Every finding on record at Rio Grande Rehabilitation and Healthcare Center

Based on observations, record review and interviews, the facility failed to ensure one (#2) of five residents was free from abuse out of 10 sample residents.Specifically, the facility failed to protect Resident #2 from physical abuse by Resident #10.Findings include:I. Facility policy and procedureThe Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 8/4/26 at 2:31 p.m. It read in pertinent part, Our residents have the right to be free from abuse. As part of the abuse prevention program, the administration will: protect our residents from abuse by anyone; require training programs that include abuse prevention and handling aggressive resident behavior; and, identify all possible incidents of abuse.II. Incident of physical abuse of Resident #2 by Resident #10 on 6/18/26A. Facility investigationThe 6/18/26 facility investigation was provided by the NHA on 8/3/26 at 11:34 a.m. The investigation documented that on 6/18/26, Resident #2 reported to a staff member that Resident #10 entered her room and was going through her dresser drawers.The investigation documented that Resident #2 said she attempted to redirect Resident #10 and Resident #10 slapped Resident #2 on the arm.The investigation revealed the facility responded by immediately separating the residents and Resident #10 was placed on 15-minute safety checks. The investigation documented Resident #10 had a prior history of wandering into Resident #2's room because her room was in the same location, but in another hallway. The investigation revealed Resident #10 had previously entered Resident #2's room on 6/11/26.The investigation revealed a housekeeper heard Resident #2 tell Resident #10 don't hit me again.The investigation indicated the facility substantiated the physical abuse when Resident #2 reported she was hit and had a red mark after being hit.B. Resident #2 (victim)1. Resident status Resident #2, age greater than 65, was admitted to the facility on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance, anxiety, and depression.The 6/8/26 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent with bed mobility, transfers, dressing, putting on her footwear, and used a walker for ambulation.The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others. 2. Record reviewThe dementia care plan, initiated 2/20/25, identified Resident #2 had impaired cognition. Pertinent interventions included administering medications as ordered, providing a consistent routine to avoid frustration and anxiety, and providing a calm and safe environment.The incident progress note, dated 6/18/26, revealed a staff member heard yelling from Resident #2's room. The progress note documented the staff member heard a smacking sound and heard Resident #2 tell Resident #10 to get out of her room or she would hit her back harder. The staff member redirected Resident #10 from Resident #2's room. The progress note documented the physician and the director of nursing (DON) were notified. The progress note revealed Resident #2 and Resident #10 were assessed and had no injuries and were placed on 15-minute safety checks.C. Resident #10 (assailant)1. Resident statusResident #10, age greater than 65, was admitted to the facility on [DATE] and discharged to another facility on 7/2/26. According to the July 2026 CPO, diagnoses included hallucinations, delusional disorders, anxiety, hearing loss, paranoid personality disorder, and unspecified dementia with other behavioral disturbance. The 7/1/26 MDS assessment revealed Resident #10 had moderate cognitive impairments with a BIMS score of nine out of 15. Resident #10 required supervision and touching assistance from staff for dressing and walking, and was independent with bed mobility and transfers.The MDS assessment indicated the resident had wandering behaviors for one to three days during the assessment look-back period. 2. Record reviewThe wandering care plan, initiated 4/12/26, revealed Resident #10 had wandering and exit-seeking behaviors. Pertinent interventions included redirecting and diverting the resident's attention, placing a wander guard on the resident and referring the resident to a behavior specialist.-There were no revisions to Resident #10's wandering care plan after the 6/11/26 and 6/18/26 wandering incidents into Resident #2's room.The behavior care plan, initiated 3/31/26, revealed Resident #10 had dementia, delusional personality disorder and anxiety. Resident #10 was prescribed Risperdal (medication to stabilize mood and thoughts). On 6/20/26 the behavior care plan was updated and revealed Resident #10 was prescribed Ativan (anti-anxiety medication ) and Haldol (medication to treat severe agitation) due to her aggressive behaviors toward staff. Pertinent interventions included administering medications as ordered, monitoring medications for effectiveness, offering encouragement to maintain independence, and providing a calm and safe environment (initiated 3/31/26).A behavior progress note, dated 6/11/26, revealed Resident #10 was found in Resident #2's room with her fist up and ready to hit Resident #2. A certified nurse aide (CNA) intervened and Resident #10 scratched the CNA. Resident #2 was taken to the dining room for her dinner.A behavior progress note, dated 6/18/26, revealed Resident #10 was found in Resident #2's room. Resident #10 was escorted to a common area and staff began 15-minute safety checks for hitting Resident #2.III. Staff interviewsCNA #1 was interviewed on 8/3/26 at 2:05 p.m. CNA #1 said she had worked at the facility for about six months. CNA #1 said when she was hired, the facility provided education and training on the facility's abuse prevention policy. CNA #1 said she was familiar with caring for Resident #2 and Resident #10. CNA #1 said she was aware Resident #10 wandered toward Resident #2's room, but staff redirected and guided Resident #10 to the hallway where she resided. CNA #1 said Resident #10 did not seek out Resident #2, but Resident #10 was probably confused because her room was in the same location as Resident #2's, just in a different hallway. The DON was interviewed on 8/3/26 at 2:25 p.m. The DON said Resident #10 was transferred to another facility with the intention for Resident #10 to live in a facility that had a less confusing floor plan (not wheel-spoke design). The DON said on 6/11/26, after Resident #10 wandered into Resident #2's room, staff were educated to observe and redirect Resident #2 to her correct hallway. The DON said after the 6/18/26 incident, facility staff separated Resident #2 and Resident #10 immediately and followed the facility's policy for assessments, monitoring and reporting. The DON said after the 6/18/26 incident, facility staff identified Resident #10 had increased agitation and behaviors toward others. The DON said the physician prescribed a new medication to treat the agitation. The DON said Resident #10 continued to have wandering behaviors and agitation, which prompted discharge planning with Resident #10's responsible party. The DON said Resident #2 was not injured during the 6/18/26 incident and had no changes in her mood or behaviors.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to:-Ensure staff did not touch ready-to-eat food with their bare hands; -Ensure staff performed proper hand hygiene during meal service;-Ensure expired food was discarded;-Ensure equipment was in good repair; and,-Ensure artificial nails and jewelry were not worn. Findings include: I. Failure to ensure staff used proper hand hygiene and did not touch ready-to-eat foods with bare hands during meal service.A. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/29/26. It revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15) Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301.11)B. Facility policy and procedureThe Food Preparation and Service policy and procedure, revised November 2022, was provided by the NHA on 4/22/26 at 6:38 p.m. It read in pertinent part, Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use.C. ObservationsDuring a continuous observation on 4/19/26, beginning at 4:04 p.m. and ending at 5:17 p.m., the following was observed:At 4:04 p.m. an unidentified DA was offering hand sanitizer to residents while taking their orders. She was pulling a small spray hand sanitizer out of her pocket then placing it back into her pocket. At 4:10 p.m. DA #4 took a cup of iced tea from a resident, added more ice to the cup and gave it back to the resident by the rim of the glass. At 4:40 p.m. licensed practical nurse (LPN) #3 cut an unidentified female resident's patty melt and handed a slice of the sandwich to the resident with her bare hand. LPN #3 then began assisting another resident at the same table. She did not sanitize her hands before handling the food. At 4:42 p.m. LPN #3 handed another slice of the patty melt to the unidentified female resident using her bare hands. She did not sanitize her hands prior to handling the food or after assisting the other resident at the table. At 4:56 p.m. DA #4 continued to pass drinks while touching the rims of the cups without sanitizing her hands.At 5:05 p.m. DA #4 tore a resident's patty melt into two smaller pieces for the resident with her bare hands. She then handed one of the two pieces to the resident and placed the other piece on the plate. The resident then began to eat the patty melt. During a continuous observation on 4/21/26, beginning at 10:34 a.m. and ending at 12:04 p.m., the following was observed:At 10:45 a.m. DA #1 walked into the dishroom from the dining room, then entered the main kitchen. He began putting away the snacks that were sitting on the prep table. He did not wash his hands when he entered the kitchenAt 10:45 a.m. CK #1 did not wash her hands when she was finished at the two compartment sink. At 10:51 a.m. CK #1 scooped shrimp from the steam table into a bowl, she then dumped the shrimp back into the pan on the steam table. -CK #1 did not wash her hands prior to scooping the shrimp.At 10:53 a.m. CK #1 moved the dishes from the two-compartment sink into the dishroom and ran them through the dishwasher. At 11:01 a.m. DA #1 exited the bathroom that was in the kitchen and did not wash his hands. He then went into the dining room to serve drinks and take orders. At 11:16 a.m. without washing her hands after touching dirty dishes, CK #1 wiped down the service table and service line after she finished taking the meal temperatures. She then grabbed the recipe binder to check for scoop serving sizes. At 11:22 a.m. CK #1 started serving room trays. She was not wearing gloves. She then cut a slice of corn bread, used tongs to place it on the plate. She set the knife directly on top of the corn bread with the handle touching the bread. At 11:25 a.m. CK #1 turned and placed some frozen chicken in the fryer basket, then using her bare hands put the fryer basket into the fryer. At 11:26 a.m. without washing her hands CK#1 pulled the fryer basket out of the fryer, she pulled the chicken out of the fryer. She did not take the temperature of the chicken. She was using her bare hands, she did not wash her hands. At 11:27 a.m. CK #1 cut a piece of corn bread, then placed the knife back in the pan of corn bread. The handle of the knife was touching the corn bread. At 11:29 a.m. DA #1 was touching the rim of a cup with his bare hand. At 11:33 a.m. CK #2 came to help CK #1 serve the meal. CK #2 wiped her bare hands on the back of her pants and was touching meal tickets. At 11:35 a.m. without washing her hands, CK #2 was cutting corn bread with her right hand and had a meal ticket in her left hand. Using the tongs she placed the corn bread on the plate, she then took the meal ticket that was in her left hand and slid it underneath the corn bread so the bread was holding the ticket in place on the plate with the other food. At 11:40 a.m. CK #2 wiped her hands on her shirt and grabbed meal tickets. She did not wash her hands. At 11:41 a.m. without washing her hands, CK #2 made a grilled cheese. She cut the grilled cheese at a diagonal. She used her right hand to cut the grilled cheese and held the grilled cheese in place with her left hand. At 11:44 a.m. DA #1 came into the kitchen, did not wash his hands and grabbed a stack of red cups. He touched the rims of some of the cups when he grabbed the stack, and went back into the dining room. At 11:45 a.m. CK #2 was plating a meal, she touched some rice and mechanical soft shrimp with her bare hands when it spilled over and touched in the middle of the plate. She then placed the meal ticket underneath the corn bread on the plate. The plate was then placed in the window to be served to the resident. At 11:46 a.m. CK #2 was touching rice on a plate with her bare hands, she then wiped her hands on her shirt. She did not wash her hands. At 11:47 a.m. without washing her hands, CK #2 touched pieces of shrimp with her bare hands while she was plating the food. At 11: 49 a.m. CK #2 was touching meal tickets, then touching squash on a plate, and then placed the meal ticket underneath the corn bread. At 11:50 a.m. a meal ticket fell to the floor, CK #2 picked it up off of the floor with her bare hands, she then placed the ticket on the service counter with the other tickets. She did not wash her hands. She continued to plate food. At 11:52 a.m. CK #2 was plating food, she touched the rice, the squash and the shrimp with her bare hands, she moved the food on the plate so the food was not touching. She then wiped her hands on her shirt. She did not wash her hands. At 11:53 a.m. without washing her hands CK #2 touched the shrimp, and corn bread with her bare hands then served the plate. At 11:54 a.m. CK #2 went to the refrigerator, grabbed a premade peanut butter and jelly sandwich that was wrapped in plastic wrap, she unwrapped the sandwich and placed it on a plate. CK #2 then went to the freezer and grabbed a bag of french fries. CK #2 then opened the bag of fries and with her left hand she held the bag and with her right bare hand she reached into the bag and pulled two to three handfuls of french fries and put them in the fryer basket then dropped the fries into the fryer. She replaced the bag of fries into the freezer. She did not wash her hands. At 11:57 a.m. CK #2 pulled the basket of fries out of the fryer, using her bare hands. She then touched some of the fries with her bare fingers to see if they were done. After touching the French fries she plated them. She did not wash her hands before or after touching the french fries. At 11:58 a.m. CK #2 went to the refrigerator and grabbed one slice of cheese with her bare hand, she then went to the freezer and grabbed a frozen hamburger patty. She then went to the stove and put the frozen hamburger patty on a skillet, she then placed the slice of cheese that she had been holding in her hand on the frozen hamburger patty. She then pulled the cheese off of the frozen hamburger patty and proceeded to hold the slice of cheese in her left hand while the hamburger patty cooked. At 12:04 p.m. CK #2 placed the slice of cheese that she had been holding in her bare hand on to the top of the cooked hamburger. She then placed the hamburger onto the bun and then plated squash and rice with the hamburger. CK #2 touched the rice and squash with her bare hands. She did not wash her hands. D. Staff interviewsCK #1 was interviewed on 4/21/26 at 12:19 p.m. She said staff were supposed to wash their hands whenever they changed tasks. She said staff should not touch ready-to-eat foods with their bare hands. She said she had not realized she had touched the cheese and bread during meal service. CK #2 was interviewed on 4/21/26 at 12:24 p.m. She said staff should wash their hands anytime their hands come into contact with anything that was not clean or when they go outside. She said she should not have wiped her hands on her shirt or clothing. She said she should not have touched ready-to-eat foods with her bare hands. DA #3 was interviewed on 4/21/26 at 12:30 p.m. She said staff should wash their hands any time they give out food to the residents and when staff goes in and out of the dishroom. She said when she was working the dishroom she always washed her hands when she went from dirty to clean dishes. DA #1 was interviewed on 4/21/26 at 12:33 p.m. He said staff should wash or sanitize their hands every three plates when they are serving residents or every two minutes. He said staff should wash their hands when they come out of the bathroom, when they leave or comeback into the kitchen. The DM was interviewed on 4/21/26 at 12:35 p.m. She said she expected her staff to wash their hands when they walk into the kitchen, before and after putting and taking off gloves, coming out of the bathroom, and when they change tasks. She said that no one should be touching ready-to-eat foods with their bare hands.II. Failure to discard expired foodA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/29/26. It revealed in pertinent part, A food that is unsafe, adulterated, or not honestly presented as specified under S 3-101.11shall be discarded or reconditioned according to an approved procedure. (3-701.11)B. ObservationsOn 4/19/26 at 1:01 p.m. there was a plastic bag on the bread rack in the dry storage. The bag contained at least one identifiable croissant; the other bread-like substance that was in the bag was covered in dark green/ black fuzz. On 4/21/26 at 12:10 p.m. the same plastic bag with the one identifiable croissant remained on the bread rack in the dry storage. C. Staff interviewThe dietary manager (DM) was interviewed on 4/19/26 at 12:10 p.m. She said the bag of croissants should have been thrown out. She said she had not seen the bag in the dry storage. III. Failure to ensure equipment was in good repairA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/29/26. It revealed in pertinent part, Exhaust ventilation hood systems in food preparation and dishware washing areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from dripping onto food, equipment, utensils, linens, and single-service and single-use articles. (4-204.11)B. ObservationsOn 4/19/26 at 1:05 p.m. half of a wooden pencil was holding up the drip pan for grease in the top left corner of the hood ventilation system above the grill. On 4/21/26 at 12:10 p.m. the same half wooden pencil was still holding up the drip pan for grease in the top left corner of the hood ventilation system above the grill. C. Staff interviewsThe DM was interviewed on 4/21/26 at 12:35 p.m. She said she did not know why the pencil was there holding up the drip pan. She said she was unsure of who or why someone put the pencil there. She said she thought a company came out quarterly to clean the hoods. She said the maintenance director was the one who was in charge of scheduling the hood cleaning. The nursing home administrator (NHA) was interviewed on 4/21/26 at 4:34 p.m. He said the maintenance director was out due to an injury and was only allowed to work a certain amount of hours per week. He said the last time the company came out was in March 2026. He said they come out every six months. He said this was not the first time that the company did something wrong. He said he was not sure why the pencil was there. He said there should be a notch that the pan slides into, he said they must have broken it and used the pencil to fix it. IV. Failed to ensure artificial nails and jewelry were not wornA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/29/26. It revealed in pertinent part, Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. (2-302.11) Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. (2-303.11)B. Facility policy and procedureThe Food Preparation and Service policy and procedure, revised November 2022, was provided by the NHA on 4/22/26 at 6:38 p.m. It read in pertinent part, Food and nutrition services staff keep fingernails trimmed and clean. Jewelry is worn minimally and hand jewelry ( wedding ring) is covered with gloves. C. ObservationsDuring a continuous observation on 4/19/26, beginning at 4:04 p.m. and ending at 5:17 p.m., the following was observed:At 4:29 p.m. dietary aide (DA) #4 was taking meal orders, passing drinks, and passing meals to residents. She had artificial nails on that were approximately half an inch long and multiple fabric-type bracelets on her wrists. D. Staff interviewThe DM was interviewed on 4/21/26 at 12:35 p.m. She said she was not aware that DA #4 had artificial nails and wore multiple bracelets. She said she expects her staff to have trimmed nails or wear gloves with artificial nails. She said she expects her staff to wear minimal jewelry when serving meals. She said it was due to infection control.

Based on interviews and record review, the facility failed to ensure three (#15, #28 and #30) of five residents out of 31 sample residents had the right to choose their own attending physician. Specifically, the facility failed to allow Resident #15, Resident #28 and Resident #30 to choose their primary care physician while the resident resided in the facility.Findings include: I. Facility policy and procedure The Choice of Attending Physician policy and procedure, revised November 2025, was provided by the nursing home administrator (NHA) on 4/22/26 at 5:09 p.m. It revealed in pertinent part, Residents have the right to choose their own attending physician or licensed healthcare provider who meets the requirements and responsibilities of an attending physician/provider. If the resident does not choose their own physician or provider, the resident is informed in writing of the name, specialty, and contact information of their attending physician or provider during the admission process, any time the information changes or upon the resident's/representative's request.II. Resident #15A. Resident status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a progressive lung disease, also known as emphysema), cirrhosis of the liver and osteoarthritis. The 3/14/26 quarterly minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The 1/27/26 annual MDS assessment revealed it was very important to the resident to take care of her personal belongings or things, and somewhat important to have family or a close friend involved in discussions about her care. B. Resident interview Resident #15 was interviewed on 4/21/26 at 10:02 a.m., during a group interview with Resident #28, Resident #30, Resident #44 and Resident #32. Resident #15 said she had a primary care physician in town she wanted to continue to see while in the facility. She said she was told she was not able to see that physician and could only see the medical director (MD) at the facility. Resident #15 said she did not remember who told her that but it was someone who was part of the nursing staff. C. Record review -Review of Resident #15's electronic medical record (EMR), including the admission agreement, revealed there was no documentation to indicate the resident was provided with a choice of who she wanted as her primary care physician. III. Resident #28 A. Resident status Resident #28, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included type 2 diabetes mellitus, asthma, osteoarthritis (degenerative joint disease) and transient ischemic attack and cerebral infarction (TIA - a ministroke). The 3/2/26 quarterly MDS assessment revealed the resident was cognitively intact with a BMS score of 15 out of 15. The 6/19/25 annual MDS assessment revealed it was very important to the resident to take care of her personal belongings or things, and very important to have family or a close friend involved in discussions about her care. B. Resident interview Resident #28 was interviewed on 4/21/26 at 10:02 a.m., during a group interview with Resident #15, Resident #30, Resident #44 and Resident #32. Resident #28 said she did not have a choice in who her physician could be while at the facility. Resident #28 said she had to see the facility's MD. C. Record review-Review of Resident #28's EMR, including the admission agreement, revealed there was no documentation to indicate the resident was provided with a choice of who she wanted as her primary care physician. IV. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included type 2 diabetes mellitus, wedge compression fracture of T11-T12 (thoracic) vertebrae and third lumbar vertebra (a spinal injury that causes a hunchback) and hypertension (high blood pressure). The 3/12/26 quarterly MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The 12/18/25 annual MDS assessment revealed it was very important to the resident to take care of his personal belongings or things, and somewhat important to have family or a close friend involved in discussions about his care. B. Resident interview Resident #30 was interviewed on 4/21/26 at 10:02 a.m., during a group interview with Resident #15, Resident #28, Resident #44 and Resident #32. Resident #30 said he did not have a choice in who his physician could be while at the facility. Resident #30 said he had to see the facility's MD. C. Record review-Review of Resident #30's EMR, including the admission agreement, revealed there was no documentation to indicate the resident was provided with a choice of who he wanted as his primary care physician. V. Staff interviewsThe NHA was interviewed on 4/22/26 at 1:16 p.m. The NHA said it was the residents' choice for who they wanted for their physician. He said residents were able to choose who they wanted as their attending physician when they were admitted to the facility. He said the attending physician choice was reviewed in the admission agreement. The NHA said the facility had one physician the residents could choose from when they were admitted to the facility. The NHA said he was not aware of any residents who wanted to change physicians or wanted to see their primary physician. The NHA was familiar with Resident #15, Resident #28 and Resident #30 and said he did not know that any of them wanted a different attending physician.

