/o (complains of) mouth pain - dental consult placed. Dislikes pureed food, SLP to screen once seen by dentist Per nutrition risk screen resident with moderate protein calorie malnutrition 4/14 returned from the hospital with ~3# (pounds) weight loss, dental consult in place for mouth and sinus pain .Date Initiated: 12/05/2025 .A Physician's order dated 12/2/25 revealed the following: Dental evaluation and treatment as indicated.Nurses note dated 12/7/25: Patient complains of pain in right side of the face, affecting her ability to chew food. Downgraded to full liquids after patient chose to only drink ensure all weekend, despite effort by Nurse to try puree and different type of textured foods.Physician progress note dated 12/8/25: .Seen today for follow-up UTI (urinary tract infection) and follow-up mouth pain .has been having oral pain. On exam patient missing multiple teeth and white patches consistent with Candida stomatitis (oral fungal infection). She reports for the past eight days she has been having oral pain discussed with nursing ensure patient is rinsing her mouth post administration .Assessment and Plans-Candidal stomatitis: Reports oral discomfort, white patches in mouth noted. Start oral nystatin swish/swallow ensure pt (patient) rinses mouth after inhaler use. Monitor for acute change .Dietary note dated 12/10/25: Resident dislikes pureed texture food, SLP following. Ensure ordered TID (three times a day) with meals which she accepts well Would also like to try magic cup with meals for added nutritional support. Continues to report facial swelling/puffiness and mouth pain r/t thrush Nurses note dated 12/17/25: Patient and family concerned with difficulty swallowing, patient compaplains <sic> of sore throat when swalowing <sic> .Physician progress note dated 12/20/25: .Her mouth is dry and having creamy white patches on the tongue. When assisting her drinking water, she seems having pain during swallowing .Discuss with her to order nystatin mouthwash for the fungus infections and encourage fluid intake .Physician History and Physical dated 12/30/25: .was resident in facility and was rehospitalized for sepsis with source unclear-pulmonary vs (verses) oral infection and was treated with IV (intravenous) ABX (antibiotics) .Assessments and Plans-Sepsis, Unspecified Organism: Source pulm (pulmonary) vs oral giving poor dentition .Nurse Practitioner (NP) progress note dated 1/1/26: .was recently sent to the hospital due to facial pain and swelling. She was found to have leukocytosis secondary to odontogenic infection (infection of the tooth or surrounding tissues) and received antibiotics .Her tongue is pinkish without cottage cheese like appearance and continue nystatin mouth wash .Nurse Practitioner progress note dated 1/5/26: .Her lips dry and skin peeling. NP encouraged hydration and continue nystatin mouth wash Assessment and Plans-Encounter for dental exam and cleaning w/ abnormal findings: Still patient has dry lip and mouth infection .Nurse Practitioner progress note date 1/6/26: Writer summoned to patient room for c/o (complaints of) difficulty swallowing and sinus pain .She complains facial swelling and pain. She also c/o (complains of) food getting stuck when she eats with difficulty swallowing .Patient some swelling to bilateral cheeks. On light palpation, patient has pain to Ethmoid and maxillary (upper teeth) since bilaterally. Patient attempting move writers hands stating Pressure hurts. Treatment: Doxycycline (antibiotic) 100mg (milligrams) BID (twice daily) x five days .Discussed with SPL .for evaluation and treatment for swallow issues .Nurses note dated 1/6/26: Resident was c/o face swollen and pain when she eats ans <sic> swallow. New orders were put in SLP twice weekly, diet change to regular texture, puree and thin liquids. Doxycycline 100 twice a day.Nutritional Evaluation dated 1/6/26: .Diagnoses: Facial pain and swelling .Current diet order-Regular diet, pureed texture, thin liquids .Nutritional risk & Recommendations- .Seen by SLP today and downgraded to a regular diet, pureed texture, with thin liquids. Visited resident at breakfast, didn't eat the biscuits and gravy at breakfast. Offered other options but she declined. Ensure on tray table which she consumed 100%. found to have thrush at the hospital, receiving nystatin SLP will follow for safest diet .Dietary note dated 2/1/26: Patient was complaining that she wants regular diet. She is currently on a puree diet and after eating she reported she is so hungry. She requested to be assessed by dietary and speech to possibly being changed to regular diet.Dietary note dated 2/5/26: Met with resident today. She confirmed she dislikes pureed food. Offered to increase other items with trays but she declined. Ensure TID (three times a day) ordered which she confirms she likes and accepts well. Message sent to SLP for screen to see if she is a candidate for a diet upgrade .Dietary note dated 2/5/26: Resident seen by SLP, unable to trial mechanical soft texture diet due to resident c/o dental pain and sinus pressure. Referred to Social Services to be seen by the Dentist and message sent to NP for eval for sinus pressure.Physician progress note dated 2/6/26:Per staff, complained of oral discomfort and swelling .Assessments and Plans- .Poor dentition and swelling noted oral care will start Augmentin BID oral intake as tolerated and monitor for any issues. Discussed with nursing-needs dental/omfs (oral maxillofacial surgeon) follow up .SLP Therapy note dated 2/6/26: Patient referred to SLP d/t (due to) disliking puree texture diet. Patient has already completed skilled speech therapy, throughout tx (treatment) patient refused mechanical soft texture trials or would spit out trials d/t (due to) difficulty chewing. Patient has reported since pain and dental pain since November-December 2025. This has been reported to multiple RN (Registered Nurses) and [Nurse Practitioner] who has placed dental evaluation order on 12/20/25. Until dental evaluation completed, Patient not indicated for further skilled ST (Speech Therapy) services.Nurse Practitioner progress note dated 2/11/26: .Seen for acute follow up visit .Patient has oral discomfort and swelling. Patient is on Augmentin ABT (antibiotics) for 10 days until 2/16/26 .SLP Interdisciplinary Therapy Screen dated 3/10/26: Patient referred to SLP again d/t disliking puree texture diet (last referral on 2/6/26). Patient has already completed skilled speech therapy, throughout tx (treatment) patient refused mechanical soft texture trials would spit out trials d/t difficulty chewing. Patient continues to report sinus pain and dental pain currently and since November-December 2025. This has been reported to multiple RN and NP previously, who has placed dental evaluation order on 12/20/25-however this continues to not be completed. Until dental evaluation completed, patient not indicted for further skilled ST services. Notified [Director of Rehab] and [Dietician]. SLP Therapy note dated 4/8/26: Patient referred to SLP again for puree diet level (last referral on 2/6/26, and 3/10/26). Patient continues to tolerate puree diet well, however multiple staff members continue to refer to SLP for possibility of upgrades. Patient has already completed skilled speech therapy in January 2026 and throughout tx patient refused mechanical soft texture trials or would spit out trials d/t difficulty chewing. Met with patient again this date to screen. Patient continues to report sinus pain and dental pain now and since November 2025, with difficulty chewing. This has been reported to multiple RN (Registered Nurse) and NP previously, who has placed dental evaluation order on 12/20/25-however this continues to not be completed. Until dental evaluation completed, patient not indicated for further skilled ST services. Again, notified [Director of Rehab] and [Dietician]. Dental Evaluation dated 4/22/26: .Teeth: Condition: Poor; Soft Plaque/Food Debris Buildup-Heavy .Hard Calculus Deposits-Heavy .[NAME] (Gingivitis) Infalm (inflammation)/Swollen, Bleeding Gums-Severe. Periodontal Condition-Poor. Risk for Caries- High .Treatment Notes- .Patient presents with retained roots, .refer to OS (oral surgery) for ext (extractions) of all remaining root tips .Action Required by Nursing Home Staff-Refer to MD(Medical Doctor)/OS (Oral Surgeon) for extraction of all remaining root tips .Dietary note dated 4/30/26: .Resident on a pureed texture diet which she dislikes. Recently seen by Dentist and is being referred out to an oral surgeon for removal of remaining roots. Will be able to be reassessed by SLP once dental work is complete .SLP Interdisciplinary Therapy Screen dated 6/9/26: .Patient referred to SLP again for puree diet level (last referrals on 2/6/26, 3/10/26, 4/8/26). Patient continues to tolerate puree diet well, however multiple staff members continue to refer to SLP for diet updates d/t patient not finishing or refusing some meals. Patient has already competed skilled ST in [NAME] 2026 and throughout tx patient refused mechanical soft texture trials or would spit out trials d/t difficulty chewing. Met with Patient again to screen. Patient continues to report dental pain now and since November 2025, with difficulty chewing. this has been reported to multiple RN, NP, dietary and Social Work previously, who placed dental evaluation on 4/22/26. [Dentist] states she found 'retained roots, refer to oral surgery for extractions'. See note for more. Until further dental/surgery completed, patient not indicated for further skilled ST services. notified NP, DON (Director of Nursing), DOR (Director of Rehab), family, Social Work and MDS (Minimum Data Set) RN.A secondary review of R901's medical record did not reveal any documentation that an appointment to an Oral Surgeon for extractions had been made during their stay at the facility.On 7/22/26 at approximately 10:15 a.m., during an interview with Registered Dietician F (RD F), RD F was queried reading R901's nutritional status during their stay at the facility. RD F reported R901 was ordered health shakes (two ensures with each meal) totaling six shakes a day because R901 did not like the pureed diet/foods. RD F further indicated R901 was not able to upgrade their diet from pureed level due to mouth pain and was a choking/aspiration risk due to stroke and seizure combination. Speech pathology worked with R901, but could not do much because of their mouth pain. On 7/22/26 at approximately 10:45 a.m., Speech and Language Pathologist G (SLP G) was interviewed pertaining to R901's speech therapy progression. SLP G reported they tried to work with R901 to upgrade their diet from pureed to mechanical soft but was unable to due to R901's mouth pain. SLP G indicated that R901 had mouth pain due to her dentation/teeth roots being exposed and had informed multiple staff members throughout R901's stay at that facility that R901 required a dental evaluation to treat the exposed root tips. SLPG indicated the dental delay had been ongoing since December 2025. SLP G further reported they were unable to continue to work with R901 in Speech Therapy due to the delay in getting R901's teeth extracted and no dental evaluation was done until April 2026, at which time the Dentist could not do anything and made a referral to oral surgery. SLP G reported the oral surgery appointment was never made during R901's stay at the facility. On 7/22/26 at approximately 11:06 a.m., Social Worker H (SW H), was interviewed pertaining to the ongoing delay in obtaining a dental evaluation for R901 since December of 2025. SW H reported they were not made aware of R901's need for a dental evaluation by any facility staff until 3/26/26 and they thought it was for a routine dental appointment. SW H reported nobody had informed them that R901 was having mouth pain, needed extractions or was having trouble chewing foods. SW H was asked if R901 was ever made an oral surgery appointment during their stay, and they reported no oral surgery appointment was ever made. On 7/22/26 a facility document titled Dental Services was reviewed and revealed the following: Policy-The facility will provide, or obtain from an outside resource, routine and twenty-four (24) hour emergency dental services to meet the needs of the resident and also when requested by the resident. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the state plan Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums or palate; broken or otherwise damaged teeth; or any problem of the oral cavity that required immediate attention by a dentist .Referral for Routine Dental Services The resident may request to be seen for routine dental services. A. Physician's order for a dental consult must be obtained by nursing. B. Signed consent, to receive the services, prior to initiation of services, is to be obtained from the resident or resident representative, if needed. C. Social services/designee makes a referral to the outside service and provides demographics and signed consent, as needed. D. The Report of Consultation form may be utilized for outside services, if needed, for documentation of care and plan. E. Progress notes from the service provider are to be obtained and placed in the resident's medical record. F. The resident's physician, family, and/or resident representative should be informed of the results of the service and any recommendations should be reviewed with the physician. A physician's order is obtained for changes in the plan of care. G. Service providers' recommendations are to be integrated into the resident's care plan, if adopted H. Follow up visits will be scheduled as needed .

This citation pertains to intake #3074446. Based on interview and record review, the facility failed to address concerns/grievances for one resident (R108) of one resident reviewed for grievances, resulting in verbalized frustration and lack of resolution for concerns/grievances. Findings include: On 7/21/26 from 9:18 AM until 9:40 AM, an interview was conducted in R108's room with Family Member 'D'. They verbalized numerous complaints/concerns including staff attitudes, wound care, pureed food not provided, and medications given late. They were asked if they reported their concerns to staff and said they had, numerous times. On 7/21/26 at 12:21 PM, an interview was conducted with the complainant, and they verbalized frustration with R108's care but primarily focused on R108 missing several doses of their IV (intravenous) antibiotic medication, and medications being administered late. They were asked if they brought their concerns to the attention of staff and said they had, several times but felt like staff, didn't listen to them. They further indicated on several occasions they called the facility's ADON (Assistant Director of Nursing) and verbalized concerns. They were asked if they had ever filled out a facility concern form and said they filled out numerous forms but did not feel it did any good because their concerns persisted. They were asked if facility staff ever followed up with the concern forms for their resolution and satisfaction and if they signed them and said, Those forms just go into a void. The complainant further reported they had a care conference a few weeks ago and said, I laid it all out. The complainant continued to say they verbalized numerous concerns during the conference and staff at the care conference said they were going to write it all down and send it to the DON (Director of Nursing) via e-mail. The complainant said they requested to be copied on the e-mail to the DON; but never received a copy. They went on to say two days after the care conference they met with the DON who denied receiving an e-mail from the staff in attendance at the care conference. A review of a document titled, Interdisciplinary Care Conference v1.1 - V 3 was reviewed and revealed a care conference for R108 was conducted on 7/7/26 and attendees included, Social Services, Family and an MDS (Minimum Data Set) Nurse (a nurse who monitors, assesses, and documents patients' health at a residential or long-term care facility). Section C. of the document read, .C. Nursing Summary .(Family Member Name, relationship), concerned with how resident is repositioned .wants IV ATB [sic] (antibiotic) to be extended to cover missed dosages . A review of R108's, Resident, Family, Employee, and Visitor Assistance Form(s) provided by the facility was conducted and did not reveal any forms submitted by Family Member 'D' or any forms for the concerns voiced at the care conference on 7/7/26. On 7/22/26 at 9:15 AM, an interview was conducted with Social Worker 'B' (who attended R108's care conference on 7/7/26). They were asked if they recalled R108's family having voiced any concerns at the care conference and said they did voice concerns. They were asked if they recalled anything specific and said they couldn't recall, but most of the concerns were regarding nursing services and MDS Nurse 'C' took notes and was supposed to send the concerns to the DON. They were then asked if they knew if Nurse 'C' relayed the concerns to the DON and said they did not know, and Nurse 'C' no longer worked at the facility. On 7/22/26 at 9:35 AM, an interview was conducted with the facility's ADON, and they were asked if R108's family member(s) ever verbalized any concerns to them regarding R108's care. The ADON said they had. The ADON was then asked if they filled out concern forms when they received concerns/complaints and said when the family verbalized concerns/complaints they did not consistently fill out the forms but knew they should have. On 7/22/26 at 9:59 AM, an interview was conducted with the facility's DON. They were asked if R108's family had ever voiced any concerns/complaints and said they had. They were asked if they filled out any concern forms and said when R108's family verbalized concerns they did not fill out the forms, rather; they tried to act on it at the time and fix the issues. On 7/22/26 at 12:07 PM, an interview was conducted with the facility's Administrator who explained that when a resident or family has a concern/complaint, staff were to fill out a concern form so it can be addressed. The Administrator acknowledged R108's family had verbalized many concerns, and the forms should have been filled out. A review of a facility provided policy titled, Care Program revised 7/8/26 was conducted and read, Purpose .To ensure the facility actively resolves any concerns/grievances submitted orally or in writing to the Administrator, Director of Nursing, or any other member of the facility's staff .Any resident, his or representative, family member, employee, or appointed advocate may file a concern/grievance without fear of threat or reprisal. All concerns/grievances are investigated, resolved, and documented .

