Every finding on record at Regina Senior Living

Based on observation and interview, the facility failed to clean and sanitize food-contact equipment, remove a paper bowl used as a scoop in a sugar container and keep food boxes off walk-in freezer unit floor. Findings include: During the initial kitchen tour on 2/23/26 at 12:15 p.m., with the culinary director (CD), the following was identified: seven boxes were stored on the Walk-in freezer floor, a brown paper bowel used as scoop left in the sugar container and the can opener part that meets the top of the can (blade and gear) was covered with dark dry substance. CD confirmed the scoop in the sugar container, is not the usual practice indicated it could cause for cross contamination. During a follow up kitchen tour 2/25/26 at 7:52 a.m., the can opener blade and gear remained covered with the dark dry substance and additionally a red paste was noted on the blade. Head cook (HC) indicated it was used and must have gotten dirty yesterday.In the walk-in freezer, five food boxes remained on the floor. HC stated the boxes were not supposed to be on the floors and were delivered the day prior. During an interview on 2/25/26 at 8:46 a.m., CD stated, the expectation was for the can opener to be cleaned weekly, when asked about the substance covering the can opener blade and gear-can remove this. CD confirmed, (could remove this also) and the boxes in the walk-in freezer should not be on the floor. A facility policy on food safety procedures was requested and not received.

Based on observation, interview and document review the facility failed to correctly establish and ensure staff followed appropriate transmission-based precaution (TBP) for 1 of 1 resident (R66) who required enhanced respiratory precautions for COVID-19. Further, the facility failed to ensure appropriate personal protective equipment (PPE) was used for residents in enhanced barrier precaution (EBP) during podiatry treatments in a common area for 1 of 3 residents (R57) reviewed for EBP. Additionally, the facility failed to initiate EBP for 1 of 1 resident (R33) who required EBP due to a pressure ulcer.Findings include: R66 was admitted to the facility on [DATE] from a hospital, her Minimum Data Set (MDS) assessment had not been completed at time of survey. R66's progress note dated 2/21/26 indicated R66 had severe cognitive impairment. R66 had a diagnosis of dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and Covid-19. According to the Centers for Disease Control (CDC), residents diagnosed with COVID-19 require additional TBP that included an isolation gown, N95 respirator or higher-level respirator, eye protection (goggles or face shield), and gloves. During observation on 2/24/26 at 10:52 a.m., physical therapy (PT)-A was observed entering R66's room with a standard mask (not an N95) and without an isolation gown or gloves, placed a gait belt in her room and exited room. During an interview on 2/24/26 at 11:08 p.m., PT-A stated he had only put on a standard mask (not an N95) when he returned the gait belt to the room he had used when working with R66. PT-A stated when returning the gait belt, he should have put on the appropriate PPE before entering the room that included the isolation gown, N95 mask, and gloves. PT-A stated it is important to wear the appropriate PPE every time you enter the room to prevent the spread of infection. During observation on 2/26/26 at 9:08 a.m., nursing assistant (NA)-C was delivering the meal tray to R66. NA-C put on an isolation gown, standard mask (not an N95), gloves, and eye protection. NA-C opened R66's door, walked inside room with meal tray and closed the door. At 2/26/26 at 9:11 a.m., NA-C exited R66's room, performed hand hygiene, then moved down hall to continue delivering meal trays. During an interview on 2/26/26 at 10:11 a.m., licensed practical nurse (LPN)-E stated they receive infection control education upon hire, annually, and if something changes. LPN-E stated the infection control education contains information about proper PPE for the different types of infections they see at the facility. LPN-E stated for a resident who was in isolation for COVID-19, the isolation required included an isolation gown, gloves, face mask, and an N95 mask. LPN-E stated staff should wear the appropriate PPE every time you enter the room of someone with COVID-19; this is important to prevent the spread of infection. During an interview on 2/26/26 at 10:17 a.m., NA-C stated staff receive education about infection prevention when they are hired, annually, and if something changes. NA-C stated the infection prevention education they received included how to apply and take off PPE, when to use PPE, and what type of PPE to use for the infections they typically see in the facility. NA-C stated the proper PPE to use when caring for someone with COVID-19 included an N95 mask, isolation gown, gloves, and goggles. NA-C stated she had been delivering morning meal trays that included R66. NA-C stated she was aware R66 had been diagnosed with COVID-19 and required additional PPE for that. NA-C confirmed she had not had a N95 mask on when delivering R66's meal tray. NA-C stated she did not wear the N95 mask because the isolation sign on the door stated she could wear an N95 mask or a standard mask. NA-C stated she thought residents with COVID-19 infections required an N95 mask but since the sign said she could wear a standard mask, that is why she wore the standard mask. During observation and interview on 2/26/26 at 10:28 a.m., director of nursing (DON) and regional director of clinical sales (RDCS) confirmed R66 had COVID-19; requiring additional PPE that would include an N95 mask, isolation gown, face mask, and gloves. RDCS confirmed staff are educated about isolation procedures when they are hired, yearly, and if there are any updates to isolation procedures. DON stated it is her expectation all staff at the facility should wear the appropriate PPE prior to entering R66's room. Additionally, DON and RDCS reviewed the isolation sign placed on R66's door, the isolation sign reflected staff would be required to wear: -Gown -Facemask or -N95 Respirator for aerosol-generating procedures -Eye protection (goggles or face shield) -One pair of gloves -Hair cover (optional) DON and RDCS confirmed the isolation sign currently on R66's door was not the correct sign; they were unsure where this sign came from or how it was placed on R66's door. RDCS stated the correct sign the facility uses read: -Gown -N95 Respirator or higher-level respirator - Eye protection (goggles or face shield) -One pair of gloves DON and RDCS stated it is important to apply the appropriate PPE to prevent the spread of infection. Additionally, the appropriate PPE should be worn every time facility staff enter R66's room. R57 R57's comprehensive MDS assessment, dated 11/26/25, indicated R57 had limited cognitive impairment . Further, R57 required a wheelchair for mobility, required set-up assistance for hygiene/oral care, and was independent with eating. R57's diagnosis included prostate cancer, chronic kidney disease requiring a urinary catheter (tube inserted into the body to drain urine), and difficulty walking. R57's care plan dated 11/11/24, had previously acquired infections and due to the placement of the urinary catheter, R57 now required EBP when receiving cares. During observation on 2/23/26 at 1:24 p.m., R57 was observed in the facility day room with 3 other residents; all 3 residents were receiving podiatry care. The podiatry team did not put on the appropriate PPE when providing treatment to R57; as recommended by the CDC. Medical doctor (MD)-A donned standard gloves removed R57's shoes and socks, performed callous shaving and clipping toenails. When completed, medical assistant (MA)-A assisted R57 with putting his shoes and socks back on; MA-A had not applied the appropriate PPE prior to assisting him. During an interview on 2/23/26 at 1:24 p.m., MA-A stated she was unsure if R57 required staff to wear special PPE when providing podiatry treatments. MA-A stated the podiatry team does not wear PPE when providing treatment, unless facility staff direct them to. MA-A stated she had not worn any additional PPE while caring for any of the residents today. During an interview on 2/23/26 at 1:41 p.m., MD-A stated he was unaware that R57 required podiatry staff to wear additional PPE when providing podiatry treatments. MD-A stated his team primarily performs callous removal and toenail clipping. MD-A stated he was aware of why residents would require additional PPE such as required for EBP; the primary reason being to reduce the spread of infection from one resident to another. When asked if residents in EBP or higher-level isolation should have podiatry treatments in a common area; MD-A stated only bed bound residents get podiatry care in their rooms. MD-A stated he would prefer the day room to be a private setting but, facility staff kept bringing more residents into the room. During an interview on 2/25/26 at 9:19 a.m., director of nursing (DON), regional director of clinical sales (RDCS), and administrator stated they would expect all ancillary service providers to adhere to the facility's infection prevention precautions such as EBP. The administrator confirmed he had walked through the day room during the podiatry treatments, PPE was not worn for residents receiving podiatry treatments. DON and RDCS stated it is important to apply the appropriate PPE to prevent the spread of infection. Additionally, the appropriate PPE should be worn every time facility staff or ancillary staff provide cares such as podiatry treatments. A facility policy titled COVID-19 Program Overview dated 9/29/22, healthcare workers caring for residents with suspected or confirmed COVID-19 should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator.) A facility policy titled Enhanced Barrier Precautions dated 4/1/24, residents with indwelling medical devices (such as a urinary catheter) require EBP when providing hygiene cares. R33 R33's admission Minimum Data Set (MDS) assessment, dated 1/14/26, indicated, intact cognition, R33 required substantial assistance with toileting and bed mobility, was occasionally incontinent of bladder and continent of bowel. R33 was at risk for a pressure ulcer, had no pressure ulcer/injury on admission. R33's diagnoses included, cerebral infarction-(CVA) (blood clot in the brain), pressure induced deep tissue damage of left heel, chronic systolic (congestive) heart failure (a serious condition of the heart's ability to pump blood efficiently), edema (swelling). R33 was diagnosed with pressure induced deep tissue damage of left heel (bedsore) on 2/19/26 and had an order for daily wound dressing change. R33 's after visit note by nurse practitioner (NP)-E dated 2/19/26 Identified the following: Skin: left heel popped blister with purple color. DTI (deep tissue injury) and a large blister that has popped on left heel. Non weight bearing to left heel, wound care referral for left heel, cleanse wound with vashe (wound cleanser), allow to dry, cover with ABD pad and wrap with kerlix. R33's room or outside the room lacked EBP precautions. No signage on the door and no isolation cart (mobile container that stores personal protective equipment (PPE)- gowns, gloves, face shield, used by staff to prevent the spread of infection). During an interview on 2/25/26 at 9:40 a.m., DON and regional director of clinical services (RDCS) indicated R33 was not to be on EBP. Indicated, EBP is only required for Chronic wounds, diabetic wounds, and Pressure Ulcers per the facility policy. The facility policy titled: Enhanced [NAME] Precautions, reviewed on 3/28/24, indicates enhanced barrier precautions to be used for chronic wound care and defines chronic wound care as any skin opening requiring a dressing (excludes- shorter-lasting wounds, such as skin breaks or skin tears covered with adhesive bandage.

Based on interview and record review, the facility failed to monitor for effectiveness of a medication prescribed for sleep for 1 of 5 residents (R47) reviewed for unnecessary medications. Findings include: R47's Minimum Data Set (MDS) assessment, dated 12/2/25 identified R47 had no cognitive impairment, had lower extremity impairment on one side, maximum assistance with transfer and bed mobility, independent with toilet transfer, incontinent of bowel and bladder.R47 diagnoses include polyneuropathy (a condition in which multiple peripheral nerves are damaged, leading to weakness, numbness and impaired function in various parts of the body), type 2 diabetes, major depressive disorder, anxiety, obstructive sleep apnea, and laceration to right great toe. R47's medication orders included: Melatonin tablet 5 milligram (mg), oral at bedtime: Start date 11/22/24. R47's Medication Administration Record (MAR) record review from 1/01/26 to 1/31/26 and 2/01/26 to 2/25/26 indicated medication was administered. R47's record lacked sleep tracking or monitoring assessment. During an interview on 2/26/2026 at 8:10 a.m., the director of nursing (DON) confirmed R47 taking melatonin 5 mg by mouth at bedtime for sleep. DON stated, sleep tracking was only initiated when ordered by the prescribing provider. DON also stated, sleep tracking would have been available in progress if it was ordered. Progress note review from 12/01/25 to 02/26/26 showed no sleep tracking notes. A facility policy on monitoring sleep was requested and not received.