Based on record review and interviews, the facility failed to ensure four (#1, #41, #34 and #22) of nine residents were free from chemical restraints out of 31 sample residents. Specifically, the facility failed to:-Document a physician's rationale for Resident #1, #41, and #34's psychotropic medications in order to justify the continued use of the medications;-Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #1, #41, and #34's psychotropic medications; and, -Ensure Resident #22's as needed (PRN) antipsychotic medication had corresponding documentation of identified behaviors and use of non-pharmological interventions.Findings include:I. Facility policy and procedureThe Psychotropic Medication Use policy, revised February 2025, was provided by the nursing home administrator (NHA) on [DATE] at 10:09 a.m. It read in pertinent part,Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction.The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record.Documentation must include that behavioral (non-pharmacological) interventions were attempted but not successful, and these interventions were deemed clinically contraindicated.Alternatively, documentation from a physician must describe that alternative treatments are clinically contraindicated and the rationale for this conclusion.Psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. Psychotropic medications may be used on a PRN basis in certain situations, for example,while the dose is being adjusted; to address acute or intermittent symptoms; or in an emergency. II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included post traumatic stress disorder (PTSD), anxiety and depression. The [DATE] minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident did not exhibit any behaviors.B. Resident interviewResident #1 was interviewed on [DATE] at 8:53 a.m. Resident #1 said she used to have a therapist that would she her at the facility but the therapist did not come to the building anymore. Resident #1 said it had been a few months and the facility had not helped her make arrangements to find a new therapist or set up telemedicine (a virtual physician visit) so she could talk to a therapist on her tablet. Resident #1 said the medical director (MD) managed her psychotropic medications, not a psychiatrist. She said she did not know what psychotropic medications she took and she was not aware she could ask the staff when they were passing medications to her or ask about medications in her quarterly care conference meetings. C. Record reviewThe psychosocial care plan, revised [DATE], revealed Resident #1 took psychotropic medications related to depression, anxiety and PTSD. Interventions, revised [DATE], included monitoring her depression screen scores for indication of worsening signs/symptoms of depression, offering her non-pharmacological behavior interventions, such as calm approach, positive reassurance, one-on-one, quiet environment, offering of fluids/snacks, diversion activities, re-orientation, and re-direction. Review of Resident #1's [DATE] CPO revealed the following physician's orders:Offer non-pharmacological behavior interventions for any behaviors noted. Non-pharmacological interventions that are effective include calm approach, positive reassurance, one-on-one, quiet environment, offering of fluids/snacks, diversion activities, re-orientation, and re-direction, ordered on [DATE].-The physician's order failed to identify which non-pharmological interventions should be attempted for specific behaviors Buspirone (antianxiety medication) 10 milligrams (mg). Give two tablets by mouth three times a day, ordered on [DATE].Valium (a benzodiazepine used to treat anxiety) 5 mg. Give one tablet by mouth at bedtime, ordered on [DATE].Monitor behaviors for buspirone. Behaviors: panic with crying outbursts, ordered on [DATE].Monitor behaviors for Lexapro (an antidepressant medication). Behaviors: loss of appetite and fidgeting,ordered on [DATE].Duloxetine (an antidepressant medication) 30 mg. Give one tablet by mouth one time a day for behavior monitoring target behavior agitation/outbursts, ordered on [DATE].Lexapro (an antidepressant medication) 10 mg. Give one tablet by mouth one time a day for anxiety, ordered on [DATE].Monitor behaviors for duloxetine (an antidepressant medication). Behaviors: agitation as evidenced by outbursts, ordered on [DATE].-The [DATE] CPO failed to reveal any mental health or psychologically identified diagnoses for Resident #1's buspirone, valium, or duloxetine. Resident #1's Level II preadmission screening and resident review (PASRR) evaluation for mental illness and/or intellectual disabilities, dated [DATE], revealed Resident #1 had a history of self harm, suicidal thoughts, mood swings, loss of interest in activities, and low energy. The resident expressed during the evaluation that she enjoyed puzzles, games and painting. Specialized services recommended to ensure Resident #1's stability included developing therapeutic interventions to help her understand the source of her mood swings, developing coping skills to manage mood, psychiatric case consulting (psychiatrist oversight) to ensure symptoms were maximally managed by medications and to determine if another dosage would be beneficial, and increased socialization and participation in activities. -The resident's specific behaviors and non-pharmological interests identified in the Level II PASRR were not incorporated in Resident #1's behavior monitoring physician's orders or the resident's care plan (see physician's orders and care plan above).A review of psychotropic medication review meeting minutes revealed the last time Resident #1's medications were reviewed was in the meeting on [DATE]. Review of Resident #1's electronic medical record (EMR), from [DATE] to [DATE], failed to reveal any documented behaviors exhibited by the resident. -Review of Resident #1's EMR did not reveal documentation of a physician's rationale to justify the continued use of the resident's psychotropic medications, despite there being no documentation to indicate the resident was exhibiting behaviors. III. Resident #41A. Resident statusResident #41, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included schizoaffective disorder, dementia, anxiety and depression. The [DATE] MDS assessment documented the resident was unable to participate in the BIMS assessment. A staff assessment for mental status revealed the resident had short term memory loss and severely impaired decision-making abilities. The MDS assessment indicated the resident did not exhibit hallucinations or delusions and did not have physically or verbally abusive behaviors.B. Record reviewThe psychosocial care plan, revised [DATE], revealed Resident #41 had diagnoses of schizophrenia, depression and insomnia. Interventions, revised [DATE], included monitoring her depression screen scores for indication of worsening signs/symptoms of depression, offering her non-pharmacological behavior interventions: offering of fluids/snacks, toileting, removing her from overstimulation, one-on-one, repositioning, and re-approaching at a later time.The mood care plan, revised [DATE], revealed Resident #41 had behaviors of yelling out random things or calling out to her husband. She had increased sadness, calling her husband's phone, and screaming at staff when they were trying to calm her down. Interventions, initiated [DATE], included monitoring for behaviors of screaming out at staff, allowing the resident time to call her husband and allowing her to express her emotions and thoughts.Review of Resident #41's [DATE] CPO revealed the following physician's orders:Offer non-pharmacological behavior interventions for any behaviors noted. Non-pharmacological interventions that are effective include calm approach, positive reassurance, one on one, quiet environment, offering of fluids/snacks, diversion activities, re-orientation, and re-direction-ordered on [DATE].-The physician's order failed to identify which non-pharmological interventions should be attempted for specific behaviors.Monitor behaviors for Lexapro. Behaviors: screaming at staff, ordered on [DATE].Olanzapine (an antipsychotic medication) 20 mg. Give one tablet by mouth two times a day for schizophrenia, ordered on [DATE].Monitor behaviors for olanzapine. Behaviors: hallucinations, kicking, yelling, ordered on [DATE].Lexapro 20 mg. Give one tablet by mouth in the morning for depression, ordered on [DATE].Resident #41's Level II PASRR evaluation for mental illness and/or intellectual disabilities, dated [DATE], revealed Resident #41 had a history of auditory hallucinations to include frequently hearing the devil inside of her head. The resident expressed during the evaluation that praying to the rosary calmed and soothed her. She had a family history of a schizophrenic father who committed suicide and multiple other suicides in her family along with mental illness. Resident #41 had at least two psychiatric hospitalizations for medication management. Specialized services recommended to ensure Resident #41's had psychiatric medication management (psychiatrist to manage medications). -The resident's specific behaviors and non-pharmological interests identified in the Level II PASRR were not incorporated in Resident #41's behavior monitoring physician's orders or the resident's care plan (see physician's orders and care plan above).A review of psychotropic medication review meeting minutes revealed the last time Resident #41's medications were reviewed was in the meeting on [DATE]. Review of Resident #41's EMR, from [DATE] to [DATE], revealed:A social services assessment note, dated [DATE], documented the resident was taking Lexapro for screaming at staff and olanzapine for hallucinations.-The social services assessment failed to indicate any non-pharmacological interventions utilized for the resident's behaviors. A long-term care evaluation note, dated [DATE], revealed Resident #41 was not experiencing unwanted behaviors and had been stable this month. A long-term care evaluation note, dated [DATE], revealed the resident was not experiencing unwanted behaviors and was moody sometimes with no negative behaviors.-Review of Resident #41's EMR did not reveal documentation of a physician's rationale to justify the continued use of the resident's psychotropic medications, despite there being no documentation to indicate the resident was exhibiting behaviors. IV. Resident #34A. Resident statusResident #34, age [AGE], was admitted on [DATE]. According to the [DATE] CPO, diagnoses included vascular dementia, anxiety and PTSD.The [DATE] MDS assessment documented the resident was unable to participate in the BIMS assessment. A staff assessment for mental status revealed the resident had short and long term memory loss and severely impaired decision-making abilities. The MDS assessment indicated the resident had behaviors of delusions, difficulty focusing her attention and disorganized thinking. C. Record reviewThe psychosocial care plan, revised [DATE], revealed Resident #34 had diagnoses of depression, dementia, anxiety, insomnia and PTSD. Interventions, initiated [DATE], included monitoring her depression screen scores for indication of worsening signs/symptoms of depression, offering her non-pharmacological behavior interventions: offering of fluids/snacks, toileting, removing from overstimulation, one-on-one, repositioning, and re-approaching at a later time. If the resident cried or became confused, she enjoyed going to her room and watching her favorite program or listening to 80's rock music.Review of Resident #34's [DATE] CPO revealed the following physician's orders:Abilify (an antipsychotic medication) 5 mg. Give one tablet by mouth at bedtime for depression, ordered on [DATE].Mirtazapine (an antidepressant medication) 15 mg. Give one tablet by mouth at bedtime for insomnia, ordered on [DATE].Sertraline (an antidepressant medication) 100 mg. Give one tablet by mouth in the morning for depression, ordered on [DATE].Offer non-pharmacological behavior interventions for any behaviors noted. Non-pharmacological interventions that are effective include calm approach, positive reassurance, one on one, quiet environment, offering of fluids/snacks, diversion activities, re-orientation, and re-direction, ordered on [DATE].-The physician's order failed to identify which non-pharmological interventions should be attempted for specific behaviors.Monitor behaviors for sertraline. Behaviors: verbal aggression towards staff, including foul language directed at staff, ordered on [DATE].Monitor behaviors for Abilify. Behaviors: verbalizing wanting to leave, including exit seeking, ordered on [DATE].Monitor behaviors for Abilify. Behaviors: tearfulness and crying, ordered on [DATE].Clonazepam (a benzodiazepine medication used to treat panic disorders) 0.5 mg. Give one tablet by mouth for anxiety, ordered on [DATE].Clonazepam 1 mg. Give one tablet by mouth at bedtime for insomnia, ordered on [DATE].Monitor behaviors for clonazepam. Behaviors: attempting to hit staff, ordered on [DATE].Review of Resident #34's EMR, from [DATE] to [DATE], revealed:A review of psychotropic medication review meeting minutes revealed the last time Resident #34's medications were reviewed was in the meeting on [DATE]. A long-term care evaluation note, dated [DATE], revealed Resident #34's mood was pleasant with no unwanted behaviors witnessed.A long-term care evaluation note, dated [DATE], revealed the resident's mood was pleasant with no unwanted behaviors witnessed.An alert note, dated [DATE], revealed Resident #34 was being tested for a urinary tract infection. She was tearful, agitated, and would become angry with staff. The resident was upset and asked to call her daughter. -Review of Resident #34's EMR did not reveal documentation of a physician's rationale to justify the continued use of the resident's psychotropic medications despite there being no documentation to indicate the resident was exhibiting behaviors. V. Resident #22A. Resident statusResident #22, age [AGE], was admitted on [DATE] and died on [DATE]. According to the [DATE] CPO, diagnoses included dementia and depression.The [DATE] MDS assessment documented the resident was severely cognitively impaired with a BIMS score of six out of 15. The MDS assessment indicated the resident did not exhibit hallucinations or delusions and did not have physically or verbally abusive behaviors.B. Record reviewThe psychosocial care plan, revised [DATE], revealed Resident #22 had impaired psychiatric and mood status related to an introduction to a skilled nursing facility, with new people and routines. Interventions, revised [DATE], included assisting the resident to cope by discussing possible solutions to conflict, encouraging the resident to to ask questions when concerned with his medical condition to reduce anxiety, encouraging participation from the resident to make his own decisions, providing him with quality listening time and encouraging expressions of feelings, and monitoring the resident for the following behaviors for haloperidol: swinging at staff, aggression toward staff, and agitation. Review of Resident #22's [DATE] CPO revealed the following physician's orders:Lexapro 10 mg. Give one tablet by mouth at bedtime for depression, ordered on [DATE].Monitor behaviors for Lexapro. Behaviors: lack of interest in day-to-day activities, ordered on [DATE].Monitor behaviors for Seroquel (an antipsychotic medication). Behaviors: aggressive behavior towards staff, failure to follow the plan of care, refusal to wear his oxygen or use his wheelchair, ordered on [DATE].Haloperidol injectable solution 5 mg. Inject 5 mg every six hours PRN for swinging at staff and agitation, ordered on [DATE].-The physician's order did not have a diagnosed specific condition listed in the order, only the behaviors associated with administering the medication.Seroquel 25 mg. Give one tablet by mouth three times a day for dementia with behaviors, ordered on [DATE] and discontinued on [DATE].Seroquel 25 mg. Give 50 mg (two tablets) by mouth three times a day for dementia with behaviors, ordered on [DATE] and discontinued on [DATE].Monitor behaviors for haloperidol. Behaviors: swinging at staff, aggression toward staff, and agitation two times a day until [DATE], ordered on [DATE].Offer non-pharmacological behavior interventions for any behaviors noted. Non-pharmacological interventions that are effective include calm approach, positive reassurance, one on one, quiet environment, offering of fluids/snacks, diversion activities, re-orientation, and re-direction, ordered on [DATE].-The order for non-pharmacological interventions to use for behaviors was not initiated until [DATE], despite Resident #22 being on psychotropic medications (including PRN haloperidol) since [DATE]. Review of Resident #22's EMR, from [DATE] to [DATE] revealed the following:The medication administration records (MAR), from [DATE] to [DATE], revealed that Resident #22 was provided with a PRN haloperidol injectable solution of 5 mg on [DATE], [DATE], [DATE], [DATE] and [DATE]. A behavior note, dated [DATE], revealed that Resident #22 was walking down the hallway without his oxygen on and he was not using his wheelchair. He attempted to swing his arms at staff when they attempted to get him to wear his oxygen. The resident did agree to sit in his wheelchair and allowed the staff to take him to the dining room and put his oxygen on him. An order administration note, dated [DATE], revealed the resident was given a haloperidol injectable solution of 5 mg.-Prior to the administration of the PRN haloperidol, there were no attempted non-pharmacological interventions documented.An order administration note, dated [DATE], revealed Resident #22 was given a haloperidol injectable solution of 5 mg.-The EMR failed to reveal documented behaviors and/or attempted non-pharmacological interventions prior to the administration of the PRN haloperidol on [DATE].An incident note, dated [DATE] at 1:08 p.m., revealed Resident #22 was attempting to urinate in the common area. Staff were able to stop the resident. An order note, dated [DATE] at 5:06 p.m., revealed that the resident was attempting to ambulate and refused to sit back in his wheelchair but allowed staff to sit him down in a regular chair. He continued to be restless, trying to get up and the staff encouraging him to sit down was ineffective. An order administration note, dated [DATE] at 5:10 p.m., revealed he was given a haloperidol injectable solution of 5 mg. -Prior to the administration of the PRN haloperidol, no attempted non-pharmacological interventions were documented other than encouragement to sit down, despite a physician's order being in place as of [DATE] to offer the resident a calm approach, positive reassurance, one-on-one, quiet environment, offering of fluids/snacks, diversion activities, re-orientation, and re-direction (see physician's orders above).An order administration note, dated [DATE] at 9:56 a.m., revealed Resident #22 was attempting to walk and refusing his wheelchair. He began to yell at the staff and would grab the staff by the arms and waist when they attempted to redirect him. The resident received a haloperidol injectable solution of 5 mg.-Prior to the administration of the PRN haloperidol, no attempted non-pharmacological interventions were documented other than redirection, but the note did not specify what redirection was attempted or why the other interventions were not attempted or effective.An order administration note, dated [DATE] at 11:01 a.m., revealed the resident refused assistance to his wheelchair and was observed swinging at staff and trying to rip the shelf off of the nurses' medication cart. The resident received a haloperidol injectable solution of 5 mg.-Prior to the administration of the PRN haloperidol, no attempted non-pharmacological interventions were documented. A behavior note, dated [DATE], revealed Resident #22 was sitting in his chair in the common area and would not allow the staff to put his oxygen on and was swinging at staff. The resident received a haloperidol injectable solution of 5 mg.-Prior to the administration of the PRN haloperidol, no attempted non-pharmacological interventions were documented. VI. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on [DATE] at 1:31 p.m. CNA #3 said the CNAs looked for the resident-specific behaviors in the care plan and by watching the residents. CNA #3 said if there were changes in a resident's behaviors or non-pharmacological interventions, the nurses would relay this information to the CNAs verbally. CNA #3 said Resident #1 had behaviors of raising her voice when she felt passionately about something she was talking about. She said Resident #1 did not have many behaviors and enjoyed painting when she was upset. CNA #3 said that Resident #41 would chitter her teeth when mad but that was her only behavior. She said putting on music in her room or calling her husband were effective when she was upset. CNA #3 said that Resident #34 got overwhelmed in highly stimulating environments and sometimes refused to allow the staff to provide care to her, but she was unaware of any interventions that worked for her. Licensed practical nurse (LPN) #3 was interviewed on [DATE] at 3:06 p.m. LPN #3 said that the resident-specific behaviors were in the CPOs for the nurses. LPN #3 said if a resident displayed a behavior, the nurse would document it on the MAR and then make a progress note regarding which interventions were used from the template list provided in the CPO. She said if a resident was taking a PRN psychotropic medication, the nurse would document in the progress notes what non-pharmacological intervention was tried and its effectiveness before the administration of the PRN.LPN #3 said that Resident #1 was generally happy without behaviors but sometimes would have crying outbursts. She said she was unaware of any-non pharmacological interventions for Resident #1. LPN #3 said that Resident #41 would sometimes scream out in her room that she wanted to go home but if the staff talked with her, she only really wanted to call her husband. She said the staff could also play her religious compact discs for her. LPN #3 said that Resident #34 got overwhelmed in highly stimulating environments but she was unaware of any interventions that worked for her. The social services director (SSD) and the social services clinical resource were interviewed together on [DATE] at 4:00 p.m. The social services clinical resource said the behavior monitoring in the residents' CPO was turned over to the director of nursing (DON) about two years ago and the SSD only provided the DON with resident-identified behaviors. The SSD said he had only been in his current position for a month and was still receiving training from the social services clinical resource. The social services clinical resource said the facility was currently seeking a new mental health care provider to provide therapeutic services for residents who required it and a provider who could also manage psychotropic medications. He said the current mental health care provider the facility had used refused to share any documentation of visits or recommendations to the facility, citing patient confidentiality. The DON was interviewed on [DATE] at 9:04 a.m. The DON said she took over the position of DON in January of 2026 and she had identified inconsistencies in the psychotropic management process. The DON said the purpose of the psychotropic medication meeting was to review behaviors, interventions, and medications; however, the facility had not had a meeting since she had started in [DATE]. She said since the SSD was new and was in housekeeping prior to his new position, she had been trying to identify behaviors and interventions for the residents to demonstrate the effectiveness and necessity of the medications. The DON said one of her challenges was that the medical director (MD),who managed the psychotropic medications, would not accept recommendations from her or any outside providers. The DON said the facility had had many transitions of staffing in the DON and the SSD positions but the facility did not have a system in place to ensure that there were no interruptions in the continuity of the psychotropic management process due to staffing. She said that the non-pharmacological interventions listed in the residents CPOs were generic and not resident-specific. The DON said she expected the staff to attempt a non-pharmacological intervention prior to the use of a PRN antipsychotic medication and document the effectiveness to justify the necessity of using the PRN medication. She said that every resident on a psychotropic medication should have a mental health or psychologically identified diagnosis attached to the medication. The DON said Resident #1 was taking buspirone for panic with crying outbursts, Lexapro for self isolation, loss of appetite and fidgeting and duloxetine for agitation evidenced by outbursts. She said she did not know what the resident was taking valium for. The DON said she could not determine when the staff marked that Resident #1 was having a crying outburst, self isolating, or showing a loss of appetite that it was related to her PTSD or depression versus being due to a behavior warranting psychoactive medications. The DON said Resident #41 was taking Lexapro for screaming out at staff and olanzapine for hallucinations/kicking yelling. The DON said that Resident #41 had advanced dementia and no longer would use her call light for help but instead yelled out in her room. The DON said she could not determine when the staff marked Resident #41 was yelling out which medication was associated due to both medications being indicated for yelling, nor could she determine if Resident #41 had been yelling out due to a behavior warranting psychoactive medications and not related to an unmet need. She said the staff did not know the difference between Resident #41 yelling out in her room for help because she did not know how to use her call light verses yelling out related to hallucinations. The DON said Resident #34 was taking sertraline for depression, Abilify for depression, clonazepam for anxiety and a second dose of clonazepam for insomnia. The DON said when staff marked that Resident #34 had displayed verbal aggression, the DON said she could not determine if it was due to a behavior warranting psychoactive medications and not instead related to an unmet need or a lack of staff understanding of how to address verbal aggression. The DON said without a training program on how to identify resident-specific behaviors and how to utilize behavior monitoring, she could not ensure that the staff understood how to tell the difference between behaviors of situational distress or unmet needs (crying, outbursts, anger) verses behaviors being properly managed by psychotropic medications. She said the information from the behavior monitoring was used to make decisions on increases or decreases of psychoactive medications and it was important that the information was accurate to prevent the utilization of psychoactive medications for staff convenience for undesirable behaviors. The DON said that the behaviors identified on the monitoring and interventions provided should be resident-specific and individualized.