This citation pertains to intake #2963192. Based on observation, interview and record review the facility failed to prevent a fall for one Resident (R121) and failed to assess and provide interventions to prevent choking for one Resident (R79) out of seven residents reviewed for falls/accidents, resulting in R121 sustaining a fracture to the right femur, pain and extended hospital stay. Findings include: R121 A complaint was filed with the State Agency (SA) that alleged R121 fell out of bed and broke their hip. A review of R121's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: fracture of right femur, chronic kidney disease and type II diabetes. A review of R121's Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 12/15 (moderate cognitive impairment). Continued review of R121's clinical record revealed the following: 3/30/26: Nursing Comprehensive: ADL (Activities of Daily Living) Status: .Transfers: 2 person assist.Weight Bearing: Non-weight bearing.Bed Mobility: 1 person assist.Ambulation: Bedrest. 4/6/26: Nurses Note: .Writer walked into room to change the dressing on her bottom; the resident was laying flat on her back with her leg propped up on the air conditioner. Residents (Certified Nursing Assistant- CNA) was in the room with her. CNA stated that she turned the resident on her side to be changed but then realized she needed new dressings. CNA stated that she told the resident she would be right back, came and told writer and went back into the room.She didn't realize the CNA was out of the room she said she was saying I'm slipping as she was falling.Resident was sent to the hospital. (Authored by Nurse T) 4/7/26: Orthopedic Surgery/Hospital Records: .(R121).presents after a fall out of bed today at nursing home.states she has been bed-bound for 8 months.Imaging: XR (x-ray) right hip obtained and immediately reviewed.demonstrates a displaced subcapital femoral neck fracture (fracture where the bone breaks directly beneath the ball/head of the thigh bone).admit to Orthopedic surgery. 4/15/26: History and Physical: .(R121).had fall from bed resulting in R (right) femoral neck fracture.no surgery d/t (due too) wounds and non-ambulatory status.pain control-scheduled Norco (pain medication). A review of R121's Incident/Accident (IA) report and investigation form noted the following: .Fall.Date: 4/6/26.Resident (R121).Incident Description:.CNA turned the resident on her side to get changed and realized she needed dressing for her bottom she came to tell writer she needed new dressings and went back to room to the resident being on the floor.Description: IDT (inter-disciplinary team).interventions are to provide education to staff on safety and positioning in bed. Staff educated on not to leave resident on her side if assistance is needed, she can press call light – Staff should make sure resident is middle of bed and in comfortable position.1 to 1 education: Employee Name (CNA U) Subject: Resident was left on side of bed with bed in high position during resident care. Staff left the room before placing resident in safe position which resulted in resident falling with injury. Best practice states to ensure resident safety by staying with resident and/or placing resident in safe position with low bed prior to leaving bedside. On 6/9/26 at approximately 3:31 PM a phone interview was conducted with Nurse T. Nurse T was queried as to R121's fall on 4/6/26. Nurse T reported CNA U was changing the resident and realized that they needed a dressing change and left the resident on their side to report their concern to them. Nurse T then went to the room and found R121 on the floor complaining of hip pain. Nurse T reported that CNA U never should have left the resident on their side with their bed in a high position. On 6/9/26 at approximately 3:37 PM a phone interview was conducted with CNA U. CNA U reported that they had been employed by the facility for approximately four months. When asked about R121's fall that occurred on 4/6/26, CNA U reported that they were assigned to work on the floor where the resident resided but noted that that was not their usual assignment and was not that familiar with the resident. CNA U stated that R121 needed a new patch on their bottom and they left the resident on their side to go and get the nurse. When they returned with the nurse the resident was on the floor. Following the fall, they were re-educated on not leaving a resident alone on their side and that they should have pressed the call light to have a Nurse respond. On 6/10/26 at approximately 9:31 AM, the Director of Nursing (DON) was interviewed about the incident. The DON reported that they were not employed by the facility at the time of the incident. However, when they were made aware of the fall, they noted that R121 should never have been left alone on their side. On 6/10/26 at approximately 1:42 PM, the Administrator was interviewed regarding R121's fall on 4/6/26. The Administrator reported that they were aware of the incident and CNA U should never have left the resident alone. The facility policy titled, Fall Management (7/8/25) was reviewed and documented, as follows: Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls .Fall refers to unintentional coming to rest on the ground, floor or other lower level .If a resident rolled off a bed or mattress that was close to the floor, this is considered a fall . R79 On 6/8/26 at 11:08 AM, R79 was observed seated in a wheelchair wearing navy blue pants and a white shirt that were visibly soiled with emesis. Emesis was also observed on the floor near the resident. A suction machine with inline suction tubing was present on the resident's bedside table. When asked what had occurred, R79 stated, I choked this morning and they had to stick that tube deep down my throat to get it all out. The resident further stated that she felt better following the incident. A review of the medical record revealed that R79 was re-admitted to the facility on [DATE] with the admission diagnosis of Dysphagia oral phase, Lack of Coordination and Other symptoms and signs concerning food and fluid intake. R79 had a brief interview for mental status score of 10 which indicates mild cognitive impairment. On 6/8/26 at 12:43 PM, an interview was conducted with the Nurse Practitioner (NP), the NP reported that nursing staff notified them that R79 had been vomiting and that there were streaks of blood present in the emesis. The NP stated that the resident had food lodged in her throat and required suctioning after reportedly placing too much oatmeal in their mouth, resulting in choking and vomiting. The NP reported that they ordered a chest x-ray and notified the physician as a precautionary measure, and to have the staff just monitor R79. The NP was asked whether R79 required meal supervision or assistance. The NP stated that the resident did not require meal assistance and reported that this was the first choking incident of this nature involving the resident. On 6/9/26 at 10:30 AM, a review of R79 medical record revealed no nursing notes, progress notes, incident reports, or documentation describing the choking episode, vomiting, suctioning intervention, or subsequent resident assessment. A review of the resident's care plan revealed a focus area dated 11/25 indicating, Resident trialed on mechanical soft diet following MBSS (Modified Barium Swallow-a test to view how well a person can swallow), unable to tolerate due to eating too quickly; diet downgraded to pureed texture. The care plan goal stated, Will tolerate modified consistency diet as evidenced by no episodes of pain while swallowing, coughing, choking, pocketing, or signs/symptoms of aspiration through next review date. On 6/9/26 at 10: 45AM, an interview was conducted with the Director of Nursing (DON). The DON was asked whether she was aware of R79 choking incident on 6/8/26 that reportedly required suctioning intervention. The DON stated that she was made aware hours after the incident had occurred. The DON was further asked what her expectations would be if a resident experienced a choking episode requiring suctioning. The DON stated that nursing staff should assess the resident, notify the physician and responsible party as appropriate, monitor the resident for signs and symptoms of aspiration or other complications, complete nursing documentation regarding the event and interventions provided, and update the resident's care plan if indicated. The DON further stated that an event of this nature should be documented in the medical record so that the resident's condition could be monitored and the interdisciplinary team could evaluate whether additional interventions were necessary to prevent recurrence. The DON reviewed the medical record and was unable to locate nursing documentation related to the choking episode, however the NP did put in a note for the resident's vomiting (after the interview with surveyor), including the suctioning intervention. The DON acknowledged that the record did not reflect the facility's expected process for documenting and evaluating a significant choking event.

Based on interviews and record reviews the facility failed to maintain an ongoing Infection Control Program, ensure consistent and accurate surveillance of the facility's infections and failed to consistently implement the facility's Infection Prevention Program policy, this had the ability to affect all residents' that resided in the facility, including R31.Findings include:A review of the facility's Infection Surveillance Program (December 2025 to May 2026) revealed the following:December 2025, January 2026, February 2026, March 2026, April 2026, and May 2026 - documented multiple Infection(s) as unknown with no signs/symptoms documented, however noted multiple antibiotics and other treatments administered to the residents.Infection Surveillance from December 2025 to May 2026 also noted multiple residents with signs/symptoms of chills, cough, shortness of breath, congestion, fatigue, nausea, vomiting and diarrhea - that were not tested for COVID-19 as recommended by CDC (Centers for Disease Control and Prevention) Symptoms of COVID-19 | COVID-19 | CDC.A review of the CDC Infection Control Guidance: SARS-Cov-2 dated 6/24/24, documented in part . This guidance applies to all U.S. (United States) settings where healthcare is delivered, including nursing homes. Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Infection Control Guidance: SARS-CoV-2 | Covid | CDC).A review of the January 2026 infection surveillance, failed to identify R31 to have returned from the hospital on 1/29/26 with diagnoses that included scabies, as noted in the hospital documents provided to the facility. The resident was released with a medication Permethrin (Elimite)- treatment for the scabies. A review of the February 2026 infection surveillance documented in part, . (R31's name). Infection Unknown. Permethrin External Cream 5% .Further review of R31's medical record revealed the resident was treated in December 2025 at the facility on 12/11/25 with Calamine External Lotion (over the counter medication) for a rash and Diphenhydramine HCl (Benadryl) cream on 12/24/25 for itching.Further review of the surveillance data revealed multiple residents treated for skin concerns.A review of the facility's policy titled Infection Prevention Program revised 2/28/25, documented in part . The infection prevention and control program (IPCP) must include, at a minimum, the following elements. Investigates, identifies, prevents, reports and controls infections. There is on-going monitoring to identify possible communicable disease or infections among residents and staff and subsequent documentation of infections that occur. Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks. Infection Preventionist. serves as the coordinator of an Infection Control program. Collecting, analyzing, and providing infection data. Consulting on infection risk assessment, prevention, and control strategies.On 6/10/26 at 10:59 AM, an interview was held with the Infection Preventionist (IP) G. The concerns of the facility's Infection Surveillance were discussed for the months of December 2025 to May 2026. IP G reported they were newly hired as the Infection Preventionist on 6/1/26. IP G reported they had identified many issues with the Infection Surveillance Program and started the work on correcting the Infection Surveillance in the facility moving forward. IP G was asked to provide any additional information or documentation for the concerns identified for R31. At 1:22 PM, IP G returned and stated they were unable to provide any additional information or documentation for the concerns regarding the concerns discussed.

Based on interview and record reviews the facility failed to ensure ongoing oversight of the appropriateness of antibiotics and failed to ensure the criteria for infections were met, this had the ability to affect multiple residents that resided in the facility that was prescribed antibiotics.Findings include:A review of the facility's Infection Surveillance Program (December 2025 to May 2026) revealed the following:Multiple infections documented as unknown.Multiple infections noted without supporting documentation of the criteria of an infection to have been met.Multiple prescribed antibiotics for residents with no signs/symptoms documented.The Surveillance Program did not contain documentation to support the appropriateness of multiple antibiotics prescribed.On 6/10/26 at 10:59 AM, an interview was held with the Infection Preventionist (IP) G. IP G was asked how they determine if an infection met criteria for treatment and IP G stated the facility utilizes the McGeer's criteria. IP G was asked to provide documentation of the facility's infections to have met criteria and IP G reported they were newly hired as the Infection Preventionist on 6/1/26 and had identified issues with the program to not have contained all the required components. The concerns of the facility's oversight of the Antibiotics in the facility were discussed for the months of December 2025 to May 2026. IP G reported they had also identified the same concerns and had started the work on correcting the Antibiotic Stewardship program in the facility.Review of a facility policy titled Infection Control Antibiotic Stewardship & MDROs revised 4/17/25, documented in part . Antibiotic Stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials. The program will encourage appropriate prescribing. to help ensure antibiotics are prescribed only when appropriate. The facility has adopted McGeer's criteria for infection surveillance. The facility will communicate with the physician based on guest/resident history, evaluation, signs and symptoms, and diagnostic tests if applicable of suspected guest/resident infections to determine the best course of treatment.

Based on interview and record review, the facility failed to provide one monthly medication pharmacy review and three physician responses to pharmacy recommendations for one Resident (R11) of five residents reviewed for drug regimen review and responses. Findings include: Review of R11's Electronic Medical Record (EMR) including assessments revealed one missing monthly medication regimen pharmacy review (MRR) for the month of April (2026) of four monthly reviews beginning in January 2026. It was noted the assessments present were as follows: 5/14/26, 3/30/26, 2/20/26, and 1/23/26. Review of R11's MRR's for 5/14/26, 2/20/26, and 1/23/26 revealed there were irregularities and or recommendations made to the physician, which referenced their report, specifically, .(checked box): See report for any noted irregularities and/or recommendations. Review of R11's MRR reports described an irregularity as, an event or circumstance that is substantially inconsistent with customary, accepted clinical approaches to providing pharmaceutical products and services, or that could reasonably be expected to impede or interfere with the achievement of intended or reasonably expected outcomes. Review of the EMR including with the Director of Nursing (DON) on 6/10/26 at approximately 3:40 p.m. showed they also could not find these four documents. The DON said they would contact the pharmacist to see if they could find the missing reports. The DON said they would immediately follow-up with this Surveyor after their call. No response was received on 6/10/26 by 4:19 p.m. An email was sent to the Nursing Home Administrator (NHA) on 6/10/26 at 4:19 p.m., which informed them this Surveyor had not received the requested documents, including the April (2026) MRR and no physician responses to pharmacy recommendations to the MRR's for 5/2026, 2/2026, and 1/2026. A response was received from the NHA via email on 6/10/26 at 4:36 p.m., indicating they had requested a pharmacy response for April 2026, with no comment regarding the three requested physician responses to MRR's. An email reply was sent to the NHA on 6/10/26 at 4:42 p.m. which reclarified the requested documentation and provided an opportunity to place any pharmacy documents or physician responses in the electronic data share file system, and an opportunity to respond to concerns prior to survey exit. No documents were received, and no additional comment or input was provided upon survey exit, or during the exit conference. Review of the policy, Timeliness of Medication Regimen Review Reports, revised 9/07/23, revealed, The pharmacist will review and report any medication irregularities at least once a month .2. Clinically significant medication issues, identified by the consultant pharmacist during the admission medication Regimen Review, must be communicated to the prescriber or designee and resolved by 11:59 p.m. the following day. 3. The consultant will provide monthly MRR reports addressed to the Medical Director, Director of Nursing, and Attending Physician within 3-5 days of completion via secure e-mail or hard copy. 4. The attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's recommendations within 14 days of receipt. 5. If the attending Physician does not respond to the resident's MRR report within 14 days the Director of Nursing (DON) will notify the physician of pending MRR reports. 6. If by the 21st day the attending physician has not yet responded to the resident's individual MRR report, the Director of Nursing (DON) will notify the Medical Director to review and respond to the pending MRR reports. 7. If the Medical Director is also the attending physician, the Director of Nursing will escalate the issue to the facility Administrator. 8. When the consultant pharmacist identifies a recommendation that requires immediate or urgent attention, the pharmacist will notify the Director of Nursing (DON) and the assigned nurse at the time the recommendation is identified.

This citation pertains to Complaint #3014976Based on interview and record review the facility failed to ensure a resident received necessary physician ordered medication upon admission for one (R129) out of one resident reviewed for significant medication errors. Findings include: A complaint was filed with the State Agency (SA) that alleged R129 was not receiving needed treatment and medication and the failure to receive them resulted in sepsis and death.A review of R129's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: left hip fracture requiring operative repair , scoliosis and chronic back pain.Continued review of R129's clinical record noted the following:4/2/26: Hospital Discharge Order Sheet: History: .patient (R129) underwent hemiarthroplasty of the left hip on December 1, 2025 followed by multiple dislocations.A subsequent occurred on February 10, 2026.Persistent drainage from the surgical site has been ongoing for approximately three months.patient reports significant pain in the left leg.Discharge Summary (4/3/26).Start taking these medications: Abx (antibiotics): zerbaxa (intravenous antibiotic): Inject 3 g (gram) into the vein every 8 (eight) hours. stop date 4/27/26.Eravacycline (antibiotic used to treat complicated infections) Inject 80 mg (milligrams) into the vein every 12 (twelve) hours.stop date 4/27/26. Fluconazole (antibiotics): Take 3 tablets (450 mg) by mouth daily.stop date 4/27/26).4/3/26: Encounter:.Patient was admitted last night: 1. Zerbaxa IV ((intravenous) 3 G (Grams) every 8 hours.2. Fluconazole 150 mg (milligrams) -3-q (every) day.'. *The Eravacycline/Xerava was noted in this list.A review of R129's initial orders noted, in part, the following:4/6/26: Ceftlolozane -Tazobactam Intravenous Solution(Zerboxa) use 3 gram intravenously every 8 hours for wound. *There were no orders for this medication starting 4/3/26 when R129 was admitted .4/6/26: Eravacycline Dihydrochloride Intravenous Solution use 80 mg intravenously every 12 hours for wound. *There were no orders for this medication starting 4/3/26 when R129 was admitted .A review of R129's Medication Administration Record (MAR) for April 2026 was reviewed and noted as follows:Eravacycline : 4/6/26 9PM (not available) and 4/7/26- 9AM (not available)Ceftlolozane: 4/6/26- 2 PM (not available), 10 PM (not available)On 6/10/26 at approximately 9:32 AM an interview was conducted with the Director of Nursing (DON). The DON was queried as to why the two IV antibiotics (Eravacycline and Ceftlolozane) were not ordered and available when R129 was admitted to the facility on [DATE] and additionally why the same medications that were ordered on 4/6/26 were not available until 4/7/26. The DON reported that they were not employed by the facility at that time but would investigate the concern. The DON also noted that when they started employment at the facility, they noticed some concerns regarding medication orders and administration.On 6/10/26 at approximately 3:21 PM a second interview was conducted with the DON. The DON reported that they were not certain as to why R129 did not receive their intravenous antibiotics 4/3/26 through 4/7/26.On 6/10/26 at approximately 4:01 PM an interview was conducted with the Administrator regarding the delay in R129 receiving intravenous antibiotics. The Administrator reported that (name redacted) hospital does not send medication with the resident(s) upon discharge. *It should be noted that the hospital the Administrator mentioned was not the same hospital where R129 was treated. The Administrator was asked even if the hospital could not send the resident with needed medications what caused the delay in obtaining it upon their admission and/or if the facility was not able to obtain it timely why was the resident accepted to the facility. The Administrator reported that they were not certain what caused the long delay.The facility policy titled, Physician's Order (Revised 8/20/25) was reviewed and documented as follows:.Purpose: Physician orders are obtained to provide a clear direction in the care of the resident.On a regular basis or as required by state and/or federal law the attending physician will review the plan of care, including physicians orders.admission Physician orders not signed timely will be identified by the facility for physician signature.