Based on interview and record review the facility failed to ensure medications were available for administration per physician order for 2 of 2 residents (R1, R54) reviewed for pharmacy services. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact with no behaviors, have pressure reducing devices, nutritional supplementation, and dressings. R1 was independent with eating, set up for oral hygiene and required assistance for all activities of daily living. R1's care plan indicated R1 had wounds to both feet, impaired cardiac output, enhanced barrier precautions related to wounds, and diabetes, R1's diagnoses list included, cerebral palsy (brain disorder causing decreased muscle coordination) , peripheral vascular disease (disorder affecting circulation in the arms and legs), diabetes (disorder affecting blood sugar levels), respiratory failure (disorder affecting breathing), lymphedema (disorder causing fluid collection under the skin), and venous insufficiency(disorder that causes blood to pool in the legs instead of returning to the heart). R1's provider orders included: wound care: right dorsal [top] foot every other day and as needed (PRN) Sprinkle metronidazole [medication used to treat fungal infection] 500 mg crushed tablet into wound bed every other day. R1's medical record indicated the following: 2/5/26-Wound Clinic provider wrote order for Metronidazole 500 mg to wound every other day 2/6/26-health unit coordinator entered order into electronic medical record 2/9/26-order was confirmed by facility nursing staff adding the location to apply metronidazole 2/10/26-R1's medication administration record (MAR) indicated medication was not given with a progress note stating Metronidazole currently unavailable. Writer left a message with pharmacy to see if this could be ordered. 2/12/26-medication was signed off as given however facility progress note indicated Metronidazole currently unavailable. Spoke with Rx (pharmacy), 30 day supply was delivered on 2/2 and 5 tablets were delivered on 2/5. 2/16/26-MAR indicated metronidazole was not given 2/17/26-facility progress note indicated pharmacy to deliver metronidazole tonight for dressing changes to right foot. 2/19/26-Wound nurse practitioner provider note indicated metronidazole still hasn't come in or been applied. Nurse manager is going to look into Flagyl [metronidazole] 2/22/26-MAR indicated metronidazole was not given During an interview on 2/25/26 at 2:38 p.m., licensed practical nurse (LPN-A) confirmed R1 had chronic wounds to both feet that were followed by the wound clinic. LPN-A reviewed R1's MAR and confirmed dates metronidazole was not administered. LPN-A stated the medication should be in the automated dispensing unit (ADU) (machine used to dispense certain medications). During an interview on 2/25/26 at 3:31 p.m., the wound clinic nurse practitioner (NP)-B confirmed R1 had chronic wounds to both feet that are difficult to heal due to his diagnosis of venous insufficiency. NP-B stated she saw R1 for several months before referring R1 to the vascular clinic (clinic that treats circulatory issues). NP-B stated she started seeing R1 again 2-3 weeks ago. On 2/5 NP-B ordered metronidazole to R1's right foot due to a possible fungal infection. NP-B confirmed she saw R1 on 2/5, 2/12, and 2/19 and the metronidazole was not available at each visit. NP-B stated the medication had to be reordered last week. During an interview on 2/25/26 at 4:00 p.m., licensed practical nurse (LPN)-B confirmed R1's treatment order included metronidazole 500 mg to right foot. LPN-B recalled 1 day the medication was not available and a message was left to the pharmacy to deliver. LPN-B stated the next day a supervisor told her the medication was located in the ADU. During observation and interview on 2/25/26 at 4:15 p.m., a tall locked cabinet was noted in the medication room. LPN-A stated staff log into the computer in order to dispense medications. A list of available medications was located on the front of the machine which included metronidazole 500 mg tablets. During interview on 2/26/26 at 9:15 a.m., LPN-C stated new orders received from the provider are given to the health unit coordinator to enter and then verified by a nurse the same day. If the order is received on the night shift, it will be verified the next morning. LPN-C stated if a medication is not available in the medication cart, she would see if the medication were available in the ADU. If it is not, she would update the nurse manager and let the provider know a dose was missed. During an interview on 2/26/26 at 11:07 a.m., the pharmacy tech (tech) stated if a medication isn't available in the ADU the pharmacy will send a separate bubble pack card to the facility containing the medication. If the ADU is out of medication, the facility must request it because the pharmacy is not automatically alerted. The tech stated they received the order for metronidazole for R1 on 2/9/26 however the original date is 2/6/26. The tech stated metronidazole was dispensed from the ADU on 2/14, 2/20, 2/22, and 2/23 and confirmed no metronidazole was dispensed from the machine from 2/9-2/13. A report received from the facility and the pharmacy confirms the dates of metronidazole was removed from the ADU. During a joint interview with the director of nursing (DON) and Regional Director of Clinical Services (RDCS) on 2/26/26 at 11:18 a.m., the DON stated new orders are transcribed in the electronic medical record by either the health unit coordinator or a nurse and verified by a nurse. The DON stated she expects orders to be entered and verified the same day they are received. If an order is received late, she would expect it to be verified by the next morning. If a medication is not available, staff are expected to call the pharmacy, and update the provider. Some medications are available in the ADU or the e-kit (emergency kit). The DON and RDCS verified the order for metronidazole was dated 2/5/26 and entered on 2/6/26 by the HUC however was not verified until 2/9/26. The DON stated she would have expected the metronidazole order to be processed by the next day. The DCS stated some medications are automatically dispensed via the ADU and some are sent from the pharmacy in bubble packs. Night nurses obtain all scheduled medications from the ADU and disperse them in the appropriate medication carts for the following day. If a medication is not scheduled to be dispensed, nurses do have the ability to manually request the ADU to dispense a medication. The DON stated she was first made aware of the missing metronidazole on 2/19/26 and verified the medication was in the ADU. The DON stated she spoke to the pharmacy on 2/25/26 who stated the metronidazole was officially loaded to be dispensed on 2/12/26 however the machine didn't start automatically dispensing it until 2/20/26. A policy titled Medication Ordering and Receiving From Pharmacy dated 12/2017 did not reference the ADU machine. A policy regarding processing of provider orders was requested and not received. R54 R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R54 had no cognitive impairment. Further, R54 was independent with ambulation, toileting, and hygiene. R54's diagnosis included cellulitis (bacterial infection) of left lower limb, cellulitis of right second toe, and amputation of right lesser toe. R54's care plan for skin has issues related to left lower limb cellulitis, right foot amputation, and skin tears. Interventions included moisture barrier and creams to be used to protect skin. R54's record indicated the following: 2/12/26 R54 was prescribed 25% urea lotion to both feet twice daily. 2/12/26 at 10:14 p.m., progress note recognizing new prescription of 25% urea lotion, additionally from pharmacy: this is on over the counter (OTC) medication and pharmacy will not be providing it. 2/19/26 at 2:23 p.m., progress note between pharmacy and facility, 25% urea lotion had been moved to the non-transcribed file at the pharmacy, facility requested immediate delivery of medication, additionally from pharmacy: they do not carry the specific percent of urea lotion-would need further clarification from ordering provider. 2/21/26 at 10:09 p.m., progress note between pharmacy and facility, pharmacy only carries 20% or 40% urea lotion, please clarify with ordering provider. Message sent to triage to send new orders for urea cream. 2/23/26 at 8:38 a.m., new order written for R54 for 20% urea cream to both feet twice per day. 2/23/26 at 12:19 p.m., progress note, new orders received from triage for 20% urea cream to both feet twice per day. Order transcribed into electronic medical record (EMR). During observation on 2/23/26 at 1:19 p.m., R54 was observed in facility day room receiving podiatry cares. Medical doctor (MD)-A asked R54 if he had been using the urea lotion on his feet twice per day. R54 stated, he had not been using any lotion on his feet because the facility had not gotten the lotion yet. MD-A stated R54 needs the lotion to help reduce the dryness of his feet. R54 stated he didn't know when the facility would get the lotion. During a joint interview on 2/25/2026 at 2:08 p.m., director of nursing (DON), administrator, and regional director of clinical services (RDCS), DON stated new orders are typically ordered by the health unit coordinator (HUC) and a nurse verifies the orders. Further to this, orders should be completed and ready within 24 hours. RDCS stated the initial urea lotion order was received on 2/12/26 and confirmed there were issues with processing due to order clarification. DON stated the medication was reordered on 2/23/26 and was not available for use. DON stated it is important to obtain medications when ordered so residents can begin treatments as expected. A facility policy titled Medication Ordering and Receiving from Pharmacy dated 12/17, medications and related products are received from the dispensing pharmacy on a timely basis.

Based on interview, observation and record review, the facility failed to develop a person-centered care plan for 2 of 2 residents (R24, R33) reviewed for care planning.Findings include: R33's admission Minimum Data Set (MDS) assessment, dated 1/14/26, indicated intact cognition. R33 required substantial assistance with toileting and bed mobility, was occasionally incontinent of bladder and continent of bowel. R33 was at risk for a pressure ulcer, had no pressure ulcer/injury on admission. R33 had a pressure reducing device for chair and bed. R33's diagnoses included, cerebral infarction (CVA) (blood clot in the brain), pressure induced deep tissue damage of left heel, chronic systolic (congestive) heart failure (a serious condition of the heart's ability to pump blood efficiently), and edema (swelling). R33's admission skin risk assessments, dated 1/8/26 indicated at risk for pressure ulcers with an intervention to reposition every two to three hours. R33's care plan dated 1/12/26, indicated R33 needs assistance with bed mobility, transfers, ambulation, and locomotion due to CVA. Interventions included assist to turn and reposition. R33's record lacked the implementation of a care plan for risk of developing pressure ulcers and injuries. R33's mobility care plan dated 1/12/26, indicated R33 needs assist with bed mobility, transfers, ambulation, and locomotion due to CVA. Intervention dated 1/12/26, per skin care plan was to assist with turning and repositioning, although R33 care plan lacked a skin section care plan. R33's Care Sheet dated 02/24/26 lacked interventions to prevent developing pressure ulcers and injuries. During an interview with R33 on 2/24/26 at 4:05 p.m., R33 denied being assisted with frequent repositioning in bed and or chair. During an interview on 2/24/26 at 2:26 p.m., nursing assistant (NA)-B stated being unsure of R33 turning and reposition schedule. NA-B stated the schedule should be in point of care for charting and on the care sheet in a binder at the nursing station. During an interview on 2/25/26 at 8:34 a.m., director of nursing (DON) stated, there was no skin category or risk for pressure ulcer on R33's care plan. R24 R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R24 had no cognitive impairment. R24 required a walker for ambulation and was independent with eating, hygiene, and dressing. R24's diagnosis included COPD (progressive and irreversible lung disease causing shortness of breath), emphysema (progressive lung disease that causes damage to the air sacs in the lungs), and chronic respiratory failure with lack of oxygen. R24 record dated 2/13/26 was admitted to hospice. R24's comprehensive care plan lacked patient-centered hospice care plan. During an interview on 2/24/26 at 10:17 a.m., nursing assistant (NA)-A stated she is unsure why R24 was put on hospice. NA-A indicated there is a hospice binder although that includes just hospice numbers and miscellaneous. NA-A stated she was unsure what end-of life preferences R24 wanted. During an interview on 2/24/26 at 10:51 a.m., director of nursing (DON) and regional director of clinical services (RDCS) stated after the resident chooses a hospice company, the hospice banner is added in the electronic medical record (EMR), hospice contact information is added to the resident profile, and the resident care plan. The hospice care plan would include the hospice company information, hospice diagnosis, and any known resident choices and preferences. DON confirmed R24 was admitted to hospice on 2/13/26 and R24's care plan did not have a hospice care plan. DON and RDCS stated the hospice care plan is important, so all staff are aware of the resident status and how to care for them during the end-of-life stage. A facility policy titled Comprehensive Assessments and Care Planning dated 9/27/23, the facility will provide a comprehensive person-centered interdisciplinary care plan.

Based on interview and record review, the facility failed to ensure an evaluation was completed prior to renewal of PRN (as needed) antipsychotic medications for 1 of 5 residents (R10) reviewed for unnecessary medications. Findings include: R10's quarterly Minimum Data Set (MDS) assessment, dated 2/10/26 indicated R10 had severe cognitive impairment with a history of verbal behaviors. The MDS also indicated R10 was receiving hospice care and received antipsychotic medications (medications used to treat mental health disorders and behavioral disturbances). R10's diagnoses list included, unspecified dementia, cognitive communication deficit, anxiety, protein-calorie malnutrition.R10's care plan indicated mood state related to diagnosis of anxiety and restlessness and agitation, high risk medications including Haloperidol (antipsychotic medication), hospice services, and cognitive loss related to dementia.R10's medication administration record indicated R10 received haloperidol 1 mg every 4 hours PRN from 1/26-2/8 (21 doses given), haloperidol 1 mg every 1 hour 2/10-2/12 (4 doses given), and haloperidol 1 mg every hour 2/12-2/15 (8 doses given). R10's hospice enrollment history and physical signed by the hospice provider dated 1/19/26 indicated terminal illness attestation based on my review of this patient's available medical record and discussion with the hospice admission nurse. R10's hospice orders dated 1/20/26 indicated a verbal order for haloperidol 0.5 mg every 4 hours as needed for confusion, restlessness, agitation, nausea with a hand written stop date of 2/2/26. R10's hospice orders dated 1/26/26 indicated a verbal order for haloperidol 1 mg by mouth every 4 hours as needed for agitation and hallucinations with a hand written stop date of 2/8. R10's hospice orders dated 2/10/26 indicated a verbal order for haloperidol 1mg every hour PRN agitation with a stop date 2/23/26. R10's medical record indicated R10 was seen by the facility provider on 1/8/26. R10's record indicated hospice provider last seen 1/20/26. During an interview on 2/25/26 at 2:34 p.m., licensed practical nurse (LPN)-A stated residents who receive as needed antipsychotic medications are seen by a provider every 14 days. LPN-A stated the facility has updated the hospice provider several times of the requirement residents must be seen face to face every 14 days when receiving an PRN antipsychotic medication. LPN-A verified, R10 was seen by the hospice provider on 1/20/26, the facility provider on 1/8/26, and an acute visit by the facility nurse practitioner on 2/19/26. During an interview on 2/26/26 at 8:36 a.m., the hospice registered nurse (HRN) stated R10 enrolled in hospice 1/20/26 and is seen weekly by nursing staff. HRN confirmed R10 is receiving scheduled and as needed haloperidol. She stated hospice manages the medication however it is the facility's responsibility to determine if the resident is having breakthrough issues. The haloperidol is ordered every two weeks based on a mutual discussion between herself, facility staff, and if needed, the hospice medical provider. Hospice providers are involved in the interdisciplinary meeting to recertify a resident every 90 days, however, do not begin seeing residents until after their second 90 day recertification. At that time, the hospice provider will see the resident face to face every 8 weeks. Hospice providers do not see the resident face to face to re-order as needed antipsychotic medications. During a joint interview on 2/26/26 at 10:54 a.m., with the facility director of nursing (DON) and the Regional Director of Clinical Services (RDCS), the DON stated PRN antipsychotic medications are good for 14 days and the facility will automatically put a stop date. The DON stated hospice is the one managing R10's PRN haloperidol and would be the ones to see R10 in person. The DON and RDCS reviewed R10's medical records and could not provide documentation R10 received a face-to-face visit by a provider every 14 days. A policy titled Psychotropic Medication Use dated 9/7/23 indicated parameters required for antipsychotic medications that included PRN anti-psychotic orders are limited to 14 days and cannot be renewed unless the attending provider evaluates the resident for the appropriateness of that medication. It continued Documentation will reflect implementation of the above [referring to the list of required parameters].

Based on observation, interview, and document review the facility failed to ensure privacy was maintained during treatments for 3 of 3 residents (R29, R54, R57) reviewed for privacy.Findings include:During an observation on 2/23/26 at 1:19 p.m., R57 was in the facility day room receiving podiatry (foot)cares. R54 and R29 were in the day room waiting for their podiatry appointments. Upon completion of foot care, R57 was removed from room by the podiatry medical assistant (MA)-A. MA-A returned and moved R54 so his foot cares could be completed. R29 remained in the day room during R54's podiatry treatments. Once completed R54 was assisted out of the room by facility staff. MA-A then moved R29 so she could have her podiatry cares completed. During R29's podiatry treatment, nursing staff and cleaning staff were walking through the day room. Upon completion, R29 was taken back to her room by facility staff.R29's quarterly Minimum Data Set (MDS)assessment, dated 1/8/26, indicated R29 had severe cognitive impairment. Further, R29 was dependent on facility staff for all cares. R29's diagnosis included neurocognitive disorder with Lewy-bodies Dementia (progressive neurodegenerative disease caused by abnormal protein deposits that destroy brain cells), chronic pain syndrome, and cognitive communication deficit.During an interview on 2/23/26 at 4:48 p.m., family member (FM)-A stated R29 would not have wanted to have her podiatry treatment performed with other residents around to watch. FM-A stated she has a lot of pain in her feet and would have wanted to have her podiatry treatments in private.R54R54's quarterly MDS assessment, dated 11/12/25, indicated R54 had no cognitive impairment. Further, R54 was independent with ambulation, toileting, and hygiene. R54's diagnosis included cellulitis (bacterial infection) of left lower limb, cellulitis of right second toe, and amputation of right lesser toe.During an interview on 2/23/26 at 5:10 p.m., R54 stated he would prefer to have his podiatry treatments done in his room.R57R57's comprehensive MDS assessment, dated 11/26/25, indicated R57 had limited cognitive impairment. Further, R57 required a wheelchair for mobility, set-up assistance for hygiene/oral care, and was independent with eating. R57's diagnosis included prostate cancer, chronic kidney disease, and difficulty walking.During an interview on 2/23/26 at 5:57 p.m., R57 stated he would prefer to do his podiatry treatments in a private space.During an interview on 2/23/26 at 1:34 p.m., MA-A stated the podiatry team comes to the facility every 9 weeks. MA-A stated the services provided include callus shaving and nail clipping. Podiatry treatments are done in the day room, unless the residents are not able to get out of bed then the podiatrist will go to the residents room. During an interview on 2/23/26 1:41 p.m., medical doctor (MD)-A stated he provided podiatry services roughly every 9 weeks. The services he provided were callus shaving and nail clipping, occasionally helping with ingrown toenails if this can be treated safely at the facility. When asked how treatments are handled in the clinic setting the MD-A stated the treatments would be done in a private room at his clinic. The facility staff bring in multiple residents at a time.During an interview on 2/25/26 9:19 a.m., director of nursing (DON), administrator, and regional director of clinical services (RDCS) confirmed medical procedures or treatments such as wound care, optometry, dental, or podiatry should be done in private. Administrator confirmed the podiatry treatments done on 2/23/26 were conducted in the day room. Further, stating multiple residents can be in the day room during podiatry treatments. DON and RDCS confirmed the importance of completing podiatry treatments in a private setting to ensure resident privacy.An undated facility policy titled Resident Rights and Notification of Resident Rights, the facility will ensure a residents right to privacy and confidentiality.