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing for three (#34, #1 and #5) of five residents out of 31 sample residents. Specifically, the facility failed to:-Ensure expressions of suicidal ideations were addressed in order to secure Resident #34's safety;-Ensure Resident #1, who had a history of trauma and suicidal ideations, was monitored for signs and symptoms of suicidal ideation; and, -Ensure individualized care approaches were provided and monitored with ongoing assessment for Resident #5 in order to meet the emotional and psychosocial needs of the resident.Findings include: I. Failed to monitor and address suicidal ideations for Resident #34 and Resident #1 A. Resident #34 1. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included vascular dementia, anxiety, and post-traumatic stress disorder (PTSD). The 3/8/26 minimum data set (MDS) assessment documented the resident was unable to participate in the brief interview for mental status (BIMS) assessment. A staff assessment for mental status revealed the resident had short and long term memory loss and severely impaired decision-making abilities. 2. Record review The mood care plan, revised 8/7/24, revealed Resident #34 was at risk for alterations in her psycho-social well-being related to dementia, depression and PTSD. Interventions, initiated 7/13/23, included monitoring the resident for psycho-social changes. (self-isolation, decreased activity participation, feelings of no self-worth). -The care plan failed to identify the resident expressed suicidal statements or ideations (see below). -Review of Resident #34's April 2026 CPO failed to reveal behavior monitoring for suicidal statements or ideations (see below). Review of Resident #34's electronic medical record (EMR), from 12/1/25 to 4/21/26, revealed the following: A long-term care evaluation note, dated 12/2/25, revealed Resident #34 had chronic behaviors potentially causing harm to self or others. -The note did not explain the behaviors or what interventions were being used to address those behaviors. A depression screen, dated 12/9/25, revealed the resident indicated on the screen she had little interest or pleasure in doing things nearly everyday. She felt down, depressed or hopeless nearly everyday. She had difficulty with appetite, sleep and energy half or most of the time. A social services assessment note, dated 12/9/25, revealed Resident #34 had a history of suicidal ideations. -The note did not explain what interventions were in place to address Resident #34's suicidal ideations. A long-term care evaluation note, dated 1/2/26, revealed that the resident was tearful with disruptive and unwanted behaviors. The resident was withdrawn. -The note did not explain what interventions were in place to address Resident #34's tearful or withdrawn behaviors. A depression screen, dated 2/24/26, revealed Resident #34 indicated on the screen she had little interest or pleasure in doing things nearly everyday. She felt down, depressed or hopeless nearly everyday. She had difficulty with appetite and energy half or most of the time. She felt bad about herself, felt like a failure, or felt she had let herself or her family down half or most of the time. A depression screen, dated 3/8/26, revealed the resident indicated on the screen she had little interest or pleasure in doing things nearly everyday. She felt down, depressed or hopeless nearly everyday. She had difficulty with appetite and energy half or most of the time. She felt bad about herself, felt like a failure, or felt she had let herself or family down half or most of the time. -Review of Resident #34's EMR failed to reveal further follow-up documentation after each time the resident expressed depression in her depression screens. A long-term care evaluation note, dated 4/2/26, revealed that Resident #34 was anxious with disruptive and unwanted behaviors. The resident was withdrawn. -The note did not explain what interventions were in place to address Resident #34's anxious or withdrawn behaviors. A behavior note, dated 4/15/26, revealed the resident expressed she was going to kill herself. The resident was kept in the common area and police and mental health assessors were contacted. -There was no documentation in the resident's EMR to indicate the facility put any interventions in place to keep the resident safe after the threat of suicide or monitored her for further signs and symptoms of suicidal ideations. B. Resident #1 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included PTSD, anxiety and depression. The 3/19/26 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment indicated the resident did not exhibit any behaviors. 2. Resident interview Resident #1 was interviewed on 4/20/26 at 8:53 a.m. Resident #1 said she used to have a therapist that would see her at the facility but the therapist did not come to the building anymore. Resident #1 said it had been a few months and the facility had not helped her make arrangements to find a new therapist or set up telemedicine so she could talk to a therapist on her tablet. She said it was hard for her to get over her past and she was going to therapy to help with that. She said as far as her PTSD, the facility had never asked her what her triggers were or what interventions would work for her. Resident #1 said there were several residents in the facility that had behaviors and were upsetting for her to be around. She said the facility instructed her to just avoid those residents. 3. Record review The depression care plan, revised 9/23/25, revealed Resident #1 was at risk for an alteration in psycho-social well-being related to anxiety, depression and a history of various traumatic life experiences. Interventions, revised 7/22/24, included monitoring the resident for psycho-social changes (self-isolation, decreased activity participation, feelings of no self-worth). The mood care plan, revised 2/24/26, revealed Resident #1 experienced panic attacks with crying outbursts and restlessness related to anxiety. Interventions, initiated 7/22/24, included offering her time to express her feelings and thoughts when she began to panic. -The care plan failed to identify a history of suicide attempts and ideations (see below). Review of Resident #1's April 2026 CPO failed to reveal behavior monitoring for suicidal attempts or ideations (see below). Review of Resident #1's EMR from 12/1/25 to 4/21/26 revealed: A depression screen, dated 12/27/25, revealed Resident #1 indicated on the screen she had little interest or pleasure in doing things and felt down, depressed or hopeless half or most of the time. She had difficulty with appetite and sleep nearly everyday. A depression screen, dated 3/19/26, revealed the resident indicated on the screen she felt down, depressed or hopeless and she felt bad about herself, felt like a failure, or felt she had let herself or family down half or most of the time. -Review of Resident #1's EMR failed to reveal further follow-up documentation after each time the resident expressed depression in her depression screens. Resident #1's Level II preadmission screening and resident review (PASRR) evaluation for mental illness and/or intellectual disabilities, dated 9/20/24, revealed that Resident #1 had a history of self harm, suicidal thoughts, mood swings, loss of interest in activities, and low energy. The resident expressed during the evaluation that she had suicidal thoughts but no plan. She reported believing that things would be better if she was dead and feeling like she could not do it anymore. The resident indicated a history of trauma; homelessness, exploitation by family members, neglect, the death of her daughter, numerous suicide attempts, and sexual abuse by family members. The resident reported she started using illicit drugs at the age of nine to cope. The facility's social worker was interviewed for the evaluation and reported that the resident had mood swings and made statements that she wanted to die. The social worker said that the resident would get triggered easily related to her history of abuse. Specialized services recommended to ensure Resident #1's stability included developing therapeutic interventions to help her understand the source of her mood swings, developing coping skills to manage mood, psychiatric case consulting (psychiatrist oversight) to ensure symptoms were managed appropriately, and creating a safety plan so that the resident knew the next steps to take to ensure she remained safe when she was having suicidal thoughts. -The resident risk factors and specialized services necessary for stability identified in the Level II PASRR were not incorporated in Resident #1's behavior monitoring physician's orders or the resident's care plan (see physician's orders and care plan above). -Review of Resident #1's EMR revealed no safety plan documented for the resident. C. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 4/20/26 at 1:31 p.m. CNA #3 said the CNAs looked for the resident specific behaviors in the care plan and by watching the residents. CNA #3 said if a resident had behaviors of suicidal ideations, the charge nurse would tell the CNAs verbally and if the resident showed signs or symptoms of suicidal ideations, the CNAs would report that to their charge nurse. She said the signs and symptoms to watch for were residents verbally expressing a desire to kill themselves. She said she was not aware of any other signs or symptoms to monitor for. CNA #3 said Resident #1 had behaviors of raising her voice when she felt passionately about something she was talking about. She said the resident did not have any history of PTSD or suicidal ideations. CNA #3 said she was not aware of any other behaviors for Resident #1. CNA #3 said Resident #34 got overwhelmed in highly stimulating environments and sometimes refused to allow the staff to provide care to her. She said the resident did not have any history of PTSD or suicidal ideations. CNA #3 said she was not aware of any other behaviors for Resident #34. Licensed practical nurse (LPN) #3 was interviewed on 4/21/26 at 3:06 p.m. LPN #3 said if a resident expressed suicidal ideations, the nurse would determine what level of severity the threat was and respond accordingly. She said sometimes the staff would just document the expressions in a behavior note or if necessary, contact the behavioral health care provider for guidance. LPN #3 said the facility had not provided staff with training on how to respond to or how to determine levels of severity for suicidal ideations. LPN #3 said Resident #1 had behaviors of agitation and crying outbursts. She said the resident did not have any history of PTSD or suicidal ideations. LPN #3 said she was not aware of any other behaviors for Resident #1. LPN #3 said Resident #34 would get overstimulated and scared easily. LPN #3 said Resident #34 would sometimes say that she wanted to die, but because she had dementia, the staff just put her on 15-minute checks because Resident #34 would not remember she said that. LPN #3 said she did not know where the 15-minute checks were documented. She said Resident #34 had expressed suicidal ideations in the past, but had not for a long time. The social services director (SSD) and the social services clinical resource were interviewed together on 4/21/26 at 4:00 p.m. The SSD said he had only been in his current position for a month and was still receiving training from the social services clinical resource. The SSD said he conducted the residents' depression screens and talked to the residents in depth about their answers, but he did not document these conversations or update the residents' care plans. The SSD said if a resident expressed suicidal ideations, he would let the director of nursing (DON) know and contact the behavioral health care provider for guidance. The SSD said he was not familiar with Resident #1's history, but that should be in her care plan and behavior monitoring. The SSD said he was not aware of what happened after the police and behavioral health care provider were contacted on 4/15/26 for Resident #34's statements of wanting to kill herself. The social services clinical resource said the facility staff should contact the SSD and nursing home administrator (NHA) if a resident was expressing suicidal ideations. He said the resident should be assessed for suicide lethality and monitored, with updates to the care plan and behavior monitoring. The social services clinical resource said the behavior monitoring in the residents' CPOs was turned over to the DON about two years ago and the SSD only provided the DON with resident-identified behaviors. The DON was interviewed on 4/22/26 at 9:04 a.m. The DON said the staff did not receive any formal training on how to respond to residents expressing suicidal ideations. The DON said if a resident expressed suicidal ideations or threats, the staff were to contact emergency medical services and request a behavioral health care professional come to the facility to do a suicide lethality assessment because the behavioral health care provider was the specialist in that field and would provide the facility with recommendations on next steps. The DON said she had not provided the nurses with levels of severity education to determine whether a resident had the ability or intent to harm themselves. The DON said the nurses did not have the training to make those determinations. She said the care plans and behavior monitoring for Resident #1 and Resident #34 should have been updated to include their histories of suicidal ideations. II. Failed to ensure individualized care approaches were provided and monitored with ongoing assessment for Resident #5 in order to meet the emotional and psychosocial needs of the resident A. Resident #5 1. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder and cognitive communication deficit. The 3/13/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. 2. Observations and resident interview Resident #5 was interviewed on 4/19/26 at 3:45 p.m. in his room. Resident #5 said there was an incident a few weeks prior in which he touched a nurse's breast, but he was a changed man. He said he gave himself to the Lord. On 4/20/26 at 2:07 p.m. Resident #5 made six laps around the nurses' station while staring at a visitor. Resident #5 stared at the visitor and said You're really cute, I'm just reminiscing and Wow repeatedly. -Several staff members were near the nurses' station and failed to intervene. On 4/20/26 at 3:16 p.m. Resident #5 walked behind the certified nurse aide with medication authority (CNA-Med) #1, who stood at the hallway E and F medication cart. The resident looked her up and down and said Wow. CNA-Med #1 did not respond or acknowledge the resident. 3. Record review Review of Resident #5's EMR revealed the following progress notes: On 4/8/26 at 12:03 p.m. the DON documented Resident #5 was in the dining area listening to the music and watching the dancers. The DON documented she was in the dining room with the resident and he reached out and squeezed her breast. The resident immediately apologized. The DON documented she discussed the inappropriateness of this action with Resident #5. He apologized and said I won't do it again; I don't want to get into trouble. Review of Resident #5's comprehensive care plan, initiated 1/25/23, revealed the resident had behaviors related to occasional verbal/physical aggression toward others due to his diagnosis of Autism Disorder. He could become easily upset by situational stressors and he had a history of inappropriate sexual behaviors. Pertinent interventions, initiated 3/13/23, included approaching the resident in a calm manner to avoid frustration and behavior escalation; encouraging the resident to go to his room if he showed signs of agitation toward others; avoiding providing the resident access to provocative media; behavior monitoring for lorazepam, monitoring target behaviors, including physical aggression towards other residents; intervening and redirecting the resident when his behaviors began to escalate to prevent altercations with staff and residents; keeping the resident and other residents safe during episodes of behaviors and attempting to redirect; monitoring and documenting episodes of inappropriate behaviors; and, placing the resident on 15-minute behavior monitoring when behaviors escalated and if the behaviors continued during the 15-minute behavior monitoring, assign staff to provide one-to-one supervision until behaviors discontinued. -However, the care plan was not revised to reflect a person-centered intervention specific to Resident #5's documented sexual behavior toward the DON on 4/8/26 (see above). Review of Resident #5's electronic medical record (EMR) revealed the resident was placed on 15-minute behavior monitoring for 24 hours after the incident on 4/8/26. Further review of Resident #5's EMR revealed a behavioral agreement, dated 1/6/26, between the resident and his peer support. The behavioral agreement revealed the resident agreed to talk with staff when he felt uncomfortable, go to his room until the feeling passed, engage in activities, call the DON/pastor and avoid close contact with the individuals the feelings were directed towards. B. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/20/26 at 3:30 p.m. CNA #1 said if she saw a resident demonstrating behaviors, she would try to calm the resident and go to her charge nurse. She said Resident #5 was pretty good when she worked with him and he did not usually demonstrate sexual behaviors. CNA #1 said she had heard him make some sexual comments with the dietary staff, but that was months ago. She said if she were to witness Resident #5 demonstrating inappropriate behavior, she would tell him not to talk to staff like that. Registered nurse (RN) #1 was interviewed on 4/20/26 at 3:45 p.m. RN #1 said some residents had behaviors even at their baseline, and any behaviors outside of their baseline would be documented as a behavior note. She said interventions implemented should be documented in the resident's medication administration record (MAR). RN #1 said Resident #5 was driven by a motor at times, and she had seen the resident walking laps in circles. She said there was sometimes a component to the circling that could be considered a sexual behavior. RN #1 said when Resident #5 demonstrated sexual behaviors, she discussed with the resident the inappropriateness of the behavior. She said a lot of the times, the conversation went in one of Resident #5's ears and out the other. RN #1 said she knew interventions for Resident #5 included activities and distraction. The DON was interviewed on 4/20/26 at 4:00 p.m. The DON said a behavior was something outside of the resident's normal day-to-day person or baseline. She said she experienced Resident #5's inappropriate behavior on 4/8/26 when he sang, danced and then impulsively reached out and grabbed her breast at an event. The DON said Resident #5 was apologetic and afterward, Resident #5 told her he was afraid and he gave himself to the Lord. She said the thing was, Resident #5's behavior was impulsive and the facility staff did not know when he was going to do it again. The DON said she documented the behavior in a behavior note. The DON said a few interventions had been put in place for Resident #5, including a behavioral contract agreement between the resident and his peer-to-peer counselor. The DON suggested that Resident #5 needed medication to decrease his internal sex drive because the resident wanted a girlfriend; however, there was not a girlfriend in the building for him. She said Resident #5 did not qualify for the local adult day services for developmentally delayed people, and the facility did not want to go in the direction of adding medications to the resident's regimen. The DON said the most effective intervention for Resident #5 was calling a close family friend of the resident to come to the facility to talk with him about his sexual behaviors and inappropriateness. She said afterward, however, Resident #5 would get scared and ask if he would be sent to jail. The DON said the next step for the facility might have been to add a hormone-suppressing medication because she just could not find an adult day service for him to go to. She said the discussion to add medication to Resident #5's regimen was not documented in the interdisciplinary team (IDT) note because it was a verbal discussion. The DON searched Resident #5's care plan for the interventions the nursing staff should have implemented. She said the nursing staff should have approached the resident in a calm manner and attempted to redirect him by encouraging him to go to his room, monitored the resident's behavioral episodes and attempted to determine the cause of the behavior and offered positive conversation/activities to keep the resident engaged in a positive, nonsexual interaction. The DON said Resident #5 should have been placed on every 15-minute behavior monitoring and if his behaviors escalated or persisted, he should have been assigned a one-to-one sitter. She said the resident loved to walk outside and she should put that in his care plan. The DON was interviewed again on 4/21/26 at 4:52 p.m. The DON said Resident #5's behavioral health center did not allow the facility to view their notes due to patient confidentiality. She said if the resident spoke about a serious issue, such as suicidal ideation (SI) or homicidal ideation (HI), they would have communicated that specific finding with the facility via a note. The DON was interviewed a third time on 4/22/26 at 1:15 p.m. The DON said her nursing staff did not know what person-centered interventions for Resident #5 were, and the interventions that were in place were ineffective. She said she discussed with someone else earlier in the day about getting the CNAs involved in the care plan process.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two of four hallways.Specifically, the facility failed to:-Ensure hand hygiene was performed appropriately when incontinence care was provided to Resident #2; -Ensure the vital signs equipment was disinfected between residents; and, -Ensure blood sugar glucometers were disinfected appropriately between residents.Findings include:I. Failed to ensure hand hygiene was performed appropriately when incontinence care was provided to Resident #2A. Facility policy and procedureThe Handwashing/Hand Hygiene policy, dated December 2025, was provided by the nursing home administrator (NHA) on 4/22/26 at 10:25 a.m. It read in pertinent part, Hand hygiene is the primary means for preventing healthcare-associated infections (HAIs) and the transmission of multidrug-resistant organisms (MDROs). Hand hygiene is indicated: before touching a resident; before preparing or handling food, medications or parenteral solutions; before clean or aseptic (sterile) procedures; before moving from work on a soiled body site to a clean body site on the same resident; after exposure to blood, body fluids, excretions or contaminated surfaces; after touching a resident; after touching the resident's environment or belongings; after glove removal; and, whenever the hands are visibly soiled. Use an alcohol-based hand rub (ABHR) containing at least 60 percent (%) alcohol for most clinical situations. Unless the hands are visibly soiled, ABHR is the preferred method of hand hygiene in clinical situations because it is more effective at killing germs, faster to use and less irritating to the skin than soap and water. Wash hands with soap and water: when the hands are visibly soiled with blood or body fluids; before eating and after using the restroom; after contact with a resident with infectious diarrhea including, but not limited to, infections caused by norovirus, salmonella, shigella and clostridium difficile (c-diff); and, during suspected or confirmed outbreaks of norovirus or c. difficile.B. ObservationOn 4/20/26 at 12:37 p.m. certified nurse aide (CNA) #1 responded to Resident #2's call light. The resident said he wanted to be changed and put in bed. CNA #1 said she needed to grab a second CNA and she would be right back.At 12:41 p.m. CNA #1 returned with certified nurse aide with medication authority (CNA-Med) #1 and a hoyer lift (mechanical lift). CNA #1 and CNA-Med #1 donned a gown and gloves as appropriate because the resident was on enhanced barrier precautions (EBP). Resident #2 was turned toward CNA-Med #1 when CNA #1 began to clean the resident's buttocks. CNA #1 stopped cleaning the resident's buttocks, walked away from the resident, and without changing her gloves, opened the top drawer of the resident's vanity and removed a cleansing spray and wipes.-CNA #1 failed to change gloves and perform hand hygiene after providing incontinence care and before opening the resident's vanity drawer to obtain the cleansing spray and wipes.Resident #2's son entered the room during incontinence care and noticed the nurses did not have the barrier cream readily available. With his bare hands, Resident #2's son opened the same drawer CNA #1 had opened previously with soiled gloves and removed the barrier cream.Without changing her gloves or performing hand hygiene, CNA #1 took the container of barrier cream from the resident's son, opened the container, used her gloved hand to scoop the cream out of the container and applied the cream to the resident's bottom.