This citation pertains to intake 3030553 Based on observations, interviews, and record reviews the facility failed to develop, implement, and monitor an effective restorative nursing program for two (R26 & R27) of three residents identified as having the potential to maintain or improve their functional abilities. The facility did not consistently assess residents for restorative nursing needs, establish individualized restorative goals, or ensure restorative interventions were provided as planned. Findings include: R26 On 6/08/26 at 1:30 p.m., R26 was observed in their hospital bed in their room, laying on their back, wearing a gown. Their heels were positioned directly on the mattress. R26's family member, FM AA, was present in their room with them. There was a tall bariatric recline wheelchair in their room with a wheelchair cushion in newer condition. It was noted R26's left hand was curled into a fist. R26's left leg was extended and rotated, with minimal edema, more pronounced on the dorsum of their left foot. On 6/08/26 at 1:33 p.m., R26 was asked about their positioning with FM AA present, and how often they were up in their wheelchair. R26 said they loved their wheelchair however there was a miscommunication among staff. R26 explained they used to get up in their wheelchair to go to the activities room but stopped because staff were leaving them up all day in the wheelchair, until the evening, which was too long for them. R26 indicated they would get up in their wheelchair for therapy or for activities for a specified time period. R26 said they liked being in therapy to sit up on the edge of the bed and for movement as they were not getting exercise or range of motion anymore. R26 said they liked it when their left leg was stretched out especially and said they used to have a left-hand splint which they liked but it was gone. It was noted R26 was oriented to his name, situation, and place during the interview. On 6/08/26 at approximately 1:37 p.m., FM AA said they had spoken to the former Director of Nursing (DON) about getting R26 up in their wheelchair for shorter periods, as they could not be up in their wheelchair all day. FM AA reported they were R26's guardian. R26 and FM AA both said R26 was positioned on their back only recently, but did get turned when they were changed, and denied having any skin concerns. FM AA said they both wanted therapy to improve his core strength to sit up in the wheelchair again, feeding himself without spilling food often, for the hand splint, and range of motion. Review of the Electronic Medical Record (EMR) revealed FM AA was R26's guardian. Review of R26's Minimum Data Set (MDS) assessment, dated 5/14/26, revealed R26 scored 14 on the Brief Interview for Mental Status (BIMS) assessment, which showed they scored in the cognitively intact range. The assessment revealed R26 required supervision to contact guard (cueing) assistance for eating and was dependent for toileting and chair-to-bed transfers. On 6/09/26 at 11:25 a.m., R26 was observed in their hospital bed wearing a gown laying on his back. R26's left hand was curled shut. R26 attempted and could not move their hand. R26 named their former Occupational Therapist (OT) and said they did not know why the splint was taken away, and said, It served its purpose with opening their hand. FM AA who was present was able to open R26's left hand to nearly full range with gentle gradual range of motion. On 6/09/26 at 3:40 p.m., R26 was observed in their hospital bed lying on their back. FM AA said they were present all day and had not observed R26 offloaded or on their side partially, which R26 confirmed. R26 denied getting any range of motion for their hand or extremities. FM AA said they had to do range of motion on R26 when they could since staff were not providing any range of motion. FM AA said they were in the facility at least three to four days a week for long days. On 6/09/26 at approximately 3:50 p.m., Licensed Practical Nurse (LPN) C was asked if there was a restorative program. LPN C said there had been one in the past but not for a considerable time, at least a few months. On 6/09/26 at approximately 3:55 p.m., LPN A was asked if there was a restorative program for R26, as they were their nurse. LPN A' said there had not been a restorative program for some time, and there was an open job posting for the position when they last checked. Review of R26's tasks showed they had not been receiving any range of motion, mobility, or splint application under tasks. Review of R26's tasks showed a positioning task, which showed repositioning of R26 was marked as completed, but not observed. On 6/09/26 at approximately 4:30 p.m., the Director of Nursing (DON) was asked if there was a current restorative nursing program or range of motion program for R26 in place. The DON reported they were newer to their position and hired in April and acknowledged there was no restorative nursing program. The DON said at the end of May (2026) they began initiating a program and hired a restorative aide and they had been doing training with them and therapy had done many evaluations of residents. The DON explained they had been educating the CNA they hired and were planning to initiate the program shortly. The DON shared this aide was currently working on the floor still as an aide and the program had not gotten off the ground yet but would be soon. The DON acknowledged R26 had not been getting range of motion exercises and was not receiving therapy. The DON said they received a list from therapy on Friday of the residents who had been recommended for a restorative nursing program and were not receiving services and said they would provide the list. The DON stated they are definitely going to get it started, and it will help with mobility and range of motion to prevent contractures. On 6/09/26 at 4:57 p.m., the DON returned with a list of residents who were supposed to be receiving restorative therapy services. There were seven residents on the list, including R26. On 06/09/2026 at approximately 5:26 p.m., R26 was observed with the DON, with FM AA present. R26 was offloaded slightly off their right side with a pillow underneath their shoulder and upper trunk. R26 had soft heel protectors in place, which FM AA stated were provided after the State survey started this week. FM AA reclarified to the DON and then said R26 had a left-hand splint which was lost in the laundry and they had not seen it for a few weeks and wanted another splint for R26's hand to hold it open. R26 and FM AA discussed their preferences regarding sitting up in the wheelchair but only for shorter periods per their tolerance. FM AA showed the DON R26's leg splint and said it was not being applied. Review of R26's current orders showed no orders for a left hand or leg positioning device / brace. Review of R26's Care Plan revealed the following: (R26) has a functional ability deficit and requires assistance with self-care/mobility r/t (related to) impaired mobility, hemiplegia and hemiparesis (weakness and paralysis) affecting L (left) non dominant side, cervical disc degeneration at C6-C7, CVA (stroke), impaired mobility, low back pain. Dated initiated 2/08/25 Left knee brace 2 hours per day for skin integrity before and after placement .initiated 5/14/25. L LE (lower extremity) brace on for 4 hours/day. Date initiated 5/18/26, pt (R26) to wear L hand (WHO) splint during sleep (nighttime hours 1 p (p.m.) to 7 a (a.m.). please gently perform rom (range of motion) prior to post splint wear. report any changes to OT dept (department). No observation of skin was noted. Review of documentation requested via email during the survey provided by the facility showed R26 had a restorative program prescribed for range of motion which was not being implemented, and no restorative notes. Program was dated 12/2025. On 6/10/26 at 8:57 a.m., the Director of Rehabilitation (DOR), Occupational Therapist (OT) B, was asked about R26's splint and restorative program, as well the facility restorative referral process. OT B acknowledged R26's left hand splint order was current, and nighttime wear was recommended as of 12/04/26 including the splint and upper extremity range of motion. OT B said R26 was just seen by PT (Physical Therapy) from 3/30/26 thru 5/13/26 including for their left leg brace, and they were supposed to be wearing this as well per their understanding. OT B noted R26 had been resistant at times about participating in therapy and getting out of bed however had not been made aware R26 reported sitting up all day. OT B indicated nursing services would designate how long a resident would be scheduled to stay up in a wheelchair, despite improving sitting tolerance in a wheelchair and sitting balance being a potential therapy goal, per standards of practice, if deemed appropriate by an evaluating therapist familiar with R26. OT B said they did not write orders for sitting or schedule days. OT B said they had not been made aware R26's splint was gone and offered to search their room with R26's permission. OT B said they could rescreen them and order another splint. Surveyor shared R26's goals of sitting up edge of bed for strength, range of motion, and going to activities. OT B concurred they would address R26's sitting tolerance as appropriate pending screening/ reevaluation. On 06/10/26 at 9:12 a.m., OT B was asked about a restorative program and said they we are making recommendations what (floor) staff can do since there is no restorative program currently. OT B acknowledged residents were declining without the program as evidenced by screening residents more frequently and picking people up residents in therapy since no restorative program. Review of R26's most recent therapy discharges from occupational and physical therapy revealed they were referred to restoratives therapy service upon discharge on [DATE] and 5/13/26 respectively, with no documentation of such found by OT B, surveyor, or DON. On 6/10/26 at 9:32 a.m., OT B met with R26 with Surveyor present and told OT B their left-hand splint had been gone for three weeks. OT B found R26's leg splint in their closet but did not find their left-hand splint. R26 shared they would like to participate in therapy services again and have another left-hand splint to hold their left hand open. R26 prior showed they had no volitional use of their left hand. R26 was wearing the left heel protective foam boots and was lying on their back. R27 On 6/08/26 at 11:45 a.m., R27 was in their room in their bed, and reported they fell when their knees collapsed, so they were counting on getting range of motion to their legs to strengthen them, as they hoped to get back onto therapy July 1 (2026). R27 said their legs were weak too and they wanted to strengthen their arms as well and wished someone was coming to their room to work with them until they could get onto therapy services. R27 was oriented to themselves, time, situation, and place and their schedule. On 6/09/26 at 12:33 a.m., R27 was observed in the dining room, seated in a standard manual wheelchair, feeding themselves with their left hand. No contractures were observed. Review of the EMR showed R27's BIMS assessment revealed they were cognitively intact. On 6/09/26 at 5:15 p.m., the DON was made aware R27 was requesting range of motion for their legs and strengthening for their arms, as well as therapy. Review of R27's physical and occupational therapy notes showed they had been referred to services for range of motion and walking upon discharge (from PT and OT), with no restorative notes or documentation showing any visits, attempts, or programming was found in the EMR, or received from the facility upon request. Review of R27's tasks showed no interventions for range of motion, mobility, or exercises in the past 30 days, per therapy discharge recommendations. Review of R27's physician orders showed no orders for range of motion or walking. On 6/10/26 at approximately 9:17 a.m., OT B noted R27's therapy discharge summaries referred R27 to restorative services upon discharge and noted they had a restorative program in place. On 6/10/26 at 11:04 a.m., the Nursing Home Administrator (NHA) was asked if they had a comment regarding the lack of a current restorative program or evidence of range of motion being done with two residents reviewed, R26 and R27. The NHA said they had been made aware R26's splint was missing but found this unusual and said it had not been found. The NHA acknowledged they were trying to get the restorative program up and running and shared a restorative aide quit so they had to identify another aide. The NHA said the nursing aides could also do range of motion and be assigned. Surveyor shared this was also not found on the tasks. The NHA reportedly understood the concerns regarding residents not receiving restorative programming recommended by therapy or range of motion by nurse aides and planned to continue to support the development of the program. The NHA noted R26's BIMS was 14 and understood the concerns. Review of the policy, Restorative Nursing, revised 4/26/24, revealed, The facility strives to enable the residents to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. The interdisciplinary team (IDT) works with the resident and family to identify measurable restorative goals and practical interventions that can be implemented and achieved with nursing support. A licensed nurse will help manage the restorative program with assistance of nursing assistants trained in restorative care .Components of the restorative program include, but are not limited to, the following: Referral from skilled therapy services .

This citation pertains to intake 2987034.Based on interview and record review, the facility failed to ensure interdisciplinary care plan reviews were completed with the resident and/or legal representative, included the required interdisciplinary team (IDT) members, and were done in accordance with each Minimum Data Set (MDS) assessment for two (R43 and R120) of three residents reviewed for care plan review, resulting in the lack of opportunity for the resident and/or legal representative to participate in discussion of treatment options and decisions which pertain to all aspects of their plan of care. Findings include:Review of a complaint to the State Agency on 4/17/26 included concerns with care planning conferences and alleged there was no nursing involvement and only the physical therapist, dietician and the social worker came to the meeting. R43Review of the clinical record revealed R43 was initially admitted into the facility on [DATE], discharged on 4/12/26 and readmitted on [DATE] with diagnoses that included: end stage renal disease, metabolic encephalopathy, sepsis, bacteremia, methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, hypo-osmolality and hyponatremia, rhabdomyolysis, and acute metabolic acidosis.According to the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/19/26, R43 had intact cognition, received a therapeutic diet, and received dialysis.Review of the care planning documentation revealed the most recent documented care conference was done on 2/4/26. There was no documentation that a care planning review was completed with R43 and the IDT for the quarterly MDS assessment with an ARD of 3/19/26. R120Review of the clinical record revealed R120 was initially admitted into the facility on 9/25/25 and readmitted on [DATE] with diagnoses that included: vascular dementia moderate with anxiety, anxiety disorder, post-traumatic stress disorder unspecified, suicidal ideations, major depressive disorder recurrent moderate, hypertensive heart disease without heart failure, other speech disturbances, metabolic encephalopathy, type 2 diabetes mellitus with diabetic neuropathy, obesity, Alzheimer's disease, personal history of traumatic brain injury, and obstructive sleep apnea.According to the quarterly MDS assessment with an ARD of 3/23/26, R120 had severe cognitive impairment. The profile information in the electronic health record (EHR) documented R120 was their own responsible party, and their spouse was their emergency contact.Review of the care planning documentation revealed the most recent documented Interdisciplinary Care Conference evaluation was done on 12/31/25. The one prior to this was on 10/1/25. There was no documentation that any other Interdisciplinary Care Conference evaluation were completed with R120 and/or their family or the IDT for the significant change MDS with an ARD of 2/5/26, or the quarterly MDS assessment with an ARD of 3/23/26.Review of an additional document scanned into the EHR revealed a Care Plan Report that further documented By signing below, you are verifiing <sic> that you participated in this resident's plan of care. This document contained signatures from activity staff, social work, dietician, and the Physician. There was none for nursing staff and the section for Resident/Family was blank.On 6/9/25 at 10:25 AM, an interview was conducted with the MDS Coordinator (Nurse 'E'). When asked to explain the facility's process of scheduled and conducting care planning reviews with residents and their family/representatives, Nurse 'E' reported the MDS staff were responsible for scheduling and sending the care conference invitations and the first care conference is done within 72 hours of admission and a second one is done within 7-10 days and documented in the EHR. Nurse 'E' further reported then a care conference would be held every three months for the long term residents. When asked who was involved in those reviews, they reported it would be the dietician, social work, and nursing. When asked about nursing assistants that work directly with the residents and/or the physician/providers, Nurse 'E' reported they looked at that documentation as well and referenced the care plan report document for signatures. On 6/9/26 at 2:55 PM, another interview was conducted with Nurse 'E'. When asked to review R43's MDS assessments and care conference documentation of any reviews that were done and identify who the involved staff were, Nurse 'E' confirmed there was no care conference completed since 2/4/26. When asked about the quarterly MDS assessment with an ARD of 3/19/26 and why there wasn't another care conference completed with this review, Nurse 'E' reported their corporate staff told them to complete the quarterly with an ARD of 3/19/26 in order to not affect their quality measures. When asked if another MDS assessment was completed such as the quarterly or significant change, why wouldn't the resident and/or family and IDT be included in that review, Nurse 'E' reported they should have been and was unable to explain why that didn't happen.On 6/9/26 at 3:16 PM, an interview was conducted with the Director of Nursing (DON) who reported they had been in their role for about 35 days. When asked about the facility's process for who participates in the care planning conference reviews with the residents and/or their family/representatives, the DON reported for the quarterly and annual MDS's the MDS nurses should attend and for the initial 72-hour conferences that should be the floor nurses and/or unit managers. The DON did report a recent turnover with nurse management staff. The DON was informed of the process reported by Nurse 'E' and concerns from residents that not all disciplines were in attendance and further acknowledged the breakdown in communication and need for further evaluation.According to the facility's policy titled, Care Planning Conference dated 2026: .On Admission, Quarterly, Annually, with a Significant Change and as needed, the interdisciplinary team will hold a care planning conference with the resident, family or representative in participation. The Care Conference will be used to identify the resident's potential or actual problems, needs, goals and discharge plans .In addition to the advance invitation, the resident will be notified and invited to attend the care conference on the care conference date .Each discipline is responsible for updating their care plans and Kardex. IDT members should have their information updated prior to the care conference to assist with timeliness .The recommended members of the interdisciplinary team care conference may include: Nursing Representative, Social Services, Activities, Dietary, Nurse Assistant, Resident, Family and/or responsible party, Therapy as needed, Other member of the IDT as needed .Documentation and notes will be taken on the Interdisciplinary Care Conference evaluation in (EHR) .Care Plan Signature page can be printed from (EHR) print options on the Care Plan. All attending parties will sign and then this page will be scanned into the residents EHR in the Document tab .A summary of the residents plan of care will be provided to the resident &/or resident representative.

Based on observation, interview and record reviews the facility failed to ensure a resident with a mental disorder (R101) of one resident reviewed for PASARR (Preadmission Screening (PAS) / Annual Resident Review (ARR), was referred to have a Level II evaluation completed.Findings include:On 6/8/26 at 9:37 AM, R101 was observed in their wheelchair on the unit hallway. R101 was observed screaming at the nurse that they were in pain and needed their pain medication. At 12:45 PM, an interview was conducted with the resident.A review of the medical record revealed R101 was admitted to the facility on [DATE], with diagnoses that included: paranoid schizophrenia, bipolar disorder with manic severe psychotic features, and dementia.A review of the Physician orders and May 2026 Medication Administration Record (MAR) noted the resident to currently receive Quetiapine Fumarate 400 MG (Milligrams) once a day at bed time for Paranoid Schizophrenia.A review of the medical record contained one Level I PASARR screening completed 10/29/25.On 6/9/26 at 2:21 PM, the Social Worker Director (SWD) F was interviewed and asked if R101 had a Level II evaluation completed. SWD F stated they would look into it and follow back up. At 2:26 PM, SWD F returned and reported they only found the Level I completed in October 2025. SWD F reported that R101 has . significant mental health issues and a Level II will definitely need to be completed. SWD F reported they would submit the documentation for a Level II screening to be completed for R101. At 2:35 PM, SWD F returned and reported they were able to locate the documentation submitted for the Level II screening to be completed. SWD F was asked to provide the documentation for review.A review of the documentation submitted revealed the following in part, . the recipient does not require a Level II Evaluation under the PASARR provisions at this time due to: Nursing home staff shared that (R101 name) has been deemed incompetent but there is no current paperwork to show legal representation. Please submit 3877 once paperwork is obtained.A review of the medical record revealed guardianship documentation of R101's sister to have been granted full guardianship on 1/13/26, however the facility failed to submit the 3877 as directed.No further explanation or documentation was provided for review by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure assessment for self-administration of medication for one Resident (R27) of one resident reviewed for self-administration of medication. Findings include: On 6/08/26 at 11:48 a.m., R27 was observed dressed in their room in their bed. On 6/08/26 at 11:49 a.m., R27's thumbnail and left hand were observed, which showed their left thumb nail had a dark brown growth along the right side of their nail bed, and their third digit fingernail was largely moving off the nail bed, which appeared to have a new nailbed forming underneath. On 6/08/26 at 11:49 a.m., R27 was asked about their care. R27 reported they had a fungus on their hand, which they were treating with a fungal cream. R27 opened their top drawer to the left on their bed in their nightstand, which showed a small bottle of fungal nail remover. R27 was asked if they had been assessed to apply the nail treatment themselves. R27 said their family member had brought them the treatment, after recommended by the podiatrist. R27 said they had been applying the medication themselves for a long time at their bedside. Review of R27's Electronic Medical Record (EMR) showed R27 scored 14/15 on the Brief Interview for Mental Status (BIMS) assessment, which showed they were cognitively intact. Review of R27's physician orders, accessed 6/09/26 at 2:48 p.m. showed no order for self-administration of any medication, and there was no order for a foot anti-fungal treatment. Review of R27's Care Plan, accessed on 6/10/26 at 9:21 a.m., revealed no documentation of a fungal infection, treatment, or self-administration medication directive. On 6/09/26 at approximately 2:20 p.m., the EMR was reviewed withe DON, who concurred they did not see an assessment for self-administration of an anti-fungal treatment, or a physician order for an anti-fungal nail treatment. On 6/09/26 at 2:26 p.m. the Director of Nursing (DON) accompanied Surveyor to R27's room. It was observed R27 had an anti-fungal natural treatment in the top drawer of their nightstand. The DON removed the bottle and confirmed this bottle should not have been in R27's nightstand. It was noted it would have been accessible to other residents and was not secured or locked. Review of the label with the DON revealed the active ingredient was tea tree oil. The DON gave the bottle to R27's nurse, Licensed Practical Nurse (LPN) A') and asked them to do a self-medication administration assessment. The DON confirmed a self-administration assessment and securing a medication by nursing staff in a locked area was necessary, for any medication, including natural or over the counter (OTC). On 6/09/26 at approximately 2:45 p.m., LPN A reported they followed up with R27's medical provider and said they had done a self-administration assessment. LPN A explained they were not aware R27 was self-administering the natural fungal treatment in their room and were not aware of the new growth on R27's left thumb. LPN A explained the typical process would have been for a self-administration assessment completed, and the medication would be stored at the nurse's station, to secure the medication safely, not at the residents' bedside. Review of R27's EMR including physician orders, assessments, and podiatry consults with LPN A yielded no order related to this antifungal medication, no self-administration medication assessment, and no podiatry consults looking in past year which recommended the natural anti-fungal treatment for R27. On 6/10/26 p.m. at approximately 11:00 a.m., the Nursing Home Administrator (NHA) was asked about R27 self-administering the natural anti-fungal treatment at their bedside. The NHA confirmed the process should have been in place, however said they could not have known R27's family member had brought in the medication for them without being informed. Review of the policy, Medication Administration, revised 10/17/23, revealed, Resident medications are administered in an accurate, safe, timely, and sanitary manner .Self-administration - residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administrating process. Self-administration of medication will be reflected in the resident care plan along with any special considerations .