Based on interview and document review, the facility failed to assess and evaluate the appropriateness of the colostomy care supplies and ensure proper fitting of the wafer to prevent leakages and failed to provide physician-ordered care for colostomy care for one resident (R1). This failure caused psychosocial harm to R1 when his colostomy care was delayed, and he suffered emotional distress and suicidal ideation. Findings include:On 7/15/25, at 10:21 a.m., R1 stated he had several episodes of his colostomy leaking in the first few weeks at the facility. R1 stated he repeatedly asked the facility to use the products he was familiar with, including rings (intended to create a secure and comfortable seal between an ostomy pouch and the skin around the stoma, to prevent leakage) and wings (small flexible pieces of hydrocolloid adhesive that attach to the edges of an ostomy skin barrier to provide extra security and prevent leaks). R1 stated the facility started providing the requested supplies, after he became suicidal due to lack of sleep, from the colostomy leaking four times on 6/25/25. R1 stated the colostomy leaked stool on the bed, on the floor and on himself. He stated this made him feel filthy, dramatic, depressed, and dirty. He stated it made it harder to socialize because he was afraid it would leak. R1 stated his colostomy has had fewer incidents of leaking since the facility has provided the supplies he needed.R1's hospital record dated 6/1/25 to 6/5/25 indicated R1 was brought by ambulance because of a fall related to weakness, lack of sleep due to burning around his leaking colostomy bag. R1 had problems with ostomy leakage and the hospital would facilitate the necessary ostomy supplies. R1 was discharged on 6/5/25 in stable condition. R1's hospital discharge orders and instructions dated 6/5/25 instructed the facility to care for R1's ostomy.Procedure for pouch change:1) Prepare new pouch, using a Coloplast 16716 or your normal pouches. Opening should be 1/16- 1/8 larger than the stoma. Set pouch aside.2) Remove old pouch, and discard.3) Cleanse peristomal area with warm water only and Versalon 4 x 4's (#118746). *Do not use soap, wipes, adhesive remover, or skin prep to cleanse peristomal skin.4) Allow skin to dry. At this point - CRUST the peristomal skin 1x. See below for crusting steps.5) Apply Adapt barrier ring (#116786) and then apply new pouch.6) Press down firmly all-around stoma and have patient place hand over pouch for 2-3 minutes to enhance seal.7) Change pouch two times week or immediately if there is a leak. Procedure for crusting:1. Clean skin gently with warm water and gauze, paper towel or soft wash cloth2. Sprinkle a layer of ostomy powder over area to be treated-red, irritated, weeping skin surrounding stoma. Gently brush off excess powder using a 4x4 gauze, tissue, or your finger. You want a thin layer of powder completely covering the moist area.3. Blot/pat or spray Cavilon No Sting Barrier Film over powder. Allow barrier film to dry. If an area is missed, allow the entire area to dry first, then go back and spray or blot the area that was missed.4. Reapply with pouch change until redness clears up. Do not do this procedure if your skin is clear and intact. If your skin worsens or does not heal, please contact your ostomy nurse as you may need a stronger treatment. R1's nurse note, dated 6/5/25, indicated he was admitted to the facility from the hospital after a fall and weakness. It also indicated the skin around his colostomy was irritated and painful. R1 had reported he fell off the toilet from weakness due to lack of sleep from his colostomy bag leaking for 4 days. R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care. R1's nurse note, dated 6/11/25, indicated his colostomy bag was changed. [NAME] brand used and cut to measure to size of stoma. R1's nurses notes indicated his colostomy bag was changed on 6/6/25, 6/11/25, 6/15/25, 6/20/25, 6/23/25, and 6/25/25. No identifying information was noted related to colostomy supplies used, R1's ostomy redness, or leakage. R1's nurse note, dated 6/25/25, indicated R1 was up the majority of the night dealing with his colostomy bag, as it needed to be changed and reinforced multiple times throughout the night. The note indicated at 6:15 a.m. the nurse found R1 picking at it stating it needed to be changed again and was in clear emotional distress. He reported he was traumatized, devastated, and became tearful, stating he did not get sleep. The note indicated at 8:45 a.m. R1 reported his colostomy was leaking again. R1 was very upset with the situation and made the comment, I should put a shotgun to my head and making comments he did not want to be alive any longer. R1's nurse note, dated 6/25/25, indicated colostomy bag and appliance were changed that morning. The skin area was red and macerated around the appliance. R1 voiced this was not the typical appliance he used at home and facility would order device familiar to R1. R1's social work progress note, dated 6/26/25, indicated when discussing discharge with R1, R1 told the social worker if he had to discharge to home, he would shoot himself when he got home because he was frustrated from lack of sleep. R1's physician regulatory visit note, dated 7/9/25, indicated R1 continues to have leakage from his ostomy at night such that it interferes with his sleep. R1 told the physician he has not slept well the last couple of nights. R1 was distressed, telling the physician if he goes home with the ostomy leakage, he will consider ending his life. R1 has had his ostomy for approximately six years with very infrequent leakage, never as persistent as it has been while at the facility. R1's Associated Clinical Psychology note, dated 7/11/25, indicated R1 had anxiety surrounding his colostomy leakage, at time being traumatic affecting his sleep and mood. Suicidal ideation was noted after multiple nights of not sleeping becoming increasing depressed. R1 stated he did not have this problem at home because he had the necessary supplies to manage his ostomy care.A physician order, dated 7/9/25, directed facility to consult with an ostomy nurse to review R1's current set up and offer suggestions about decreasing frequency of nighttime leaks, which are very distressing for him. R1's medical record review 7/15/25 did not indicate the facility followed R1's physician order dated 7/9/25 to schedule an ostomy consult. A letter from the facility's medical director, dated, 7/17/25, indicated R1 was admitted to the facility on [DATE] following a hospitalization for weakness and fall, following his colostomy bag leaking for several days. During the hospitalization R1 reported frustration with appliance issues in regards to the ostomy bag not obtaining a proper seal. This caused him significant distress. There were documented notes in his clinical record prior to his care at the facility of frustration that mention appliance issues causing sleep disturbance and lack of sleep leading to suicidal ideation, on 8/11/23 and 11/8/24. During his stay at the facility, R1 continued to voice frustration because of appliance leakage and additional supplies were ordered for him. On the evening of 6/24/25 and into the morning of 6/25/25, R1 mentioned to the staff he was very frustrated, confused, and distressed and if he had access to firearms, he would likely shoot himself because of his low quality of life. The pattern predated his stay at the facility. The facility used appropriate and standard ostomy equipment to make every effort to accommodate R1's needs. And R1's historical concerns, including suicidal ideations, were not communicated at the time of his admission to the facility and were not included to his problem list on external records.R1's admission Minimum Data Set, dated [DATE], indicated R1 had diagnoses of Crohn's disease (chronic inflammatory bowel disease) and had a colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface). R1's MDS indicated he was cognitively intact.On 7/15/25, at 1:32 p.m., licensed practical nurse (LPN)-A she was wound and ostomy certified. She verified that she did not assess or evaluate R1's oblong shaped stoma to get the right wafer fit. She stated the facility did not have the exact appropriate supplies R1 wanted for his colostomy. She stated he was experiencing more incidents of leaking during his first few weeks at the facility. She stated she was responsible to order colostomy supplies. She stated she did not put in an order for the Coloplast brand of ostomy supplies for R1. She stated she obtained the required products after R1 was sent to the hospital on 6/25/25. She stated the supplies for each resident were placed in their rooms. She stated the care plan lacked the step-by-step process and the specific supplies required to manage R1's ostomy care. LPN-A acknowledged that when R1's colostomy leaked with bowel movement (BM), it affected him causing suicidal thoughts and was sent to ER, and added we did not know it was affecting him psychologically. She stated the HUC entered the physician orders for R1 and should have listed all the steps in the process, as they were written. She stated she expected the nurses would know how to change the colostomy bags and did not do much training on ostomies. She stated R1 taught staff his (referring to R1) preference. LPN-A stated the appointment with the ostomy clinic, chosen by R1, had not yet been arranged, although it was ordered 6 days prior, on 7/9/25. When questioned about the steps taken from 7/9/25, to ensure proper colostomy care orders and determine the root cause of the leakage, LPN-A did not respond. On 7/15/25, at 2:20pm, RN-A stated, I do not know if he has the right product (referring to R1's colostomy supplies) and R1 was very worried and was very sensitive about his colostomy. RN-A also verified that the hospital orders dated 6/5/25 were not followed and stated the care plan did not specify the colostomy product to be used. On 7/15/25, at 3:01 p.m., the director of nursing (DON) stated a physicians provide orders for colostomy care. She stated the health unit coordinator (HUC) enters the orders into the system exactly as they are written by the physician. The DON stated the facility has company formulary colostomy supplies. She stated she was not aware of an order to change the supplies ordered for R1's colostomy care or a change of orders to change the step-by-step process provided upon his admission to the facility. The DON stated the facility was not ignoring the order written on 7/9/25 to set up an appointment for R1 with an ostomy nurse consultation. She stated he was in the process of discharging. A facility document, Comprehensive Assessments and Care Planning, dated 2017, directed the purpose of the policy was to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the State. 2)The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. The baseline care plant includes the minimum healthcare information necessary to care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury. Baseline care plans address, at a minimum, the following: physician orders. 6) The assessment must include at least the following: j) special treatment and procedures. 11) All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.A facility document, Physician Services, dated 2022, directed all physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift.