-CNA #1 failed to change gloves and perform hand hygiene after providing incontinence care and prior to reaching into the container of barrier cream with her soiled gloves.After the incontinence care was completed, CNA-Med #1 assisted Resident #2 to roll onto his back and returned the incontinence supplies, including the container of barrier cream, to the top drawer of the resident's vanity.-CNA-Med #1 failed to remove her gloves and perform hand hygiene after providing incontinence care and prior to replacing the barrier cream in the resident's vanity.Before they left Resident #2's room, CNA #1 and CNA-Med #1 doffed their gowns and gloves appropriately and performed hand hygiene with soap and water.C. Staff interviewsCNA #1 and CNA-Med #1 were interviewed together on 4/20/26 at 1:00 p.m. CNA #1 said she knew that it was wrong to use soiled gloves to touch the resident's environment and scoop cream out of a container. She said the potential negative outcome of not performing hand hygiene appropriately was cross-contamination of germs among the residents.The director of nursing (DON) was interviewed on 4/22/26 at 1:15 p.m. The DON said indications for hand hygiene included upon entrance into the residents' rooms, after any resident care, if the hands were visibly soiled, contact with any bodily fluids or secretions and during medication administration and wound care. The DON said CNA #1 and CNA-Med #1 should have changed their gloves before they did anything else outside of the incontinence care, including opening a container of barrier cream and using a soiled gloved hand to scoop the barrier cream out of the container. She said proper hand hygiene was important to prevent the transmission of infections. The infection preventionist (IP) was interviewed on 4/22/26 at 1:35 p.m. The IP said she conducted handwashing education at least annually, when the facility had residents who required isolation precautions and when the facility noticed concerns with infection control practices. The IP said she had already noticed that hand hygiene was a concern in the building. She said she liked to provide the hand washing and personal protective equipment (PPE) education on a one-to-one basis with staff so she knew she did not miss any staff members.II. Failed to ensure staff disinfected the vital signs equipment and glucometers appropriately between residentsA. Professional referenceAccording to Super Sani-Cloth Germicidal Disposal Wipe, PDI, (2018), retrieved on 4/29/26 from https://pdihc.com/wp-content/uploads/2018/08/Super-Sani-Cloth-Tech-Data-Bulletin_0619-UPDATE_07168610.pdf, Super Sani-Cloth germicidal disposable wipe is a premoistened, nonwoven durable wipe containing a quaternary ammonium chloride/alcohol based solution. Recommended for use in hospitals and other critical care areas where the control of the hazards of cross-contamination between treated surfaces is required. Some organisms are removed from the surface by thoroughly wiping the surface with the wipe. Most remaining organisms are killed within two minutes by exposure to the liquid in the wipe.According to Microdot Minute Wipes, Cambridge Sensors, retrieved on 4/29/26 from https://www.microdotcs.com/assets/minutewipe_disinfection-and-control-guide.pdf, Protocol to disinfect Microdot glucometer: open Microdot minute wipe pop-up canister; remove a pre-saturated wipe; thoroughly wipe the Microdot glucometer surface to be disinfected with the Microdot minute wipe; wrap the Microdot glucometer with the Microdot minute wipe; place the wrapped Microdot glucometer face down inside the Microdot disinfection case; close disinfection case lid and activate timer; allow the Microdot glucometer to remain in contact with the minute wipe for one minute; and, dispose of the wipe in the trash after use.According to True Metrix Self Monitoring Blood Glucose System, Trividia Health, (2026), retrieved on 4/29/26 from https://www.trividiahealth.com/wp-content/uploads/2026/02/RE4TVH35r52_020426.pdf, To clean the meter: Make sure the meter is off and a test strip is not inserted. With only Super Sani-Cloth wipes, rub the entire outside of the meter using three circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. To disinfect the meter: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for two minutes. Make sure no liquids enter the test port or any other opening in the meter.B. ObservationsDuring a continuous observation of CNA #2 on 4/20/26, beginning at 8:24 a.m. and ending at 8:33 a.m., the following was observed:At 8:24 a.m. CNA #2 measured an unidentified resident's blood pressure (BP) in the common area. There were no disinfecting wipes observed in the vital signs equipment cart. After measuring the resident's BP, CNA #2 removed the BP cuff from the resident's arm and placed it in the vital signs equipment cart. CNA #2 pushed the vital signs equipment cart to the entrance of the B hallway.At 8:33 a.m. CNA #2 approached the vital signs equipment cart and pushed it down the B hallway. CNA #2 entered Resident #30's room and said I need to grab a blood pressure, before he closed the resident's closed door. -CNA #2 failed to disinfect the vital signs equipment between residents.During an observation of the medication administration on 4/21/26, the following was observed:At 10:53 a.m. CNA-Med #1 donned (put on) an isolation gown and gloves before she entered Resident #2's room. She appropriately collected the resident's blood and measured the blood glucose (sugar) level.After she measured Resident #2's blood glucose level, CNA-Med #1 opened the Microdot minute wipes, removed one wipe and wiped the front, back and side surfaces of the glucometer for ten seconds. The surface of the glucometer was not wet or shiny looking when CNA-Med #1 placed the glucometer in a basket.-CNA-Med #1 failed to doff (remove) her soiled gloves and don clean gloves prior to disinfecting the glucometer.-CNA-Med #1 failed to follow the chemical dwell time to properly disinfect the glucometer (see professional reference above).CNA-Med #1 returned to the hallways E and F medication cart and documented Resident #2's blood glucose level before she continued administering medications to other residents. C. Staff interviewsCNA-Med #1 was interviewed on 4/21/26 at 11:00 a.m. CNA-Med #1 said the glucometer she used to measure Resident #2's blood glucose level was a shared glucometer. She said she thought the dwell time for the Microdot minute wipes was five minutes, and it was important the chemical dwell times were followed in order to remove all of the germs from the device and get the device clean. CNA-Med #1 said in hallways E and F there were six residents who shared the glucometer on a daily basis and one resident who used the glucometer on a monthly basis.Licensed practical nurse (LPN) #1 was interviewed on 4/21/26 at 11:20 a.m. LPN #1 said after she would collect a resident's blood sugar level, she would use Caviwipes to clean the glucometer. She said the Caviwipes were kept at the nurses' station. She said she did not know the chemical dwell time for the wipes, but she would find out. At the nurses' station, LPN #1 showed the wipes she used to clean the glucometer, however she showed the Super Sani Cloth germicidal wipes. She said the chemical dwell time for the wipes was two minutes, and it was important to follow the dwell time in order to kill bacteria/viruses and prevent the transmission of bloodborne illnesses.CNA #1 was interviewed on 4/21/26 at 12:25 p.m. CNA #1 said after she collected a resident's vital signs, she sanitized the vital signs equipment. She said she wore gloves and used alcohol wipes to ensure the blood pressure cuff and the vital signs equipment tower was sanitized. CNA #1 said the alcohol wipes were kept at the nurses' station and she did not know the chemical dwell time. She said the facility had provided education on infection control practices, but she was unable to recall the education she received. LPN #3 was interviewed on 4/21/26 at 12:29 p.m. LPN #3 said she typically worked as the minimum data set (MDS) coordinator, but she was working as the charge nurse today (4/21/26). She said if she had collected the residents' vital signs she would have disinfected the vital signs equipment on the way into the resident's room, but not always on the way out of the room - it depended on who the resident was. LPN #3 said she used the Caviwipes to disinfect the vital signs equipment, but said she was unable to locate the wipes. She said the facility usually kept the wipes at the nurses' station. LPN #3 said she did not know the chemical dwell time of the Caviwipes.LPN #3 said it was important to follow the chemical's dwell time because not following the dwell time affected the cleanliness of the equipment. She said not following the dwell time could cause a risk of infection transmission between the residents. LPN #3 said she was not sure when the last time she received education on infection control practices was because she did not participate in the all-staff meetings as the MDS coordinator.LPN #1 was interviewed again on 4/21/26 at 12:55 p.m. LPN #1 said the glucometer was stored in a basket in the top drawer of the medication cart, and there were three residents who shared the glucometer in hallways A and B.The DON was interviewed on 4/21/26 at 2:04 p.m. The DON said the glucometers could be shared between residents if they were sanitized appropriately after every use. She said there was a checklist at the nurses' station to ensure the glucometers were cleaned daily. She said the glucometers should be cleaned after each resident and they were stored in a basket in the locked top drawer of the medication carts. The DON said on hallways A and B, there were three residents who shared a glucometer and each used the device three times per day. She said on hallways E and F, there were six residents who used the device daily and one resident who used it monthly. The DON said CNA-Med #1 should have cleaned the glucometer for the appropriate amount of time and then allowed it to dry appropriately before it was returned to the basket. She said the glucometer should not be returned to the basket until it was fully dry.The DON said the facility typically used the Assure Platinum glucometers but they ran out of the glucometer test strips on Monday 4/20/26 and the replacement strips would not arrive until Wednesday 4/22/26. She said they purchased the Leader True Metrix glucometer to have in the meantime.The DON was interviewed again on 4/21/26 at 2:48 p.m. The DON said she called the True Metrix glucometer's manufacturer and they told her the Super Sani-Cloth wipes were recommended for disinfection. She said she threw the Microdot wipes away and placed the Super Sani-Cloth wipes on the medication carts for nursing staff to use. The DON said the manufacturer's recommendations reported that other types of sanitizer wipes had not been tested on the device.The DON was interviewed a third time on 4/22/26 at 1:15 p.m. The DON said when the nursing staff was measuring vital signs, the vital signs equipment should be disinfected with Super Sani-Cloth wipes between each resident. She said she thought the chemical dwell time for the wipes was three minutes and it was important to follow the chemical dwell time for infection control and to prevent cross-contamination.

Based on interviews on record review, the facility failed to ensure two (#35 and #41) of three residents reviewed for Medicare or Medicaid covered services out of 31 sample residents were notified of changes in their services covered, including their financial responsibility and their appeal rights. Specifically, the facility failed to: -Ensure Resident #35 was provided notification that his Medicare Part A covered skilled services were ending within the required time parameter; -Ensure Resident #41's representative was provided written notification of the Medicare Notice of Non-Coverage (NOMNC) letter when Resident #41's Medicare Part A covered skilled services were ending; and,-Ensure Resident #41's representative was notified of the right to appeal when the resident's Medicare Part A covered skilled services were ending.Findings include: I. Resident #35 A. Resident status Resident #35, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD - a progressive lung disease restricting airflow), schizophrenia (a chronic severe brain disorder characterized by hallucinations and delusions), dementia and anxiety. The 4/13/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. B. Record review Review of Resident #35's electronic medical record (EMR) revealed Resident #35 was discharged from Medicare Part A skilled therapy services on 12/12/25. The NOMNC for Resident #35 identified the resident's skilled services were to end on 12/12/25. Resident #35 signed the NOMNC on 12/12/25, the same day the skilled services were ending.- A review of Resident #35's EMR revealed no documentation to indicate that Resident #35 was given at least a two-day notice that his Medicare Part A skilled services would be ending on 12/12/25. II. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included schizophrenia, COPD, dementia with anxiety and heart disease. The 3/14/26 MDS assessment revealed a BIMS assessment was not conducted because the resident was rarely or never understood. According to the staff assessment for mental status, the resident had short and long-term memory problems and her cognitive skills for daily decision making were severely impaired. B. Record review Review of Resident #41's EMR revealed Resident #41 was discharged from Medicare Part A skilled therapy services on 11/28/25. The NOMNC notice revealed verbal notification was provided to Resident #41's representative on 11/25/25. The resident continued to live in the facility. -However, a review of Resident #41's EMR revealed no documentation to indicate that Resident #41's representative was provided with a written notice that Resident #41's Medicare Part A skilled therapy services were ending, given the estimated cost of services the resident would incur if the representative chose to pay out of pocket to continue skilled therapy services, the reason why the Medicare Part A skilled therapy services were ending and/or the information the representative needed to appeal the decision, if desired.III. Staff interviewsThe NHA was interviewed on 4/22/26 at 1:16 p.m. The NHA said the social services director (SSD) was responsible for notifying the resident or the resident's representative when Medicare Part A skilled services would be ending. The NHA said the notification was to allow 48 hours prior to the end of services. The NHA said the SSD needed to educate the resident or the resident's representative of their right to appeal the decision if they wanted to remain on Medicare Part A skilled services longer. The NHA said a signed copy of the NOMNC letter was supposed to be provided to the resident or the resident's representative. The NHA said if the notice was given over the phone, there should be documentation on the NOMNC letter of the verbal notification and documentation to indicate appeal rights were explained to the resident or the resident's representative. The NHA said the SSD was new to the position. The NHA said Resident #35 was at the facility with a different SSD who no longer worked at the facility. The NHA said he did not know why the resident was provided notice the same day the resident's skilled services ended. The NHA said Resident #41's Medicare Part A skilled services coverage ended when a different SSD worked at the facility. The NHA said he did not know why there was no documentation that the resident's right to appeal was explained and that a copy of the NOMNC letter was provided to the resident's representative.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#3 and #7) of two residents out of 31 sample residents. Specifically, for Resident #3 and Resident #7, the facility failed to:-Ensure that the resident's representatives were informed of the potential risks and benefits of a wanderguard (a wearable device that helps prevent residents from eloping from the facility);-Ensure the wanderguard was the least restrictive approach for the residents;,-Ensure the residents' wanderguards were monitored for continued use; and,-Develop and implement interventions for reducing the restraint.Findings include:I. Facility policy and procedureThe Tab Alarms, Bed Alarms, Wanderguard System policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/22/26 at 6:38 p.m. It read in pertinent part, The wanderguard will be used for residents at risk for elopement. For each resident to reach his/her highest practicable well being in an environment that prohibits the use of restraints for discipline or convenience. A nursing assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for falls or elopement. A plan of care must be formulated with the interdisciplinary team (IDT - nursing, physical therapy, occupational therapy, dietary, activities, social worker, and resident/family), to determine the need for tab or bed alarms or a wanderguard bracelet and documented in the care plan. The wanderguard bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed. The wanderguard bracelets are checked daily on the night shifts by the supervisor and are documented in the treatment book on the units.II. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), asthma, muscle weakness and dementia with behavioral disturbance. The 3/24/26 minimum data set (MDS) assessment revealed Resident #3 had moderate impaired cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident needed supervision or touching assistance with most of her activities of daily living (ADL). The assessment documented Resident #3 did not wander. The assessment documented Resident #3 used a wander/elopement alarm daily. B. ObservationsDuring a continuous observation on 4/20/26, beginning at 12:35 p.m. and ending at 3:05 p.m., the following was observed:At 12:35 p.m. Resident #3 came out of her room and wheeled herself into the common area. A wanderguard was observed on the resident's right ankle.At 12:40 p.m. Resident #3 left the common area and went back to her room.At 12:52 p.m. Resident #3 left her room and went back into the common roomAt 1:00 p.m. Resident #3 played a card game with other residents and the activities staff member in the common area. At 1:52 p.m. Resident #3 continued to play the card game. At approximately 2:30 p.m. Resident #3 went to her room. At approximately 2:45 p.m. Resident #3 went back to the common area. At 3:05 p.m. Resident #3 was playing table pong in the common area.Resident #3 displayed no attempts to exit-seek during the approximately three and a half hour continuous observation. C. Record reviewResident #3's elopement care plan, initiated 10/13/25, revealed the resident was at risk for elopement due to exit seeking, verbalizing leaving the facility and wandering. Interventions included applying a wanderguard, monitoring the placement and function of the wanderguard, periodically evaluating the wanderguard for continued need and promptly checking when the wanderguard alarm system went off to ensure Resident #3 was safe and remained in the facility. -However, the facility failed to document measures taken to systematically reduce or eliminate the need for the wanderguard (see below). An elopement evaluation, dated 10/13/25, revealed Resident #3 was a high elopement risk. The evaluation documented Resident #3 wandered in the facility, verbalized or exhibited exit-seeking behavior and was capable of leaving the facility. However, the evaluation documented the resident did not have a history of elopement.-Review of Resident #3's electronic medical record (EMR) revealed no documentation to indicate additional elopement evaluations were completed for the resident.Review of Resident #3's April 2026 CPO revealed the following physician's orders:Place wanderguard related to exit-seeking behavior, ordered 10/13/25.Wander Guard: Ensure that wander guard is functioning properly every day, ordered 10/14/25.Wanderguard: Check for placement every shift, ordered 10/14/25.The nurse progress note, dated 10/12/25 at 7:04 p.m., documented Resident #3 pushed the front door of the facility open and said I am leaving this place, my brother is outside waiting for me. The nurse explained to the resident that her brother was not outside and that she would have to come back into the facility because that was where she lived. The resident was angry, but hesitantly came back into the facility. The order administration note, dated 10/12/25 at 9:35 p.m., documented Resident #3 opened thefront door and was stating that she wanted to leave with her sister-in-law, who was not in the facility. The resident was stating that the staff were trying to kill her. The resident was administered a dose of as needed Haldol (antipsychotic medication used to treat acute agitation) which was effectiveThe nurse progress note, dated 10/13/25 at 12:11 p.m., documented a wanderguard bracelet was placed on the resident's right ankle and the director of nursing (DON) was aware.-However, review of Resident #3's EMR failed to reveal that the facility discussed the risks versus benefits of the wanderguard with the resident's representative or that consent was obtained from the representative for the placement of the wanderguard.The progress note, dated 10/13/25 at 3:58 p.m., documented Resident #3 had received Haldol last night (10/12/25) and had been sleeping all day. The resident would continue to be monitored.-The note did not indicate the reason the wanderguard was placed on the resident as she was not continuing to exit-seek after receiving Haldol the night before.A behavior note, dated 10/29/25 at 3:09 a.m., documented Resident #3 was saying I am not staying here! What are you trying to do to me? The note documented Resident #3 thought that staff members were trying to harm her. The note documented that she was given pain medication in case she was in pain. -However, the note did not indicate that Resident #3 was trying to leave the facility. A progress note, dated 11/4/25 at 1:05 p.m. documented the resident's wanderguard was replaced and the new one was placed on her left ankle. -However, the note did not document that the wanderguard was re-evaluated to determine if it was still appropriate and necessary for Resident #3.The behavior note, dated 11/13/25 at 1:57 p.m. documented the resident had increased anger, frequent episodes of talking to herself in frustration and was wandering the hallways with no goal in mind.-The note did not indicate that the resident was attempting to leave the facility.The physician's progress note, dated 11/20/25 at 1:28 p.m., documented Resident #3 had worsening behaviors of visual hallucinations and exit-seeking The resident's Seroquel (antipsychotic medication) was increased by the physician.-However, there was no documentation in the resident's EMR to indicate the resident had additional exit-seeking attempts between 10/12/25 and 11/20/25 (see above).The nurse progress note note, dated 11/24/25 at 4:30 p.m., documented Resident #3 was in the hallway stating that she was waiting for an employee to pick her up and he did not pick her up. The note documented Resident #3 stated she wanted to get the hell out of there and then went to her room and put herself to bed. -However, the note did not indicate Resident #3 tried to leave the facility.The long-term care evaluation note, dated 12/15/25 at 7:16 p.m., documented Resident #3 had chronic wandering behavior noted and wandered at night. The resident had a wander/elopement alarm in use.-However, the note did not indicate that the resident attempted to exit-seek and/or leave the facility. The long-term care evaluation note, dated 2/16/26 at 2:07 a.m., documented the resident had no unwanted behaviors witnessed and did not wander at night. The resident had a wander/elopement alarm in place due to a history of elopement.-However, there was no documentation to indicate the resident had attempted to leave the facility other than on 10/12/25 (see progress notes above). Review of Resident #3's EMR did not reveal any further exit-seeking behaviors or verbalization that Resident #3 tried to leave the building or talked about leaving the building from 11/24/25 to 4/21/26.-However, there was no documentation to indicate the facility had re-evaluated the resident between 11/24/25 to 4/21/26 to determine if the wanderguard was still appropriate and necessary for Resident #3. -Additionally, review of the resident's EMR failed to reveal documentation that a less restrictive method was offered or tried with the resident, prior to the wanderguard being implemented. III. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dementia, muscle weakness, cardiac murmur and edema.The 2/25/26 MDS assessment revealed Resident #7 was unable to complete the BIMS assessment. The staff assessment for mental status documented Resident #7 had long-term memory problems, she was able to locate her own room, but her cognitive skills for daily decision-making were severely impaired. The assessment revealed Resident #7 needed partial to moderate assistance with most of her ADLs. The assessment documented Resident #7 did not wander. The assessment documented Resident #7 used a wander/elopement alarm daily. B. Resident's representative interviewResident #7's representative was interviewed on 4/20/26 at 10:26 a.m. The representative said she did not know what a wanderguard was. She said to her knowledge, Resident #7 did not have a wanderguard. She said Resident #7 did not wander and had not tried to leave the facility and did not have a history of trying to leave the facility. C. ObservationsDuring a continuous observation on 4/20/26, beginning at 12:45 p.m. and ending at 3:09 p.m., the following was observed:At 12:45 p.m. Resident #7 was sleeping in the dining room at her table. The table was empty in front of her and there were no employees in the dining room. The resident had a wanderguard on her ankle.At 1:06 p.m. Resident #7 walked from the dining room into the common area. The resident's pants were visibly soiled with a large brown stain on the back of her pants and the back of her shirt at the bottom. At 1:08 p.m. an unidentified activities staff member asked Resident #7 if she wanted to play cards. The social services clinical consultant noticed that Resident #7 needed to be changed and a certified nurse aide (CNA) took the resident to be changed in her room. At 1:50 p.m. Resident #7 was sitting in the common area with a new pair of pants on and a new shirt. At 2:39 p.m. Resident #7 stood and began to walk down the hallway to her room. At 2:40 p.m. an unidentified staff member redirected Resident #7 back to the common area to watch television. At 3:09 p.m. Resident #7 was sleeping in the common area on the couch.