Based on interview and record review, the facility failed to ensure pharmacy services were provided to ensure prescribed medication was available for administration in accordance with physician orders for two (R119 and R122) of five residents whose medication was reviewed. Findings include: R122 A complaint was made with the State Agency (SA) that alleged residents, including R122, were not receiving their ordered medication. A review of R122's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: pneumonia, anxiety and Alzheimer's disease. A review of the resident's Minimum Data Set (MDS) dated [DATE] noted R122 had a Brief Interview for Mental Status (BIMS) score of 3/15 (severely cognitive impairment). Continued review of R122's clinical record noted that on 5/5/26, R122 did not receive the following medication (#5 was noted by each medication that indicated see nurse notes) at 9:00 AM: Flomax (alph-blocker to treat enlarged prostate), Folic Acid (Vitamin B9), Lipitor (cholesterol medication), Potassium (electrolytes), Eliquis (blood thinner), Saccharomyces (supports gastrointestinal health). *It should be noted that on 5/4/26 and 5/7/26 the medication noted above was marked as administered. A review of R122's progress notes revealed six Medication Administration Notes authored by Nurse Z that indicated No supply in response to why the medications were not administered. On 6/9/26 at approximately 4:32 PM, a phone interview was conducted with Nurse Z. Nurse Z reported they started working at the facility in March 2026. When asked about the lack of supply for R122 on 5/5/26, Nurse Z noted that they did not specifically recall what occurred as to the medication but noted the medication must not have been available if that is what they entered. On 6/10/25 at approximately 9:34 AM, an interview was conducted with the Director of Nursing (DON). The DON reported that they were fairly new to the facility but were aware that there had been issues regarding whether medication was either available or nursing staff not fully understanding on how to obtain medication from other sources. The DON reported that they would review R122's record and report on why the medications were not administered and/or not available. On 6/10/26 at approximately 3:25 PM, a follow-up interview was completed with the DON. The DON reported that they would complete an in-service with nursing staff on how to obtain necessary, physician ordered medication. Review of multiple complaints reported to the State Agency included allegations that residents were not receiving their medication as scheduled, and there were concerns with coordination of medication provision with the pharmacy. During the resident council interview with eight residents that were alert and able to participate in discussion, concerns were expressed that there were delays in having their medication provided timely by the pharmacy. R119 Review of the closed clinical record revealed R119 was admitted into the facility on 3/9/26 and discharged to hospital on 3/17/26. Diagnoses included: metabolic encephalopathy, critical illness myopathy, acute cystitis without hematuria, malignant neoplasm of overlapping sites of left female breast, hypothyroidism, hypertensive heart disease without heart failure, hyperlipidemia, adult failure to thrive, unspecified severe protein-calorie malnutrition, hypokalemia, diverticulosis of intestine, hypomagnesemia, other hypotension, acidosis, sepsis, adrenocortical insufficiency, other symptoms and signs concerning food and fluid intake. According to the Minimum Data Set (MDS) assessment dated [DATE], R119 had moderately impaired cognition, received tube feeding and a mechanically altered diet. Review of R119's physician orders included: Ordered to start on 3/11/26 at 2100 (9:00 PM): Phos-NaK (Potassium and Sodium Phosphates) Oral Packet 280-160-250 MG (Milligrams) Give 1 packet by mouth two times a day for supplement for 7 Days - Start Date - 03/11/2026 2100. The times to be given were at 9:00 AM and 9:00 PM. Review of the corresponding Medication Administration Record (MAR) revealed multiple discrepancies in the nursing documentation. These included various nurses documenting the order was given (via a check mark on the MAR) and others documenting a code of 5 which meant see progress note. The corresponding progress notes included: On 3/11/26, the 9:00 PM entry was noted by Nurse 'X' as on order. On 3/12/26, the 9:00 AM entry was noted by Nurse 'Y' as completed (via check mark). On 3/12/26, the 9:00 PM entry was noted by Nurse 'X' as on order. On 3/13/26, the 9:00 AM entry was noted by Nurse 'V as not available. On 3/13/26, the 9:00 PM entry was noted by a Nurse as completed (via check mark). On 3/14/26, the 9:00 AM entry was noted by Nurse 'W' as not available. On 3/14/26, the 9:00 PM entry was noted by a Nurse as completed (via check mark). On 3/15/26, the 9:00 AM entry was noted by Nurse 'W' as not available. On 3/15/26, the 9:00 PM entry was noted by a Nurse as completed (via check mark). On 3/16/26, the 9:00 AM entry was noted by a Nurse as completed (via check mark). On 3/16/26, the 9:00 PM entry was noted by Nurse 'X' as not available. There was no other documentation available in the resident's electronic health record (EHR) of what efforts the nursing staff had done to contact the pharmacy, or follow-up other than multiple entries of the order not provided due to not being available or on order. Although some nurses documented this order was completed several times from 3/11 – 3/16/26, the resident did not receive this order prior to discharging back to the hospital on 3/17/26. On 6/10/26 at 9:09 AM, a phone interview was attempted with Nurse 'X' but the number provided was not a working number. On 6/10/26 at 9:17 AM, a phone interview was conducted with Nurse 'W'. When asked about what the facility's process was when physician ordered medications and/or supplements were not available from the pharmacy to administer, Nurse 'W' reported they would routinely call the pharmacy and find out. When asked about their multiple entries of R119's order not being available and what they did about that, Nurse 'W' reported they were unable to recall anything specific about R119. When asked if they had attempted to reach out to the pharmacy, would that be documented and Nurse 'W' reported if they did, that should be in the progress notes. On 6/10/26 at 9:22 AM, an interview was conducted with the Director of Nursing (DON). When asked what the facility's process was when medications and/or supplements were not available for administration, the DON reported the nurses would check the (name of back up medication). The DON further reported they were aware of some resident concerns with medication not being available and have had discussions with the pharmacy representative. When asked if they medication was not available in the back-up supply, what would the next process be, the DON reported will send a message and should be sent on midnights or might get different order but the drop ship should be within 2-4 hours. The DON further reported the Nurses would be expected to follow-up with the pharmacy and notify the physician if medications were not provided as ordered. According to the facility's policy titled, Medication Management dated 2026, this policy did not address the facility's process for processing medication with the pharmacy. According to the facility's pharmacy contract dated 12/18/2024: .Pharmacy agrees to provide delivery services to Facility as agreed to by the Parties.Orders received by Pharmacy prior to the applicable order cut off time indicated on the delivery schedule, shall be delivered with the corresponding scheduled delivery.Pharmacy shall provide emergency (STAT) deliver services for Products not available in the Interim Supply.

This citation pertains to Intake(s): 2795651, 2796703, 2786658, 2725790, 2634630 Based on observation, interview and record review the facility failed to ensure a resident at risk for pressure ulcers was timely assessed and timely treated for pressure ulcers for one (R706) of five residents reviewed for pressure ulcer/wound care resulting in R706 obtaining a facility acquired stage 4 pressure ulcer that required hospitalization and surgery and pain. Findings include:A complaint was filed with the State Agency (SA) that alleged the resident went to (name redacted) hospital on 2/17/26 with a right buttock wound and it could not be determined when the woundstarted. Hospital records from 2/17/26 to 2/24/26 were reviewed and revealed, in part, the following: .chief complaint: WOUND CHECK.Patient is alert and oriented x3.She presented via EMS (emergency medical services) from (facility) for evaluation of sacral wound.Patient reports an open wound on her right buttock which has worsened over the past week. Patient is unable to recall when her buttock wound started.she reports she is mistreated at her facility which caused her buttock wound.she has a wound on the base of her right buttock with an opening the size of a quarter. The skin surrounding the wound is black, with foul smelling drainage.Imaging via CT (computed tomography).demonstrate no acute fractures, however shows a phlegmonous lesion (soft tissue infection) of the inferior right gluteal region with concerning for abscess.plan.Patient boarded for OR (operating room) debridement of sacral wound.pt underwent incision and drainage of right gluteal abscess, debridement of necrotic skin on 2/17/26. Focal examination of wounds:.Location: Right ischium - stage 4 pressure injury, status post debridement on 2/17/26.Measurements: 8X5.5X4.5 cim (centimeters).Wound cx (laboratory test) grew S aureus (staphylococcus infection) and ESBL (extended -spectrum beta-lactamases/e-coli). On 3/17/26 at approximately 10:40 AM, R706 was observed lying in bed. The resident was alert and able to answer most questions asked. R706 was asked about their most recent hospitalization pertaining to their wound. The resident reported that they still have the wound on their bottom and it hurts sometimes. They stated that it was currently being treated. R706 was not able to provide when the wound started and noted that they did not receive any treatment before they went to the hospital. R706 reported that they just wanted to leave the facility and go home as they worried about some staff members as some of them were rude and they do not always get help. A review of R706's clinical record revealed the resident was initially admitted to the facility on [DATE]. R706's last admission to the facility was on 2/24/26 with diagnoses that included: pressure ulcer of right buttock, stage 4, type II diabetes and schizophrenia. A review of the residents Minimum Data Set (MDS) with a target date of 2/26/26 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13/15 (cognitively intact). Braden (assessment used to assess residents' risk of developing a pressure ulcer) scores obtained upon admission and continuously throughout their stay at the facility noted the resident was at mild risk for developing pressure ulcers. Continued review of R706's clinical record revealed the following: 11/18/25: Hospital Discharge Record: .Sacral shallow partial thickness wound.no drainage.Left gluteal wounds.one shallow partial thickness wound that measures .5 cm (length) x 2.5 cm (width).Interventions: Buttocks and sacrum: cleanse wound space with bath wipe.apply a dime thick layer of Triad ointment BID (twice a day) and PRN (as needed).continue [NAME] isotour bed (pressure mattress). 11/18/25: Nursing Comprehensive Evaluations (SKIN): No risk.Does the resident have any skin condition: YES.Description: .left trochanter (hip).open area.left buttocks areas not open. 11/19/25: Skin/Wound Progress Note: The writer assessed (R706) skin and noted no active wounds. Authored by Wound Nurse (WN) F. 11/23/25: MDS Section M- Skin Conditions: .Resident has a pressure ulcer/injury over bony prominence.NO.Is this resident at risk of developing pressure ulcers: YES. A review of the residents' MAR/TAR (medication/treatment administration record) and skin treatment orders for the months November 2025, December 2025 and January 2026 showed no indication that any treatments, including prophylactic treatments, pertaining to wounds/pressure ulcers were provided. 2/12/26: Skin Issues: .Location: Right Gluteal Fold.New wound. Wound acquired in house.length 5.11 width (cm): 4.25 Depth (cm).sanguineous fluid, typically pale, read, and watery. Authored by WN F. 2/14/26: Order/TAR (Treatment Administration Record): Right Gluteal fold: Clean with wound cleanser, pat dry, apply triad paste, cover with dry gauze or foam dressing every day shift or foam dressing every day shift for promoting wound healing.*It should be noted that treatment for the wound started two days after it was found. 2/17/26: Wound Care: .Visit type: Wound Care.patient being seen today for wound evaluation and assessment.Positives: Wounds.Notes: Pressure unstageable Right Gluteal Fold. Measures 4x4 x 5.9 cm. 100% slough. Small hole present draining purulent drainage. Malodor present.Patient will be sent to the hospital. (Authored by Wound Nurse Practitioner (WNP) G. 2/25/26: History and Physical: .R706 was a resident in facility and re-hospitalized for a R (right) buttock necrotic would with abscess and underwent I & D (incision and drainage) on 2/17/26.I am seeing her today for readmission.mild generalized pain.complete abx (antibiotics) with minocycline. Local wound care and pressure offloading. On 3/18/26 at approximately 11:00 AM, an interview and record review were conducted with WN F. WN F reported they had been employed by the facility for over a year. WN F was asked about the facility protocol pertaining to wounds/pressure ulcers and their involvement with all residents. WN F reported that all newly admitted residents are assessed for skin concerns upon admission. As a Wound Nurse they also will do an initial evaluation. Thereafter, care plans and treatments are put into place to either prevent or start treating the wound. WN F also noted that following the initial assessments, nurse staff should, at a minimum, do weekly skin checks and report any concerns to them. They also noted that CNAs (certified nursing assistants) should also report skin issues to the nurses. The interview continued with WN F and R706's clinical record was reviewed. During the review it appeared that R706 had received only four noted skin checks from in-house nurses since their initial admission on [DATE]. WN F confirmed that skin checks should have been performed weekly. WN F was asked why R706's initial skin assessment/hospital records (11/18/25) that noted on discharge to the facility continue to apply a dime thick layer of Triad ointment BID (twice a day) and PRN (as needed). WN F noted that no treatments were put into place as they observed the resident upon initial admission and did not believe they had any open areas. When asked when and how the wound to the right buttock was discovered, WN F reported that a nurse informed them about the wound on or about 2/12/26. When asked who the nurse was, WN F was able to provide a first name only. WN F was asked about their observation of the wound on 2/12/26 and they reported they believed the wound was unstageable with slough and eschar and confirmed the wound was acquired in house. WN F was asked if they believed 2/12/26 was the day R706 acquired the wound. They reported that based on their observation the wound was not acquired on 2/12/26 and as nursing staff did not do weekly skin checks they were unable to determine the actual date. WN 'F was asked about R706's hospitalization pertaining to the wound and they reported WNP G recommended the resident be sent to the hospital as they believed the wound was infected and needed further treatment. On 3/18/26 at approximately 3:24 PM, a phone interview was conducted with WNP 'G. WNP G was queried as to when they were informed of R706's wound and decision to send the resident to the hospital. WNP 'G reported that the first time they saw R706 was on 2/17/26. They reported that the wound had a strong odor with drainage and believed the wound needed to be debrided. When asked if they were aware of R706's risk for wounds and when the wound started, WNP G reported they believed the resident was a new admit and again saw the resident for the first time on 2/17/26. An attempt to contact the Nurse(s) (hereinafter Nurse H and Nurse I) based on the first name provided by WN F was made on 3/18/26 at approximately 3:34 and 3:36 PM. Voice messages were left for both nurses. Nurse H returned the call at approximately 3:43 PM. When asked if they had reported R706 skin concerns to WN F they indicated they did not. Nurse I did not return the call prior to the end of the survey. On 3/18/26 at approximately 3:50 PM, an interview was conducted with the Director of Nursing (DON). The DON was queried about R706's facility acquired pressure wound. The DON reported that they were not employed by the facility at that time, however based on the resident's history and the facility's protocol R706 should have received timely and at least weekly skin assessments/checks. The facility policy titled Skin Management (1/28/26) was reviewed and revealed the following: .Policy- It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries.those at risk for compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing .A skin check evaluation is completed for each resident by the licensed nurse weekly. The licensed nurse will document findings on the skin check evaluation. The CNA will report any new skin impairment to the licensed nurse that is identified during daily care.A Resident at Risk meeting will be conducted at least monthly by the Interdisciplinary Team (IDT). During this meeting, the IDT will evaluate skin changes, review treatment modalities, interventions and will make recommendations as needed. Care Plan and resident Kardex will be updated.