Based on interview and document review, the facility failed to develop and implement a comprehensive, individualized care plan for 1 of 3 residents (R1) reviewed for ostomy care. The facility failed to have a process in place to instruct staff on physician ordered ostomy care. This resulted in R1's colostomy bag leaking on multiple occasions and emotional distress for R1.Findings include: R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care.R1's medication administration record (MAR), dated June and July 2025, directed to change ostomy bag two times weekly and as needed for leakage, on Monday and Wednesday evenings.R1's bowel assessment, dated 6/8/25, failed to appropriately assess his ostomy site with measurements and description.R1's admission Minimum Data Set, dated [DATE], indicated R1 had diagnoses of Crohn's disease (chronic inflammatory bowel disease) and had a colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface). R1's MDS indicated he was cognitively intact.A progress note, on 6/11/25, indicated colostomy bag was changed. [NAME] brand used and cut to measure to size of stoma. Skin surrounding stoma is clean, intact and free of breakdown/maceration. No redness, foul odor or signs/symptoms of infection. A progress note, on 6/25/25, indicated colostomy bag and appliance changed. Area is red and macerated around appliance. Skin barrier applied. Patient denies pain but voices that this is not typical appliance he uses at home. Facility will order device familiar to patient.A progress note, on 6/25/25, indicated R1 was up the majority of the night dealing with his colostomy bag. R1 was in clear emotional distress. He reported to writer that he is traumatized and devastated and began to become tearful stating he got no sleep. The progress note indicated he was very upset and stated, I should just put a shotgun to my head and making comments he did not want to be alive anymore. On 7/15/25, at 10:21 a.m., R1 stated he had several episodes of his colostomy leaking in the first 20 days at the facility. R1 stated he repeatedly asked the facility to use the products he was familiar with, including rings (intended to create a secure and comfortable seal between an ostomy pouch and the skin around the stoma, to prevent leakage) and wings (small flexible pieces of hydrocolloid adhesive that attach to the edges of an ostomy skin barrier to provide extra security and prevent leaks). R1 stated the facility started providing the requested supplies, after he became suicidal due to lack of sleep, from the colostomy leaking four times on 6/25/25. R1 stated his colostomy has had fewer incidents of leaking since the facility has provided the supplies he needed. On 7/15/25, at 1:14 p.m., licensed practical nurse (LPN)-B stated R1's colostomy bag changes required the use of skin prep (creates a protective barrier) and the supplies located in his room. She stated the orders in his chart indicated frequency of scheduled colostomy changes. On 7/15/25, at 1:32 p.m., LPN-A stated the facility did not have the exact supplies R1 wanted for his colostomy, as the facility had formulary colostomy supplies. She stated he was experiencing more incidents of leaking during his first few weeks at the facility. She stated she obtained the required products after he was sent to the hospital on 6/25/25. She stated R1 taught the staff how to perform the colostomy bag changes. She stated two other products were tried for him prior to using the supplies he was prescribed. She stated the supplies for each resident were placed in their rooms. She stated the care plan did not list the process or specific supplies required. She stated she expected the nurses would know how to change the colostomy bags. LPN-A stated the HUC should have listed all the steps ordered by the physician for the colostomy care in the orders for R1. On 7/15/25, at 2:28 p.m., registered nurse (RN)-B stated the facility obtained R1's correct colostomy supplies after he went to the hospital on 6/25/25. RN-B stated the colostomy supplies were located in the residents' rooms. She stated, There is not anything in the care plan for the step-by-step process or the specific products required. RN-B stated she had changed R1's colostomy on one occasion. She stated she could not confirm if the physician order was followed at that time. She stated she had not seen the order. On 7/15/25, at 3:01 p.m., the director of nursing (DON) stated, the order is part of the care plan. The DON also stated, the order feeds the MAR. She stated the facility was using formulary colostomy supplies. She stated there was not an order from the physician to use the facility's formulary colostomy supplies or change the physician ordered process. A facility document, Comprehensive Assessments and Care Planning, dated 2017, directed the facility must make a comprehensive assessment of the resident's needs. Baseline care plans address at a minimum, the following: physician orders. The assessment must include at least the following: Continence and Special treatment and procedures. A facility should use the results of the assessment to develop, review and revise the resident's person-centered comprehensive care plan. All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) reviewed for ostomy care, received colostomy care as ordered by the physician. This resulted in inappropriate care, as evidenced by frequent leakage incidents for R1.Findings include: R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care. R1's after discharge orders from the hospital, dated 6/5/25 directed:Procedure for pouch change:1) Prepare new pouch, using a Coloplast 16716 or your normal pouches. Opening should be 1/16- 1/8 larger than the stoma. Set pouch aside.2) Remove old pouch, and discard.3) Cleanse peristomal area with warm water only and Versalon 4 x 4's (#118746). *Do not use soap, wipes, adhesive remover, or skin prep to cleanse peristomal skin.4) Allow skin to dry. At this point - CRUST the peristomal skin 1x. See below for crusting steps.5) Apply Adapt barrier ring (#116786) and then apply new pouch.6) Press down firmly all-around stoma and have patient place hand over pouch for 2-3 minutes to enhance seal.7) Change pouch 2x/week or immediately if there is a leak. Procedure for crusting:1. Clean skin gently with warm water and gauze, paper towel or soft wash cloth2. Sprinkle a layer of ostomy powder over area to be treated-red, irritated, weeping skin surrounding stoma. Gently brush off excess powder using a 4x4 gauze, tissue, or your finger. You want a thin layer of powder completely covering the moist area.3. Blot/pat or spray Cavilon No Sting Barrier Film over powder. Allow barrier film to dry. If an area is missed, allow the entire area to dry first, then go back and spray or blot the area that was missed.4. Reapply with pouch change until redness clears up. Do not do this procedure if your skin is clear and intact. If your skin worsens or does not heal, please contact your ostomy nurse as you may need a stronger treatment. R1's admission Minimum Data Set, dated [DATE], indicated R1 had diagnoses of Crohn's disease (chronic inflammatory bowel disease) and had a colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface). R1's MDS indicated he was cognitively intact. R1's nurse note, dated 6/11/25, indicated his colostomy bag was changed. [NAME] brand used and cut to measure to size of stoma. R1's nurses notes indicated his colostomy bag was changed on 6/6/25, 6/11/25, 6/15/25, 6/20/25, 6/23/25, and 6/25/25. No identifying information was noted related to colostomy supplies used, R1's ostomy redness, or leakage. R1's medication administration record (MAR), dated June and July 2025, directed to change ostomy bag two times weekly and as needed for leakage, on Monday and Wednesday evenings. A physician order, dated 7/9/25, directed facility to facility and consult with an ostomy nurse to review R1's current set up and offer suggestions about decreasing frequency of nighttime leaks, which are very distressing for him. R1's medical record review 7/15/25 did not indicate the facility followed R1's physician order dated 7/9/25 to schedule an ostomy consult. On 7/15/25, at 10:21 a.m., R1 stated he had several episodes of his colostomy leaking in the first 20 days at the facility. R1 stated he repeatedly asked the facility to use the products he was familiar with, including rings (intended to create a secure and comfortable seal between an ostomy pouch and the skin around the stoma, to prevent leakage) and wings (small flexible pieces of hydrocolloid adhesive that attach to the edges of an ostomy skin barrier to provide extra security and prevent leaks). R1 stated the facility started providing the requested supplies on 6/25/25. R1 stated his colostomy has had fewer incidents of leaking since the facility has provided the supplies he needed. R1 stated he had not seen an ostomy nurse. On 7/15/25, at 1:14 p.m., licensed practical nurse (LPN)-B stated R1's colostomy bag changes required the use of skin prep (creates a protective barrier), and the supplies located in his room. She stated orders indicated frequency of scheduled colostomy changes. On 7/15/25, at 1:32 p.m., LPN-A stated the facility did not have the exact supplies R1 wanted for his colostomy. She stated he was experiencing more incidents of leaking during his first 20 days at the facility. LPN-A stated the health unit coordinator entered R1's orders and should have listed all steps, as the physician wrote them. LPN-B stated she was responsible to order colostomy supplies. She stated she obtained the required products after he was sent to the hospital on 6/25/25. She stated the supplies for each resident were placed in their rooms. She stated the care plan did not list the process or specific supplies required. She stated she expected the nurses would know how to change the colostomy bags. LPN-A stated the appointment with the ostomy clinic, chosen by R1, had not yet been arranged, although it was ordered 6 days prior. She stated the facility was working on discharge planning. On 7/15/25, at 2:28 p.m., registered nurse (RN)-B stated the facility obtained R1's correct colostomy supplies after he went to the hospital on 6/25/25. RN-B stated the colostomy supplies were in the residents' rooms. She stated, There is not anything in the care plan for the step-by-step process or the specific products required. RN-B stated she had changed R1's colostomy on one occasion. She stated she could not confirm if the physician order was followed at that time. She stated she had not seen the order. She stated his appointment with the ostomy clinic had not been arranged due to transportation issues with family. On 7/15/25, at 3:01 p.m., the director of nursing (DON) stated the HUC enters the physician orders. She stated physician orders were to be entered in the system exactly as they were written. The DON stated the facility had attempted to use their formulary colostomy supplies. The DON stated, the order is part of the care plan. The DON also stated, the order feeds the MAR. The DON stated the facility did not have an ostomy nurse on staff. She stated R1 was in the process of discharging. The DON stated the facility did not have a policy for ostomy care. A facility document, Ostomy Care Orientation Checklist, undated, directed to check the client care plan as the first step in the process. A facility document, Skill Competency Medication and Treatment, undated, Ostomy Care directed to check the client care plan as the first step. A facility document, Physician Services, dated 2022, directed all physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift. A facility document, Comprehensive Assessments and Care Planning, dated 2017, the purpose of the policy was to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the State. 2)The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. The baseline care plant includes the minimum healthcare information necessary to care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury. Baseline care plans address, at a minimum, the following: physician orders. 6) The assessment must include at least the following: j) special treatment and procedures. 11) All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.

Based on interview and document review, the facility failed to offer a care conference during 1 of 3 residents (R1) reviewed for ostomy care. This resulted in R1's inability to participate in his care planning.Findings include:R1's care plan, dated 6/6/25, indicated he required assist of one staff for personal cares. The care plan lacked individualized care for R1's colostomy, as it did not specify the supplies requires or the process to complete the colostomy care.R1's medication administration record (MAR), dated June and July 2025, directed to change ostomy bag two times weekly and as needed for leakage, on Monday and Wednesday evenings.R1's admission Minimum Data Set, dated [DATE], indicated R1 had diagnoses of Crohn's disease (chronic inflammatory bowel disease) and had a colostomy (a surgical procedure that creates an opening in the abdominal wall, bringing a portion of the large intestine to the surface). R1's MDS indicated he was cognitively intact.R1's chart lacked documentation of a care conference.On 7/15/25, at 10:21 a.m., R1 stated he would prefer his colostomy bag be scheduled in the morning. He stated there was only one time that it was changed in the morning. He stated he had never attended a care conference in the 5 1/2 weeks had been at the facility. R1 stated he had several episodes of his colostomy leaking in the first 20 days at the facility. R1 stated he repeatedly asked the facility to use the products he was familiar with, including rings (intended to create a secure and comfortable seal between an ostomy pouch and the skin around the stoma, to prevent leakage) and wings (small flexible pieces of hydrocolloid adhesive that attach to the edges of an ostomy skin barrier to provide extra security and prevent leaks). R1 stated the facility started providing the requested supplies on 6/25/25. R1 stated his colostomy has had fewer incidents of leaking since the facility has provided the supplies he needed.On 7/15/25, at 1:32 p.m., licensed practical nurse (LPN)-A stated there was not a care conference documented in R1's chart.On 7/15/25, at 3:01 p.m., the director of nursing (DON) stated she was not aware if R1 had a care conference.A facility document, Comprehensive Assessments and Care Planning, dated 2017, directed the residents and resident representatives will be involved in the comprehensive person-centered care planning. If participation of resident and representative in development of plan not practicable explanation must be in resident's medical record.A facility document, Resident Rights and Notification of Resident Rights, 2017 directed Resident Rights include: Planning and Implementing Care.

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. In addition, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher observed, and failed to monitor sanitation level of the three-compartment sink and cleaning of food equipment. This deficient practice had the potential to affect all 53 residents who received food from the refrigerators and the kitchen, as well as staff, who ate food served from dishes and tableware that were cleaned in the dishwasher. Findings include: Label, cover and date: During an observation and interview on 3/17/25 at approximately 7:15 p.m., there were two large clear plastic undated containers with Raisin Bran and [NAME] Krispies. The regional director clinical services (RDCS) verified the cereal should be labeled and dated. The RDCS requested dietary aide (DA)-A to throw the unlabeled cereal as there was no date. During an observation on 3/17/25 at 7:20 p.m., in the walk-in freezer there were tomato paste balls on a sheet pan that were not covered or dated. Also, there was partially covered Tator tots on a pan that had no date. During an observation on 3/17/25 at 7:25 p.m., in the reach in cooler there was a 12-quart container that was not labeled or dated which contained assorted melons and grapes. During an observation on 3/17/25 at 7:26 p.m., in the walk-in cooler there were frozen pancakes in shallow pan labeled [NAME] but not dated. There was a covered quarter pan of sausage that was covered but not dated. During an interview on 3/18/25 at 11:15 a.m., food service director (FSD) verified all items should be labeled, covered and dated as soon as food is removed from its original container. The FSD stated it was important to label and date food items to know when food items are fresh. During an observation on 3/18/25 at 11:20 a.m., tater tots were in a deep pan in the walk-in freezer. The tater tots were not labeled or dated. At 2:34 p.m. the FSD stated the tater tots were not labeled and dated but should have been. Equipment: During two observations on 3/17/25 at approximately 7:15 p.m., and 3/18/25 at 11:53 a.m., the standing food mixer had dried creamy white substance around the knob that connects the whip. During an observation on 3/17/25 at 7:38 p.m., there was a thick black substance on both the range grate and grill grates. The corner grate of the stove had about one to two ounces of raw ground beef under the grate. During an observation on 3/17/25 between 7:15 a.m., and 7:45 p.m., there was a sign which indicated the daily weekly cleaning schedule for cooks with a beginning date of 3/14/25. The sheet indicated 3/17/25, cleaning duties had been signed off. There were no entries for the 3/14/25, 3/15/25, or 3/16/25. During an interview on 3/18/25, between 11:15 a.m. and 11:45 a.m. the FSD verified the cleaning check list should be completed daily. 3 compartment sinks: During an observation and interview on 3/17/25 at 7:15 p.m. to 7:45 p.m., an observation was made of no log to monitor the sanitizer of the three-compartment sink. DA-A stated the three-compartment sink had test strips, but most dishes went through the dishwasher. DA-A stated she was not aware of how to use the sanitation test strips for the three-compartment sink. During an observation and interview on 3/18/25 at 11:46 a.m., an observation was made of no sanitation log for the three-compartment sink. The FSD stated there was no log to test the sanitation of the sanitizer in the three-compartment sink. During an observation and interview on 3/18/25 11:37 a.m., the third sink in the three-compartment sink contained water that was rust color and was 1/3 full of liquid. The FSD verified they did not have a log to monitor the sanitation of the 3-compartment sink. The FSD stated she planned to implement a sanitation log to monitor the sanitation level starting 3/19/25, after she scheduled a staff meeting. Dish machine: During an observation and interview on 3/17/25 between 7:15-7:45 p.m., the dishwashing log was missing 15 days of monitoring the temperature of the dish machine. DA-A stated temperatures of dish machine should be taken three times a day. During an observation and interview on 3/18/25 at 11:46 a.m., the temperature log for the dish machine was missing several entries to monitor the temperature of the wash and rinse cycles. The FSD stated it was her goal to document the dish machine temperatures at least twice a day, but each shift should complete at each meal. The FSD verified the documentation to monitor the temperature of the dish machine was not completed and was not acceptable. The FSD confirmed it was important that the dishes were sanitized properly before dishes were used. The Dish Machine Temperature Log dated 3/25, indicated there were a total of 32 missing entries out of 51 entries of documentation for the dish machine temperature from March 1, 2025, until March 17, 2025. The facility Food Protection Methods and Standards policy dated 2012, indicated all food items should be labeled, and date marked to identify when food was prepared or opened or when food must be used or discarded. The facility Dishwashing Procedures policy dated 2019, indicated a three-compartment sink may be used to wash pots and pans by hand. Sanitation is completed in the third compartment. Complete immersion for at least 30 seconds in 170-degree water or 75-degree water containing 50 ppm hypochlorite or 12.5 ppm iodine or a quaternary sanitizer dispensed per manufactures directions. The facility Dishwashing Temperature Monitoring Logs policy dated 2019, indicated a log must be completed of the wash and rinse temperatures. Entries must be made daily. The Culinary Director was responsible to monitor daily completion of the dishwashing temperature logs.

Based on observation and interview and policy review, the facility failed to ensure medications were securely and safely stored and under direct observation of authorized staff in areas where residents, staff and guests could access them. This had the potential to affect 37 residents whose medications were stored in the cart. Findings include: During observation on 3/17/25 at 6:15 p.m., an unattended and unlocked medication cart was observed in alcove across from resident room with no staff in sight. One female resident in wheelchair wheeled past the cart. At 6:22 p.m., nursing assistant (NA)-A walked towards the medication cart and stated, Yeah it is unlocked. Anyone can get in there [pointing to the medication cart] if they want. Registered nurse (RN)-A walked around the corner and approached the medication cart. RN-A stated it was her cart and verified, it is unlocked. Should not be because anyone can get in there and get narcotics and other medications. During observation and interview on 3/18/25 at 9:38 a.m., an unlocked and unattended medication cart was observed between two resident rooms with no staff in sight. At 9:42 a.m., a male resident in a wheelchair wheeled himself past the unlocked medication cart. During interview with director of nurse (DON) on 3/20/25 at 11:04 a.m., DON stated unlocked and unattended medication carts, should not happen. DON declined to comment further. Facility policy titled Medication Storage in the Facility Storage of Medications, revised 3/2017, state Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on interview and document review, the facility failed to ensure the quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and depressive symptoms were evaluated for 2 of 4 residents (R36, R12) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified the RAI consists of three basic components including the MDS, the Care Area Assessment (CAA) and the utilization guidelines and this process (i.e., use of the entire RAI) was mandated by CMS. The manual outlined a quarterly assessment was a non-comprehensive assessment which was to be completed every 92 days and was used to track a resident' status between comprehensive assessments . to ensure critical indicators of gradual change in a resident's status are monitored. The manual included a section labeled, SECTION C: COGNITIVE PATTERNS, which outlined the section would be used to help determine the resident's attention, orientation and ability to register or recall information adding, These items are crucial factors in many care-planning decisions; with provided methods and instructions to ensure accurate, thorough coding of the MDS. Further, the manual included another section labeled, SECTION D: MOOD, which outlined the section would be used to help address mood distress and social isolation adding, Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity, and again, the manual provided methods and instructions to ensure the comprehensive evaluation of these conditions. R36 R36's quarterly MDS, dated [DATE], identified R36 had several medical conditions including high blood pressure, renal insufficiency, diabetes, and used a Foley catheter. The 'Section C - Cognitive Patterns' was reviewed and the spacing to record a completed Brief Interview for Mental Status (BIMS) was left blank and not completed and, in addition, the subsequent section for the staff assessment (used if the resident is rarely or never understood) was also left blank and not completed. In total, section C 0200 to C1000 was left blank and not completed. The 'Section D - Mood' was reviewed and the spacing to record a mood interview, including with symptom presence of frequency of depression, was left blank and not completed and, in addition, the subsequent section for the staff assessment (also used if the resident is rarely or never understood) was left blank and not completed. In total, section D0150 to D0600 was left blank and not completed or addressed. R36's medical record was reviewed and lacked evidence either of these sections and corresponding evaluations (i.e., BIMS, PHQ-9) had been completed during the quarterly assessment reference date (ARD) to determine what, if any, complications or issues R36 demonstrated with those corresponding areas. On 3/18/25 at 2:58 p.m., registered nurse (RN)-C was interviewed, and verified they complete the MDS for the campus. RN-C reviewed R36's quarterly MDS (dated 2/17/25) and verified the sections were dashed. RN-C stated they were dashed as the corresponding assessments to code them, such as a BIMS and PHQ-9, were not completed or in the medical record. RN-C explained the social services department was responsible to complete those assessments, however, due to turn over they likely had been missed adding aloud, Then stuff falls through the cracks. RN-C stated they felt the situation had improved lately, however, verified the importance of ensuring assessments and, in turn, the MDS are completed accurately adding to dash items could result in missed Medicare reibursement. RN-C added, It's major Medicare dollars if not [done]. 49034 R12 R12's quarterly MDS dated [DATE], indicated that Section C - Cognitive Patterns, which included the BIMS assessment and/or subsequent section for the staff mental status assessment, with subsections, C0100 to C1000 was left blank and not completed. The Section D - Mood which included a mood interview and/or subsequent staff mood assessment, with subsections D0100 to D0700 was left blank and not completed. R12's medical record was reviewed and lacked evidence of either of these sections and corresponding evaluations (i.e., BIMS, PHQ-9) had been completed during the quarterly assessment. During an interview on 3/19/25 at 1:48 p.m., RN-C confirmed she had reviewed R12's most recent quarterly MDS and verified Section C and Section D of the MDS were not completed. RN-C stated they had a social worker who oversaw the completion of these sections but was new to the role at the time of the assessment and thought it must have been missed. RN-C acknowledged that they had a problem with getting these sections of the MDS complete previously when they had staff turn over in social services and were unsure who would complete that MDS section if this occurred again. A facility policy regarding MDS completion was requested and not received.