-Resident #7 displayed no attempts to exit-seek during the approximately two and a half hour continuous observation. D. Record reviewResident #7's elopement care plan, revised 12/10/24, documented Resident #7 was at high risk for elopement due to exit-seeking and wandering behaviors. Interventions included calmly redirecting and diverting the resident's attention, distracting the resident by offering activities, food, conversation, television and books, evaluating the need for a wanderguard, monitoring placement and functionality of the wanderguard and promptly checking when alarm system went off to ensure the resident was still safe in the facility. The elopement evaluation, dated 4/23/24, documented Resident #7 was a high risk for elopement. The evaluation documented Resident #7 was capable of leaving the facility, was not alert and oriented by three, wandered throughout the facility, verbalized or exhibited exit-seeking behavior and had a history of attempted or actual elopement. -However, review of Resident #7's EMR revealed no documentation to indicate the facility had re-evaluated the resident between 11/23/24 to 4/21/26 to determine if the wanderguard was still appropriate and necessary for the resident.Review of Resident #7's April 2026 CPO revealed the following physician's orders:Wander Guard: Ensure that the wander guard is functioning properly every day, ordered 4/23/24.Wanderguard: Check for placement every shift, ordered 4/23/24.-However, there was no physician's order to place the wanderguard.The behavior note, dated 11/18/25 at 3:59 p.m. documented Resident #7 had two episodes where staff found her in the wrong rooms going through the contents of the rooms, including food, and attempting to remove items from the rooms. The resident was not easily redirected on both occasions. The resident offered fluids and snacks but continued to state this is my room. The resident was taken to her own room and showed her belongings and then she calmed down.-However, the note did not indicate that the resident was attempting to leave the facility.The progress note, dated 12/4/25 at 5:51 p.m., documented Resident #7 was in another resident's room rummaging through the drawers. A CNA went and got Resident #7 and redirected her to her room.-However, the note did not indicate that the resident was attempting to leave the facility.The physician's progress note, dated 1/12/26 at 9:37 a.m., documented Resident #7 had advanced dementia with behaviors of wandering into other residents' rooms or not respecting personal boundaries.-However, the note did not indicate that the resident was attempting to leave the facility.The long-term care evaluation note, dated 2/9/26 at 11:50 p.m., documented Resident #7 had chronic wandering behaviors noted and wandered at night. The resident had a wander/elopement alarm in use related to elopement risk.-However, the note did not indicate that the resident attempted to exit-seek and/or leave the facility.The long-term care evaluation note, dated 4/9/26 at 10:03 p.m., documented the resident had no unwanted behaviors witnessed and wandered at night. The note indicated the resident did not have any restraints or alarms in place.-However, observations during the survey revealed the resident had a wanderguard.-Additionally, review of Resident #7's EMR revealed there was no documentation to indicate the resident had attempted to leave the facility.-Review of Resident #7's EMR failed to reveal that the facility discussed the risks versus benefits of the wanderguard with the resident's representative or that consent was obtained from the representative for the placement of the wanderguard.-Additionally, review of the resident's EMR failed to reveal documentation that a less restrictive method was offered or tried with the resident, prior to the wanderguard being implemented. IV. Staff interviewsCNA #3 was interviewed on 4/21/26 at 3:38 p.m. CNA #3 said she had only been working at the facility for a month. She said she was able to identify if a resident was an elopement risk if they were wearing a wanderguard. She said if she saw a resident trying to leave the building or wandering, she would try to redirect them by offering a snack or trying to give them something else to do. She said she had not seen Resident #3 try to leave the building. She said she had only seen Resident #3 go from her room to the dining room, but she said she was not that familiar with the resident. She said Resident #7 wandered into other residents' rooms. She said Resident #7 was redirectable. CNA #2 was interviewed on 4/21/26 at 4:00 p.m. CNA #2 said he was able to identify if a resident was an elopement risk because the resident would be wearing a wanderguard. He said he also would get reports from other CNAs and the charge nurses if a resident had a wanderguard. He said there was a place in the EMR where it would list if a resident was an elopement or wander risk. He said he did not think that it listed the interventions to be used if a resident exhibited those behaviors. He said that Resident #3 was very independent and would yell at people that no one else could see. He said he never saw Resident #3 try to leave the building or wander, other than down to her room and the common areas. He said Resident #7 would wander into other residents' rooms. He said she did not like male staff members so he tried his best to respect that boundary. Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 4/21/26 at 4:18 p.m. CNA-Med #1 said she identified residents who were wander risks and elopement risks because they wore wanderguards. She said staff kept a closer eye on residents who had wanderguards. She said the standard interventions that staff used were redirection, giving them a different activity, offering them snacks and toileting. She said she was unsure if the interventions were resident-specific. CNA-Med #1 said Resident #3 did not wander and was not an elopement risk. She said Resident #7 would try and go out the back door that was down her hall. She said she would also wander into other residents' rooms. She said Resident #7 used to be a nurse and staff thought that the reason why Resident #7 wandered at certain times was because she thought she was doing her nursing rounds. She said there were times when she would try and give Resident #7 nursing tasks and that helped distract her from wandering. CNA-Med #1 said she was unsure if that intervention was documented anywhere. She said it should be documented on the care plan. -However, the nursing intervention to offer the resident nursing tasks was not documented on Resident #7's care plan (see record review above). Licensed practical nurse (LPN) #3 was interviewed on 4/21/26 at 4:37 p.m. LPN #3 said there was a list of residents that wandered and were at risk for elopement at the nurses' station. She said the residents who were on that list had wanderguards. She said the residents were reassessed quarterly for their wanderguards. She said the care plans had the residents' interventions listed. She said that a wanderguard was not a restraint, it was an alert safety device. -However, there was no documentation in Resident #3 or Resident #7's EMRs to indicate the facility had reassessed the residents to see if their wanderguards continued to be appropriate and necessary for the residents (see record review above).Registered nurse (RN) #2 was interviewed on 4/22/26 at 10:33 a.m. RN #2 said residents were assessed for elopement on admission and if a resident tried to leave or started to talk about leaving, the facility would assess them for elopement risk. She said she thought that residents would get reassessed for elopement every three months. She said interventions for wandering and elopement were on the residents' care plans. She said she did not consider a wanderguard a restraint because it did not stop the resident from leaving,but it alerted the staff that the resident was trying to leave. The DON was interviewed on 4/22/26 at 11:20 a.m. The DON said the facility assessed a resident for a wanderguard with an elopement evaluation and by monitoring the resident's behaviors. She said residents were reassessed quarterly for the wanderguard. She said the assessments were done in the EMR by the charge nurse. The DON said that a wanderguard was a restraint because it limited the resident's ability to leave the facility. She said the risk versus benefits was not listed on the consent that was given to the resident's responsible party. She said interventions should be listed on the care plan for residents who wandered or eloped. She said when a resident tried to leave the building, she expected staff to approach the resident in a calm manner and use the listed interventions from the resident's care plan. She said she did not think that the facility documented the root cause or triggers of why a resident wandered or tried to elope. She said the facility needed to add what interventions were used when a resident wandered or tried to leave the facility. She said the interdisciplinary team (IDT) would determine what the best intervention (least restrictive) were for a resident. She said they made the determination as a group, based on observations and the resident's behaviors. She said it was documented in the IDT notes. She said the assessments for the wanderguards were reviewed quarterly during the IDT meeting. -However, there was no documentation in Resident #3 or Resident #7's EMRs to indicate the facility had reassessed the residents to see if their wanderguards continued to be appropriate and necessary for the residents (see record review above).The DON said she thought that Resident #7 was due for a re-evaluation of her wanderguard, but she thought the resident still required the wanderguard due to her wandering. She said Resident #3 was also due for a re-evaluation of her wanderguard. She said Resident #3 had not tried to leave the building during her (the DON's) time working for the facility. She said she thought Resident #3 would be a good candidate to have her wanderguard removed.

Based on record review and interviews, the facility failed to ensure residents were provided services that met professional standards of quality for one (#5) of nine residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #5, who was receiving an anticoagulant medication (blood thinner), received international normalized ratio (INR) blood draws (a blood test that measures how long it takes the blood to clot) per the physician's orders.Findings include:I. Professional referenceAccording to Shikdar, Sufana et al., International Normalized Ratio (INR): Assessment, Monitoring, and Clinical Implications, StatPearls Publishing, (2025), retrieved on 4/27/26 from www.ncbi.nlm.nih.gov/books/NBK507707/, The INR is the preferred parameter for monitoring patients taking vitamin K antagonists. This variable is also used to assess the risk of bleeding and to evaluate the coagulation (clotting) status of these patients. Individuals on oral anticoagulants must monitor their INR values to adjust doses of vitamin K antagonists. Patients are typically monitored every three to four weeks. INR monitoring is most commonly required for patients taking warfarin, a vitamin K antagonist. The warfarin dose is adjusted based on INR values to maintain the therapeutic range. The anticoagulant effect of warfarin, as indicated by an INR within the target range, also helps determine when to discontinue heparin therapy.II. Resident #5A. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included the presence of a prosthetic heart valve, type 2 diabetes mellitus and long term use of anticoagulants.The 3/13/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment indicated the resident was receiving anticoagulant medication.B. Record reviewReview of Resident #5's April 2026 CPO revealed the following physician's orders:Prothrombin time (PT - measures how many seconds it takes blood to clot) and INR, in the morning every four weeks on Monday, ordered 12/1/25.Warfarin sodium tablet 5 milligrams (mg), give one tablet by mouth in the evening for treating/preventing blood clots, ordered 10/8/25. Review of Resident #5's electronic medical record (EMR) revealed the following:Resident #5's PT/INR was measured at least every four weeks as ordered by the physician throughout 2025.For 2026, Resident #5's PT/INR was measured on 1/5/26, 2/12/26 and 4/21/26.-However, the facility failed to ensure Resident #5's PT/INR was measured in March 2026.III. Staff interviewsThe director of nursing (DON) was interviewed on 4/22/26 at 1:15 p.m. The DON said Resident #5's INR was not drawn in March 2026 because the facility had a new charge nurse, and she (the DON) did not follow up with the charge nurse on the PT/INR lab draws for the month of March 2026. She said administering warfarin without knowledge of the resident's coagulation status could cause bleeding or a change of condition. The DON said the nursing staff should follow the physician's orders.Pharmacist #1 was interviewed on 4/22/26 at 2:42 p.m. Pharmacist #1 said Resident #5's PT/INR should be measured, at a minimum, monthly. She said there were target parameters for the resident's INR specific to warfarin monitoring. Pharmacist #1 said it was important to monitor the resident's INR status closely because an abnormal INR test result could increase the risk of bleeding or cause excess clotting of the resident's blood.

Based on observations, record review and interviews, the facility failed to provide supervision, assistance, services, and implement effective person-centered interventions to prevent falls for one (#34) of five residents reviewed for accidents/hazards out of 31 sample residents.Specifically, the facility failed to thoroughly assess Resident #34's falls to reduce individual risks and ineffective interventions.Findings include:I. Facility policy and procedureThe Fall- Clinical Protocol policy, revised March 2018, was provided by the nursing home administrator (NHA) on 4/22/26 at 10:09 a.m. It read in pertinent part,The staff and practitioner will review each resident's risk factors for falling and document in the medical record. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system.After a first fall, the staff (and physician, if possible) should watch the individual rise from a chair without using his or her arms, walk several paces, and return to sitting. If the individual has no difficulty or unsteadiness, additional evaluation may not be needed. If the individual has difficulty or is unsteady in performing this test, additional evaluation should occur.The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant).Falls should be categorized as those that occur while trying to rise from a sitting or lying to an upright position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor.If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors andunderlying causes.II. Resident #34A. Resident statusResident #34, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included vascular dementia, anxiety and PTSD.The 3/8/26 minimum data set (MDS) assessment documented the resident was unable to participate in the brief interview for mental status (BIMS) assessment. A staff assessment for mental status revealed she had short and long term memory loss and severely impaired decision-making abilities. The MDS assessment indicated the resident had behaviors of delusions, difficulty focusing her attention and disorganized thinking. The resident required moderate staff assistance with eating and personal hygiene. The resident only required staff supervision with toileting, showering, dressing, standing, transfers and walking. The assessment indicated the resident did not use a wheelchair. The assessment revealed the resident had not had any falls in the last six months. -However, the resident had an unwitnessed fall on 2/25/26 (see record review below). B. ObservationsDuring a continuous observation of Resident #34 in the common area on 4/20/26, beginning at 1:40 p.m. and ending at 2:57 p.m., the following was observed:At 1:40 p.m. Resident #34 was sitting in her wheelchair up against the wall in the common area across from the nurses' station. The medical records clerk was sitting at the nurses' station and two nurses were standing next to the nurses' station next to the medication cart. Resident #34 was watching the staff and then she bent down and moved her foot pedals on her wheelchair from the down position to the up position so the pedals were out of the way of her legs.At 1:42 p.m. Resident #34 put both of her hands on her arm rests and attempted to push herself up, but then sat back down. There was a staff member in the hallway three feet away from the resident and a nurse and the medical records clerk were at the nurses' station. However, no one interacted with the resident or tried to determine what she might need. At 1:44 p.m. Resident #34 bent down and locked the brakes on her wheelchair. She continued watching the staff at the nurses' station. At 1:47 p.m. Resident #34 put both of her hands on her arm rests and attempted to push herself up to stand but then saw the medical records clerk start to leave the nurses' station and she sat back down in her chair. The medical records clerk never acknowledged the resident when he walked by her. The nurse who had been sitting at the nurses' station with the medical records clerk left the nurses' station and walked away. No staff members remained at the nurses' station. At 1:50 p.m. Resident #34 put both of her hands on her arm rests and attempted to push herself up to stand. The resident was unsteady and sat back down in her chair. At 1:52 p.m. a nurse walked by and put Resident #34's foot pedals back down but did not interact with the resident or offer any stimulation to her. The nurse left the common area and left the resident alone. At 1:53 p.m. a nurse and a certified nurse aide (CNA) came to the nurses' station and sat with their backs to Resident #34. At 1:56 p.m. Resident #34 put both of her hands on her arm rests and attempted to push herself up to stand but saw the director of nursing (DON) walking by and sat back down. The DON came over to the resident and spoke with her for less than two minutes and then took the resident who was sitting next to Resident #34 away. At 1:57 p.m. the nurse and the CNA at the nurses' station walked away and left Resident #34 alone. The resident put both of her arms on her arm rests and attempted to push herself up to stand. The resident was shaky and sat back down in her chair. At 1:59 p.m. the nurse and the CNA returned to the nurses' station but turned their backs to Resident #34 when they sat down. At 2:02 p.m. the resident bent down to move her foot pedals on her wheelchair from the down position to the up position so the pedals were out of the way of her legs, then saw a CNA walking by and stopped. The DON approached the resident and provided her with a lollipop and a drink of water. At 2:10 p.m. Resident #34 finished her candy and drink and bent down to lock the left side brake on her wheelchair and lift up her left foot pedal. She continued watching the nurses' station. At 2:12 p.m. Resident #34 bent down and checked that the brakes on her wheelchair were locked. At 2:13 p.m. Resident #34 saw the DON walking by and asked to be taken to activities. The DON took her to the activities table but there was no activity going on. The DON sat Resident #34 at the table with two other residents, who ignored her, and another resident who was asleep. There were no staff members present and no one was interacting with Resident #34. From 2:13 p.m to 2:31 p.m. Resident #34 sat at the activities table waiting. At 2:31 p.m. the resident began to propel herself in her wheelchair backwards from the table. A CNA walked by, gave one of the other residents at the table a tissue and did not acknowledge that Resident #34 was trying to push herself backwards. At 2:34 p.m. a dietary aide brought drinks and snacks to the table and left. Then the activities staff member arrived and turned her back to Resident #34 while talking to another resident. The staff member did not notice that Resident #34 had pushed herself back from the table. At 2:42 p.m., while the activities staff member had her back turned, Resident #34 put both of her hands on her arm rests and attempted to push herself up to stand but then her wheelchair started to roll backwards and she sat back down. At 2:44 p.m., while the activities staff member was playing ping pong with another resident, Resident #34 reached down to lock her left brake and put the foot pedal in the upright position. At 2:45 p.m. the activities staff member came to Resident #34's table, talked to the resident sitting next to her and then walked away. During this interaction, Resident #34 was sitting in her wheelchair with one hand on the chair next to her and the other hand on her arm rest, leaning forward with her buttocks slightly lifted from her seat in a posture of attempting to go from a sitting position to a standing position. The activities staff member did not acknowledge the resident. At 2:46 p.m. Resident #34 sat back down and called a staff member over to take her to the nurses' station to call her daughter. She was tearful and appeared distressed, with the corners of her lips pulled down, in the opposite expression to a smile, and wide eyes. The two nurses at the nurses' station did not acknowledge the resident. At 2:54 p.m. Resident #34 finished her phone call and still remained tearful and distressed. The nurses at the nurses' station got up and left her sitting there. At 2:57 p.m. the DON took the resident to her office. On 4/21/26 at 9:10 a.m. Resident #34 was sitting in her wheelchair up against the wall in the common area across from the nurses' station. She put both of her hands on her arm rests and pushed herself up to a standing position. The resident stood up for five seconds and then sat back down. There were two nurses and a CNA all sitting at the nurses' station with their backs turned to Resident #34. None of the staff members observed Resident #34 standing up from her wheelchair. On 4/21/26 from 1:46 p.m. to 1:49 p.m. Resident #34 was sitting in her wheelchair up against the wall in the common area across from the nurses' station. The resident put her hands on her arm rests and attempted to push herself up to a standing position four times. A therapy staff member walked by but did not acknowledge Resident #34's multiple attempts to stand up. C. Record reviewThe fall care plan, revised 12/11/25, revealed Resident #34 was at risk for falls related to muscle weakness, back pain, dementia, insomnia, tremors, new-onset seizure (4/16/25) and medication side effects. Interventions included assisting the resident in keeping her room clutter free (initiated 2/26/26), encouraging the resident to call for assistance with ambulation/transfers when she was feeling ill or dizzy (revised 2/26/26) and not raising the footrest on her recliner (revised 4/20/26, during the survey). -The care plan failed to identify that new interventions were implemented or that the care plan was reviewed to determine if new interventions were needed following the resident's falls on 3/14/26, 3/27/26, 3/28/26, 3/31/26, 4/5/26 or 4/7/26 (see falls below). Review of Resident #34's April 2026 CPO revealed the following physician's orders:Abilify (an antipsychotic medication) 5 milligrams (mg). Give one tablet by mouth at bedtime for depression, ordered on 12/22/25.Mirtazapine (an antidepressant medication) 15 mg. Give one tablet by mouth at bedtime for insomnia, ordered on 12/22/25.Sertraline (an antidepressant medication) 100 mg. Give one tablet by mouth in the morning for depression, ordered on 12/22/25.Clonazepam (a benzodiazepine medication used to treat panic disorders) 0.5 mg. Give one tablet by mouth for anxiety, ordered on 3/17/26.Clonazepam 1 mg. Give one tablet by mouth at bedtime for insomnia, ordered on 3/17/26.Skilled physical therapy up to 36 times within 12 weeks to include therapeutic exercise, neuromuscular retraining, gait training, and wheelchair mobility/management, ordered on 4/3/26.Review of Resident #34's EMR, from 1/1/26 to 4/21/26, revealed the following:A pharmacist medication regimen review, dated 3/18/26, revealed the pharmacist had identified Resident #34 was on several medications that could increase her risk of falls, including clonazepam, sertraline, mirtazapine and Abilify. The pharmacist documented the following: Benzodiazepines are not recommended to be used in the elderly due to an increased risk of adverse effects, including death. Consider a slow taper off clonazepam, while increasing the dose of mirtazapine for insomnia. If the resident is experiencing anxiety, consider increasing the dose of sertraline for both anxiety and depression. Consider assessing the resident's vision to ensure it is not contributing to the resident's falls.The medical director (MD) responded that the resident's falls were unrelated to the above medications and no medication changes were warranted at this time. -Record review failed to reveal the facility made an optometrist appointment as recommended by the pharmacist in order to determine if possible changes in Resident #34's vision could be a potential contributor to the resident's falls. The physical therapy treatment plan, dated 4/3/26, revealed Resident #34 required therapy related to bilateral lower extremity weakness, impaired transfers, inability to walk, decreased activity tolerance and high fall risk. Physical therapy treatment notes, dated 4/3/26 to 4/22/26, revealed the resident would participate with bilateral upper extremity pull ups on hand rails but with limited tolerance for standing. The resident was inconsistent in agreeing to sessions, showing fear and anxiety related to weakness. -After 4/17/26, the resident stopped agreeing to physical therapy, however, no restorative therapy was recommended to maintain any functional gains the resident had achieved from therapy. 