This citation relates to Intake 2702800, 2746398, 2800213, 2651998, 2646662, 2634630, 2795651, 2796703, 2649843, 2785783, and 2749201. Based on observation, interview, and record review, the facility failed to ensure adequate provision of activities of daily living care including incontinence care for four Residents (R703, R708, R709, and R715) of ten residents reviewed for activities of daily living and incontinence care. Findings include: Review of several complaints received by the State Agency revealed allegations of residents waiting extended times for their call lights to be answered, resulting in residents laying in urine-soaked briefs, hygiene concerns, and staffing and care concerns. Three of the complaints were reviewed as follows: Received on 3/04/26. Alleged R703 was regularly left soaked in urine for 12 hours at a time, several times during their three week stay. Alleged resident was only given three showers in a week and had poor hygiene care including grooming. Received on 2/13/26: Alleged the facility was short staffed, causing R708 and R709 to be left soiled and (allegedly) developed UTI's (urinary tract infections). Received on 10/23/25: Alleged staff did not respond appropriately to R715's call lights, provide timely incontinence care, respond to grievances adequately, and alleged low staffing. On 3/16/26 at 11:26 a.m., Licensed Practice Nurse (LPN) O was asked about resident care and any residents being left wet. LPN O acknowledged they were finding residents left soaked (with urine) sometimes when they arrived on their morning shift. LPN O reported they tried to find the aides to talk with them but they typically had left already. LPN O explained they knew residents were waiting sometimes at least a couple hours to be changed, by finding a dark ring of urine in their briefs when they changed them. LPN O explained the third floor where they worked held up to 57 residents, and said they needed five aides during the day on their unit to provide adequate resident care. LPN O said when there were only three aides, the residents care suffered, which resulted in residents who waited 1-2 hours for care including incontinence care on the day shift, because the residents wanted to get up at the same time. During further interview regarding what they did about their concerns, LPN O said they provided education (when care was lacking) to the aides and reported their concerns to management. LPN O said the concern was the quality of the workers and not enough workers at times. LPN O was asked if they believed residents were getting urinary tract infections from laying in wet briefs for extended periods, and responded it was possible. LPN O shared some residents' showers were getting missed when staffing was low, and they sometimes gave residents showers themselves when this occurred. LPN O believed if the building had a shower team, this would resolve the problem and said they had recommended this to management but there was no shower aide as of yet on the unit. R709 On 3/17/26 at 12:28 p.m., R709 was observed in their room, dressed and seated in a wheelchair. On 3/17/26 at 12:30 p.m., R709 was asked about their care, and said during the day they waited at least an hour often for assistance, and sometimes at night they waited more than one hour for their brief to be changed. R709 said this caused them to feel uncomfortable, upset, and frustrated. R709 asked Surveyor to speak with their family member about their concerns. R709 said they, their family, and other residents had shared their concerns about long call wait times with the administrator however the situation remained. R709 was able to tell time accurately from the clock in her room and was alert and oriented to themselves, their surroundings, situation, schedule, and place. Review of R709's Minimum Data Set (MDS) assessment, dated 2/09/26, revealed R709 was admitted to the facility on [DATE] with diagnoses including heart disease, morbid obesity, and anxiety. The assessment showed R709 was dependent for toileting and transfers and was frequently incontinent of urine and occasionally incontinent of bowels. The standardized cognitive assessment showed R709 was cognitively intact. Review of R709's Care Plan revealed they transferred with two-person assistance to and from the toilet, per their preference. On 3/17/26 at 2:56 p.m., Certified Nurse Aide (CNA) P was asked about resident care and any residents being left wet. CNA P indicated they worked all the shifts, and were concerned about short staffing, which was happening on all shifts, but at night the most. CNA P said there were many residents who needed two-person assistance on R709's floor, at least five residents on R709's assignment wing, who required longer time for extended care needs. CNA P said when there were three aides to 50 residents, that gave each of the aides on the floor 16 to 17 residents a piece to provide care especially morning care to get them up including showers. CNA P explained they struggled because there were many residents in the facility who were heavy wetters (urinated at a higher volume) and needed two-person assistance to be changed or transfers, including R709. CNA P said they struggled to take a break because when they did there were not enough staff to cover the unit, and residents could fall without enough supervision. CNA P said everybody was waiting one to two hours at night for their call lights to be answered, and described they were finding residents wet when they started their morning shift, which concerned them for the residents, some of whom complained. CNA P stated sometimes they found R709 soaked when they arrived on shift, which upset them and caused them to have behaviors. CNA P said they believed R709 when they said they waited one to two hours to be changed as they were fully oriented and could tell time. On 3/18/26 at 9:29 a.m., R709's Family Member (FM) S, was asked in a phone interview about R709's care at the facility. FM S explained on weekends, nights, and holidays the staff called off frequently, and said R709 waited 1-2 hours for their brief to be changed when they were incontinent. FM S said they knew this because their mother called them when this occurred. FM S said this last occurred two weekends ago and had happened over the last few months. FM S said in February (2026) there was a weekend when were only two aides on R709's floor on the night shift. FM S spoke to the aides, who told them they had 26 patients each to care for, which they said was too many residents. FM S said another resident across the hall, R708, also waited extended periods and was found soaked by their family member. FM S reported they also came in and completed their mother's showers when the facility was short staffed, which was hard on them because they worked many hours. FM S said R709 still received their showers but only because they assisted when the aides did not have time, and their family member required them at least twice a week due to incontinence and per their preference. Review of the (Name of) unit assignment sheet on 2/27/26 showed two aides worked from 11 p.m. to 7:00 a.m. They were assigned to rooms 314 - 328, room [ROOM NUMBER], and rooms 331-2 to 339-2. There was no aide (name) next to rooms 301 - 313, 329 - 1, 329-2 and 331-1. This documentation was obtained from the midnight schedule binder at the 3rd floor nurse's station. It was noted R708 and R709 were in rooms 301 - 313. R708 On 3/18/26 at 10:03 a.m., R708's Family Member, FM Q, was asked during a phone interview about their care at the facility. FM Q said they were very excited for their family member to come to the facility but then disappointed their family member would lay there 45 minutes to 1 hour in a wet brief frequently, especially during the night shift. FM Q reported they decided not to bring their family member back to the facility after a second hospitalization for another urinary tract infection, when the problem (lacking incontinence care) kept recurring. FM Q said they filed several grievances, and the management staff were aware, however the poor incontinence care continued to recur, which was upsetting to them and R708. FM Q alleged the management said they did not have enough staffing and they were sorry. FM Q explained there were only two staff on (working) at night occasionally (verses three required) on R708's unit. Review of R708's grievance form, received via email from the facility, dated 10/12/25, completed by FM Q , showed concerns regarding R708 being left wet all night and found soaked and crying by the morning aide, which FM Q found inexcusable. The employee (name withheld) was removed from working with the resident and education was provided on answering call lights and completely care timely in the response. Review of R708's MDS assessment, dated 1/08/26, revealed R708 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive neurological disorder), anxiety, and depression. The assessment showed R708 was dependent for toileting and toileting transfers and was frequently incontinent of bowel and bladder. The standardized cognitive assessment showed they had moderate cognitive impairment. R703 Review of an email received by Surveyor from FM T on 3/17/26 at 11:04 a.m., revealed a picture of a dark yellow large urine-soaked open brief, with the title, First Incident. Attached was a grievance form, which was dated 1/11/26, signed by Family Member T . The grievance form showed, in part, .Today is the second time in four days my mom has not had her brief changed at night. When changed by the day shift today at 10 a.m., her brief was excessively saturated from top to bottom. I was told there would be check and changes every two hours as required by the state. Additionally, I was assured she would be checked frequently due to her UTI and it is not happening.When did the .incident occur. Fri (Friday) 1/9, and Sun (Sunday) 1/11 (2026). I personally changed her at 11:30 a.m. 1/11, 10:00 a.m (discovered).How can we address your issues? Ensure that check and changes occur every two hours and that she is changed if at all soiled. There should be a tool that logs all changes with time noted. The lack of changes is a serious health concern.Is this an ongoing problem? Yes. Since she became a resident. It was signed as received by a supervisor. Review of a second email by FM T received on 3/17/26 at 11:05 a.m. was titled, Second Incident, with a picture of a large dark yellow heavily urine-soaked brief. This grievance showed, in part, .When did the problem occur? Today, Wed (Wednesday), Jan (January) 14 (2026). 10 a.m. (discovered) when changed.Make it a requirement that my mother is changed at a minimum every 4 hours as well as disciplinary action for night shift aide. Is this an ongoing problem? Yes. Ever since admission. Have you contacted us in the past about this issue? Yes. DON (Director of Nursing) and Administrator. Signed by FM T and dated 1/14/26. Review of a third email by FM T received on 3/17/26 at 11:05 a.m. was titled, Third Incident, with a picture of a large yellow urine-soaked brief read, in part, .Again, my mom did not have her diaper changed last night. It is overly saturated and the bed pad was wet. They used a pull up (incontinence brief) after her shower last night verses her normal brief and it was still on her. Additionally, she was in the exact same position I left her in last night - wedge and pillows. When did the problem occur? Night shift. 1/15/26. 9:00 a.m. (discovered).How can we address your issues? Write a dr order to be changed every 4 hours and ensure it happens, disciplinary action, document each change so aides know when the last one took place. Is this an ongoing problem? Yes. Since admission. Have you contacted us in the past about this? Yes. DON.Admin. Review of a fourth email by FM T , received on 3/17/26 at 11:07 a.m, was titled, Fourth Incident, which stated, I did not file an incident each time, only on the worst instances. She (R703) was only there 3 weeks and typically was only changed 3 times per day unless I forced (pushed) them (staff) to add a 4th in the afternoon. Totally substandard care.There were two grievances included in this email, which the first read as follows: Review of the first grievance stated, My mother did not get her shower last night when she is scheduled to get one on night shift on Sat (Saturday) and Wed (Wednesday). This is the second Sat (Saturday) in a row it did not happen. Nurse (unnamed) advised it was never assigned to a CNA. When did the problem.occur? Night shift 1/17/26.How can we address your issues? Ensure showers are happening as scheduled as this is critical to proper hygiene.Is this an ongoing problem? Yes. 2 Saturdays in a row. Have you contacted us before about this issue? Yes. This was dated 1/18/2026 and signed by FM T . Review of a second grievance form attached in the same email by FM T showed, My mom was changed about 5 p.m. I assumed she was still dry when they put her to bed so I called about 10:30 p.m. and asked for her to be changed. I got the feeling it would not happen based on the call so I stopped by on my way home about 12:15 a.m She (R703) had not been ch (anged). (paper cut off). This was signed and dated 1/18/26. Review of R703's MDS assessment, dated 1/12/26, revealed R703 was admitted to the facility on [DATE], with diagnoses including atrial fibrillation (heart rhythm disorder) and a urinary tract infection (UTI). The assessment showed R703 was dependent for toileting and transfers, and frequently incontinent of bladder, and occasionally incontinent of bowel. The standardized cognitive assessment showed R703 had severe cognitive impairment. Review of R703's resident census report revealed they were a resident at the facility from 1/07/26 through 1/29/26. Review of R703's shower log record, received via email from the facility, on 3/18/26 at 6:03 p.m., for January 2026, revealed four entries for showers in January 2026, dated 1/10, 1/17, 1/21 and 1/24 (2026). Two of the four entries were initialed by staff. The other two entries showed one was designated, NA and the second was designated, RR. The facility Director of Nursing (DON) was asked for clarification of what these meant. No clarification was received by the end of the survey. It appeared NA may have been indicative of Not Attempted and RR may be indicative of Refused so there was no way to verify R703 received more than two showers during a 22-day period. It was noted R703's shower days were on Monday and Wednesday per the log, with Wednesday, 1/14/26, showing as a blank box (no indication of why or if missed). The DON confirmed the only shower records were in the Electronic Medical Record (EMR) and there was no other shower documentation. R715Review of R715's grievance, received from the facility via email, dated 12/04/25, revealed, .Extremely negative demeanors and attitudes. Length of call light on as long as 1 1/2 hours, staff having private phone calls while I'm being cared for. Never return after turning off call light. When did problem occur? 2-3 times a week, Saturday 11/30, Sunday 12/01 (2025). Time (checked) a.m. and p.m. It was noted they told the Administrator. The facility response was noted as, Weekend supervisor has been hired. Customer service training for all staff. Action to be taken: Continued education and promotion of customer service skills. The response was dated 12/09/25. Review of R715's grievance, received via email from facility, dated 10/02/25, revealed, .6 am call light put on and out at 6:30 a (a.m.), was ignored.Action to be taken: Staff educated on call light response time. The response was dated 10/07/25. Review of R715's grievance, received via email from facility, dated 10/04/25, revealed, .Call light (on) 11 a.m.- 1:15 p (p.m.), told will be back to assist but never came back. Common occurrence. dated 10/04/25. Response was, Facility to do follow-up. Inservice with all staff on response times and helping w/ (with) call lights. The response was dated 10/13/26. Review of R715's grievance, dated 10/18/25 thru 10/19/25, revealed, No services (assistance) after 12-hour period for personal changing. Call light used three times. It was shut off but no aide provided (care). When did this occur? Friday into Saturday. Who else knows about the problem? General staff and voice messages to management and to State Offices. How can we address your issues? (Alleged) as of todays date no bath service.Action to be taken: Educated staff on proper notification if there are barriers to care. The response was dated 10/31/25. Review of R715's census showed they were a resident at the facility from 9/30/24 to 1/21/26. Review of R715's MDS assessment, dated 1/06/26, revealed R715 was admitted to the facility on [DATE] with diagnoses including kidney disease, muscle atrophy and weakness, anxiety, and depression. R715 was dependent for toileting hygiene and transfers and was frequently incontinent of bladder and occasionally incontinent of bowel. They were cognitively intact per the standardized cognitive assessment. Review of R715's grievances, including other grievances during their stay, showed they expressed ongoing concerns related to extended call light wait times related to not being changed timely. The grievances showed management had been made aware however ongoing care concerns remained.On 3/18/26 at approximately 5:00 p.m., the R703's, R708's, R709's, and R715's concerns and grievances related to adequate provision of activities of daily living and incontinence care respective to showers and call lights not being answered timely, and residents being left in wet briefs for extended periods were reviewed with the DON. The DON reported they understood the concerns related to lacking incontinence care for these residents. R703's shower log was reviewed with the DON, who wished to follow up with possible explanation for the interpretation of the initials (meaning) on two of the four logged shower entries, when Surveyor shared it appeared R703 only received two showers during their three week stay (22 days), as only two of the entries were clearly initialed by staff. On 3/18/26 at approximately 5:30 p.m., the same residents and concerns respective to adequate provision of activities of daily living including incontinence care and R703's missed showers were reviewed with the Nursing Home Administrator (NHA). The NHA acknowledged there was a grievance process in place, and they had responded to the grievances, and had no additional comment. The NHA noted R103's family member had reported they sent several grievances however they had not received or seen them all. The NHA was made aware of the concerns regarding the DON wishing to review R703's shower log further, in the event either had an additional comment. On 3/18/26 at 6:06 p.m., R703's shower log was received, with no explanation provided regarding logged identifiers for two of the four dates. Review of the policy, Routine Resident Care, revised 3/12/25, revealed, Residents receive the necessary assistance to maintain good grooming and personal/ oral hygiene. Steps are taken to ensure that a resident's capacity for self-performance of these activities does not dimmish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure resident safety at all times. Guidelines.8. Incontinence care is provided timely according to each resident's needs. 9. Resident's call lights are answered timely and resident's requests are addressed if permitted.

This complaint pertains to Intake #2702800. Based on observation, interview and record review the facility failed to ensure a resident with a history of Urinary Tract Infections (UTI) received timely urine samples causing a delay in treatment and extended pain for one (R702) out of three residents reviewed for UTI's. Findings include: A complaint was filed with the State Agency (SA) that alleged it took over four days to obtain a urine specimen to determine treatment for a UTI. The complainant further alleged that staff blamed the delay on the resident not drinking enough water and noted that R702 could only drink water with staff assistance, and they felt there was either a lack of staff or staff did not respond timely to residents call light. On 3/17/26 at approximately 10:20 AM, R702 was observed lying in bed. Both the right and left hand were contracted. There was food items located near the window and several cups of water that were out of reach of the resident. The resident was alert and able to answer questions asked. When asked about care at the facility, R702 reported that staff were generally nice, but they did not believe there was enough staff to take care of their needs. They noted that they needed assistance with most everything, including eating and drinking. R702 reported that at times they wait hours to get changed and have frequent UTIs. A review of R702's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: Parkinsons Disease, Depression and muscle weakness. A review of R702's Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 (cognitively intact cognition). Continued review of the residents MDS noted the resident was dependent on others to bring utensils and liquid to their mouth once the meal is placed in from of them. Continued review of R702's clinical record revealed, the following: 2/1/26: Nurses Notes: Late entry for 1/31/26.Resident c/o (complains of) mild pain when urinating. Logged in MD (medical doctor) book to visit resident. 2/2/26: Progress Notes: .As per patient and staff patient has dysuria (pain and/or burning during urination).mild suprapubic (lower abdomen) tenderness.NP (nurse practitioner) encouraged hydration. Ordered UACS (uranalysis culture). 2/2/26: Nurses Notes: UA sample needed attempted twice. Will endorse to the incoming nurse. 2/3/26; Nurses Notes: Straight catheterization for UA sample, collection done along with CNA (certified nursing assistance). But backflow is so limited to a few milliliters. Residents brief is soaked. 2/4/26: Nurses Notes: Writer unsuccessful at attempting to obtain UA sample.endorsed to oncoming shift. 2/4/26: Progress Notes: .seen today for an acute visit regarding UTI symptoms.patient states that she has burning with urination. On examination, patient has suprapubic/flank tenderness. Urine same collected via a straight catheter. Urine is yellow, cloudy with heavy sediment and odorous.patient encouraged to increase oral fluid intake. 2/4/26: Nurses Notes: Urine sample collected on this day by NP and was put in fridge but was mistakenly discarded will endorse to the next shift. 2/5/26: Nurses Notes: Attempted straight catheterization x3 and unsuccessful. 2/7/26: Nurse Practitioner Note: UA + (positive).awaiting culture for appropriate antibiotic treatment. 2/11/26: Progress Notes: .follow up visit regarding urine culture results.patient reports she still has suprapubic tenderness and burning.Nitrofurantoin (Macrobid -antibiotic) 100 mg Q6h (every 6 hours) x 5 days.Encouraged patient to increase oral fluid intake.patient anxious and tearful concerning UTI. On 3/18/26 at approximately 5:16 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked as to the facility protocol on obtaining urine samples for a resident with signs of a UTI. The DON reported that generally a urine sample is obtained and the culture takes five days to determine the correct antibiotics to administer to a resident. The DON was asked as to the long delay in obtaining a urine sample for R702. The DON noted that they were not employed at the time but noted it appeared as if there were some difficulties obtaining the urine via a straight catheter and could not explain why it was discarded and had to be started over again. The DON was not able to provide an answer as to the extended delay. The facility policy titled, Urine Culture (11/24/25) was reviewed and noted the following: .Description: Helps

This citation pertains to intake: 2634630.Based on interview and record reviews the facility failed to report an allegation of mistreatment to the State Agency (SA) and failed to follow the facility policy for one (R716) of three residents reviewed for abuse. Findings include:A review of a complaint submitted to the SA documented in part . the staff is being aggressive and rough with (R716 name) resulting in her feeling injured afterwards.A review of the medical record revealed R716 was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, macular degeneration and conductive hearing loss. A Minimum Data Set (MDS) assessment dated [DATE], that documented a Brief Interview for Mental Status (BIMS) score of 8 (moderately impaired cognition). R716 required staff assistance for all Activities of Daily Living (ADLs).A review of a grievance dated 9/24/25, completed by Social Services Technician (SST) D documented in part . Son (son name) informed me that he would like his mother moved to another facility, as (R716 name) feels she is being treated rough by staff. Hair pulled, legs pulled, current cut on her leg as well. (R716 name) is fearful of retaliation from staff. Action To Be Taken - Resident moved to 1st floor.On 3/17/26 at 1:41 PM, the Administrator who is also the facility's abuse coordinator was interviewed and the 9/24/25 grievance was reviewed. When asked, the Administrator stated they were unaware of the rough care and mistreatment allegation. When asked if it should have been reported, the Administrator stated it should have.On 3/17/26 at 1:49 PM, SST D was interviewed and asked about the grievance. SST D remembered having the conversation with R716's son and stated the resident was transferred to another facility. When asked who they reported the allegation to, SST D stated they reported the concern to the Administrator.A review of the facility policy titled Abuse Prohibition Policy dated 10/14/22, documented in part . Each guest/resident shall be free from abuse. mistreatment. The staff will report any allegations or suspicions of mistreatment. and injuries of unknown source to the Administrator and DON (director of nursing) immediately. The Administrator or designee will notify. State or Federal agencies of allegations per state guidelines (2 hours if abuse allegation or serious injury; all others not later than 24 hours).