Based on interview and document review, the facility failed to ensure voiced grievances and complaints about the offsite laundry service were acted upon and, if needed, investigated or resolved for 1 of 1 resident (R2) reviewed who complained their clothing was missing or damaged due to the service. Findings include: R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition and demonstrated no delusional thinking during the review period. On 3/18/25 at 9:53 a.m., R2 was interviewed and expressed frustration with the facility's laundry service which was completed offsite. R2 explained she stated many of her clothing items taken through the service, and several items such as various shirts and pants, either didn't return until several weeks later, didn't return at all, or were damaged with holes in them upon return. R2 stated they had talked with staff about it but had been told there was nothing they [staff] can do about it. R2 stated her voiced concerns remained unresolved to her liking or satisfaction adding aloud, Most certainly not! [resolved] When interviewed on 3/18/25 at 1:46 p.m., nursing assistant (NA)-E stated they had worked with R2 multiple times prior and described her (R2) as being pretty close to a total assist with mobility and activities of daily living (ADLs). NA-E stated the facility's laundry, including personal items and linens, was done offsite by another company. NA-E stated they had not heard R2 make complaints about missing or damaged items from the laundry service, however, had heard other residents voice complaints about not getting items back timely adding aloud, Most people complain about how long it takes [to get items back]. On 3/19/25 at 10:21 a.m., NA-D was interviewed and expressed R2 had complained about her clothes being missing or damaged due to the offsite laundry service adding aloud, She [R2] has complained about that. NA-D explained the laundry was all sent offsite and multiple residents, including R2, had complained about it adding, It's a terrible service. NA-D stated clothing seemed to not return or was quite slow in coming back. NA-D stated R2 had last voiced a comment about the laundry service within the last month and reiterated the poor service with the laundry adding aloud, It's sad. NA-D stated they had talked with the nurses about the resident' complaints, however, they were unsure if management was aware of the voiced concerns from R2 and other residents. NA-D stated the facility had used the outside laundry service for several years without issue, however, it seemed to become a problem within the last six months or so adding, It's gotten to be a real issue. A facility provided surveyor_report_25031 . excel spreadsheet, dated 3/2024 to 3/2025, identified all facility logged grievances during the time period and listed them to include the resident name, date of grievance, staff assigned to it, and the general concern being voiced. This listing identified a concern was logged in February 2024 by a family member which outlined, Resident [not R2] is always getting the wrong clothes, she is being given someone else's clothes and then staff are placing them on resident and they are too big for this resident. However, R2's concern about the laundry service and her missing/damaged items was not listed on the log despite direct care staff having knowledge concerns were voiced. Further, R2's medical record was reviewed and lacked evidence the voiced concern about untimely clothing return and potentially damaged items had been reviewed or acted upon for resolution. On 3/19/25 at 11:34 a.m., the account manager for the offsite laundry service (AM) was interviewed via telephone. AM explained they were the contact person the facility used for anything related to the service, and verified their company provided the offsite laundry services for personal clothing and linens. AM stated they picked up and returned clothing to the care center five days a week and explained soiled items were placed into a mesh-bag which was specific to each resident. The items were never removed from the bag(s) and laundry, in general, was picked up and returned within 48 hours. AM stated they were unaware of any recent concerns about their service adding nobody from the care center had reached out to them to discuss it, or what, if any, action needed to be taken to help resolve the concerns either by the company or the care center. AM stated they had one issue they could recall from several months prior where clothing from another site had accidentally been sent to [NAME] Senior Living, however, that was like six months or so prior and they haven't heard anything from them [[NAME]] for awhile. AM stated if the mesh-bags were not closed properly, then items could spill out during wash and possibly end up with wrong people as a result. AM stated they had noticed some issues with that happening in the past. During the recertification survey, from 3/17/25 to 3/20/25, no documentation or evidence the laundry concern(s) were acted upon, investigated or resolved was provided. On 3/19/25 at 1:05 p.m., the administrator, social services designee (SSD)-A, director of nursing (DON, regional director of clinical services (RDCS) and director of facilities (DOF) were interviewed. The administrator verified the provided grievance listing include all grievances, and the DON expressed they try to ask residents to have seven days worth of clothing when they admit to account for the turn-over with the laundry service. DOF explained the offsite laundry service had been used for several years and there had not been an issue until more recent when some incorrect bags were being used to transport the soiled items (i.e., clear bags vs mesh bags). This made a situation where staff have no idea who they [items] belong to which had just happened again that day. DOF verified soiled items should be sent in the mesh bag to be laundered, however, the DON expressed there may be some instances where a clear, non-permeable bag may be needed such as if heavily soiled with bodily fluid. DON stated they were unaware the floor staff were hearing complaints from residents about the laundry service or missing/damaged items adding, I didn't hear about that. DOF stated they were unaware residents were reporting extended turn-around times with items, too, adding aloud, That's a new one on me. DOF stated they had toured the offsite laundry site and the process for washing and cleaning could be very aggressive. However, the DON and administrator both acknowledged there had been no investigation or PIP (performance improvement process) to review the complaints about laundry from R2 or anyone, since they were unaware of the comments the floor staff were hearing. DON added aloud, [It] sounds like we should. Further, the administrator stated had the comments been brought to management' attention, then a triage of the concern would have been done to see what, if any, areas of the process maybe needed a deeper dive on it. A facility-provided Concerns, Grievances policy, dated 2017, identified residents or customers had the right to voice grievances or concerns without discrimination or reprisal. The policy outlined, The term 'voice concerns' is not limited to a formal, written grievance process, but may include a resident's verbalized concerns to staff. The policy outlined a procedure which included having voiced concerns or complaints placed on a written form and forwarded to the grievance officer. The concern would then be screened and assigned to a responsible member who then investigates the issue or concern. The policy outlined, The staff person responsible investigates, resolves the issue, and responds back to the customer without five business days and documents action [taken].

During observation, interview and record review, the facility failed to comprehensively assess and monitor a resident with new onset of respiratory symptoms for 1 of 1 residents (R11) reviewed for respiratory complications. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE] identified R11 had intact cognition, was dependent on staff for toileting, bathing, dressing, and personal hygiene. In addition, R11 had diagnoses of diabetes, anxiety, morbid obesity, and chronic obstructive pulmonary disease and was utilizing oxygen. R11's physician orders (PO) with start dates of 8/31/23, identify the following: -Guaifenesin liquid; 100 milligrams (mg)/5 milliliters (mL); Amount to administer: 10 ml; oral. Every 4 hours-prn (as needed) for cough, and -Benzonatate capsule; 100 mg; Amount to administer: 100 mg; oral every 4 hours prn. take 1 Every (q) 4 hours prn for cough. R11's PO with start date of 1/29/25, identified: Proventil HFA (albuterol sulfate) HFA aerosol inhaler; 90 mcg/actuation; Amount to Administer: 2 puffs; inhalation Every 4 Hours-PRN as needed for wheezing, cough for chronic obstructive pulmonary disease. R11's February 2025 Medication Administration Record (MAR) identified no administrations of Benzonatate, Guaifenesin, and albuterol. R11's March 2025 MAR downloaded 3/20/25 identified first dose of Guaifenesin was provided on 3/14/25 at 12:03 a.m., and received subsequent doses on 3/15/25 at 3:53 a.m., and 3/16/25 at 3:40 p.m., and 11:12 p.m. R11's first dose of Benzonatate was provided on 3/13/25 at 7:46 p.m., and received subsequent doses on 3/15/25 at 10:48 p.m., and 3/16/25 at 2:29 a.m., and 5:52 p.m., and 3/17/25 at 1:21 a.m. R11's albuterol inhaler first dose for March 2025 was documented on 3/20/25 at 12:45 a.m. R11's progress notes (PN) in electronic medical record (EMR) downloaded 3/18/25 for dates 3/3/25 to 3/18/25 failed to identify assessment or monitoring for cough or sore throat. R11's vital signs (blood pressure, pulse, respirations, oxygen saturation) documentation from EMR downloaded 3/18/25, identified vital signs were documented on 3/9/25 and 3/16/25. Vital signs were not documented on 3/14/25, and 3/15/25. During observation and interview with R11 and registered nurse (RN)-A on 3/17/25 at 7:00 p.m., RN-A entered R11 room with evening medications. R11 had audible coughing stating, my throat is hurting now. [I] need something stronger than a cough drop. RN-A walked out of R11 room to the medication cart. R11 stated, [I] can't get rid of it with cough. [sic] feel like it is getting worse. RN-A stated R11 had complained of cough and was not sure if R11 was tested for Covid-19. RN-A stated R11 was not on enhanced barrier precautions or transmission-based precautions right now pointing to no personal protective equipment cart located outside resident room. During observation and interview on 3/17/25 at 7:43 p.m., R11 was lying in bed with head of bed elevated. R11 was using oxygen at two (2) liters via nasal cannula and had a productive strong cough. R11 stated, it sounds like [I] have pneumonia. No one has tested me or asked me about it. I have had a cough for four days. It is not getting better. No one has done anything about it. I cough up phlegm. R11 also stated, I want to see a doctor. I need to see a doctor or I am going to be dead. I told them last week. During observation and interview with registered nurse (RN)-A on 3/17/25 at 7:47 p.m., stated it was second time I have been assigned to care for her. She told me last night and today about her cough. And I don't know if [R11] she was seen by a provider. RN-A stated expectation for staff to document in the progress note about any changes in respiratory status and to follow up. RN-A stated, I had [R11] as a patient last night as well and no, I did not contact the provider for [R11's] coughing. R11's PN dated 3/19/25 stated, [R11 was noted today to have increased lethargy and coughing. And described some crackles to mid/lower left lungs and decrease in appetite. In addition, Was noted to have some diaphoresis (flushing of face with perspiration) prior to last administration of scheduled tylenol[sic]. R11's PN dated 3/20/25 stated, Res has noted wet sounding occasional coughing and nasal congestion noted with vital signs. In addition, R11 requested and given the following PRN's[sic] throughout the night: Albuterol inhaler 2 puffs at 2300, Benzonatate 100mg at 0100 and tussin (Guaifenesin) 10mls at this time. During interview with LPN-A on 3/20/25 at 8:36 a.m., LPN-A stated expectation, for new onset of cough, we are to get vitals and lung sounds. Then, call triage. Get a weight. Offer something for cough if [on standing orders]. I would put it in progress note and give verbal report. LPN-A stated, [R11] sounded crappy yesterday. LPN-A verified R11's first dose of Benzonatate was documented on 3/14/25, Oh, this has been going on since the 13th. I did not know that. LPN-A stated, [staff] should have followed up on the new onset of cough if someone is taking it prn. Does not look like it was done. Nothing in the nursing progress notes that I see. We still need to follow up. I hate to say it but this has been going on too long and should have been looked at before yesterday. During interview with nurse practitioner (NP) on 3/20/25 at 10:10 a.m., NP stated expectation of facility to, perform vital signs and lung sounds including temperature to be monitored right away for new onset of respiratory symptoms. After 24-48 hours if the symptoms are persistent and not getting better then [provider] should be notified. NP stated R11 is high risk for respiratory compromise if new onset of cough and using prn meds are started. NP verified facility failed to contact R11's provider team until 3/19/25, regarding R11's respiratory symptoms. We should have been notified several days ago. During interview with director of nursing (DON) on 3/20/25 at 11:12 a.m., DON stated expectation of staff to do assessment and vital signs including lung sounds as soon as possible if new symptoms occur and, It must be documented. I can't teach nurse's common sense. This was not done for R11. Facility policy titled Change in Condition, reviewed 10/2/23 state: - Assess significant change in the resident's condition noted through direct observation, interview or report for other staff, -Conduct a symptom review and assessment, as condition warrants, -Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. The policy defined Notification of Changes as commence a new form of treatments[sic] to deal with a problem.

Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were maintained for 1 of 3 residents (R12) reviewed for EBP. Furthermore, the facility failed to implement and maintain respiratory precautions and have proper infection survelliance for 1 of 1 resident (R11) reviewed who had active symptoms of a potential respiratory illness. Findings include: EBP The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities. The article indicated high-contact activities include providing hygiene, changing briefs, dressing, urinary catheter care, etc. The article indicated that EBP should be implemented (when contact precautions did not apply) for residents with indwelling medical devices (urinary catheter) or chronic wounds regardless of MDRO colonization status. R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 was diagnosed with heart failure, peripheral vascular disease (blood vessel disorder that affects blood flow to the limbs), and obstructive uropathy (blockage of normal urinary flow). The MDS indicated R12 had two venous ulcers (slow healing sores on the leg) present and had an indwelling urinary catheter. R12's care plan dated 3/12/25, indicated R12 was on EBP related to a suprapubic catheter and chronic wounds. The care plan indicated staff were to apply a gown and gloves before high-contact care activities. During an interview and observation on 3/20/25 at 8:33 a.m., nursing assistant (NA)-E and NA-C were observed to complete hand hygiene, put gloves on, and enter R12's room. NA-C and NA-C were not observed to put on gowns. R12 was observed lying in bed with wrapped dressings applied to both of his lower extremities and a catheter bag hanging off the side of the bed. NA-C was observed to empty R12's catheter into a urinal and dispose of the urine with NA-E's assistance holding the catheter bag. After removing her gloves and completing hand hygiene, NA-C was observed to leave the room and came back dressed in a gown and gloves. NA-E (still not wearing a gown) and NA-C were observed to assist the resident with dressing and complete hygiene care after a bowel movement. During an interview on 3/20/25 at 9:11 a.m., NA-C stated she did not feel she needed to wear a gown when emptying the catheter if she used gloves and washed her hands. NA-E stated that a gown only had to be worn when nurses were completing wound care or catheter care but did not feel he needed to wear one when assisting a resident with dressing or performing personal hygiene tasks as he did with R12. During an interview on 3/20/25 at 10:26 a.m., the infection control preventionist (ICPC) stated whenever a staff member touches a resident who is on EBP, she would expect them to be wearing a gown and gloves including during catheter and personal hygiene care and this was important to stop the spread of infection. A policy regarding EBP was requested and not received. 49339 RESPIRATORY / SURVEILLANCE R11's quarterly MDS, dated [DATE], indicated R11 had intact cognition with no hallucination, delusions or other behavioral symptoms noted and required maximal assistance for personal hygiene, set up for eating and dependent on staff for all other activities of daily living (ADLs). Section 0 special treatment and programs indicated R11 received oxygen therapy. During observation and interview on 3/17/25 at 7:43 p.m., R11 was observed to have a productive cough. R11 stated she had the cough for 4 days and was not getting better. R11 stated, I cough up phlegm .I need to see a doctor, or I am going to be dead .I told them last week. There was no precautions signs or personal protective equipment outside of R11's room. During interview on 3/17/25 at 7:51 p.m., registered nurse (RN)-A stated they had worked with R11 previously. RN-A stated R11 told her last evening and today about her cough along with having an itchy throat. RN-A stated R11 had an order for Tessalon [NAME] (benzonatate - a medication used to relieve coughs due to colds given in a capsule form). RN-A stated they are unsure if R11 had been seen by a provider and stated, I did not contact the provider for her coughing. Furthermore, RN-A stated all changes and reports of coughing, testing, x-rays and labs should be in the patient chart in the progress notes. During interview, R11 stated she wanted to see the doctor adding she was not seen by a doctor today. R11's March Medication Administration Record (MAR), dated 3/20/25, indicated the following, -benzonatate capsule (Tessalon [NAME]) - 100 milligram (mg) capsules take 1 every 4 hours PRN (as needed) for cough with a start date of 8/31/23, with the following administrations: -3/13/25 at 7:26 p.m., which was effective -3/15/15 at 10:48 p.m., which was effective -3/16/25 at 2:49 a.m., which was effective -3/16/25 at 5:52 p.m., which was effective -3/17/25 at 1:21 a.m., which was effective -3/17/25 at 7:38 p.m., which was effective -3/18/25 at 11:34 p.m., which was effective -3/18/25 at 11:44 p.m., not given too early -3/19/25 at 9:51 a.m., which was documented as unknown for effectiveness -3/19/25 at 8:59 p.m., which was effective -3/19/25 at 4:41 a.m., which was documented as mistake in charting -3/20/25 at 12:58 a.m., which was documented as some relief -3/20/25 at 6:57 a.m., which was effective -guaifenesin (cough syrup) liquid 100 mg/5 milliliter (ml) give 10 ml orally every 4 hours as needed for cough with the following administrations: -3/14/25 at 12:03 a.m., which was effective -3/15/25 at 3:53 a.m., which was effective 3/16/25 at 3:40 p.m., which was somewhat effective -3/16/25 at 11:12 p.m., which was effective -3/17/25 at 10:12 a.m., which was documented as unknown for effectiveness -3/20/25 at 4:57 a.m., which was effective R11's progress notes reviewed from 3/10/25, to 3/20/25, included the following: -3/20/25 at 4:49 a.m.,: (R11) has noted wet sounding occasional coughing and nasal congestion noted. VS obtained as follows: B/P 122/68, P 78, R 18, T 97.9, O2 sats (oxygen saturation) 96% on 2 lpm (liters per minute) via NC (nasal cannula). Res requested and given the following PRN's throughout the night: Albuterol inhaler 2 puffs at 2300 (11:00 p.m.,), Benzonatate 100mg at 0100 (1:00 a.m.,) and tussin 10mL at this time. Also encouraged fluids which she took well and kept HOB elevated. Writer encouraged res to get up out of bed later today and into w/c, reminding her laying in bed constantly isn't the best for her lungs and some movement and activity can help clear mucus. -3/19/25 at 2:13 p.m.: (R11) was noted today to have increased lethargy and coughing. Cough is productive but she swallowed the sputum without spitting it out for observation. Has some crackles to mid /lower left lungs. Decreased appetite today also. Denies nausea. Denies sore throat, no nasal drainage noted. Was noted to have some diaphoresis (sweating) prior to last administration of her scheduled tylenol. T- 96.8, P- 73, R- 18, BP- 128/78, Sao2 97% with o2 at 2L. Call placed to triage with the above orders. Waiting for a reply from NP. Will pass on to oncoming shift. Progress notes lacked evidence of R11 being placed on respiratory precautions, monitoring of symptoms since increased use of PRN use (had started using PRN cough medication 6 days prior to first progress note entry), notification of physician prior to 6 days after symptoms started and assessment of lung sounds being completed. Review of facility infection tracker report, dated 3/18/25, revealed R11 was not listed as a resident with a infection or possible infection being followed. During interview on 3/20/25 at 8:36 a.m., licensed practical nurse (LPN)-A stated for a resident with a new onset of cough, we (nursing) would get vitals and lungs sounds, call triage (provider), and offer medication for cough if have an order. LPN-A stated a progress note would be entered in the electronic medical record (EMR) along with giving verbal report to the next shift and keeping the resident in their room until it was known what the resident was ill with. LPN-A verified, after review of EMR, first dose of Tessalon [NAME] was administered on 3/13/25, and added, I did not know about that. LPN-A stated this still needed follow up and I hate to say it, but this has been going on too long and should have been looked at before yesterday. During an interview on 3/20/25 at 8:43 a.m., regional director of clinical services (RDCS) and infection preventionist (ICPC) stated illnesses were tracked on the infection event log in the EMR system by creating an event. The expectation was any nurse could create an event with the onset of symptoms and the infection preventionist oversaw all the infection events. RDCS stated if a resident had respiratory symptoms such as cough and fever then a respiratory event would be open and tracked. During an interview on 3/20/25 at 9:01 a.m., RDCS reviewed R11's EMR. RDCS verified administrations of Tessalon [NAME] as listed above. RDCS verified first progress note entered was 3/19/25 at 2:15 p.m. regarding R11's cough. RDCS stated they were unaware of R11's prn use or onset of cough and symptoms or would have acted accordingly. RDCS stated R11 should have been added to the infection surveillance (infection tracking) for follow up and placed on respiratory precautions. RDCS stated she was going to follow up immediately. During continued interview on 3/20/25 at 9:05 a.m. IPCP verified R11 should have been on the infection surveillance (infection tracking log) and precautions should have been implemented, and verified neither were completed. During interview on 3/20/25 at 9:37 a.m., director of nursing (DON) stated the expectation was all nurses would create an infection event with respiratory symptoms. DON stated that staff had all been trained on how to create an event. DON stated there should have been an event (infection tracking event) made for R11 which would have triggered for additional follow up which included being added to the surveillance log. DON stated R11 should have been placed on respiratory precautions. During interview on 3/20/25 at 10:44 a.m., LPN-B stated an infection event should be created for a resident when there was a change of condition and after the initial information was gathered. LPN-B stated if a resident was utilizing a PRN cough suppressant more than a couple times, an assessment needed to be completed, triage notified, family notified, progress note entered, and an event created. LPN-B stated a resident would also be placed on precautions. A facility policy titled Surveillance, revised 8/23, indicated infection surveillance will be collected on a routine, systematic and ongoing basis and the results will be used to recognize need for reporting, staff educations, as well as to identify individual resident problems in need of intervention.

Based on observation and interview, the facility failed to ensure dignity was maintained for 3 of 3 residents (R24, R51, R151) observed for long call light response times. Findings include: R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had intact cognition, did not reject cares, and required substantial to maximal assistance with toileting hygiene and upper and lower body dressing. In addition, R24's medical diagnoses include paralysis on left side from stroke, and depression. During continuous observation and interview on 3/19/25 from 12:42 p.m., to 1:11 p.m., for a total of 28 minutes and 48 seconds, R24 call light was activated and beeping outside R24 room before staff entered room. During interview at 1:27 p.m., R24 stated she had turned on the call light for changing [sic] brief. It is frustrating for me to wait to have [staff] answer my light. I have to wait and wait. My brief was dirty and I had to sit in it until [staff] got around to it. Made me feel gross. R51 R51's face sheet downloaded 3/20/25 at 7:54 a.m., identified R51 with admission to facility's transitional care unit (TCU) following left hip replacement surgery. In addition, R51 with diagnoses of heart failure, arthritis, and depression. R151 R151's face sheet downloaded 3/20/25 at 7:46 a.m., identified admission to facility's TCU for osteomyelitis (bone infection) to left ankle and foot resulting in partial bone removal. In addition, R151 had diagnoses of diabetes, and depression. During continuous observation on 3/20/25 from 6:35 a.m., to 7:20 a.m., call light was activated for R51 for twenty-two minutes and sixteen seconds before staff entered room. During interview with R51 at 8:11 a.m., R51 stated, it made me cry to wait that long for help. It upsets me when I feel that no one is out there to help me. During same continuous observation R151 call light was activated for twenty minutes and thirty-two seconds. During interview on 3/20/25 at 8:20 a.m., R151 stated, I don't want to be sitting here in my wet diaper. This is horrible to have to wait so long for help. I know [staff] are busy but I cannot wait that long for them to answer my light. During interview with nursing assistant (NA)-B on 3/19/25 at 10:38 a.m., NA-B stated expectation of staff to answer call lights right away but due to staffing and facility's use of agency staff, every one of us is busy and too much to expect [nursing assistants] to get fourteen people up, dressed, changed, before breakfast. During interview with NA-C on 3/19/25 at 10:51 a.m., NA-C stated expectation to respond right away when call lights are activated, if I am busy then I cannot answer it. NA-C stated normal patient assignment is eight to ten residents, But today is 14. Too much to keep up. Can't answer call lights promptly when [staff] are busy. During interview with NA-E on 3/20/25 at 8:29 a.m., NA-E stated call light times, too long is more than twenty minutes. Important to me to meet their needs and are safe. Some [residents do] complain. They can be frustrated waiting so long. During interview with licensed practical nurse (LPN)-B on 3/20/25 at 8:26 a.m., LPN-B stated call light times, over five minutes is too long. Because we don't know what they need and we want to make sure they are safe. During interview with director of nursing (DON) on 3/20/25 at 11:04 a.m., DON stated expectation of staff to answer call lights as soon as possible. Also, long call light times, [are] a concern for dignity. [Patient] could be hungry or scared. DON stated facility was not short staffed and that 28 minutes is too long for a call light response time. Facility policy titled Call Lights-Call System Activation and Response dated 5/28/24 state, Calls for assistance may be triaged and answered as soon as possible based on immediate needs.

Based on observation and interview, the facility failed to ensure resident identifiable personal health information (PHI) was kept secured and not accessible to unauthorized personnel. This had the potential to affect 2 of 2 residents (R31, R37) whose personal information was listed on exposed care sheets. Findings include: R31 R31's quarterly Minimum Data Set (MDS) dated [DATE] identified R31 with intact cognition. R37 R37's quarterly MDS dated [DATE] identified R37 with intact cognition. During continuous observation on 3/20/25 from 6:28 a.m., to 7:19 a.m., a care sheet was left unattended in an alcove across the hall from nursing station. The care sheet identified R31 and R37 with name, room number, diet, allergies, assistance needed with personal care, days of showers and weights, preferences reminders, transfer assistance needed, and reminders for bowel and bladder monitoring. During fifty-one minutes there were seventeen instances of staff walking past and four instances of residents being wheeled past the unattended care sheet. During interview with licensed practical nurse (LPN)-B on 3/20/25 at 7:19 a.m., LPN-B pointed to the unattended care sheet and stated, [it] should not be left in open because it has[sic] HIPAA [Health Insurance Portability and Accountability Act] violation. Not supposed to have that out at all. During interview with R31 on 3/20/25 at 7:41 a.m., R31 stated, Yeah, I believe my medical information should only be seen and used by those that absolutely need it. My info should not be left out for anyone to see. That would embarrass me and I don't think strangers that do not know me should see anything about me unless I want them to. In fact, I would be miffed. None of anyone's business. During interview with director of nursing (DON) on 3/20/25 at 11:12 a.m., DON stated unattended care sheets were not acceptable. Part of HIPAA training. Facility policy titled Introduction to HIPAA Privacy Policies reviewed 1/28/25, identified Protected Health Information. The Privacy Rule applies to any information that (1) is created or received by a health care provider; (2) either identifies the resident or could reasonable be used to identify the resident; and (3) relates to the past, present, or future physical or mental condition of a resident, the provision of health care to a resident.