1. Fall on 2/25/26 - unwitnessed A fall progress note, dated 2/25/26, revealed Resident #34 was found sitting on the floor right inside her door with her knees bent in front of her. The resident was unable to tell the staff how she ended up on the floor.A post fall huddle, undated, revealed the resident did not sustain any injuries from the fall on 2/25/26. The root cause of the fall was determined to be due to an unsteady gait. No new interventions were documented as being put into place.A rehabilitation post-fall screen, dated 2/25/26, revealed that therapy recommended removing obstacles from the environment to prevent risk of falls and to set up the resident with television or music to redirect her attention. No skilled services (therapy) provided.2. Fall on 3/14/26- unwitnessedA fall occurrence note, dated 3/14/26, revealed Resident #34 was found in her room on the floor laying on her back with her legs bent up next to her bed. The resident was unable to tell the staff how she ended up on the floor.A post-fall huddle, undated, revealed the resident did not sustain any injuries from the fall on 3/14/26. The root cause of the fall was determined to be due to a new change in medication. The new intervention put into place was to conduct a medication review.A rehabilitation post-fall screen, dated 3/14/26, revealed that therapy recommended reviewing the resident's medications. No skilled services were provided.A rehabilitation post-fall screen, dated 3/23/26, revealed that therapy recommended reviewing the resident's medications. No skilled services were provided.-However, a rehabilitation post-fall screen had been previously conducted on 3/14/26 and the same recommendations had been given and no therapy services were provided.An alert note, dated 3/18/26, revealed Resident #34's clonazepam changed from 1 mg twice a day to 0.5 mg in the morning and 1mg in the evening.A follow up occurrence note, dated 3/20/26, revealed the resident was no longer ambulating independently and was unsteady on her feet. She had been in a wheelchair since 3/19/26. -Despite the resident having a change in her ability to participate in activities of daily living, there was no documentation to indicate the resident was assessed for a change of condition or that therapy was notified that she was no longer ambulating. 3. Fall on 3/27/26 - unwitnessedAn incident note, dated 3/27/26, revealed Resident #34 was found on the floor sitting on her bottom next to a chair near the nurses' station. The resident was unable to tell the staff how she ended up on the floor.A post-fall huddle, undated, revealed the resident did not sustain any injuries from the fall on 3/27/26. The root cause of the fall was determined to be due to the resident getting up from her wheelchair and not being strong enough to get up all the way. No new interventions were put into place.4. Fall on 3/28/26 - witnessedA post-fall huddle, undated, revealed the resident did not sustain any injuries from the fall on 3/28/26. The root cause of the fall was determined to be due to the resident attempting to sit on a chair in the common area. The new interventions put into place were to have physical therapy evaluate her, offer sensory activities, and ask her family to bring in snacks the resident preferred. -There were no progress notes documented in the resident's EMR regarding the fall. 5. Fall on 3/31/26 - witnessedA fall occurrence note, dated 3/31/26, revealed Resident #34 was observed sitting in a chair across from the nurses' station. The resident tried to stand, slid down onto the floor and landed on her buttocks. The resident was wearing non-skid socks, however they were noted to be slippery.A post-fall huddle, undated, revealed the resident did not sustain any injuries from the fall on 3/31/26. The root cause of the fall was determined to be due to the resident being unaware of her limitations. No new interventions were documented as being put into place.A rehabilitation post-fall screen, dated 4/2/26, revealed that the resident was on speech and physical therapy services.-However, therapy services were not implemented until after the resident had sustained four other falls (see above). 6. Fall on 4/5/26 - unwitnessedA fall occurrence note, dated 4/5/26, revealed the resident was found sitting on the floor in her room, feet facing the door, knees bent, scooting towards the door. The call light cord was under her legs and she was holding the call light in her right hand. She was last seen in her recliner with her call light. The resident was unable to tell the staff how she ended up on the floor.A post-fall huddle, undated, revealed Resident #34 did not sustain any injuries from the fall on 4/5/26. The root cause of the fall was determined to be due to the resident having weakness and she had difficulty sitting in her recliner. The new intervention put into place was to have the leg rest on her recliner be in the down position.7. Fall on 4/7/26 - unwitnessedA fall occurrence note, dated 4/7/26, revealed the resident was found sitting upright on the floor in her doorway. The staff determined the fall was due to the resident being unsteady on her feet and forgetting to use her wheelchair. The resident was unable to tell the staff how she ended up on the floor.A rehabilitation post-fall screen, dated 4/9/26, revealed that the resident was on speech and physical therapy services. -There were no post-fall huddles or new interventions documented in the resident's EMR.III. Staff interviewsCNA #3 was interviewed on 4/20/26 at 1:31 p.m. CNA #3 said she was not sure how to find fall interventions for the residents in their EMRs. CNA #3 said she did not know what Resident #34's fall interventions were. She said therapy was no longer working with the resident because she kept falling down. Licensed practical nurse (LPN) #3 was interviewed on 4/21/26 at 3:06 p.m. LPN #3 said fall interventions should be in the residents' care plans, but she was not sure how the CNAs found the fall interventions. LPN #3 said she had not looked at Resident #34's fall interventions in a long time but believed the intervention was to encourage activities for the resident. LPN #3 said therapy was working with Resident #34 on strengthening and pivoting. She said when the resident was in the common area, the staff were to keep an eye on her and redirect her if she tried to stand up.-However, multiple observations revealed staff were not monitoring the resident closely when she was in the common area (see observations above). The DON was interviewed on 4/22/26 at 9:04 a.m. The DON said Resident #34 had anxiety and sitting in the wheelchair seemed to give her a feeling of security. The DON said that the resident had a lack of strength, so therapy was implemented, sensory activities were offered, and the resident's recliner was removed from her room. She said it was the resident's preference to be seated in the common area. She said when the resident's falls were reviewed, the root cause was determined to be due to her trying to get out of her recliner in her room. The DON was informed of the observations that occurred of Resident #34 in the common area during the survey and she said she would not have expected the staff to do anything different. She said the staff had tried to offer independent sensory activities to the resident and offer group activities, but the resident did not seem interested. The DON said there were volunteers that came to see the resident and she responded very well to them. She said the volunteers did individual activities with her and visited with her. The DON said she had not analyzed what the volunteers were doing with the resident that was working in order to incorporate those interventions into the resident's plan of care to prevent falls. She said other than seating the resident in the common area and offering therapy, she was not aware of any other individualized fall interventions that could be implemented for Resident #34.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received services consistent with professional standards of practice for one (#2) of one resident reviewed for dialysis out of 31 sample residents. Specifically, the facility failed to ensure staff was assessing and documenting on Resident #2's dialysis fistula (the connection between an artery and a vein for hemodialysis) site on a routine basis.Findings include:I. Professional referenceAccording to Lok, [NAME], et al., Hemodialysis Vascular Access: Core Curriculum 2025, American Journal of Kidney Foundation, (2025), retrieved on 4/28/26 from https://www.ajkd.org/article/S0272-6386%2824%2900976-4/fulltext#:~:text=Intraoperative%20mapping%20by%20the%20operator,both%20systolic%20and%20diastolic%20components.&text=Abbreviations:%20CABG%2C%20coronary%20artery%20bypass,PICC%2C%20peripherally%20inserted%20central%20catheter, An arteriovenous fistula (AVF), created by an anastomosis (surgical connection) between a native artery and a vein, is the recommended vascular access for patients requiring hemodialysis due to its substantially lower rates of thrombosis (blood clots), infection, and health care-related expenditures (costs). The AVF should have a palpable thrill (a buzzing vibration felt by hand) and a continuous bruit (an audible whooshing sound heard with a stethoscope). The rationale for monitoring is that detection of a vascular access abnormality (such as stenosis - the narrowing of vessels) in AVF can lead to a pre-emptive (early) intervention to correct a stenosis, prevent a vascular access thrombosis from occurring and improve overall vascular access patency and function. The main principles of physical examination include inspection, palpation (touch), and auscultation (listen) of the vascular access to detect for signs of stenosis and pathologic abnormalities within the vascular access.II. Facility policy and procedureThe Hemodialysis Resident policy, undated, was provided by the nursing home administrator (NHA) on 4/22/26 at 6:42 p.m. It read in pertinent part, The vascular site will be monitored daily for thrills and auscultate (listen) for bruits. If not present, then notify the physician immediately. No invasive procedures will be done on the resident's arm in which the access site/fistula is placed. The resident's access site will be assessed every (q) shift and documented.III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included sepsis, type 2 diabetes mellitus, end stage renal disease, chronic stage 5 kidney disease and dependence on renal dialysis.The 3/9/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.The MDS assessment indicated the resident was dependent on renal dialysis and received renal dialysis upon admission and while in the facility. B. Record reviewReview of Resident #2's admission evaluation, dated 3/7/26, revealed the resident had a genitourinary diagnosis, such as dialysis, received hemodialysis and had edema (swelling) to the left arm.-However, the admission evaluation failed to identify the resident's right chest dialysis port or his left arm dialysis fistula.Resident #2's re-admission evaluation, dated 4/16/26, revealed the resident had a genitourinary diagnosis, received hemodialysis and had edema to the left arm due to the dialysis shunt.-However, the re-admission evaluation failed to identify the resident's right chest dialysis port.Review of Resident #2's April 2026 CPO revealed the following physician's orders:Monitor the central venous catheter (CVC) site every shift for signs of infection, ordered 3/25/26.Dialysis: Monitor site for bleeding and signs or symptoms of infection (right chest), ordered 3/9/26.-However, there was no physician's order to assess and monitor Resident #2's left arm fistula site. Review of Resident #2's electronic medical record (EMR), including progress notes and skilled nursing documentation, revealed the resident's left arm was edematous, and the resident required dialysis services.-However, there was no documentation in the EMR to indicate that Resident #2's left arm fistula was being assessed and monitored routinely.IV. Staff interviewsThe dialysis registered nurse (RN) was interviewed on 4/22/26 at 9:46 a.m. The dialysis RN worked at Resident #2's dialysis center. The dialysis RN said Resident #2 had both a right chest dialysis port and a left arm arteriovenous fistula in place.RN #2 was interviewed on 4/22/26 at 11:08 a.m. RN #2 said she would know if a resident had a dialysis port or fistula because it would be documented on the resident's admission documentation. She said before a resident left the facility for dialysis, the charge nurse should measure the resident's vital signs and document them on the dialysis communication handoff form. RN #2 said when a resident returned from dialysis, the nurse should take another set of vital signs to make sure the resident was stable, ask the resident how they were feeling and assess the resident's fistula site for bleeding. She said if there were any abnormalities with the resident's fistula site, the physician would be notified. RN #2 said Resident #2 had both a dialysis port and an arteriovenous fistula. She said she was not sure if the resident's fistula should be assessed every day or every shift. RN #2 searched the resident's EMR for a moment, then said the fistula should be assessed every shift.-However, there was not a physician's order for the dialysis fistula to be assessed every shift in the resident's April 2026 CPO (see physician's orders above).The director of nursing (DON) was interviewed on 4/22/26 at 1:15 p.m. The DON said the facility knew an admitting resident would be on dialysis because it would be documented in the primary referral and the resident's medical diagnosis. She said Resident #2 had both a dialysis port and an arteriovenous fistula. The DON said the nursing staff did not touch the resident's dialysis port, they just monitored the site for signs and symptoms of infection. She said the resident's fistula should be monitored daily for bruit and thrill, and it should have been documented in the skilled nursing assessments in the resident's EMR.The DON looked in Resident #2's EMR for separate physicians' orders to monitor both the resident's dialysis port and the fistula. She said there was not a physician's order to assess Resident #2's fistula, but there would be an order going forward. The DON said there should have been a physician's order to monitor Resident #2's arteriovenous fistula. She said it was important to monitor the dialysis sites in order to monitor the resident's disease process.V. Facility follow-upDuring the interview with the DON on 4/22/26 at 1:15 p.m. (see above), the DON updated Resident #2's April 2026 CPO with the following physician's order:Monitor the left upper extremity dialysis site for bruit and thrill and notify the physician if absent. Every shift, document (+) for no issues and (-) for issues noted to the site. If issues are noted, then notify the physician, ordered 4/22/26.-However, there was no documentation to indicate the nursing staff were assessing and documenting on Resident #2's left arm dialysis fistula until the concern was brought to the facility's attention during the survey.

Based on record review and interviews, the facility failed to provide a rationale to act upon the pharmacist's recommendations in a timely manner for one (#15) of nine residents out of 31 sample residents. Specifically, the facility failed to provide a rationale for not acting upon the pharmacist's recommendations for Resident #15.Findings include: I. Facility policy and procedure The Medication Regimen Reviews policy and procedure, revised 2/25, was provided by the nursing home administrator (NHA) on 4/22/26 at 10:10 a.m. It revealed in pertinent part, Upon receiving the medication recommendation report (MRR) from the pharmacist, the physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendation has been reviewed and what actions were taken to address them. II. Resident #15A. Resident status Resident #15, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included traumatic brain injury, bed confinement, anxiety disorder, quadriplegia, neuromuscular dysfunction, dementia and insomnia.The 3/24/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had impairments on both upper and lower extremities and used a wheelchair. She required partial assistance with eating and substantial assistance with oral hygiene. She was dependent on toileting, showering, personal hygiene and dressing. The assessment revealed she had an anxiety disorder. She took an antipsychotic medication, an antianxiety medication, an antidepressant medication, a hypnotic medication, and an opioid medication. The assessment revealed she took antipsychotic medications on a routine basis and a gradual dose reduction (GDR) was attempted on 7/21/25. The physician documented a GDR as clinically contraindicated on 7/21/25. The assessment revealed the section asking if the complete drug regimen review identified potential clinically significant medications was not marked and the section asking if the facility contacted the physician by midnight of the next calendar day and completed prescribed recommended actions in response to the identified potential clinically significant medication issues was not marked. B. Resident interview Resident #15 was interviewed on 4/20/26 at 9:38 a.m. Resident #15 said her pain was controlled with medication and the nurse just gave her pain medication. Resident #15 said her pain level was zero. Resident #15 said she had gained weight since she was admitted to the facility. She said she tried to choose veggies and fruit. C. Record reviewReview of Resident #15's April 2026 CPO revealed the following physician's order: Mirtazapine (an antidepressant medication) 15 milligrams (mg). Take one tablet by mouth at bedtime for insomnia, ordered 3/9/26. Risperdal (an antipsychotic medication) 1 mg. Take one tablet by mouth two times a day for uncontrolled yelling, ordered 3/9/26 and discontinued 4/14/26.Risperdal 1 mg. Take 0.5 tablet by mouth two times a day for tapering the dose until 4/21/26, ordered 4/14/26. Risperdal 1 mg. Take 0.5 tablet by mouth in the morning for tapering the dose until 4/29/26, ordered 4/22/26. Gabapentin (an anticonvulsant medication) 300 mg. Take one capsule by mouth three times a day for pain, ordered 7/9/24. Oxycodone 5 mg. Take one tablet by mouth three times a day for pain and discomfort, ordered 7/9/24. Tylenol 500 mg. Take two tablets by mouth three times a day for pain, ordered 7/7/24. Pain monitoring. Assess for pain every shift, ordered 1/2/25.Review of Resident #15's March 2025 medication administration record (MAR) and April 2025 MAR (from 3/1/26 to 4/20/26) revealed the resident's pain level had been assessed two times each day during the timeframe. The resident's pain level was documented as a 0 out 10 for each pain assessment. Review of the medication regimen review (MRR) forms provided by the facility revealed there were two sections on the form. The first section was completed by the pharmacist and provided a recommendation. The second section was the physician's response section. The physician's response section had three options for the physician to check; agree, disagree or other. If the physician marked disagree, the form instructed the physician to document a clinical rationale at the bottom of the form. Review of Resident #15's MRR from 3/1/25 to 4/1/26, revealed the following: On 12/30/25, the pharmacist recommended decreasing the resident's dose or frequency of oxycodone 5 mg. The resident took oxycodone 5 mg three times a day and all recent pain levels were zero. The physician's response section was marked disagree. -However, the physician did not document a clinical rationale to explain the reason for not decreasing the resident's oxycodone, as was recommended by the pharmacist.-Additionally, review of Resident #15's electronic medical record (EMR) did not reveal a rationale for why the pharmacist's recommendations regarding the resident's oxycodone were not addressed.On 2/10/26, the pharmacist recommended obtaining routine A1c levels (a blood lab test that averages blood glucose levels to diagnose or monitor diabetes) or finger stick blood sugar checks (a finger stick blood sugar test to provide immediate, real-time measurement of blood glucose levels) monthly because Resident #15 was receiving Risperdal twice daily. The physician response section was marked disagree.-However, the physician did not document a clinical rationale to explain the reason for not obtaining A1c levels or routine finger stick blood sugar checks, as was recommended by the pharmacist.-Additionally, review of Resident #15's EMR did not reveal a rationale for why the pharmacist's recommendations regarding the resident's A1c or routine finger stick blood sugar checks were not addressed. On 3/18/26, the pharmacist recommended decreasing the resident's dose of Lexapro to 15 mg daily due to Resident #15 having started mirtazapine for insomnia. The resident was taking Lexapro for anxiety, however, Lexapro was an activating antidepressant and could cause insomnia. The physician's response was marked disagree.-However, the physician did not document a clinical rationale to explain the reason for not decreasing the resident's Lexapro, as was recommended by the pharmacist.-Additionally, review of Resident #15's EMR did not reveal a rationale for why the pharmacist's recommendations regarding decreasing the resident's Lexapro were not addressed. III. Staff interviews The director of nursing (DON) was interviewed on 4/21/26 at 4:30 p.m. The DON said she was new to the position of being a DON. She said she was responsible for reviewing the pharmacist's recommendations. She said she was aware the physician disagreed with the pharmacist's recommendations. The DON said the physician did not provide a rationale for why he disagreed with the recommendations. She said the physician was responsible for reviewing the pharmacist's recommendations. She said she printed the recommendations and the physician reviewed the recommendations when he was in the facility, which was once a week on Mondays. She said once the physician reviewed the pharmacist's recommendation, the pharmacy provided a DON report that summarized the recommendations. The DON said in addition to the physician's report that required the physician's review due to needing a physician's order, she received a DON report from the pharmacy that summarized the pharmacist's recommendations from the physician's report. The DON said she hand wrote if the physician wanted to make any changes on the DON report. -However, review of the DON report did not reveal documentation to indicate a rationale for why the pharmacist's recommendations were not addressed for Resident #15. The DON said she was familiar with Resident #15. She said she was aware the pharmacist recommended obtaining A1c levels or monthly fasting blood sugar checks due to Resident #15 being on risperidone (which can cause weight gain). She said she did not know the rationale the physician provided for not ordering laboratory (lab) blood work to be drawn or a monthly fasting blood sugar check. The DON said she was aware of the pharmacist's recommendation to decrease Resident #15's dose or frequency of oxycodone 5 mg due to the resident reporting pain levels of zero. The DON said she did not know the physician's rationale for not decreasing the dose or frequency of the resident's oxycodone. The DON said she was aware the pharmacist recommended decreasing Resident #15's Lexapro from 20 mg to 15 mg due to the resident starting mirtazapine for insomnia. The DON said she did not know the physician's rationale for not decreasing the resident's Lexapro dose. The DON said she was aware Resident #15 had gained weight. She said Resident #15 had asked for new clothes because she did not fit in the clothes she wore. The DON said she was aware mirtazapine not only helped with insomnia but with appetite loss. She said she talked to the physician about Resident #15's weight gain and he did not provide a rationale for not changing any of Resident #15's medications. Pharmacist #1 was interviewed on 4/22/26 at 2:45 p.m. Pharmacist #1 said she was the supervising pharmacist for the facility's pharmacist (pharmacist #2) who was unavailable. She said a pharmacist reviewed each resident's medications once a month and as needed. She said once a resident's medications were reviewed, there were three reports the pharmacist provided to the facility. She said the first report was a list of residents who were reviewed and no recommendations were made. Pharmacist #1 said the second report was a list of residents who the pharmacist made recommendations that the physician needed to review. She said the third report was a list of residents who the pharmacist made recommendations for that the DON needed to review. Pharmacist #1 said the pharmacist's recommendations should be reviewed as soon as possible and at the latest, reviewed within 30 days. She said once the pharmacist made a recommendation, the physician needed to check if they agreed with the recommendation, disagreed or make other comments. She said if the physician disagreed, the physician should document the rationale in the space provided on the form. Pharmacist #1 said the pharmacists followed up to see what the physician's response was. Pharmacist #1 said she was not familiar with Resident #15. Pharmacist #1 said she was aware the facility's physician was not agreeing with the recommendations made by pharmacist #2 and was not providing a rationale as to why the recommendations were not agreed with. She said it was very common for the physician to disagree with the pharmacist's recommendation and there were many conversations about concerns without providing a rationale for disagreeing with the recommendations. Pharmacist #1 said she would have pharmacist #2 call when he was available to talk about Resident #15. Pharmacist #2 was interviewed on 4/27/26 at 4:59 p.m., upon his return to the pharmacy. Pharmacist #2 said he had been the facility's pharmacist consultant for eight years. He said he had not been responsible for the medication regimen reviews since May 2025. Pharmacist #2 said a pharmacist reviewed each resident's medication regimen once a month and as needed. He said the pharmacist shared three reports with the facility. He said the first report was a list of residents who were reviewed and no recommendations were made. Pharmacist #2 said the second report was a list of residents who the pharmacist made recommendations for that the physician needed to review. He said the third report was a list of residents who the pharmacist made recommendations for that the DON needed to review. Pharmacist #2 said the recommendations should be reviewed as soon as possible and at the latest, they needed to be reviewed within 30 days. He said once the pharmacist made a recommendation, the physician needed to check if they agreed with the recommendation, disagreed or make other comments. He said if the physician disagreed, the physician should document the rationale in the space provided on the form. Pharmacist #2 said the pharmacist followed up to see what the physician's response was. Pharmacist #2 said he was familiar with Resident #15 based on attending quarterly psychotropic pharmacy meetings with the facility. Pharmacist #2 said he said he had not completed MRRs for the facility since May 2025 and another pharmacist was now responsible for that. Pharmacist #2 said he was not aware of the pharmacist's recommendations for Resident #15 and was not aware Resident #15 had gained weight. He said a pharmacist would recommend an A1c or a finger stick blood sugar test because it helped to see if the medication caused anything to change metabolically.Pharmacist #2 said medication regimen review was important because it was vital for the resident. He said often there were residents who were unable to advocate for themselves and monthly medication review was one way for pharmacists to advocate for the resident. He said monthly medication review was a way to optimize pharmacy therapy and the pharmacists strived to provide the highest quality of life to the facility's residents. Pharmacist #2 said when he completed the facility's MRRs previously, he knew the physician did not agree with the pharmacist's recommendations. He said it was important for the physician to provide a rationale for why they disagreed with the recommendations because it helped understand where the physician was coming from.