This citation pertains to intakes: 2795651 & 2796703. Based on interview and record reviews the facility failed to ensure acceptable standards of Nursing care and services was provided for one (R704) of two residents reviewed for a change in condition. Findings include: A complaint submitted to the State Agency (SA) noted the following in part: On 2/22/26 the family member of (R704) received a call that R704's oxygen had dropped under 90%. The family member raced to the nursing home to find R704 hallucinating with the oxygen tank empty and nasal cannula on the floor. They informed R704's nurse of the 02 (oxygen) tank being empty and the oxygen tubing to be observed on the floor and the nurse instructed the family member to put the oxygen tubing back into R704's nose. The family member asked the nurse if the resident was tested for a UTI (Urinary Tract Infection) and the nurse replied, We don't do those on Sunday. The family member noted the nurse did not come in to assess the resident, so the family member called 911. EMS (Emergency Medical Services) arrived and assessed the resident's 02 at 86% and transferred the resident to the hospital.A review of the medical record revealed R704 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic diastolic congestive heart failure, chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy and urinary tract infection. The family member (daughter) was noted as the resident's POA (Power of Attorney) for care/financial and documented responsible party.A review of the medical record revealed the following:On 2/22/26 at 1:14 PM, a Nursing note documented in part . pt (patient) noted to be hallucinating. NP (Nurse Practitioner) notified and assessed pt at bedside. Vita signs obtained BP (blood pressure) 124/57, HR (heart rate) 66, 02 (oxygen saturation) 90%. Pt placed on 2L (liters) 02 via nasal cannula.The Physician orders revealed the following:2/22/26 UACS (urinalysis, culture & sensitivity).2/22/26 Oxygen 2L per nasal cannula. Titrate 02 to keep oxygen saturation above 93%. Every shift for 02 Sat </= 90%.On 2/22/26 at 1:17 PM, a Nursing change in condition note that documented in part, . Altered mental status. pt stated she is seeing a lady standing in the corner and tickles her feet and legs occasionally. Primary Care Provider responded. Pt needs a UA (Urinalysis) and oxygen therapy.The Oxygen levels were reviewed and none were identified and documented under 90% for R704. There was no additional respiratory assessments completed by the nursing staff identified in the medical record.On 2/22/26 at 4:30 PM, a Nursing note documented in part . Pts daughter called 911 at approximately 1625 (4:25 PM) due to concern for pts hallucinations. Pt repeatedly removed oxygen from face despite frequent redirection. Oxygen was placed back on residents' face; however, resident continued to take it off. Education and reassurance provided without sustained compliance. Per family request pt was sent to the hospital for further evaluation. Pt transferred via EMS in stable condition. Supervisor notified.On 2/22/26 at 6:45 PM, a Nursing note documented in part . Daughter called facility requesting prior documentation be changed to reflect that pt was unstable upon departure. At the time of EMS departure pt was observed sitting upright, drinking a beverage, and was not wearing oxygen. Request to alter documentation was declined. Supervisor notified of daughter's request and situation.The above nursing notes were documented by Licensed Practical Nurse (LPN) E.A review of the EMS report dated 2/22/26 at 4:41 PM, documented in part . Upon arrival pt was sitting in bed. confused. Pt was accompanied by daughter at bedside. This morning staff notified daughter that pt had low SP02 (Oxygen Saturation) levels. Daughter requested a urinary analysis to be done but staff stated that it cannot be done on the weekend. Staff on scene stated EMS was unable to speak to pt's nurse due to her not being present so HX (history) was primarily obtained from daughter. Pt did present lethargic and confused appearing to be having visual hallucinations. Pt SPO2 was 86 on room air, we administered 02 15 lpm (liters per minute). Eyes were restricted but reactive to light. Pt remained on 15 lpm via NRB (non-rebreather) which kept SPO2 stable. Pt was continually reassessed and monitored throughout transport.On 3/18/26 at 11:25 AM, LPN E was interviewed and asked about the incident of R704's family to have called EMS to transfer the resident to the hospital on 2/22/26 and LPN E replied . I'm not sure. LPN E was asked to review their notes from that day. LPN E then stated they recalled that the resident was hallucinating. LPN E was asked if they remembered what level R704's SPO2 had reached that required the resident to need supplemental oxygen as no level under 90% was documented in the medical record and LPN E stated . I don't remember. LPN E was asked about the daughter arriving to the facility to find the oxygen tank empty and 02 tubing on the floor and not connected to the resident's nasals and informing them of the findings and LPN E stated they did not remember, but knew the resident took the oxygen off. LPN E was asked why R704's daughter had to call 911 and LPN E replied in part . Her daughter called 911 herself because her mother was having hallucinations and it was not normal for her to act that way. LPN E was asked how they ensured that the resident's oxygen was being continuously provided as ordered to keep the resident stable and safe and LPN E replied they did rounding. LPN E was asked how often they rounded to ensure R704's oxygen was in place and LPN E replied . I don't remember how often the rounding was. LPN E was asked if they were present when EMS was in the building and LPN E confirmed they were. When LPN E asked why they did not provide the EMS staff with the needed medical information and documentation for R704, LPN E replied . I don't remember. LPN E was asked if they informed the family that UA's are not completed on the weekend, LPN E replied . I'm not sure if I made that remark, but yes UA's are completed on Sundays, but would have to wait until Monday for pickup and have to be re-done anyway. LPN E was asked if they considered an SPO2 level of 86% on room air to be stable as noted in their documentation and LPN E replied No. LPN E was then asked why they documented in the medical record that the resident was stable, up drinking a beverage and not wearing oxygen, when EMS obtained a 86% pulse ox on RA and LPN E stated . I don't know.On 3/18/26 at 12:16 PM, an interview was conducted with the Administrator and Director of Nursing (DON), the medical record, EMS report and LPN E interview was reviewed and both were asked if the facility staff are able to obtain Urinalysis on the weekends and both stated they were. The DON was asked the normal protocol for a resident who is hallucinating and requiring supplemental oxygen and allegedly removing the needed oxygen. The DON replied they would expect increased rounding, keeping the resident in at eye sight and if they can't keep them safe and stable to send them out (to the hospital). They were asked about the LPN E to not provide the EMS with the necessary documentation and information for transfer and the DON stated the nurse should have provided the medication list, face sheet, and advance directives. When asked about LPN E documentation to note the resident to be stable, with findings identified by EMS of the resident to have an SPO2 of 86% on RA, and with no oxygen applied as ordered by the physician. The DON stated they understood the concern and would start education with the nurse.A review of a job description for Charge Nurse (provided by the Administrator who stated all the nurses were classified as Charge Nurses) was reviewed and revealed the following, . The Charge Nurse plans, coordinates, provides and manages nursing care, nursing services and health education to nursing home residents. The position requires patience, compassion, and a desire to care for the residents in a gentle and empathetic manner. Provides treatments per the physician order. Accurately transcribes and coordinates. Transfer of residents to hospital. Performs nursing assessments regarding the health status of residents. Accurately reports and documents the resident's symptoms, responses and status. initiate any required nursing interventions. Responds to resident and family concerns promptly; ensures that each concern is documented and a resolution is initiated. Coordinates. transfers of residents.

This citation pertains to Intake #2785783 and 2634630. Based on observation, interview and record review the facility failed to provide timely assistance with feeding for two residents who required feeding assistance (R702 and R718) out of four residents reviewed for food concerns. Findings include:Complaints were filed with the State Agency (SA) that alleged concerns with staffing and that residents that required assistance with eating were not receiving timely assistance with meals due to staffing issues and not always receiving food as ordered. On 3/17/26 at approximately 12:30 PM, an attempt to observe lunch service for residents eating in their rooms on the second-floor north hall (Willow Lane) was conducted. At 12:30 PM, no trays had been delivered to that area. A resident was observed sitting on a couch eating what appeared to be food not provided by the facility. Sitting near the resident was R718. R718 kept eyeing the other residents' food. An attempt to interview R718 was made. R718 appeared confused and not able to verbally answer the question as to whether they were hungry. Continued observations were made. At approximately 12:50 PM food trays started to be passed to residents who resided on [NAME] Lane. At approximately 1:02 PM, a tray was delivered to the resident near R718. R718 did not receive any food at that time. R718 continued to watch the other resident eat from the tray provided by the facility. A tray was delivered to R702's room at approximately 1:03 PM and placed on the entry way counter. A staff member entered R702's room to assist at approximately 1:14 PM. At approximately 1:23 PM, R718 still had not received their lunch. R718 continued to eye the other resident eating their lunch and grabbed the residents' half eaten cup of chocolate ice cream from their tray and started to eat the other residents food. Following the observation noted above, the Surveyor reported to Nurse L that R718 had taken the resident's ice cream off their lunch tray. Nurse L was then asked why R718 had not received their lunch yet as it was almost 1:30 PM. Nurse L reported that R718 needed assistance with eating and there were not enough staff to help the feeders at the same time. Nurse L was asked as to how many residents needed assistance when eating and they reported they thought at least four or five residents on [NAME] Lane. R702 On 3/17/26 at approximately 10:20 AM, R702 was observed lying in bed. Both the right and left hand were contracted. There was food items located near the window and several cups of water that were out of reach of the resident. The resident was alert and able to answer questions asked. When asked about care at the facility, R702 reported that staff were generally nice but they did not believe there was enough staff to take care of their needs. They noted that they needed assistance with most everything, including eating. R702 reported that at times they wait hours to get changed. With respect to eating, R702 stated they always need assistance with eating as they can't use their hands. They stated sometimes they don't get mechanically soft food, and they are not able to eat. The resident noted that their concerns have been reported to the facility. A review of R702's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: Parkinsons Disease, Depression and muscle weakness. A review of R702's Minimum Data Set (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 (cognitively intact cognition). Continued review of the resident's MDS noted the resident was dependent on others to bring utensils and liquid to their mouth once the meal is placed in from of them. A review of R702's diet order noted the resident was to receive a mechanically soft diet. R718 A review of R718's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease, dementia, unspecified severity with psychotic disturbance and metabolic encephalopathy. A review of the MDS noted the resident had a BIMS score of 1/15 (severely cognitively impaired). An order dated 3/6/26 noted R718 was ok to have x1 mechanical soft snack daily for pleasure with SUPERVISION. On 3/18/26 at approximately 5:20 PM, an interview was conducted with the Administrator. The Administrator was asked about concerns related to staffing and feeding assistance. The Administrator reported that the facility is well staffed but noted at times they are not clear as to the timing of services provided.

This citation pertains to Intake #2634630 Based on observation, interview and record review the facility failed to ensure wound care was administered both timely and correctly for one (R719) of five residents reviewed for wound care. Findings include:On 3/18/26 at approximately 11:30 AM, Certified Nursing Assistant (CNA) J reported that R719 had some concerns to discuss pertaining to their wound care. R719 was then observed sitting in their wheelchair. A family member was also in the room. R719 reported that on 3/17/26 at approximately 11:30 PM, they asked Nurse M if they were going to change their wound dressing as they had not had it changed since 7 AM that morning and to their understanding they had an order to change their wound two times per day (morning and bedtime). R719 reported that after they asked to have their wound dressing changed, Nurse M told them that they were not going to provide wound care because they were too busy as they had been assigned 29 residents. R719 stated on 3/18/26 at approximately 3:30 AM, Nurse M came back to their room and provided wound care. However, they were certain Nurse M did not follow the physician's order as they felt they did not have the right supplies and when they asked Nurse M what they were applying, Nurse M told them not to worry about it. The wound was observed. The dressing applied by Nurse M did not cover the wound and approximately one third of the wound was exposed. Yellow like soaked padding was attached to the wound. R719 noted that they never had yellow padding before. R719 was very worried as to the status of their wound. They stated the facility could not apply a wound vac as ordered upon admission and understood that it could not be done by the facility however, in lieu of wound vac, following the treatment ordered correctly and timely helped to ease the fear that the wound would go septic. At the time of the observation, the resident's family member noted they had been with the resident almost daily and had never seen the wound care treatment completed so poorly. The family member was leaving the room to talk with administrative staff at the time of interview. A review of R719's clinical record revealed the resident was initial admitted to the facility on [DATE] with diagnoses that included: Unspecified open wound, left lower leg, cellulitis of left lower limb, acute kidney failure and type II diabetes. A review of the residents Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (intact cognition). Continued review of R719's clinical record documented the following: 3/11/26: Nurses Summary: Resident admitted from hospital.resident diagnosis left leg debridement. 3/12/26: Nurses Note: Resident stated she was told that she would be placed on a wound vac.no current orders noted.only order for bedtime treatment. 3/12/26: Order: clean wound with wound cleaner wrap wound with wet kerlix apply ABD (abdominal-highly absorbent wound dressings) wrap with co-flex at bed time. 3/13/26: Skin Issues: Skin issues.left shin.Surgical wound.length cm (centimeters) 36 width 10.73 Depth (cm).Area (cm2) 273.25 .Granulation: 80%. Slough: 20 % .Serosanguineous mixture of serous and sanguineous fluid . 3/13/26: Skin/Wound Progress Note: The writer and unit manager attempted to apply wound vac therapy to (R719) LLE (left lower extremity) but was unsuccessful. 3/16/26: Skin/Wound Progress Note: .called (hospital).and asked for plastic surgery resident.(R719) surgical wound on her LLE & wound vac not being able to be applied properly. 3/17/26: Order: LLE: Clean with wound cleanser, pat dry, apply opticell AG, ABD pads, wrap with kerlix, then secure with Ace bandage.every day shift AND as needed. 3/17/26: Order: LLE: Clean with wound cleanser, pat dry, apply opticell AG, ABD pads, wrap with kerlix, then secure with Ace bandage.at bedtime AND as needed. 3/18/26: Medication Administration: Wound tx (treatment) completed d/t dressing soiled. On 3/18/26 at approximately 3:27 PM, an interview was conducted with Wound Nurse (WN) F. WN F was asked about R719. WN F reported that they were familiar with R719 and noted that they were aware of the residents wound. They noted that the wound was significant and initially the resident had an order for a wound vac, however the facility had difficulty applying it. When asked about the yellow pads that were applied by Nurse M, WN 'F noted that yellow pads were most likely Xerofoam and not in the resident's order. When asked if Nurse M should have left the wound exposed, they noted that it should have been covered per their order(s). On 3/18/26 at approximately 3:36 PM, a phone interview was conducted with Nurse M. Nurse M was queried as to the treatment that was given to R719 on 3/18/26. Nurse M recalled that the resident requested the treatment and that they were very busy that evening. They noted that they eventually were able to provide the treatment. When asked about the yellow pads that had been applied, Nurse M noted that they can't recall exactly what they applied but just followed the order. On 3/18/26 at approximately 3:11 PM, an interview was conducted with the Administrator. The Administrator reported that they were aware of R719's concerns and noted that treatment should be provided as ordered. The facility policy titled, Physician's Order (8/20/25) was reviewed and read, in part: .Purpose: Physicians orders are obtained to provide a clear direction in the care of the resident.Treatment rendered to a resident must be in accordance with the specific standing, written, verbal.order of a physician or other licensed health professional.

This citation pertains to intakes: 2795651 & 2796703.Based on interview and record reviews the facility failed to ensure oxygen therapy and maintenance was administered as ordered by the Clinician for one (R704) of one resident reviewed for respiratory care. Findings include:A complaint submitted to the State Agency (SA) noted the following in part: On 2/22/26 the family member of (R704) received a call that R704's oxygen had dropped under 90%. The family member raced to the nursing home to find R704 hallucinating with the oxygen tank empty and nasal cannula on the floor. They informed R704's nurse of the 02 (oxygen) tank being empty and the oxygen tubing to be observed on the floor and the nurse instructed the family member to put the oxygen tubing back into R704's nose. The family member noted the nurse did not come in to assess the resident, so the family member called 911. EMS (Emergency Medical Services) arrived and assessed the resident 02 at 86% and transferred the resident to the hospital.A review of the medical record revealed R704 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic diastolic congestive heart failure, chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy and urinary tract infection. The family member (daughter) was noted as the resident's POA (Power of Attorney) for care/financial and documented responsible party.Further review of the medical record revealed the following:On 2/22/26 at 1:14 PM, a Nursing note documented in part . pt (patient) noted to be hallucinating. NP (Nurse Practitioner) notified and assessed pt at bedside. Vita signs obtained BP (blood pressure) 124/57, HR (heart rate) 66, 02 (oxygen saturation) 90%. Pt placed on 2L (liters) 02 via nasal cannula.A Physician orders revealed the following:2/22/26 Oxygen 2L per nasal cannula. Titrate 02 to keep oxygen saturation above 93%. Every shift for 02 Sat </= 90%.On 2/22/26 at 1:17 PM, a Nursing change in condition note that documented in part, . Altered mental status. pt stated she is seeing a lady standing in the corner and tickles her feet and legs occasionally. Primary Care Provider responded. Pt needs a UA (Urinalysis) and oxygen therapy.The Oxygen levels were reviewed and none were identified and documented under 90% for R704. There was no additional respiratory assessments identified in the medical record.On 2/22/26 at 4:30 PM, a Nursing noted documented in part . Pts daughter called 911 at approximately 1625 (4:25 PM) due to concern for pts hallucinations. Pt repeatedly removed oxygen from face despite frequent redirection. Oxygen was placed back on residents' face; however, resident continued to take it off. Education and reassurance provided without sustained compliance. Per family request pt was sent to the hospital for further evaluation. Pt transferred via EMS in stable condition. Supervisor notified.On 2/22/26 at 6:45 PM, a Nursing note documented in part . Daughter called facility requesting prior documentation be changed to reflect that pt was unstable upon departure. At the time of EMS departure pt was observed sitting upright, drinking a beverage, and was not wearing oxygen. Request to alter documentation was declined.The above nursing notes were documented by Licensed Practical Nurse (LPN) E.A review of the EMS report dated 2/22/26 at 4:41 PM, documented in part . Upon arrival pt was sitting in bed. confused. Pt was accompanied by daughter at bedside. This morning staff notified daughter that pt had low SP02 (Oxygen Saturation) levels. Daughter requested a urinary analysis to be done but staff stated that it cannot be done on the weekend. Staff on scene stated EMS was unable to speak to pt's nurse due to her not being present so HX (history) was primarily obtained from daughter. Pt did present lethargic and confused appearing to be having visual hallucinations. Pt SPO2 was 86 on room air, we administered 02 15 lpm (liters per minute). Eyes were restricted but reactive to light. Pt remained on 15 lpm via NRB (non-rebreather) which kept SPO2 stable. Pt was continually reassessed and monitored throughout transport.On 3/18/26 at 11:25 AM, LPN E was interviewed and asked about the incident of R704's family to have called EMS to transfer the resident to the hospital on 2/22/26 and LPN E replied . I'm not sure. LPN E was asked to review their notes from that day. LPN E then stated they recalled that the resident was hallucinating. LPN E was asked if they remembered what level R704's SPO2 had reached that required the resident to need supplemental oxygen as no level under 90% was documented in the medical record and LPN E stated . I don't remember. LPN E was asked about the daughter arriving to the facility to find the oxygen tank empty and 02 tubing on the floor and not connected to the resident's nasals and informing them of the findings and LPN E stated they did not remember, but knew the resident took the oxygen off. LPN E was asked why R704's daughter had to call 911and LPN E replied in part . Her daughter called 911 herself because her mother was having hallucinations and it was not normal for her to act that way. LPN E was asked how they ensured that the resident's oxygen was being continuously provided as ordered to keep the resident stable and safe and LPN E replied they did rounding. LPN E was asked how often they rounded to ensure R704's oxygen was in place and LPN E replied . I don't remember how often the rounding was. LPN E was asked if they considered an SPO2 level of 86% on room air to be stable as noted in their documentation and LPN E replied No. LPN E was then asked why they documented in the medical record that the resident was stable, up drinking a beverage and not wearing oxygen, when EMS obtained an 86% SPO2 on room air and LPN E stated . I don't know.A review of a facility policy titled Respiratory assessment, respiratory therapy revised 2/24/25, documented in part . Documentation associated with respiratory assessment includes: date and time of the assessment. pulse oximetry readings. respiratory rate and rhythm. depth of respirations. presence or absence of respiratory distress. breath sound changes from previous assessment. abnormal findings. prescribed interventions. response to those interventions.A review of a facility policy titled Use of Oxygen revised 2/28/25, documented in part . To promote the safety in administering oxygen. tubing should be kept off the floor.