Based on interview and document review, the facility failed to notify the medical provider of a change in condition in a timely manner for 1 of 1 resident (R11) reviewed for respiratory care. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition, and was dependent on staff for toileting, bathing, dressing, and personal hygiene. In addition, R11 had diagnoses of diabetes, anxiety, morbid obesity, and chronic obstructive pulmonary disease and was utilizing oxygen. R11's physician orders (PO) with start dates of 8/31/23, identify the following: -Guaifenesin liquid; 100 milligrams (mg)/5 milliliters (ml); Amount to administer: 10 ml; oral. Every 4 hours-porn (as needed) for cough, and -Benzonatate capsule; 100 mg; Amount to administer: 100 mg; oral every 4 hours prn. take 1 Every (q) 4 hours prn for cough. R11's February 2025 Medication Administration Record (MAR) identified no administration of Benzonatate or Guaifenesin. R11's March 2025 MAR identified first dose of guaifenesin was provided on 3/14/25 at 12:03 a.m., and R11 received subsequent doses on 3/15/25 at 3:53 a.m., and 3/16/25 at 3:40 p.m., and 11:12 p.m. R11's first dose of benzonatate was provided on 3/13/25 at 7:46 p.m., and R11 received subsequent doses on 3/15/25 at 10:48 p.m., and on 3/16/25 at 2:29 a.m., and 5:52 p.m., and on 3/17/25 at 1:21 a.m. R11's progress notes (PN) in electronic medical record (EMR) downloaded 3/18/25 for dates 3/3/25 to 3/18/25, failed to identify assessing or monitoring for cough or sore throat. R11's vital signs (blood pressure, pulse, respirations, oxygen saturation) documentation from EMR downloaded 3/18/25 identified vital signs were documented on 3/9/25 and 3/16/25. Vital signs were not documented on 3/14/25 and 3/15/25. During observation and interview with R11 and registered nurse (RN)-A on 3/17/25 at 7:00 p.m., RN-A entered R11 room with evening medications. R11 had an audible coughing stating, my throat is hurting now. [I] need something stronger than a cough drop. RN-A walked out of R11's room to the medication cart. R11 stated, [I] can't get rid of it with cough. [sic] feel like it is getting worse. RN-A stated R11 had complained of cough and was not sure if R11 was tested for Covid-19. RN-A stated R11 was not on enhanced barrier precautions or transmission-based precautions right now pointing to no personal protective equipment cart located outside resident room. During observation and interview on 3/17/25 at 7:43 p.m., R11 was lying in bed with head of bed elevated. R11 was using oxygen at two (2) liters via nasal cannula and had a productive strong cough. R11 stated, it sounds like [I] have pneumonia. No one has tested me or asked me about it. I have had a cough for four days. It is not getting better. No one has done anything about it. I cough up phlegm. R11 also stated, I want to see a doctor. I need to see a doctor or I am going to be dead. I told them last week. During observation and interview with registered nurse (RN)-A on 3/17/25 at 7:47 p.m., stated it was second time I have been assigned to care for her. She told me last night and today about her cough. And I don't know if she [R11] was seen by a provider. RN-A stated the expectation for staff was to document in the progress note about any changes in respiratory status and to follow up. RN-A stated, I had [R11] as a patient last night as well and no, I did not contact the provider for [R11's] coughing. During interview with LPN-A on 3/20/25 at 8:36 a.m., LPN-A stated expectation, for new onset of cough, we are to get vitals and lung sounds. Then, call triage. Get a weight. Offer something for cough if [on standing orders]. I would put it in progress note and give verbal report. Until we know what it is then we keep [resident] in their room. LPN-A stated, I called triage on R11 yesterday. She sounded crappy yesterday. I called triage and gave report to oncoming nurse. I don't know what happened for follow up. I did not hear. I left [work] before triage called back. It should be in the progress note. LPN-A reviewed R11's EMR and verified no response from triage was documented. LPN-A verified R11's first dose of benzonatate was documented on 3/14/25, Oh, this has been going on since the 13th. I did not know that. LPN-A stated, [staff] should have followed up on the new onset of cough if someone is taking it prn. Does not look like it was done. Nothing in the nursing progress notes that I see. We still need to follow up. I hate to say it but this has been going on too long and should have been looked at before yesterday. During interview with nurse practitioner (NP) on 3/20/25 at 10:10 a.m., NP stated expectation of facility to, perform vital signs and lung sounds including temperature to be monitored right away for new onset of respiratory symptoms. After 24-48 hours if the symptoms are persistent and not getting better then [provider] should be notified. NP stated R11 is high risk for respiratory compromise if new onset of cough and using prn meds. NP verified facility failed to contact provider team until 3/19/25 regarding R11's respiratory symptoms. We should have been notified several days ago. During interview with director of nursing (DON) on 3/20/25 at 11:04 a.m., DON stated, if new symptoms occur the expectation was to for staff to document in the EMR including a progress note and plan for following up. DON stated expectation for staff, to use judgement when deciding to notify provider for change of condition. this was not done for R11 and should have. Facility policy titled Change in Condition reviewed 10/2/23 state purpose of policy was, To inform resident/resident representative and attending provider when a significant change in resident condition occurs. In addition, Notification of Changes-A community must immediately inform the resident; consults with the resident representative when there is a significant change in the resident's physical, mental or psychosocial status, or there is the need to alter treatment significantly. Need to alter treatment significantly, means a need to stop a form of treatment because of adverse consequences or commence a new form of treatments to deal with a problem. Also, the policy state licensed nursing associate to: Obtain a set of vital signs and repeat as needed or ordered, Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed, Document symptom(s), assessment, observations, resident/resident representative, and medical provider notification, Monitor and provide treatment as ordered by the attending provider, and Update the care plan as appropriate. Policy stated Responsible for Oversight: DON.