This citation pertains to intake: 2709710.Based on interview and record reviews the facility failed to implement adequate/effective fall interventions and ensure consistent follow up of fall interventions implemented, for one (R201) of one resident reviewed for falls. This resulted in a transfer to the hospital and the identification of a left ischium fracture. Findings include:A review of a complaint submitted to the State Agency (SA) documented in part . (R201's name) had multiple falls at (facility name). suffered a . left leg fracture. on 1/3, a nurse. and her. nurse manager at (facility name) refused to call 911.A review of the hospital referral provided to the facility upon R201's admission documented the following in part, . Hospital Problem List - Open fracture of nasal one, initial encounter. Nasal septum fracture. Nasal laceration. Fracture of fingers, left. Fall. Syncope and collapse.A History & Physical dated 12/9/25 at 10:38 AM, documented in part . presents to the Emergency Center for a fall injury. Mechanical fall falling forward hitting his face. He broke his dentures, He has a nasal injury. Has swelling and bruising surrounding the left pinky. He is complaining of left arm pain.A Otolaryngology Consultation dated 12/9/25 at 8:35 AM, documented in part . nasal bone fractures. along with anterior superior nasal septum fracture. In the ED (emergency department) they sutured his nasal dorsal laceration with nylon suture.A review of the medical record revealed R201 admitted to the facility on [DATE], with diagnosis that included: dementia, alzheimer's disease, falls, major depressive disorder, glaucoma, and fracture of the nasal bones. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 03, that indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). A review of a care plan titled . impaired communication r/t (related to) has some confusion and his primary language is Arabic as evidenced by Confusion, Language barrier.A review of an admission fall assessment dated [DATE] at 2:36 PM, documented the resident Category: No Risk. Score: 9.0. A fall care plan was implemented from this assess with the following interventions, . Encourage the resident to wear appropriate footwear as needed, Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position, PT (physical therapy)/OT (occupational therapy) evaluate and treat as ordered or PRN (as needed), Provide resident with activities that minimize the potential for falls while providing diversion and distraction, Put the call light within reach and encourage him/her to use it for assistance as needed.A review of the medical record revealed the following:On 12/12/25 at 7:59 PM, a Nursing note documented . Writer was notified by CNA (certified nursing assistant) that resident was on the floor. Writer entered the room and observed the resident sitting on his bottom by the left side of his bed. Resident stated that he was trying to reposition himself in the bed and then fell to the floor. no new injuries.On 12/13/25 at 7:24 AM, a Nursing note documented . Resident confused. Constantly sliding himself out of bed and onto floor.On 12/13/25 at 9 AM, a Telehealth encounter note documented . Change in elevation encounter. Unwitnessed. Resident was found down. Resident observed lying on back, on bedroom floor, on the side of the bed, with pillow under head. No other injuries.On 12/15/25 at 3:16 PM, a Nursing note documented . IDT (interdisciplinary team) reviewed fall on 12/12/23 no injury, root cause daughter states he told her, he dropped his book on floor and attempt to pick it up resulting in fall. Care plane <sic> reviewed and updated for therapy to assess for assist bars to increase bed mobility and reacher for hard to reach items.A review of the medical record and Physical & Occupational therapy notes revealed the resident was never assessed by the therapy department for the above intervention.On 12/18/25 at 4:55 PM, a Nursing note documented . Resident had an unwitnessed fall in the common area. No s/s (sign/symptoms) of injury. Refusing assistance. He is upset and yelling. Does have a language barrier so not sure what is bothering him to cause him to yell. Resident continued to scream.A review of the Physician orders and Medication Administration Record (MAR) for December 2025 documented, . Alprazolam Tablet 0.25 mg (milligrams), Give 1 tablet by mouth three times a day for anxiety. Start date 12/18/25 and discontinued 12/21/25.On 12/19/25 at 9:41 AM, a Nursing note documented . IDT MET CP (care plan) reviewed resident has increased agitation possible sundowning, medication added for anxiety.A review of the Physician orders and December 2025 MAR documented - Ativan tablet 0.5 mg, twice a day for agitation and anxiety- Start date 12/21/25. Seroquel 25 mg, one time dose administered on 12/21/25 at 1:06 PM, for agitation and Seroquel 25 mg at bed time for agitation and anxiety (Start dated 12/21/25.)On 12/23/25 at 1:19 AM, a Nursing note documented . Writer heard yelling and entered room to find pt (patient) on the floor with head resting on bed. On 12/23/25 at 9:29 AM, a Nursing note documented . IDT met, CP reviewed. Concave mattress added for defining mattress perimeters.On 12/24/25 at 12:56 AM, a Nursing note documented . Pt (patient) observed on floor, CNA (Certified Nurse Assistant) had just put pt in the bed. Pt was found kneeling on the left side of the bed with [NAME] <sic> and truck <sic> laying across the bed. Pt was aggressive and verbally yelling, would not allow writer to assessed for vital signs.On 12/24/25 at 9:34 AM, a Nursing note documented . IDT met and reviewed case, resident to have medication review. Resident has behaviors and has frequent agitation.A review of the Physician orders and December 2025 MAR documented- Alprazolam 0.25 mg tablet by mouth every 24 hours as needed for agitation, anxiety. Give at HS (hour of sleep). This medication was documented as administered on 12/25/25 at 9 PM.On 12/26/25 at 2:17 AM, a Nursing note documented . Family contacted to assist in redirecting pt as he was yelling out in the common area. Family request that staff put the pt in the bed, pt was placed in bed. Writer had just left the room after checking on pt, pt was in bed; bed was in the lowest position possible. CNA check on pt 10 minutes post writer checking and pt was observed on the floor. no injuries observed. Pt returned to wheelchair and placed in common area. Education render to family regarding keeping pt safe from falls. IDT met, CP reviewed.A review of the incident and accident report dated 12/26/25, confirmed the resident was observed on the floor at 2:06 AM.On 12/26/25 at 8:28 AM, a Nursing note documented . IDT reviewed care plan regarding fall w/o (without) injury, root cause resident has poor safety awareness, and impulsive. Care plan reviewed and updated sfety <sic> education provided to family, when resident is restless shouldn't be in room alone placed in areas of high vision such as common area and activities.A review of the Physician orders and December 2025 MAR documented- Seroquel 50 mg by mouth in the evening for agitation and anxiety and Xanax tablet 0.5 mg by mouth at bedtime for agitation and anxiety. Start date for both medication was 12/26/25.On 12/27/25 at 8 AM, a telehealth Encounter note documented . Witnessed fall no new injury or pain.On 12/27/25 at 8:43 AM, a Nursing note documented . Writer was notified by incoming nurse that resident was on the floor. Writer entered residents room and observed the resident on his bottom by the right side of his bed. Resident stated that he was trying to reach for his phone charger when he fell out of his bed.On 12/29/25 at 1:29 AM, a Nursing note documented . Writer heard yelling. Upon entering pt room, Pt was observed on floor laying on the left side of the bed on his left side with his head toward the foot of the bed.On 12/29/25 at 10:01 AM, a Nursing note documented . IDT met and discussed will request family to bring in a longer cellphone cord to ensure item can be within reach.A review of the Physician orders and December 2025 MAR documented- Ativan 0.5 mg, one tablet by mouth twice a day for anxiety. Start date 12/29/25.A Nursing note dated 1/3/26 at 11:11 AM, documented in part . Resident's daughter (daughter's name) is requesting that resident is sent out to Hospital related to his fall history within the last two weeks. Writer assessed resident and notified on call (on call clinician name). Residents Daughter (daughter name) called a non emergent number and EMS (Emergency Medical Services) techs arrived. Resident was sent out to the hospital via families. request via transportation service that arrived. This note was documented by Nurse Manager (NM) D.A review of an Ambulance run sheet dated 1/3/26, call received at 11:06 AM, documented in part . Primary Impression- Altered Mental Status. Secondary Impression - Urinary Tract Infection (UTI). Duration 2 weeks. 11:19 BP 144/110. And it was delayed on scene due to conflict between family and facility staff. The mental status is noted as confused, with a deviation from baseline that is difficult to ascertain based on family and facility history. a blood pressure of 144/110 mmHg; and a Glasgow Coma Scale (GSC) score of 11, with specific scores of 4 for eye-opening response, 5 for motor response, and 2 for verbal response. The pulse is irregularly irregular but strong. The ECG (Electrocardiogram), conducted with a 3-lead, shows atrial fibrillation. The patient was transported emergently without the use of lights or sirens to (hospital name), as per family choice.A hospital Emergency Medicine consultation dated 1/3/26 at 12:57 PM, documented in part .1/3/26 at 12:57 PM an Emergency Medicine consultation documented in part, . CHIEF COMPLAINT: FALL, SMELLING URINE. He presents to the Emergency Center today complaining of foul-smelling urine. Patient arrives from a facility. Per history from nursing/triage, daughter concerned that patient is not being taken care of properly at his facility. Patient has dementia, oriented to person only at baseline. Daughter is at bedside providing history. Reports the patient is at his baseline mental status though reports that he was recently moved to a rehab facility from his assisted living due to frequent falls. She reports that he continues to have frequent falls. Came to the ER (Emergency room) for fall recently. Has bruising on his face from this. Unsure of last fall. She also notes foul-smelling urine. And the patient reporting that he is having some pain with urination. Daughter has not noticed any new injuries. She states the patient at times states that he has a sore throat. Ill-appearing. Chronically ill-appearing, no acute distress. Moves all extremities symmetrically. Bilateral upper extremity tremor noted. Sensation intact throughout. Cognition is impaired. Hips Bilateral with Pelvis 3-4 Views- Impression 1. Mildly displaced avulsion-type fracture involving the left ischial tuberosity at the common hamstring origin. [AGE] year-old male with a history of dementia presenting with generalized weakness, multiple falls, foul-smelling urine. On exam, chronically ill-appearing though no acute distress. No focal neurologic deficits. At baseline neurologic/mental status. No acute signs of trauma noted. Benign abdominal exam. Patient with increased agitation here in the ER. Has underlying dementia. Daughter okay with Zyprexa. This resulted in improvement of agitation X-ray of the pelvis ordered as well given history of multiple falls which shows a left ischial avulsion fracture. I discussed with the orthopedic surgery, consistent with a hamstring injury, no operative/orthopedic needs. Labs were otherwise mostly reassuring, mildly elevated creatinine. complete blood count with mild anemia, no leukocytosis. COVID, influenza my interpretation are negative. However patient is weak, multiple falls, with urinary tract infection. Plan for admission to medicine, IV antibiotics, likely needs PT. I discussed the case with admitting hospitalist who accepts admission.Plan remains admission to medicine, now with Neurosurgery consult, neuro checks. Disposition: Admission.Final Impression: Urinary tract infection, generalized weakness, left ischium fracture.An attempt to interview the Licensed Practical Nurse (LPN) C was made on 2/2/26 at 2:12 PM and unsuccessful. LPN C did not return the surveyors phone call. This was the nurse assigned to R201 on 1/3/26 when they were transferred to the hospital.On 2/2/26 at 2:17 PM, NM D was interviewed and asked about R201's transfer to the hospital on 1/3/26. NM D stated the resident was due to be discharged from the facility and the daughter did not want to take R201 home because they did not have the means to take care of the resident. NM D stated R201's daughter asked that the resident be transferred to the hospital. NM D stated they called the on call doctor who stated they had no reason to transfer the resident out. NM D stated they informed the doctor that the family wanted the resident transferred to the hospital and the Physician agreed to the transfer. NM D stated they called the facility's Director of Nursing (DON) to update them on the situation and Emergency Medical Services was already at the facility to pick up the resident. NM D stated R201's daughter called EMS to transfer the resident out.On 2/2/26 at 2:38 PM, the DON was interviewed and asked about the interventions of the therapy screening for assist bars and reacher to not have been completed and the intervention of the family to have been educated regarding fall safety when it was the facility staff that reached out to the family because of the resident yelling in the community room in the middle of the night. The DON stated the family was educated because the family told the staff to put the resident in bed. The note was reviewed which noted the documentation of the phone call at 2:17 AM, in which the facility staff documented . Family contacted to assist in redirecting pt (patient) as he was yelling out in the common area. When asked why the resident was kept in the common area during the night considering the resident had a documented fall that occurred in the community room as well, the DON repeated that this is why the family was educated. The DON was asked how the facility provided adequate night time supervision for the resident considering most of their falls were documented to be at night and the DON stated the resident was placed in the community room for increased supervision. The DON stated they would look into the concerns and follow back up. At 4:05 PM, the DON returned and stated they were unable to provide documentation of the resident to have been assessed for the assist bars and reacher.Review of a facility policy titled Fall Management last revised 7/8/25, documented in part . The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Each resident in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk evaluation, treatment, evaluation, and monitoring of resident falls.No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake MI00152492 Based on observation, interview and record review the facility failed to accurately assess, monitor, and document, catheter care for three residents (902, 904, 905) of three reviewed for catheter use. Additionally, the facility failed to document Urology Consultations, and evaluate the long term administration for Pyridium (analgesic medication used to relieve urinary tract discomfort, including pain, burning, and urgency) resulting in the delay of diagnosing and treatment of a Urinary Tract Infection (UTI), Sepsis (an infection causing injury to its own organs) and hospitalization and subsequently death. Findings include: R902 A complaint was filed with the State Agency (SA) that alleged R902 complained of pain in the bladder area on [DATE] and the facility did not attend to the concern until [DATE]. The complainant further alleged they requested R902 be sent to the hospital and the facility failed to do so until several hours after R902 voiced their concerns of pain and no urine output. The complainant alleged when R902 arrived at the hospital it was determined that the resident was in septic shock due to a UTI and expired approximately 12 days later. Review of R902's Certificate of Death (date signed [DATE]) documented in part, . Cause Of Death .Sepsis .Immediate Cause . Urinary Tract Infection . On [DATE] at 10 :11 AM, a telephone Interview with the complainant confirmed R902's medical history, allegations, and provided a timeline of the alleged events between the facility and R902 as follows: [DATE] 9:48 AM, R902 contacted their spouse and stated they were not feeling well all night, felt shaky, and had pain in their abdominal area. [DATE] 9:52 AM, R902 expressed continuous complaints regarding severe shaking and trembling from R902 to spouse over the phone. Nursing was called by R902's spouse with their concern and there was no response. [DATE] 11:33 AM, spouse called Nurses desk, informed they (Spouse) placed a call two hours prior and still have not received a call regarding symptoms and requested that someone call back ASAP (as soon as possible). [DATE] 12:36 PM, family arrived at the facility and R902 was observed shaking while they tried to bring a cup with the straw to their mouth. Said they were hurting on the lower right side (abdomen) but sometimes felt like it was radiating to the left, and that it hurt in the middle and felt like it was their bladder area. R902 was shaky, very panicked, not themselves. Family observed no urine in their catheter bag, abdomen was firm, distended, and painful, and R902 said it hurts in my bladder. [DATE] 12:52 PM, Licensed Practical Nurse (LPN) A and Unit Manager LPN (UMLPN) E, were asked about the empty urine bag and asked when it was last emptied to which UMLPN E replied, things like that aren't kept track of. Family further informed Nursing that R902 experienced pain and distention in their right lower quadrant (abdomen) and suprapubic (bladder) areas and felt that it was bladder pain and was concerned there was no urine output. Nursing was unable to confirm when the last time there was urine. The family reminded Nursing that R902 had a history of UTI's, and requested a urine sample be tested , to which UMLPN E told the family the Nurse Practitioner (NP) ordered a stomach x-ray instead. [DATE] at 1:57 PM, Family observed no urine in the catheter bag which was not normal for R902 seeing they were diabetic. The family alleged R902 remained with a firm, distended, painful abdomen. [DATE] at 3:13 PM, Spouse called Nursing staff and requested an update on R902's pain, distention and urine output, at which time they informed there was no urine in the catheter bag. The spouse insisted because their bag had been dry for hours R902 needed immediate hospital treatment. [DATE] at 5:03 PM, R902 contacted their spouse indicating they were still in a lot of pain in the bladder area, and it is getting worse and had no update from Nursing about the stomach Xray. [DATE] at 5:28 PM, LPN A contacted the spouse informing they tried to replace the catheter with no success. [DATE] at 6:25 PM, record review of the Nursing Progress Note authored by LPN A documented: .Resident was observed not having much urine output . beige discharge was observed during catheter replacement . Record review of R902's hospital records date of service Emergency Medicine [DATE] at 7:26 PM, documented, in part, the following: .has a Foley catheter .daughter noticed an empty urine bag, and the staff could not confirm when it was last emptied . Consult from Urology .inspected Foley catheter and was determined not to be in the appropriate position . presented on [DATE] for severe sepsis secondary to UTI with obstructive uropathy . Further hospital record review of the Computed Tomography (CT) scan of abdomen and pelvis, .Findings suggestive of underlying cystitis (bladder infection) involving both kidneys .bilateral hydronephrosis (swelling of the kidneys due to the buildup of urine)/hydroureter (swelling of the ureter due to urine back up) .Later in the evening, the patient's sepsis worsened .did not want aggressive measures .transferred to Hospice [DATE] .remained under inpatient hospice care .until death [DATE] . A review of R902's clinical record revealed the resident was transferred from the hospital to the facility on [DATE] with a primary diagnosis that included: Urinary Tract Infection (UTI) and required continued medical care and physical rehabilitation. Medical clinical history included a history of diabetes, neurogenic bladder (lack of bladder control) as a result from surgery in 2024 for spinal stenosis (condition that narrows the spine and places pressure on spinal cord) and recurrent UTI's. R902 was admitted to the facility with a UTI and Foley catheter (placed in hospital prior to transfer) and was to maintain the catheter until evaluated by Urology. Brief Interview of Mentals Status (BIMS) was ,d+[DATE] indicating R902 was cognitively intact. Further review of R902's clinical record revealed there was no documentation of R902 having an order for a Foley catheter including the medical necessity and or medical diagnosis. Interventions listed within the careplan included changing the catheter and tubing per policy and as needed, yet there was no documentation in the electronic medical record (EMR) this was completed. Careplan documented .at risk for urinary tract infection and catheter related trauma has foley catheter .observe, record, report discomfort on urination and frequency . On [DATE] at 12:27 PM, a telephone interview was conducted with LPN A and confirmed they were aware R902 was complaining of abdominal pain and were being assessed for GI (gastrointestinal) and not urinary tract because R902 had complained of diarrhea. LPN A also mentioned R902 had a low blood pressure. LPN A said they were informed by family at bedside there should have been urine in the bag. LPN A acknowledged it was was unclear when it was emptied, and did not recall if there was documentation of catheter care. When questioned to clarify the Nursing Progress Note dated [DATE] at 6:25 PM documenting .beige discharge was observed during catheter replacement . LPN A confirmed they pulled the catheter and tried to insert another without success. When asked to clarify what meant without success, LPN A said they had resistance advancing the catheter, could not confirm placement, left it (catheter) in the urethra, and commented there was a liquid substance (discharge) observed leaking out the penis around the partially inserted catheter. On [DATE] at 10:33 AM, An interview was conducted with the Director of Nursing (DON), Nurse Practitioner (NP) D and UMLPN E regarding the events pertaining to R902's on [DATE]. UMLPN E confirmed they received a call from R902's spouse indicating they were complaining of chills and tremors. UM LPN E simplified they did not perform a physical assessment and only reported the complaints they received from the spouse over the phone which was the only information they conveyed to NP D. UMLPN E acknowledged they were present and assisted LPN A with replacing the catheter. UMLPN E remarked it was difficult to advance the catheter because there was a crusty discharge at the top of the penis. When inquired if there was documentation of the discharge prior to their observation, UMLPN said there was no documentation of any catheter care and therefore unable to know for certain. Record review from NP D Progress Note dated [DATE] 00:00 (per facility this is a default time, actual time of the NP being there is not recorded) documented: .Nursing staff reports that patient has hypotension and complaints of chills. Patients is still in bed and appears anxious. Patient complains of having chills and tremors .just does not feel good all over .Current blood pressure ,d+[DATE] .Positive for fatigue Notes: I have chills Blood Sugar 334 .Positive: Tachycardia .Abdomen firm and distended . Record review revealed NP D did not document a genitourinary (relating to the genital and urinary organs) assessment. On [DATE] at 10:33 AM, during an interview with NP D they acknowledged they were informed by UMLPN E the spouse had called and wanted R902 to be seen for complaints of chills and not feeling right. NP D was not familiar with R902 but because they were in the building, they came to assess. NP D confirmed based on the complaint of abdominal pain and diarrhea, NP D focused on a gastrointestinal rule out, and did not identify any assessment with R902's urinary catheter. When questioned why Midodrine (medication to treat low blood pressure) was given when R902 complained of chills, demonstrated anxiety and reported new onset hypotension, they replied that it was normal practice if the systolic blood pressure (top number) was under 100. When asked if sepsis was considered, they replied they were focused on ruling out an ileus (lack of movement in the intestines) and dehydration. NP D could not recall if they followed up on the ordered abdominal x-ray results. Record review revealed the Abdominal X-ray Radiology Result Report dated [DATE] at 13:39 (1:59 PM) concluded: Nonobstructive gas pattern. There was no documentation from the Providers that the results were reviewed as a rule out for the ileus and R902 was still having abdominal pain, distention, chills, and no/low urine output. On [DATE] at 3:40 PM, a telephone interview was conducted with NP C and inquired why they ordered two urinalyses with culture in such close date proximity. NP C could not recall why the first test ([DATE]) was ordered, but recognized on [DATE] when they went to see R902. NP C recalled the urine in the catheter bag looked cloudy and R902 was complaining of signs and symptoms of a UTI . NP C identified when they returned on [DATE], the test was not performed on [DATE] (record review documented the test was signed off by Assistant Director of Nursing) and had to be reordered. Record review revealed NP C documented on [DATE] .Urinalysis was reviewed with the patient; negative .Patient still complaining of burning at the tip of the penis .Pyridium ordered for relief; will follow up with patient for symptom relief .Medication ordered [DATE]-Phenazopyridine HCl Tablet 100 MG (milligrams) Give 1 tablet by mouth one time a day for Burning when peeing . Per the website Drugs.com-Phenazopyridine (Pyridium) is a medication used to relieve urinary tract discomfort, including pain, burning, and urgency, and works as local analgesic (pain relief) in the urinary tract (bladder and urethra). Warnings .this medication will treat the symptoms of a urinary tract infection, but this medication does not treat the actual infection .the color of the urine will turn orange or red in color .Pyridium is not recommended for more than two days and generally used for acute use to relieve urinary tract pain .using it longer than recommended may mask underlying issues that require treatment . The Medication Administration Record (MAR) revealed Phenazopyridine HCL Tablet 100 MG (milligram) Give 1 tablet by mouth one time a day for Burning when peeing Start date [DATE] and documented this medication was administered daily from [DATE] until day of day of hospital discharge [DATE]. During the interview, NP C was asked if they were aware R902 remained on Pyridium for multiple weeks, and they could not confirm why it was ordered for so long and acknowledged it was not a long-term medication. NP C was not aware Nursing was still administering based on parameters .Burning with peeing . On [DATE] at 1:48 PM, an interview with Medical Director (MD) B was conducted and when asked how long a patient should be on Pyridium, they responded only a few days. During the interview, MD B acknowledged when residents are admitted to the facility with urinary catheters, documentation is recorded in the initial History and Physical (H&P) and the Provider places an order to maintain the catheter along with the medical diagnosis and necessity for it. MD B said to confirm with the DON, but it was their knowledge that the order for the catheter should then trigger Nursing catheter care (in the EMR). Review of R902's EMR under Physician Orders revealed no documentation of an order to maintain the urinary catheter nor a diagnosis of why it was to be maintained. The DON was asked how documentation is triggered within the EMR and confirmed orders are placed by the Physician and also captured by the MDS (Minimal Data Set) Nurse. The DON reviewed R902's EMR and confirmed there were no Nursing or CNA documentation to support any catheter care was performed, including documentation to support how much urine was emptied, when catheter care was performed, and if the catheter was replaced. The DON remarked, There had to be some care done because R902 was there for two months, and the bag had obviously been emptied. When asked if the catheter was in fact being emptied over two months, how come Nursing never thought of documenting or questioning the care required for R902. The DON had no comment. On [DATE] at 3:00 PM, during record review, Urology consultations were not identified, and the DON was questioned where the Urology consults were located for R902. The DON reviewed the EMR and was unable to locate and remarked they recently terminated their Medical Records employee (week prior to this interview) and the documentation might be in a box amongst other paperwork. On [DATE] at 4:30 PM, the DON returned with newly faxed paperwork from the Urology office ([DATE] 4:17 PM) and revealed the following: R902 was seen by Urology (off site) while a resident at the facility on [DATE], [DATE], and [DATE]. The Facility had no documented collaboration with Urology from these visits and could not verify if further recommendations were made on behalf of R902 and their urinary catheter. 34275 R904 On [DATE] at approximately 12:08 PM, R904 was observed sitting in a wheelchair. Their hair appeared greasy, and they had long nails. The resident was alert and able to answer most questions asked. R904 reported they had been at the facility since the end of [DATE] for rehabilitation. The resident was asked if they had a foley catheter and they noted that they did and stated it was hooked to their leg, underneath their pants. When asked if staff were caring for them, including their catheter, the resident noted that they think so. A review of R904's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Intussusception (a form of bowel obstruction where one segment of the intestine folds inside another), type II diabetes, and acute respiratory failure. A review of the resident's most recent MDS noted the resident had a BIMS score of ,d+[DATE] (cognitively intact). Continued review of R904's clinical record, documented: [DATE]: Nurses Notes: Foley Query form placed on MD (medical doctor) board for a proper diagnosis or to start trial void . [DATE]: ORDER: Provide Foley Care Daily Q (every)-Shift . [DATE]: ORDER: DC (discontinue) Foley Catheter. Void trials. If no urine output in 6 hours: Bladder scan, if bladder scan is >350 cc (cubic centimeters), ok to straight cath . *It should be noted that there were no documents in R904's clinical record that indicated a straight cath (catheter) was attempted. [DATE]: Progress Note: .Patient is in bed alert .Right arm is swollen .Physical Exam .Positive: Urinary Catheter .Foley .Notes: thick pale-yellow urine .Assessment and Plans .Foley catheter patent with thick pale-yellow urine .Monitor of s/s of obstruction or infection. Monitor output . A review of R904's Medication/Treatment Administration Record (MAR/TAR) from [DATE] - [DATE] showed no indication of the resident's urine output. A review of R904's Kardex/TASK electronic record showed no indication that R904's urine output was recorded. [DATE]: Progress Note: .Patient states he has a fear of not going home .Physical Exam .Positive: Urinary catheter .thick pale urine with heavy sediment .Foley cath patent. Hazy yellow with sediment .UACS (Urinalysis -Culture Sensitivity) ordered. *It should be noted that no order for UACS was noted in the resident's clinical record on [DATE]. [DATE]: Nurses Notes: .Resident alert and verbally responsive .Foley cath with foul smelling urine. New order for U/A . *It should be noted that no order was noted in the resident's clinical record on [DATE]. [DATE]: Order: UACS .One time only for UTI/Heavy urinary sediment for 2 days . (Pending confirmation). Reviewed on [DATE] at approximately 9:00 AM. A review of R904's lab results was conducted on [DATE] at approximately 10:00 AM. The last lab results noted in the residents' record was dated [DATE]. On [DATE] at approximately 10:15 AM, R904 was observed in his room sitting on their wheelchair. There was a foul odor noted in the resident's room. The resident was alert and able to answer some questions, however when confused they contacted their wife via phone. When asked if the facility had obtained lab work at any time this morning, R904 and their wife were not able to provide an answer. R905 On [DATE] at approximately 12:20 PM, R905 was observed lying in bed. The resident was alert but unable to answer questions asked. The resident had a foley catheter inserted. A review of R905's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnosis that included: Urinary Tract Infection (UTI) and Type II Diabetes. A review of the resident's MDS indicated R905 had a BIMS score of ,d+[DATE] (cognitively impaired). Continued review of R905's clinical record revealed, in part, the following: [DATE]: History and Physical: .Patient .was recently hospitalized for UTI .has been discharged to (name redacted) Facility .He is non-verbal, per staff does not speak any English . [DATE]: Progress Note: .R905 .patient complains of urinary retention. Patient's daughter requesting to see provider. Daughter is present at bedside translating for patient .During discussion patient states he does not pee much and that he dribbles a lot. This is incongruent with what nursing staff has been reporting. Daughter is concerned about dad having another major urinary tract infection because he has had retention issues in the past .Discussed with daughter that we would do bladder scans for postvoid residual (PVR) and that if he has 2 or more residuals that were greater than 300 <sic> we can discuss foley insertion . (Authored by NP D). [DATE]: Progress Note: .R905 being seen today for postvoid residual greater than 350. Nursing staff reports patient has not urinated sufficient amount that patient has just been having dribbles .Foley catheter 18 French with 10 cc balloon inserted under sterile technique .Discussed with nurse to make sure that patient output is monitored encourage fluids and cath care daily and as needed .PVR >350 Suprapubic pain and dribbles .Continue to monitor urine output. Monitor of s/s (signs and symptoms) of UTI . (Authored by NP D). [DATE]: Progress Note: .Patient has leg bag .Monitor I/O (input/output). Catheter care QD (daily) and PRN (as needed) . [DATE]: Physician Note: .R905 was seen and evaluated today to assess progress with therapy. He was sleeping in bed. The patient remains very fatigued . [DATE]: Nurses Notes (7:30 AM): Resident was sent to hospital for a change in mental status. Resident was observed vomiting . [DATE]: Nurses Notes (9:55 PM): . Resident was observed lying in bed .patient was unable to stand and weak .patient stated that he was not in any pain, however, was crying. Daughter contacted to translate .Foley drained darkened urine, Fever 100.7 .Patient began to vomit with daughter at bedside . [DATE] (Hospital Records): Recent Selective lab results . Urine Protein (slightly elevated) .Urine Nitrite - Positive! (possible signs of UTI) .Leukocytes 1+! (signs of infection) .Urine Blood 3+! (possible indication of UTI) .Urine Appearance - Cloudy .Urine Bacteria 1+ (possible signs of UTI) .Urine WBC (white blood count) ,d+[DATE]! (possible signs of UTI) .Continue foley at this time .Vancomycin 750 mg (antibiotic) every 24 hours .Pharmacy will continue to monitor renal function .Follow up with (name redacted) .Specialty: Urology in 1 week .Foley catheter 3 weeks ago with a urinary retention felt to be related to constipation .After having bowel movement and increasing his activities, Foley catheter was removed this morning and awaiting for voiding trial . [DATE]: Nursing Summary (Late Entry): Resident readmission .Foley catheter was discontinued in hospital for trial period on discharge date . Observed with condom catheter . [DATE]: Encounter: .Visit Type: Telehealth .Received a call from facility .Resident HX (history) uropathy retention on running trail with condom catheter .C/o (complaints of) ABD (abdominal) pain with distension .Had prior Foley catheter inserted before hospital. Need order to reinsert foley 18f (French) d/t retention. As it appears this resident has failed his bladder training trial . *It should be noted that there was no catheter order dated [DATE] for R905. [DATE]: Progress Notes: .Patient has chronic Foley from repeated urinary retention with yellow hazy urine. Unable to do review of system with patient no family is present to interpret patient does not speak English Monitor I/O Catheter care QD and PRN . R905's Care Plan was reviewed on [DATE] at 1:04 PM and revealed the following: Focus: R905 is incontinent of bowel R/T (related to): impaired mobility, UTI .and is continent of bladder with UTI (date initiated [DATE] Revised [DATE]) Interventions: Resident uses disposable briefs (date initiated [DATE]) .Check frequently and prn for incontinence (date initiated [DATE]) .Provide incontinence care with moisture barrier .(date initiated [DATE]) .Focus: R905 is a risk of inadequate bladder emptying, bladder discomfort or infections .dx (diagnoses) of obstructive uropathy with use of condom catheter .Interventions: Encourage resident to report any worsening of symptoms .(date initiated [DATE]) .Notify MD ASAP if resident experiences s/s of UTI .(date initiated [DATE]) .Observe for signs and symptoms, decrease in urine output, bloody or concentrated urine .(date initiated [DATE]) .Urology consult as ordered (date initiated [DATE]) . *It should be noted that there was no indication in R905's Care Plan regarding Catheter care. A review of R905's Kardex revealed the following: .Resident Care: ADL (activities of daily living/foley care q shift .Bladder/Bowel/Toileting .Monitor and record urinary output . TASK recordings past 30 days ([DATE]-[DATE]) did not contain any documentation as to monitoring and recording of the resident's urinary output. The TASK area for Urinary continence noted staff documented several responses including the resident was either continent, incontinent or continence not rated due to indwelling catheter. There was no consecutive notations as to the residents continence status. The TASK area noted as ADL (activities of daily living) Care Statement/cath care q (every) shift contained only the following questions to report Yes or No to. The question were as follows: Have you provided routine standard care which includes evaluating skin daily and reporting changes, shaving and nail care as needed, turning and repositioning, oral care, washing face and hands, hair care, clean clothes and linens, ROM (range of motion), offering fluids, utilizing resident specific devices, dignity and respect, universal precautions, observing and reporting changes in behavior, keeping call light within reach, observing and notifying for pain, and encouraging and assisting to activities? *It should be noted that there was no specific question pertaining to catheter care. On [DATE] at approximately 10:36 AM, an interview and record review were conducted with the Director of Nursing (DON) and NP 'D. The DON was asked as to the facility's protocol for caring for residents with foley/urinary catheters. The DON reported that if a resident enters the facility with a catheter, they review their records to determine the purpose as to why they have a catheter. Depending on the resident's diagnosis, attempts are made to remove it to encourage continence and avoid the possibility of a UTI. The DON was not able to provide a time as to when and how often those attempts are made. The DON was asked how the facility ensures that catheter care is being completed daily. The DON reported that the CNAs and/or the Nurses follow an order and document in the resident's charts. Both the DON and NP D were asked as to why R904 and R905 did not have any I/Os recorded in their charts as it was noted to do so in their record. The DON reported that despite the notes in the residents' charts, I/O's are not done without a physician's order. The DON was further asked why R905 again had several notes indicating their I/O should be recorded and additionally their Kardex documented it should be done for output. The DON reported that generally the CNAs empty resident's catheter bags and if there is an issue they will tell the nurses but again noted nursing staff do not generally report I/O in their records. The DON could not give an explanation as to why the Kardex noted it should be done. When asked if attempts had been made to discontinue the R905's catheter, the DON reported that they would not do so until the resident was seen by a urologist and noted that the resident is scheduled to see them tomorrow ([DATE]). On [DATE] at approximately 12:20 PM, a request was made to interview the facility's Infection Control (IC) Nurse. The DON reported that the IC Nurse was out of the building and not available for interview. The DON was further interviewed regarding R904 and R905. With respect to R904, the DON was asked why the resident, who on [DATE] the NP noted hazy yellow sediment in their urine and documented a UA order was placed had not yet received had any lab work. The DON reported that while it was documented in the notes, they were waiting for the lab order and believed it would be done today. With respect to R905, the DON was asked as to whether attempts were made to remove the resident's catheter as they had seen their urologist on [DATE]. The DON reported that they were incorrect and R905 had not been seen by the urologist and believed they were scheduled to see the physician tomorrow ([DATE]). The facility policy titled, Indwelling urinary catheter (Foley) care and management -critical Notes ([DATE]) was reviewed and noted, in part: .The Centers for Disease Control and Prevention (CDC) estimates 15% to 25% of hospitalized patients have an indwelling urinary (Foley) catheter .Catheter insertion for inappropriate indications is common Appropriate indications for catheter use include: perioperative use for surgical procedures .Prolonged surgery .surgery requiring large-volume infusions or diuretic use .continuous bladder irrigation .Administration of drugs into the bladder .intraoperative urine output monitoring .prolonged immobilization .need for accurate hourly urine output .acute urinary retention or urinary obstruction .assistance healing of open pressure injuries .improved comfort during end-of-life care .inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter-associated urinary tract infection .Clinical alert: Clean the periurethral area carefully .inspect .the area for signs of inflammation and infection .Assess the securement device daily .Clinical alert .Monitor intake and output, as ordered. Monitor of changes in urine output, including volume and color .Empty the drainage bag regularly when it becomes one-half to two thirds full .Documentation: Documentation associated with indwelling urinary catheter care and management includes: indication for continued catheter use, maintenance care, assessment findings .