Based on interview and record review, the facility failed to implement interventions to prevent pressure ulcer development for 1 of 1 resident (R1) reviewed for pressure ulcers. R1 admitted to the facility without pressure ulcers, subsequently developed an unstageable pressure ulcer related to necrotic (death of tissue). The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration, and notify R1's provider of changes, resulting in R1 being hospitalized . The immediate jeopardy began on 8/15/23, when a pressure ulcer was noted to R1's buttocks without proper assessment, physician notification, and documentation of interventions and was identified on 10/4/23. The administrator and director of nursing (DON) were notified of the on 10/4/23 at 4:55 p.m. The immediate jeopardy was removed on 10/6/23 but noncompliance remained at the lower scope and severity level 2, D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revision 211, 2-3-23 indicated definitions for stage 3, stage 4, and unstageable pressure ulcers. Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. R1's admission note to the facility dated 3/24/23, indicated R1 had no skin issues except for bruising on her left arm due to lab draws and a biopsy procedure on her right arm. R1's care plan initiated on 3/27/23, noted she was at risk for skin breakdown and had interventions for turning and reposition program as needed every two hours, barrier cream to dry areas as needed, and wheelchair cushion. These interventions were discontinued on 4/26/23. The discontinue reason was Scheduled end date. R1's Physician Orders dated 3/27/23, noted skin assessment to be completed on weekly shower day, to be completed even if a shower is refused, all old and new skin abnormalities need to be documented. R1's care plan initiated 4/10/23, noted an intervention for risk for skin alteration; See eTAR (electronic Treatment Administration Record). A progress note dated 5/10/23, indicated staff reported a small sore on R1's coccyx, the nurse noted 1 centimeter (cm) x 1 cm, applied barrier cream, a foam dressing and left the provider a non-urgent voicemail. A progress note dated 5/16/23, noted R1 had a sore on her bottom and was added to wound rounds. A progress note date 5/22/23, noted R1 was seen on wound rounds and had a pea-sized pressure ulcer on her coccyx. No specific measurements, staging, description of wound bed, drainage or condition of peri-wound skin were documented. R1's Physician Orders dated 5/22/23, directed to care for the pressure ulcer as follows: cleanse with wound cleanser, skin prep to peri-wound and cover with foam daily. The order was discontinued on 6/23/23. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, required extensive assistance of one to two staff for bed mobility and transfers, and was not ambulatory. The MDS indicated R1 was at risk for pressure ulcers, had diagnoses of multiple sclerosis, weakness and abnormal posture and required the extensive assistance of one staff for bed mobility, dressing and toileting. A progress noted dated 6/29/23, indicated R1 was seen on wound rounds for a small blister on her coccyx area, which had healed. The progress note lacked further description. A progress note dated 7/5/23, indicated an open area on R1's coccyx was healed. A progress note dated 7/9/23, indicated open areas to R1's gluteal area, it was covered with a foam dressing. The noted lacked documentation of wound bed description, drainage, measurements, etiology, or peri wound skin. A progress note dated 7/17/23, indicated R1 received a shower, new open areas were found, and the wound nurse completed an assessment. The wound nurse documented a progress note that stated R1 had two open areas on her buttocks, the left buttock had visible adipose with full thickness skin loss and the right had partial thickness skin loss with exposed dermis. R1 was added to weekly wound rounds. The note lacked further description of the pressure ulcers. R1's wound management form dated 7/17/23, noted R1 had an open area on her left buttock that measured 3 cm x 3.5 cm and an open area on her right buttock that measured 2 cm x 1.5 cm, and the healing status was stable. The wound management form lacked wound bed descriptors, drainage, peri wound skin or staging of the pressure ulcer. R1's Physician Orders dated 7/17/23 directed to cleanse with wound cleaner, apply skin prep to peri-wound skin, apply a small amount of Medi-honey to the wound bed, cover with foam and change daily. A progress note dated 7/27/23, indicated R1 was seen on wound rounds, treatment was performed to bilateral buttocks, wound nurse to see weekly. R1's wound management form dated 7/27/23, noted R1's wound measurements to the left buttock measured 1.5 cm x 2 cm, and the right buttock open area measured 2 cm x 3 cm. The wound management note lacked further description of the pressure ulcer. R1's care plan dated 7/27/23 identified R1 had skin breakdown on bilateral buttocks. The care plan indicated a Braden score (assessment for risk of skin breakdown) of 19 (indicates no risk for pressure ulcer development). R1's care plan lacked any interventions, indicating only to See eTAR. R1's July 2023, eTAR did not contain pressure ulcer prevention interventions but contained orders for wound care to R1's pressure ulcer. A progress note dated 8/6/23, noted R1 was pale and tired, dressing changed as ordered to stage 3 & 4 pressure ulcers. Vital signs were temperature 97.7 F, blood pressure 97/60, O2 95% on room air, heart rate 77, and respirations were 16. R1's wound management form dated 8/10/23, noted R1's left buttock measured 3 cm x 4 cm and her right buttock measured 5 cm x 4 cm and healing status was listed as stable. The note lacked any further descriptions. A progress note dated 8/13/23, noted R1's dressing change was completed, and a foul smell and drainage was noted, R1 would be turned every 2 hours to relieve pressure to buttocks. The note lacked documentation of provider notification. A progress noted dated 8/14/23, indicated R1 had a scheduled shower and that she has open areas to left and right gluteal cleft, eschar (devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) noted on right side, total affected area measured 10.5 cm x 5.5 cm, foul smell and significant drainage noted. Repositioning was offered every 2 hours, and the nurse manager would be notified. The note lacked documentation of provider notification. A progress note dated 8/14/23, indicated the nurse and the wound medical doctor (WMD) would assess the wound on 8/17/23 when onsite for wounds, staff to encourage R1 to reposition every 1-2 hours. R1's care plan initiated on 8/15/23, noted wound MD to eval [sik] and treat. A Nurse Practitioner (NP)-E note dated 8/15/23, noted R1 was seen that day for a worsening decubitus (pressure ulcer) ulcer per request for nursing staff. The NP-E noted R1 had worsening ulcer as noted by staff with necrotic (death of tissue) tissue, odor, and increased amount of drainage. The wound was approximately 10 cm x 5 cm, pink wound base with some necrotic tissue on the right, foul odor, yellow drainage and R1 had pain with dressing changes. The NP-E ordered staff to continue change foam dressing daily and as needed if saturated, to monitor for fever, chills, or increased chills, out of bed for meals only until seen by the WMD. R1's Physician Order dated 8/17/23, noted wound MD to eval [sik] and treat. An Initial Wound Evaluation & Management Summary dated 8/17/23, noted the WMD provided an assessment to R1's wound. R1 had an unstageable (due to necrosis) pressure ulcer to her sacrum, it measured 11.2 cm x 5.6 cm x 0.2 cm, had an odor, moderate serous drainage, had 80% necrotic tissue and 20% granulation (pink-red moist tissue that fills an open wound) tissue. The WMD ordered Santyl to be applied, covered with a foam dressing daily, off load pressure ulcer, reposition per facility protocol. The WMD performed bedside debridement and as a result the necrotic tissue was removed to a depth of 0.6 cm and decreased the nonviable wound bed from 80% to 40%. R1's wound management form dated 8/17/23, noted left and right buttocks wounds were merged into one wound that measured 11.2 cm x 5.6 cm x 0.2 cm. The wound had a moderate amount of drainage, it was seropurulent (yellow or tan, cloudy and thick), there was a foul and strong odor to the wound, and it was an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur) due to 80% of the wound bed being slough and/or eschar, and 20% granulation tissue, the pressure ulcer had macerated/soft, irregular edges, the peri wound skin had blanchable erythema (redness), and the healing status was stable. A progress note dated 8/17/23, noted R1 had her dressing changed three times that day due to increased drainage and bleeding after debridement. The note lacked documentation of physician notification, or orders to increase dressing change due to drainage. A progress note dated 8/18/23, indicated R1's dressing was changed due to dressing condition and R1 had pain during the dressing change that was not controlled with as needed Tylenol. R1 was having pain when seated in her chair and with dressing changes. The note indicated an order to increase R1's pain medication was obtained, she had poor appetite eating 5% of her meal and returned to bed after mealtime was over. A progress note dated 8/19/23, noted R1's dressing was changed and the skin on the right side of the pressure ulcer was now a dark gray in color, R1 was repositioned every two hours that shift and was compliant with repositioning. The note lacked documentation that the provider was notified of the change in coloration of the pressure ulcer. A progress note dated 8/20/23, indicated R1 had increased pain related to her pressure ulcer receiving two as needed doses of narcotic pain medication - 2.5 milligrams (mg) of Oxycodone once in the morning and once at bedtime. R1's dressing was changed twice, and she was repositioned frequently due to pressure ulcer discomfort. The note lacked documentation that the provider was notified of increased pain and discomfort related to the pressure ulcer. A progress note dated 8/21/23, noted R1's dressing was changed, she was wincing and clenching which indicated pain but verbally denied pain, no odor was noted. The note lacked documentation that the provider was notified of increased pain. A progress note dated 8/22/23, indicated the dressing was changed as ordered, it had a foul odor, and the wound base was dark gray in color. The note stated the nurse had the NP-E assess the wound that day. An NP-E note dated 8/22/23, indicated that R1 had a worsening decubitus ulcer with tissue necrosis that underwent bedside debridement by the WMD last week. The NP-E stated that staff was reporting increased odor and drainage, R1 is having increased pain and current dose of Oxycodone was not effective in pain management, R1 was not having fevers. The note described the pressure ulcer as being large ulcer on her coccyx, approximately 10 cm x 5 cm, deeper than previous, with gray colored tissue at wound base with some darker black area, drainage is yellow and there was a foul odor. The note indicated the NP-E discussed the pressure ulcer with the primary physician, the note stated they decided to forego infection markers (blood labs to assess for inflammation) as it may not be reliable due to chemotherapy drugs. The NP-E and primary physician noted they would order a CT (computerized x-ray) of her pelvis and lumbosacral spine to rule out osteomyelitis and WBC with diff (blood lab to look at the percentage of white blood cells to help diagnose infection). The NP-E note indicated she spoke with R1's mother and she agreed with treatment plan, that a palliative care consult was recently canceled to continue with active treatment. The note stated the NP-E discussed R1's poor appetite, low protein stores, anemia, breast cancer, and immobility which increased R1's risk for pressure ulcers, infection, and poor healing. The note stated staff should monitor R1 daily for a fever. A Wound Evaluation & Management Summary note dated 8/24/23, indicated the WMD saw R1 for her pressure ulcer. R1's unstageable (due to necrosis) sacrum pressure ulcer measured 12 cm x 6.8 cm x 2.5 cm, it had moderate serous drainage, the peri wound skin had an odor, maceration (occurs when skin is in contact with moisture too long), and erythema, it was 80% necrotic, 10% granulation. The WMD noted the wound was exacerbated, due to nutritional compromise, infection, and a generalized decline. R1 was sent to the hospital due to the appearance of the pressure ulcer, increased size, depth and tunneling. The WMD recommended transfer to the emergency department (ER) for further evaluation, surgical debridement, and treatment with intravenous antibiotics. R1's wound management form dated 8/24/23, noted R1's unstageable pressure ulcer measured 12 cm x 6.8 cm x 2.5 cm, had moderate seropurulent drainage, a sour odor, and was 80% eschar, 10% granulation tissue, the wound edges were not attached to the base, the peri wound skin was white or gray in color, the wound healing status was declining and R1 was sent to the ER for surgical debridement. A progress note dated 8/24/23, noted R1 was seen on wound rounds by the WMD and was sent to the ER for increased necrotic tissue, inability to tolerate bedside debridement to her unstageable pressure ulcer. R1's family was present and brought her to the ER. R1's Minnesota Cause of Death Worksheet undated, indicated R1's date of death was 9/15/23. R1's immediate cause of death was due to septic shock as a consequence of parapneumonic pleural effusion (accumulation of fluid with a lung infection, mainly pneumonia typically associated with bacterial infections). Other significant conditions contributing to R1's death included multiple sclerosis, stage 4 sacral ulcer, urinary tract infection, and metastatic breast cancer. During an interview on 9/29/23, at 12:19 p. m. family member (FM)-A stated the first she knew about the pressure ulcer is when she saw it on 8/17/23, when the WMD was there, she took pictures with her phone of the pressure ulcer on that date as well as a week later when the WMD was there again. FM-A stated she was aghast when she saw the pressure ulcer and since R1 required full care and questioned why the facility did not prevent the pressure ulcer. FM-A stated just prior to R1's hospitalization the facility had started to reposition R1 but by that time, the pressure ulcer was too bad. FM-A stated an intensive care unit (ICU) nurse at the hospital told her that R1 had septic shock and she did not want this to happen to anyone else. During an interview on 10/2/23, at 11:34 a.m. licensed practical nurse (LPN)-A was also a clinical manager and wound nurse for long term care. LPN-A stated she performed weekly wound rounds and confirmed that many of R1's wound management forms were incomplete and lacked detailed descriptions of the pressure ulcer such as wound bed appearance, drainage, per wound status. LPN-A confirmed there was no notification of the provider when R1 had necrotic tissue, odor, increased drainage, pain or when it increased in size. LPN-A stated she would expect a nurse to call the provider with any change in the pressure ulcer. LPN-A stated the interventions to prevent pressure ulcers for R1 included an air loss mattress repositioning every 2 hours, protein supplement and a tilt in space wheelchair, however, confirmed R1's care plan did not reflect those interventions. During an interview on 10/2/23, at 1:30 p.m. the WMD stated she did not know when she was first contacted to see R1, but that it was the same day she saw her. The following week the wound had deteriorated, and she thought R1 needed surgical debridement. During an interview on 10/2/23, at 1:56 p.m. FM-B stated she did not know about the pressure ulcer until just prior to R1 going to the hospital and questioned why the facility did not get the WMD involved before it got so bad. FM-B stated staff at the facility told her that they were going to start repositioning her every 2 hours but noted R1 was frequently not repositioned when she visited, she questioned staff about R1 being up in her wheelchair so long and was told that it was because it was nearly mealtime. FM-B stated another time, R1 was left up in her wheelchair all night long by an agency staff and only knew because R1's roommate told her. FM-B stated a staff member at the hospital told her that R1 was in septic crisis because of the pressure ulcer on her coccyx. During an interview on 10/3/23, at 11:20 a.m. the director of nursing (DON) stated she expected nurses to complete weekly skin assessments in a progress note. The DON confirmed that R1 did not have full descriptions of her pressure ulcers in the wound management form. The DON stated R1 had pressure ulcer prevention interventions that were on a nursing assistant (NA) group sheet but since R1 was discharged , they do not have saved copies of the group sheet. The DON stated R1 had her own wheelchair cushion, she received an air mattress at the end of June and the facility obtained a tilt in space wheelchair on 8/10/23 to reduce the pressure to her sacrum. During an interview on 10/3/23, at 12:59 p.m. the NP-E stated she had not been working at this facility long and her first visit with R1 was on 8/1/23 following a urinary tract infection (UTI). The NP-E stated she did not look at the pressure ulcer then and was not sure that she knew about it at that time. The NP-E looked at the primary provider notes and stated the physician did not mention a pressure ulcer in her notes either. The NP-E stated she thought the WMD was involved and did not know about the pressure ulcer worsening until 8/15/23, when she was at the facility and a nurse stated, you need to see this wound. The NP-E stated there was necrotic tissue and yellow drainage, she ordered staff to change the dressing daily and as needed for saturation. The NP-E stated she saw the pressure ulcer again on 8/22/23, following debridement from the WMD and had increased her Oxycodone for pain. The NP-E stated at that visit the pressure ulcer had increased depth and necrotic tissue, she spoke with the primary physician, and they decided to forego any infection markers but ordered a CT to rule out osteomyelitis. The NP-E stated she also spoke with R1's emergency contact who agreed with the plan, while also trying to explain the decreased likelihood of healing. During an interview on 10/3/23, at 1:34 p.m. NA-A stated she never saw R1's pressure ulcer but remembered that she could smell it, she stated she thought R1 had a bowel movement, but another staff member told her the odor was R1's pressure ulcer. During an interview on 10/3/23, at 1:41 p.m. NA-B stated she was aware of R1's pressure ulcer and had reported it to the nurse during a shower when it was getting bad, it was getting bigger, draining more. During a follow up interview on 10/4/23, at 12:57 p.m. The DON confirmed R1 did not have consistent weekly skin assessments and that those weekly skin checks were supposed to be completed on R1's bath day. The DON expected nurses to describe skin alterations, new and old, she also expected nurses to fully describe skin alterations with location, wound bed descriptions, drainage, peri wound skin and etiology of skin alteration. The DON stated all nurses are responsible for updating care plans and that the nurse that initially discovered R1's pressure ulcer should have updated the care plan with interventions, should have been continually changed with the worsening condition of the pressure ulcer, and that turning and repositioning every 2-3 hours should be in any resident at risk for pressure ulcers care plan. The DON stated she expected all nurses to know signs and symptoms of infection and to report those signs to a provider immediately, they should not wait, should not just update the DON or wound nurse. A facility policy titled Prevention and Treatment of Skin Breakdown effective 9/1/18, noted documentation of the skin impairment should be completed, staging of pressure injury is completed by trained licensed associates, standing orders are initiated and then notification to the provider. Staff should also notify the provider if the pressure injury has not shown progress in 2 weeks and/or deteriorating unexpectedly and to re-evaluate the care plan. The policy also noted evaluation of the current pressure reduction interventions and revision of the care plan. The immediate jeopardy that began on 8/15/23, was removed on 10/6/23, when the facility assured all residents had a current Braden Scale completed, residents that were at high risk for pressure ulcers were identified and skin/body audits were completed, residents with pressure ulcers had comprehensive skin assessments completed with care plan interventions reviewed and updated, providers were notified of current status, treatment and interventions. The facility reviewed their policy and education on the policy, comprehensive skin assessments, interventions for pressure ulcers, provider notification and pressure ulcer prevention modalities in accordance with plan of care was provided to nursing staff prior to their next scheduled shift, but the noncompliance remained at the lower scope and severity level 2, D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to use the appropriate sized mechanical lift sling for 1 of 3 residents (R1) reviewed for falls. This resulted in an immediate jeopardy (IJ) for R1 who fell during a mechanical lift transfer and hit their head. The IJ began on 5/5/22, at 9:00 a.m. when facility staff utilized improper sized mechanical lift sling. R1 fell , after being suspended in the air, and hit their head. The administrator and assistant director of nursing (ADON) were notified of the IJ on 5/17/22, at 3:35 p.m. The facility implemented corrective action on 5/6/22, and the IJ was issued as past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired with a diagnosis of [CONDITION(S)] and [CONDITION(S)] affecting the right side. R1 required extensive assistance with two staff for transfers. R1's care plan dated 7/16/21, identified, R1 had a deficit with activities of daily living (ADLs) including transferring and mobility. The care plan directed two staff, with the use of a Hoyer lift (mechanical full-body lift) and a medium sling, were required to transfer R1. A incident report dated 5/5/22, at 11:36 a.m. included, R1 fell out of hoyer sling. R1 fell four feet out of hoyer sling. R1 was in a size small sling. R1 is supposed to be using a medium sling. R1's progress note dated 5/5/22, at 10:03 a.m. included, two nursing assistants were transferring R1 from the wheelchair back to bed using a Hoyer lift. R1 fell out of the sling and onto the floor. When interviewed on 5/17/22, at 11:20 a.m. nursing assistant (NA)-A stated, me and NA-B were transferring R1 back to bed after breakfast using a small Hoyer sling. R1 complained of neck pain, attempted to readjust positions, and fell from the Hoyer sling onto the floor. NA-A stated the small sling was used because it was the one always in R1's room. NA-A verified the care plan was not reviewed for the proper sling size prior to using the Hoyer lift to transfer R1. When interviewed on 5/17/22, at 11:56 a.m. NA-B stated, me and NA-A were transferring R1 back to bed after breakfast from the wheelchair using the small Hoyer sling. R1 complained of shoulder pain and started wiggling to readjust positions and fell out of the side of the Hoyer sling onto the floor. Further, NA-B stated the sling size was not checked due to being in a hurry. NA-B verified the sling tag with the size was not checked and compared with the care plan prior to using the Hoyer lift to transfer R1. When interviewed on 5/17/22, at 12:23 p.m. the executive director verified NA-A and NA-B did not follow the plan of care when transferring R1 with the Hoyer lift. Further, verified R1 had the potential for a serious injury from the fall. When interviewed on 5/17/22, at 1:32 p.m. the nurse practitioner (NP)-A verified R1 had the potential to sustain a serious injury including death due to the fall from the Hoyer. When interviewed on 5/17/22, at 2:35 p.m. the assistant director of nursing (ADON) verified not following the care plan played a role in R1 falling from the Hoyer lift onto the floor. Further, the NA's were trained on how to confirm the sling size and how to access the care plan to review the proper sling size to use during transfers. The facility integrated fall management policy undated, included, the facility was to identify and implement appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Further, interventions are implemented through the resident centered care plan. The past non-compliance IJ which began on 5/5/22, was removed on 5/6/22, after the facility implemented a systemic plan that included the following: - On 5/5/22, immediately after the incident occurred, maintenance inspected the Hoyer lift and the sling to ensure the items were working properly. This was verified by a lift inspection report. - On 5/5/22, the clinical manager completed an audit of each resident, who utilized a Hoyer lift, to ensure the appropriate sling size was care planned, listed on the group sheet, and the proper sling size was available. This was verified by a written statement dated 5/5/22. - On 5/5/22, both NA-A and NA-B completed a mechanical lift audit to ensure proper use of a Hoyer lift. This was verified by mechanical lift audit forms dated 5/5/22. - On 5/5/22, the nursing staff were educated immediately on the shift the fall occurred. Other nursing staff were educated prior to working their next shift on ensuring appropriate sling size was utilized during transfers and re-trained to refer to the group sheets and care plan. This was verified by sign in sheet dated 5/5/22. - Starting on 5/5/22, nursing completed weekly mechanical lift audits with the nursing staff. This was verified by signed and dated audit forms. - NA-A, NA-B, NA-C, and LPN-A were interviewed on 5/17/22, and verified they had received education on ensuring the appropriate sling size was utilized during transfers and referring to the group sheets and care plans.

Based on interview and document review, the facility failed to implement the care plan when 1 of 5 residents (R1) was served a meal that contained a food R1 had a severe allergy to. After a couple of bites of the allergen, the resident had an anaphylactic reaction, and required emergency services. Review of R1's care plan dated 12/27/17, indicated she had a history of [REDACTED]. R1's allergies [REDACTED]. The care plan reflects a date of 1/8/18 that R1 required assistance with feeding and pudding thick liquids. The hospital after visit summary dated 12/27/17 indicated R1 had a food allergy to fish with [MEDICATION NAME] as a potential reaction. The summary contained a signed physician order [REDACTED]. Per the form that is faxed to dietary, titled Transitional Care Unit (TCU) Admit/Discharge/Transfer/Diet Request Form, dated 1/3/18, entries on the form indicate a room transfer, a diet of NDD Level 1 and pudding thick liquids. The allergy lines are blank and not completed. Per progress note dated 1/5/18 at 6:30 p.m., Licensed practical nurse (LPN)-D indicated that R1 was eating supper and nursing assistant (NA)-C noted resident not eating the fish she was being fed. NA-C asked LPN-D if the resident was allergic to fish. R1 was noted to be wheezing, was removed from the table, and given a duo-nebulizer. R1 was escorted to the emergency room for further care. Per progress note dated 1/5/18 at 11:17 p.m. by registered nurse (RN)-F that resident had received fish for supper. RN-F went to the unit and observed R1 wheezing and able to verbalize. RN-F instructed to call triage nurse and take R1 to emergency room . Hospital record dated 1/5/18 indicated R1 required [MEDICATION NAME] and [MEDICATION NAME] as well as a drip and central line placed because of a heart rate that dropped into the 40's. The resident had an anaphylactic reaction and was transferred to the ICU for continued care. Per interview on 2/6/18 at 1:26 p.m., NA-C stated that after feeding R1 a couple of bites of the fish on the tray, the resident appeared to not like the fish. That is when he asked LPN-D about an allergy. NA-C stated that it was then that he remembered the allergen was also written on the white board in the resident's room that she was allergic to fish. No allergy to fish was listed on the meal card. Per interview on 2/6/18 at 1:44 p.m., (Dietary Manager)-B stated the diet clerk takes the info on the request form and enters it verbatim into the system that produces the meal ticket. Reviewing the 1/5/18 ticket, her ticket did not list any allergies [REDACTED]. Per interview on 2/6/18 at 2:28 p.m., DON-A stated that on the form, it should have been just left at the room change and that's all that should have been put on here. I think the problem came from is that they started addressing the diet on the form also so it got confusing when it got to the person in the dietary dept. Per interview on 4/12/18 at 11:13 a.m., DON-A stated that it is not known if an epi pen was in the resident's medication supply but there is an epi-pen in the emergency kit on the unit. DON-A referred to the standing orders which indicate to administer epi pen for suspected [MEDICATION NAME]. Staff are trained on what is in the emergency kit. Per family (FM)-H interviewed on 2/12/18 at 9:39 a.m., the ER physician said R1 had an anaphylactic reaction. Per FM-I interview on 2/12/81 at 10:35 a.m., stated that the resident had such a severe allergy to fish that she had stopped breathing from just touching the pan used to cook fish. On admission, it was discussed many times how serious the allergy was. The fish options were crossed out on the menu that was in her room. The white board in the room also had written on it that she had an allergy to fish. Per the facility policy, Abuse Prevention Plan dated (MONTH) (YEAR), neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A policy pertaining to care plans was requested but none was provided.