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#34) of four residents reviewed for antibiotic stewardship out of 31 sample residents. Specifically, the facility failed to ensure Resident #34's antibiotic therapy for a potential urinary tract infection (UTI) was discontinued in a timely manner after the facility received a negative urine culture and sensitivity (C&S - a test that identifies the organism in the urine and determines the most effective antibiotic therapy) report.Findings include:I. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 4/27/26 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, To track how and why antibiotics are prescribed, providers perform reviews on resident medical records for new antibiotics started to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.II. Facility policy and procedureThe Antibiotic Stewardship policy, dated December 2016, was provided by the nursing home administrator (NHA) on 4/22/26 at 6:43 p.m. It read in pertinent part, The purpose of our Antibiotic Stewardship program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C&S) is ordered, lab (laboratory) results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued.III. Resident #34A. Resident statusResident #34, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included vascular dementia (a decline in thinking skills caused by blockages/reduced blood flow to the brain), seizures, osteoarthritis and adult failure to thrive. The 3/8/26 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score of 99, which indicated the resident was unable to complete the assessment. The staff assessment for mental status revealed the resident had severely impaired cognition and rarely made decisions.B. Record reviewReview of Resident #34's electronic medical record (EMR) revealed the following progress notes:On 2/2/26 at 1:33 p.m. Resident #34 expressed pain/burning with urination. The charge nurse, registered nurse (RN) #2, was notified, said she would notify the physician and perform a urine dip.On 2/3/26 at 4:50 p.m. Resident #34 had a urine dip completed which identified protein and leukocytes (white blood cells) in the resident's urine. The physician was notified and a physician's order for Macrobid (an antibiotic medication) was obtained. A urine sample sent to the lab for a C&S report. The resident's representative was notified via phone.On 2/6/26 at 5:03 p.m. Resident #34's urine C&S report came back on the urine sample. Final results indicated there was less than 10,000 colony-forming units per milliliter (CFU/mL) of urogenital flora at day one and 20,000-30,000 CFU/mL mixed flora (usually indicates low-level growth of multiple bacterial types, often suggesting contamination from the skin or genital area rather than a true infection) at day two. The physician was notified.On 2/7/26 at 5:24 p.m. Resident #34 continued to receive macrobid. The note indicated the C&S report came back negative for UTI. On 2/10/26 at 12:50 p.m. The physician was contacted for a stop date for Resident #34's Macrobid. The physician said the medication should have been taken for five days, so the medication was discontinued.-However, the facility failed to ensure Resident #34 did not receive antibiotics unnecessarily and the resident was administered Macrobid for seven days before it was discontinued (see below).Review of Resident #34's February 2026 CPO revealed the following physician's order:Macrobid oral capsule 100 milligrams (mg), give one capsule by mouth two times a day for UTI, ordered 2/3/26 at 8:00 a.m. and discontinued on 2/10/26 at 12:49 p.m.-Review of Resident #34's February 2026 medication administration record (MAR) revealed the resident was administered an additional eight doses of Macrobid after the facility received the negative urine C&S report on 2/7/26 and before it was discontinued by the physician on 2/10/26.IV. Staff interviewsThe infection preventionist (IP) was interviewed on 4/22/26 at 1:35 p.m. The IP said the biggest goal of the antibiotic stewardship program was to work with the medical director (MD) to try to get him more on board with antibiotic stewardship. She said the facility used McGeer's criteria (standardized, evidence-based criteria used to identify infections in long-term care (LTC) facilities) and wanted the physician to utilize the same criteria. The IP said in this resident population, a change in mental status did not always mean a UTI was present, but if the physician at the facility was notified about a change in a resident's mental status, he would start Macrobid. The IP said the facility should be investigating further by waiting for the urine C&S report to return prior to starting the resident on antibiotics.The IP searched the charge nurse's phone for communication between the nursing staff and the MD regarding the discontinuation of Resident #34's Macrobid order, however, she was unable to find additional information. She said she made a progress note when she discontinued the Macrobid and included a note that the Macrobid was intended for five days.The IP said Resident #34's Macrobid order should have been discontinued on 2/7/26 when the urine C&S report came back, but she did not see the result until she called the physician on 2/10/26. She said it was important that antibiotic therapy was used only when clinically relevant so the facility did not get colonized residents (bacteria present on or in a host, such as skin, gut, or respiratory tract that grow without causing an immune response) or multidrug resistant organisms (MDROs - bacteria and other microorganisms that have developed resistance to multiple or all commonly used antibiotics and antimicrobial agents).

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#2) of seven residents reviewed for foley catheter care and catheter assessments out of eleven sample residents.Specifically, the facility failed to ensure staff were appropriately trained in the care needs of a resident with quadriplegia and effectively monitoring Resident #2, who had an indwelling foley catheter for signs and symptoms of urinary retention. This resulted in the resident being transferred to the hospital where she was admitted to the hospital's intensive care unit for a higher level of care. Resident #2, was admitted [DATE] with diagnoses of quadriplegia, acute renal failure, dementia, dysfunctional bladder and severe cognitive impairment. Resident #2 was admitted with an indwelling foley catheter for continuous bladder drainage. On 10/31/25 at 5:29 a.m. a night shift CNA documented Resident #2 had a urine output volume of 300 ml emptied from the urine collection bag for the overnight shift of 10/30/25 into 10/31/25. On 10/31/25 at 5:59 p.m. a day shift CNA documented Resident #2 had a urine output volume of 300 ml of urine emptied from the urine collection bag for the day shift on 10/31/25.Twelve hours later on 11/1/25 at 5:59 a.m. a night shift CNA documented Resident #2 had zero ml of urine emptied from the urine collection bag.-Resident #2 had a total of 300 ml of urine output for the 24-hour period between 10/31/25 at 5:29 a.m. and 11/1/25 at 5:59 a.m. However, the resident's decreased urinary output was not communicated to the nurse or the physician and Resident #2 was not assessed for any complications of urinary retention. The facility was not conducting nurse assessments or monitoring the resident for impaired urinary elimination or urine characteristics that could indicate a concern regarding the resident's urinary status.On 11/1/25 at 1:50 p.m. the nurse was notified by staff that Resident #2 was not responding or waking up (to verbal stimuli). The nurse assessed Resident #2 and found the resident with respiratory distress, but the resident opened and closed her eyes to physical stimuli. The resident's vital signs were as follows: blood pressure was 159/82 millimeters of mercury (mmHg), heart rate was 13 bpm (beats per minute), respirations were 22 breaths per minute, temperature was 98.6 and the resident's oxygen saturation (oxygen level in the blood) was 75% on room air. The nurse called 911 and the resident was transferred to the hospital emergency department. On 11/1/25, after being evaluated by the emergency department, Resident #2 was admitted to the hospital for altered mental status and required respiratory intubation (inserting a tube into the airway) for airway protection. The foley catheter was removed from the bladder and 2000 milliliters (ml) of bloody urine with pus was drained. The computed tomography (CT) scan in the emergency department revealed the resident had bilateral hydronephrosis (swelling of both kidneys due to a build up of urine), and debris in the bladder. Resident #2 was diagnosed with severe sepsis (the body's extreme reaction to an infection, which can lead to organ failure, tissue damage and death if not treated promptly), acute respiratory failure, and myocardial infarction (heart attack), and required placement on a ventilator. Resident #2 was stabilized and transferred to a different hospital's intensive care unit for higher level of care. Staff interviews on 11/4/25, during the survey, revealed staff were lacking important knowledge and training in regards to caring for residents that had indwelling foley catheters and those with dysfunctional bladders, as well as the care needs of residents with quadriplegia.Findings include:I. Findings of immediate jeopardyOn 10/31/25 at 5:29 a.m. a night shift CNA documented Resident #2 had a urine output volume of 300 ml emptied from the urine collection bag for the overnight shift of 10/30/25 into 10/31/25. On 10/31/25 at 5:59 p.m. a day shift CNA documented Resident #2 had a urine output volume of 300 ml of urine emptied from the urine collection bag for the day shift on 10/31/25.Twelve hours later on 11/1/25 at 5:59 a.m. a night shift CNA documented Resident #2 had zero ml of urine emptied from the urine collection bag.-Resident #2 had a total of 300 ml of urine output for the 24-hour period between 10/31/25 at 5:29 a.m. and 11/1/25 at 5:59 a.m. However, the resident's decreased urinary output was not communicated to the nurse or the physician and the resident was not assessed for any complications of urinary retention. The facility was not conducting nurse assessments or monitoring the resident for impaired urinary elimination or urine characteristics (color, odor, clarity) that could indicate a concern regarding the resident's urinary status.On 11/1/25 at 1:50 p.m. the nurse was notified by staff that Resident #2 was not responding or waking up (to verbal stimuli). The nurse assessed Resident #2 and found the resident with respiratory distress, but the resident opened and closed her eyes to physical stimuli. The resident's vital signs were as follows: blood pressure was 159/82 mmHg, heart rate was 131 bpm, respirations were 22 breaths per minute, temperature was 98.6 and oxygen saturation was 75% on room air. The nurse called 911 and the resident was transferred to the hospital emergency department. On 11/1/25 after being evaluated at the emergency department, the resident was admitted to the hospital for encephalopathy and required respiratory intubation for airway protection. The resident's foley catheter was removed and 2000 ml of bloody urine with pus was drained. The CT scan in the emergency department revealed the resident had bilateral hydronephrosis and debris in the bladder. Resident #2 was diagnosed with severe sepsis, acute respiratory failure, and a myocardial infarction, and required placement on a ventilator. Resident #2 was stabilized and transferred to a different hospital's intensive care unit for higher level of care. The director of nursing (DON) was interviewed on 11/1/25 (during the survey) and said the CNAs were expected to notify the nurse when a resident's urine output was low. The DON said when the CNAs performed catheter care they should also check the placement of the urine drainage bag and verify urine was draining from the bladder.Staff interviews on 11/4/25 (during the survey) revealed staff were lacking important knowledge and training in regards to caring for residents that had indwelling foley catheters and those with dysfunctional bladders, as well as the care needs for residents with quadriplegia.B. Facility notification of immediate jeopardyOn 11/5/25 at 12:45 p.m. the NHA was notified of the immediate jeopardy findings for failure to assess Resident #2's Foley catheter patency and monitor urine output.C. Facility plan to remove the immediate jeopardyOn 11/6/25 at 5:40 p.m. the nursing home administrator (NHA) provided a plan to remove the immediate jeopardy situation. The removal plan read:Plan of CorrectionOn 11/5/25, education for all nurses and CNAs on daily catheter care, as well as monitoring and reporting of urinary output, was completed by the DON or designee prior to the next scheduled shift. Nurses were also educated on how to perform bladder assessments for residents with indwelling catheters prior to their next scheduled shift. This education included a special focus on residents who are unable to communicate or who are paralyzed and therefore can not express or feel whether they are emptying their bladders. On 11/5/25, all residents with indwelling catheters were audited for their last catheter change date and ensured accurate physician's orders were obtained for the next catheter change. The electronic medication administration record (eMAR) was reviewed to ensure accurate orders were in place, including those for catheter care, urinary output monitoring and catheter replacement. All residents with indwelling catheters were assessed by the DON for bladder fullness to ensure proper catheter drainage. One additional resident was identified as being affected by this deficient practice. An as needed catheter change physician's order was needed and was added by the DON for the other identified resident. On 11/5/25 a shift evaluation for residents with dwelling catheters was implemented. This evaluation included assessments of bladder status, urine output, potential blockages and urine characteristics. These evaluations will include new admission and readmissions to be done upon admission and every shift thereafter. These evaluations will be conducted by floor nurses every shift and documented on a User Defined Assessment (UDA) inside the eMAR. The evaluation is named Nursing-Foley Catheter Evaluation. These evaluations will continue for the duration of the resident's indwelling catheter. Abnormal findings from the floor nurse will be reported to the director of nursing and the on-call physician. All new admissions, readmissions, and newly ordered indwelling Foley catheters will be audited by the DON or designee to ensure that catheter insertions are completed in accordance with physician's orders. Additionally, all new admissions with indwelling catheters will be audited by the DON or designee to confirm the presence of appropriate physician orders and nursing interventions for daily catheter care. The audit will be completed five times a week by the director of nursing or Designee. E. Removal of immediate jeopardyOn 11/6/25 at 5:48 p.m. the NHA was notified the immediate jeopardy situation was removed, based on the facility's plan and evidence of its implementation. However, deficient practice remained at a G level, actual harm that was not immediate jeopardy, isolated. II. Facility policy and procedureThe Urinary Catheter Care policy and procedure, undated, was received from the DON on 11/4/25 at 3:15 p.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The procedure is as follows:-Review the resident's care plan to assess any special needs of the resident;-Empty the collection bag at least every eight hours;-Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor;-Follow the facility procedure for measuring and documenting input and output;-Check the resident frequently to be sure he or she was not lying on the catheter and to keep the catheter and tubing free of kinks;-If the catheter material contributes to obstruction, notify the physician, and change the catheter if instructed to do so;-Catheter irrigation may be ordered to prevent obstruction; and,-Report unusual findings to the physician immediately. The following information should be recorded in the resident's medical record:-All assessment data obtained when giving catheter care;-Character of urine such as color, clarity, and odor;-Any problems noted at the catheter-urethral junction; and,-Any problems or complaints made by the resident.III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included quadriplegia, acute renal failure, dementia and dysfunctional bladder.The 10/29/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. Resident #2 was dependent on staff assistance for all activities of daily living (ADL). The MDS assessment identified Resident #2 had an indwelling foley catheter for continuous bladder drainage.B. Hospital nurse interviewThe hospital nurse was interviewed by telephone on 11/4/25 at 10:00 a.m. The hospital nurse said she was working on 11/1/25 when Resident #2 arrived in the emergency room. The hospital nurse said she felt Resident #2's abdomen and it was hard and full. She said when she removed the resident's brief, it was full of blood from leakage around the catheter insertion site. She said when she removed the catheter, there was projectile (forcefully ejected) drainage of 2000 ml of pus and blood from Resident #2's bladder. She said that Resident #2 appeared septic and near death and required a flight for life helicopter ambulance transfer to another hospital for a higher level of care.C. Record reviewThe baseline care plan, initiated on 10/28/25, revealed Resident #2 had an indwelling Foley catheter. Pertinent interventions included monitoring for signs and symptoms of a urinary tract infection, blood in the urine, cloudiness, foul smell, fever, change in mental status (initiated 10/28/25), irrigating the Foley catheter as indicated (initiated 10/28/25), keeping tubing free of kinks and twists (initiated 10/28/25) and providing catheter care every shift and as needed (initiated 10/28/25). -The baseline care plan did not include nursing care interventions to assess Resident #2 for urine characteristics, catheter obstruction, catheter placement, or special needs assessments of complications related to quadriplegia, such as autonomic dysreflexia. The 10/22/25 nurse admission summary revealed Resident #2 had an indwelling Foley catheter that was patent (open and draining unobstructed) and was draining yellow urine with sediment (happens when crystals, bacteria, or blood exit through the urine and can be the result of dehydration or infections) noted in the urine. The physician was notified and gave no new orders.-There were no additional nurse assessments documented in the progress noted for urine characteristics, catheter placement or catheter patency.The 11/1/25 at 2:18 p.m. nurse progress note documented that Resident #2 was unresponsive to verbal and sternal rub. The physician was notified of the resident's condition and gave an order to transfer Resident #2 to the emergency department for evaluation.The November 2025 treatment administration record (TAR) documented Resident #2 received a Foley catheter for the first shift. However, the nursing order was signed and completed by the CNA with medication authority (CNA-Med). The TAR revealed there were no physician's orders to assess the Foley catheter for placement, patency, volume or urine characteristics.On 10/31/25 at 5:29 a.m. a night shift CNA documented Resident #2 had a urine output volume of 300 ml emptied from the urine collection bag for the overnight shift of 10/30/25 into 10/31/25. On 10/31/25 at 5:59 p.m. a day shift CNA documented Resident #2 had a urine output volume of 300 ml of urine emptied from the urine collection bag for the day shift on 10/31/25.Twelve hours later on 11/1/25 at 5:59 a.m. a night shift CNA documented Resident #2 had zero ml of urine emptied from the urine collection bag.-Resident #2 had a total of 300 ml of urine output for the 24-hour period between 10/31/25 at 5:29 a.m. and 11/1/25 at 5:59 a.m. The 11/1/25 hospital progress notes documented Resident #2 was admitted into the intensive care and was diagnosed with metabolic encephalopathy, septic shock, acute cystitis, acute kidney injury, bilateral hydronephrosis (swelling of both kidneys due to build up of urine), urinary tract infection, obstructive uropathy, acute respiratory failure required respiratory intubation for airway protection, a myocardial infarction (heart attack) and required placement on a ventilator. D. Staff interviewsThe DON was interviewed on 11/3/25 at 2:30 and said the CNAs were expected to notify the nurse when the urine output was low. The DON said when the CNAs performed catheter care they should also check the placement of the urine drainage bag and verify urine was able to drain from the bladder. The DON said the CNA that documented the 11/1/25 zero ml urine output should have reported the low urine output to the nurse. The DON said if the nurse was aware the urine output was low, the nurse would assess the Foley catheter for placement or occlusion and intervene as appropriate. The DON said the nurse assigned to care for Resident #2 on 11/1/25 was a traveling nurse and was unavailable for an interview during the investigation. The DON said that CNA-Meds were CNAs that had completed certification to administer medications. The DON said the CNA-Meds should not be administering nursing care and signing off physician's orders on the TARs.CNA #1 was interviewed on 11/4/25 at 3:00 p.m. CNA #1 said she had received training on how to provide Foley catheter care to residents. She said that when a resident had a Foley catheter, the CNA was tasked with monitoring and documenting urine output during their shift. CNA #1 said she was unsure what amount of urine was considered to be low and said if she noticed a low amount or if the urine looked dark or bloody, she would report that to the nurse. Licensed practical nurse (LPN #1) was interviewed on 11/4/25 at 3:10 p.m. She said CNAs provide indwelling Foley care every shift. LPN #1 said the nurse should also monitor Foley catheters every shift to ensure the catheter was secure and not obstructed. LPN #1 said when catheters were obstructed, nurses could reposition or flush the catheter with saline in an attempt to have the catheter drain. LPN #1 said that if a catheter occlusion was not cleared, the catheter could be removed and replaced. LPN #1 said if a resident had decreased or no urine output during the shift, the physician should be notified. The medical director (MD) was interviewed on 11/5/25 at 9:06 a.m. The MD said residents that were quadriplegic could develop autonomic dysreflexia (a potentially life-threatening condition that can occur in people with spinal cord injuries) which could lead to loss of consciousness. He said it was important for nursing staff to assess residents and feel for a full bladder to make sure the Foley catheter drained the bladder properly for those that were quadriplegic because they could not feel pain from a full bladder. The MD said the fact that there was 2000 ml of urine in Resident #2's bladder at the hospital meant the resident's Foley catheter was dysfunctional and should have been assessed and replaced. The MD said nursing care to monitor urine output volume, urine characteristics, and catheter placement were considered standards of practice and should have been completed by the nursing staff.The NHA was interviewed on 11/5/25 at 12:30 p.m. The NHA said she was aware Resident #2 had a change in condition and was transferred to the hospital on [DATE]. The NHA said the facility started an investigation on 11/1/25 regarding Resident #2. The NHA said the investigation was not completed and said they had identified nursing staff would receive inservice education on Foley catheter care and for CNAs to ensure they completed frequent rounding on residents. The NHA said the CNAs should monitor urine output every two hours during their shift. The NHA said the facility had a failure of systems and communication between staff members in regards to Resident #2.

Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#10) of three residents reviewed for abuse out of 11 sample residents.Resident #10 was admitted on [DATE] with diagnoses of autistic disorder, dementia and depression.Resident #11 was admitted on [DATE] with diagnoses of dementia and schizophrenia (mental illness).On 9/7/25, Resident #10 entered the facility from outside. Resident #11 approached Resident #10 and pushed him to the floor. Resident #10 complained of left leg pain and was transferred to the hospital where he was diagnosed with a femur fracture that required surgical repair. Specifically, the facility failed to protect Resident #10 from physical abuse by Resident #11.Findings include:I. Facility policy and procedureThe Resident Rights, dated December 2021, was provided by the nursing home administrator (NHA) on 11/3/25 at 2:30 p.m. It read in pertinent part: Federal and state laws guarantee certain basic rights to all residents. These rights include the right to be free from abuse.II. Incident of physical abuse by Resident #11 towards Resident #10 on 9/7/25The 9/7/25 facility investigation revealed that on 9/7/25 at 11:10 a.m. a staff member observed Resident #10 fall. The investigation revealed the nurse on duty responded. Resident #10 reported he entered the facility from outside, Resident #11 approached him and pushed him down to the floor. The facility staff immediately separated the residents for safety. Resident #10 reported he had pain in his leg and he was transferred to the emergency department for evaluation. Resident #10 was diagnosed with a fractured femur which required surgery to repair the fracture. The investigation documented the NHA interviewed Resident #10 on 9/7/25. Resident #10 said he was very angry about the incident. He said he had not had any previous altercations with Resident #11.The investigation documented Resident #11 was assessed by the nurse and had no injuries. Resident #11 was placed on safety checks for 72 hours. The investigation documented the NHA interviewed Resident #11 on 9/7/25. Resident #11 denied that there had been any conflict with Resident #10 and said he did not do anything to Resident #10. The investigation documented the NHA reviewed camera footage on 9/7/25 and observed Resident #11 push Resident #10 to the floor. The investigation documented that Resident #11 was transferred on 9/8/25 to a new room in the facility, on a different hallway to keep the residents separated. The NHA interviewed four facility residents and they said they had no concerns about physical abuse and said they felt safe at the facility.The investigation documented the facility substantiated the incident of physical abuse. III. Resident #10 (victim)A. Resident statusResident #10, age greater than 65, was admitted on [DATE], discharged to the hospital 9/7/25 and readmitted on [DATE]. According to the November 2025 computerized physician's orders (CPO), diagnoses included fracture of the left femur, autistic disorder, dementia and depression.The 10/6/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score 12 out of 15.The assessment documented Resident #10 had no behaviors directed toward himself or others during the assessment period. Resident #10 required set up assistance/supervision for bed mobility, transfers, walking in his room, hallway, and unit. The assessment identified Resident #10 used a cane or crutch for walking. B. Resident interviewResident #10 was interviewed on 11/5/25 at 2:45 p.m. Resident #10 said he remembered when Resident #11 pushed him to the floor. Resident #10 said Resident #11 approached him as he entered the facility from the outside patio and pushed him, which caused him to fall. Resident #10 said he was upset his femur was fractured and that he had to have surgery. Resident #10 said he was healing and was working towards gaining strength while walking. Resident #10 said he had no concerns and was not afraid of Resident #11 although he was cautious about being pushed by anyone. Resident #10 said there were no previous altercations between himself and Resident #11. C. Record reviewThe behavior care plan, revised 8/21/24, revealed Resident #10 had the potential for verbal aggression. Pertinent interventions included monitoring target behavior (8/21/24), administering medications as prescribed (7/14/24) and redirecting the resident to his room or a calm area (7/14/24).The 9/7/25 nurse progress note revealed Resident #10 yelled out why did you do that. The nurse responded. Resident #10 told the nurse he was pushed by Resident #11 and he fell. The nurse completed an assessment and Resident #10 was transferred to the hospital for evaluation of leg pain.The 9/17/25 nurse progress note revealed Resident #10 returned to the facility with physician's orders for physical and occupational therapy for balance and strengthening.IV. Resident #11 (assailant)A. Resident statusResident #11, age greater than 65, was admitted on [DATE]. According to the November 2025 CPO, diagnoses included dementia and schizophrenia.The 10/6/25 MDS assessment revealed Resident #11 had severe cognitive impairments with a BIMS score of zero out of 15. The assessment revealed Resident #11 had difficulty focusing on attention, had trouble focusing on what was being said and had disorganized thinking. Resident #11 was independent with transfers and ambulationThe assessment revealed Resident #11 had no behaviors towards himself or others during the assessment look-back period. B. Record reviewThe behavior care plan, revised l2/24/23, revealed Resident #11 was at risk for behaviors. Pertinent interventions included redirecting the resident to a safe area and monitoring for safety if he appeared dangerous (2/24/23). The schizophrenia care plan, revised 7/29/24, revealed Resident #11 had a diagnosis of schizophrenia. Pertinent interventions included encouraging the resident to attend and participate in activities or hobbies to increase socialization (7/29/24), providing ongoing evaluation to document mood and medication management (7/29/24) and monitoring and documenting target behaviors (6/6/19).The 9/8/25 progress note documented Resident #11 was moved to a different room. -Review of Resident #11's electronic medical record (EMR) did not reveal documentation regarding the incident on 9/27/25.V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/5/25 at 3:00 p.m. CNA #1 said she heard Resident #10 and Resident #11 had an altercation. She said Resident #11 pushed Resident #10 to the floor. CNA #1 said she was trained to monitor residents when they were agitated and redirected the residents when necessary. CNA #1 said Resident #10 and Resident #11 enjoyed and participated in activities. She said they had had no behaviors or concerns since the 9/7/25 incident. The NHA was interviewed on 11/5/25 at 12:30 p.m. The NHA said Resident #10 and Resident #11 both had a history of behaviors but not within the previous 12 months. She said Resident #10 had a history of agitation but had an effective care plan. The NHA said Resident #11 had a history of making sexual statements towards others and had not been physically aggressive. The NHA said staff responded appropriately to the incident. She said the residents were assessed and separated and monitored. The NHA said Resident #11 was moved to another hallway in the facility as a precaution. The NHA said Resident #10 returned to the facility and received therapy. The NHA said Resident #10 was almost at his baseline for walking. The NHA said when residents at the facility had a history of behaviors, the staff monitored the residents closely. She said the staff anticipated the resident's needs and redirected residents when necessary to avoid altercations. The NHA said a staff member was in the same room at the time of the incident on 9/7/25. The NHA said Resident #11 pushed Resident #10 as they passed each other near the exit doorway.

Based on , observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for two (#1 and #2) of five residents reviewed for wound care and weekly skin assessments out of 11 sample residents.Resident #1 was admitted on [DATE] and discharged to the hospital on [DATE]. Resident #1 had a diagnosis of heart failure, multiple sclerosis, dementia and diabetes. Resident #1 had a history of hemorrhoids and was receiving as needed topical medication. Upon admission to the hospital on [DATE], it was discovered that Resident #1 had a perianal abscess which required surgery and intravenous (IV) antibiotics. Review of the facility documentation revealed the facility failed to complete skin assessments to monitor the status of the resident's hemorrhoids. Specifically, the facility failed to: -Complete weekly skin assessments for Resident #1, who had developed a perianal abscess; and,-Obtain wound care physician's orders for Resident #2.Findings include:I. Facility policy and procedureThe Skin Inspection policy, undated, was received from the nursing home administrator (NHA) on 11/6/25 at 2:37 p.m. It read in pertinent part, Every seven to 10 days each resident will have a head to toe skin inspection. The skin inspection will be documented within the EHR (electronic health record), using the skin inspection evaluation. The Wound Care policy and procedure, dated 2001, was received by the director of nursing (DON) on 11/3/25 at 2:30 p.m. It read in pertinent part, The purpose of this procedure is to provide guidance for the care of wounds to promote healing. Procedure instructions:-Verfify there is a physician's order for the procedure.-Review the care plan to assess for special needs of the resident; -Document the type of wound car given; and,-Document all assessment data (wound bed color, size, drainage) obtained when inspecting the wound.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE], discharged to the hospital on 9/30/25, readmitted to the facility on [DATE] and discharged again to the hospital on [DATE]. According to the November 2025 computerized physician orders (CPO), diagnoses included heart failure, progressive multiple sclerosis, dementia and diabetes mellitus.The 10/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. Resident #1 required substantial to maximum assistance from staff for dressing and bed mobility and was dependent on staff for transfers.The MDS assessment documented Resident #1 had no skin problems, received applications of ointments and medication during the assessment look-back period. B. Hospital nurse interviewThe hospital nurse was interviewed by telephone on 11/4/25 at 10:00 a.m. The hospital nurse said she was working on 11/1/25 when Resident #1 arrived in the emergency room. The hospital nurse said the facility reported Resident #1 had a hemorrhoid and wanted to be transferred to the emergency department. The hospital nurse said the resident arrived at the hospital with a pressure injury on his buttocks. The nurse said the resident was transferred to another hospital for higher level of care for surgical treatment of the buttocks wound.B. Record reviewThe skin integrity care plan, initiated 7/16/21, revealed Resident #1 had a risk for impaired skin integrity. Pertinent interventions included assisting with turning and repositioning as needed (6/11/25), completing skin inspections every seven to 10 days and as needed (3/23/23), notifying the physician of new areas of impaired skin integrity (3/3/23), implementing a pressure redistribution mattress to the resident's bed (3/3/23), implementing a pressure relieving pad for the resident's wheelchair (9/30/25) and reducing friction or shearing forces (6/11/25). Review of the November 2025 CPO revealed a physician's order for hemorrhoidal relief external cream 5% (percent) lidocaine (anorectal), apply to anal area topically every eight hours as needed for hemorrhoids, ordered 5/27/25.-Review of Resident #1's comprehensive care plan did not reveal documentation regarding the resident's hemorrhoids. -Review of Resident #1's electronic medical record (EMR) did not reveal documentation indicating skin assessments were completed from 10/2/25 to 10/24/25.The 11/1/25 nurse progress note documented Resident #1 complained of hemorrhoid pain and requested to go to bed. The resident's vital signs were taken. The resident's temperature was 97.5 degrees Fahrenheit, heart rate was 56 beats per minute (bpm), respirations were 26 breaths per minute, and blood pressure was 82/48 millimeters of mercury (mmHg) (normal blood pressure is 120/80). The nurse notified the physician of the resident's status and gave an order to have the resident transferred to the emergency department for evaluation. The 11/1/25 emergency department's physician documented Resident #1 reported not feeling well for several days and was sent to the emergency department because his blood pressure was low. The 11/1/25 computerized tomography (CT) scan completed at the emergency department revealed Resident #1 had a 5 centimeter (cm) by 3.7 cm by 4 cm area on her sacrum concerning to be an abscess. Resident #1 was transferred to a higher level of care for a surgical evaluation. The 11/1/25 hospital history and physical revealed Resident #1 was diagnosed with a perianal abscess. The resident required surgical drainage of the abscess and was treated with IV antibiotics. III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the November 2025 CPO, diagnoses included quadriplegia, acute renal failure, dementia and dysfunctional bladder.The 10/29/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. Resident #2 was dependent on staff assistance for all activities of daily living (ADL). The MDS assessment identified Resident #2 had an indwelling Foley catheter for continuous bladder drainage.B. Hospital nurse interviewThe hospital nurse was interviewed by telephone on 11/4/25 at 10:00 a.m. The hospital nurse said she was working on 11/1/25 when Resident #2 arrived in the emergency room. The hospital nurse said Resident #2 arrived visibly dirty and unkempt. She said the resident had significant skin breakdown on her sacrum and other areas of her body. C. Record reviewThe skin integrity care plan, initiated 10/28/25, revealed Resident #2 had stage 3 pressure wounds prior to admission. Pertinent interventions included completing a skin inspection every seven to 10 days and as needed (10/28/25) and administering medication and treatments per physician orders (10/28/25). The 10/21/25 hospital discharge orders included physician's orders for wound care that included: wound care for the sacrum, cleanse back and sacrum with body wipes and let dry. Apply a thick amount of Triad cream to areas daily and leave the area open to air.The 10/25/25 wound evaluation note read that Resident #2 had an unchanged wound on her buttocks with a plan to continue treatment as ordered.-Review of Resident #2's October 2025 and November 2025 CPO did not reveal physician's orders for wound treatments. -Review of Resident #2's EMR did not reveal documentation indicating the facility assessed the resident's skin after the 10/25/25 wound care note or provided wound care as recommended in the 10/21/25 hospital discharge instructions. IV. Staff interviewsThe DON was interviewed on 11/3/25 at 3:40 p.m. The DON said when a resident was admitted to the facility, the admitting nurse was responsible for reviewing and entering the physician's orders and the hospital discharge instructions. She said if a resident went to an appointment, the nurse on duty was responsible for entering new physician's orders after an outpatient physician appointment. The DON said after new orders were entered, a second nurse was responsible for reviewing the orders and/or instructions for accuracy and completeness. The DON said if a resident was admitted with a need for wound care, the wound care nurse (WCN) was responsible for completing the wound care evaluation and reviewing wound care orders. The DON said the wound care nurse evaluated Resident #2's skin and documented the wound was coated with cream and would reassess the wound after Resident #2 was cleaned/bathed. The DON said that the wound care nurse did not return to complete the wound evaluation and did not verify the wound care orders or initiate a wound care plan of care for Resident #2. The DON said the facility had not provided wound care to Resident #2 during her admission from 10/22/25 to 11/1/25, because they failed to initiate the physician's wound care orders.The WCN was interviewed on 11/6/25 at 4:45 p.m. The WCN said she was unsure why the admitting nurse did not enter physician's orders for wound care for Resident #1. The WCN said after she completed wound evaluations, if there was a need to change wound care orders, she contacted the physician for new orders. The WCN said she forgot to reassess the wounds and to write a baseline care plan for Resident #2's wound care. The DON was interviewed again on 11/4/25 at 11:00 a.m. The DON said Resident #1 had a history of a blister on his buttocks that was healed on 10/2/25. The DON said she was unable to find skin assessments for Resident #1 from 10/2/25 to 10/24/25. The DON said the 10/2/25 skin assessment documented Resident #1 had intact skin and had not complained about hemorrhoid pain until 11/1/25, just before he was transferred to the emergency department. The DON said the nurse assigned to provide care to Resident #1 on 11/1/25 did not assess Resident #1's skin for his hemorrhoid pain prior to his transfer to the hospital due to the resident's changing condition.The NHA was interviewed on 11/5/25 at 12:25 p.m. The NHA said she was aware the wound care orders for Resident #2 were not noted or entered by the nursing staff. The NHA said the facility identified on 11/3/25 (during the survey) that there was a system failure and the wound care orders were missed by the nursing staff. The NHA said she was working with the DON to develop a process and a checklist to ensure nurses reviewed and entered physician's orders into the EMR. The NHA said the policy for skin assessments was that a nurse completed a skin check every seven to 10 days on every resident. The NHA said she was aware the October 2025 skin assessments were not completed for Resident #1. The NHA said she was working with the DON to develop an audit and checklist to ensure skin assessments and documentation were completed according to physician's orders and facility policy.

Based on record review and interviews, the facility failed to ensure the resident had the right to be free from involuntary seclusion not required to treat the resident's medical symptoms for one (#2) of one out of seven sample residents.Specifically, the facility failed to ensure Resident #2 was not told to go to her room or taken to her room as punishment for her behaviors. Findings include: I. Facility policy and procedureThe Resident Rights policy, revised December 2021, was provided by the nursing home administrator (NHA) on 7/24/2 at 3:20 p.m. It read in pertinent part, Federal and state laws guarantee certain rights to all residents of this facility. These rights include the resident's right to a dignified existence, to be treated with respect, kindness, and dignity, to be free from involuntary seclusion, to be supported by the facility in exercising resident rights, and to have equal access to quality care.II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician's order (CPO), diagnoses included unspecified dementia with unspecified severity without behavioral disturbance and other specified depressive episodes. The 4/6/25 minimum data set (MDS) assessment revealed Resident #2 had short-term and long-term memory problems per staff assessment. Resident #2 required supervision from staff for activities of daily living (ADLs).The MDS assessment indicated the resident had no behavioral symptoms. B. Resident interviewResident #2 was interviewed on 7/24/25 at 1:22 p.m. Resident #2 said that she liked living in the facility and was happy. She said there were a few other residents who yelled a lot. Resident #2 said she liked playing Bingo and looked forward to playing it.Resident #2 said she recalled times when she was told by staff to return to her room, but she could not remember when or why.C. Record reviewThe behaviors care plan, initiated 4/13/22 and revised 8/6/24, identified Resident #2 had behaviors related to feeding and pushing other residents in their wheelchairs. Pertinent interventions included approaching the resident in a calm manner and telling her it was unsafe to feed other residents (reviewed 8/6/24), offering and providing the resident activities of interest for positive interactions (revised 8/6/24), providing the resident with positive feedback when her behavior was appropriate and emphasizing positive aspects of compliance (revised 8/6/24).-Review of the comprehensive care plan did not identify an intervention for sending the resident to her room when she displayed behaviors. Cross reference F744: failure to provide person-centered dementia care.The 6/10/25 nursing progress note revealed Resident #2 was asked to eat her lunch in her room due to her behavior in the dining room, which included yelling and taunting other residents. The 7/4/25 nursing progress note revealed Resident #2 was redirected by staff for her behavior and told that if she was not nice, she had to go to her room.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 7/24/25 at 1:55 p.m. LPN #1 said when a resident was disruptive she spoke with the resident and gave them a warning. She said she would tell the residents that they would be removed from the activity or returned to their room. She said she made her decisions on behavior management based on what she thought was appropriate for each situation. The director of nursing (DON) was interviewed on 7/22/25 at 3:10 p.m. The DON said the facility did not have a policy for resident disciplinary action that allowed the staff to send residents to their rooms and cancel participation in future activities. The DON said when residents had disruptive behaviors, it was necessary to separate the residents for the safety of others. The DON said that if residents were redirected, the resident should be offered an alternate activity or intervention and should not be sent to their room.

Based on interviews and record review, the facility failed to provide person-centered dementia care and services for two (#2 and #1) of seven residents reviewed for dementia care out of seven sample residents.Specifically, the facility failed to:-Implement appropriate person-centered dementia interventions for Resident #2; and,-Implement person-centered dementia interventions for Resident #1.Findings include: I. Facility policy and procedureThe Dementia Clinical Protocol policy, undated, was provided by the nursing home administrator (NHA) on 7/24/2 at 3:20 p.m. It read in pertinent part, For individuals with dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize function and quality of life.Direct care staff will support the resident with initiating and completing activities and tasks of daily living. The IDT will identify and document resident condition and level of support needed during care planning and review changing needs as they arise. The physician will order appropriate interventions to address significant behavioral symptoms. The staff will monitor the individual with dementia for changes in condition. The physician and staff will review the effectiveness and complications of medications used and adjust medications as needed.II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included unspecified dementia with unspecified severity without behavioral disturbance and other specified depressive episodes.The 4/6/25 minimum data set (MDS) assessment revealed Resident #2 had short-term and long-term memory problems per staff assessment. Resident #2 required supervision from staff for activities of daily living and was independent with mobility.The MDS assessment indicated the resident had no behavioral symptoms during the look back period.B. Record reviewThe behavior care plan, initiated 4/13/22 and revised 8/6/24, identified Resident #2 had behaviors related to feeding and pushing other residents in their wheelchairs. Pertinent interventions included approaching the resident in a calm manner and telling her it was unsafe to feed other residents (revised 8/6/24), offering and providing the resident activities of interest for positive interactions (revised 8/6/24), providing the resident with positive feedback when her behavior was appropriate and emphasizing positive aspects of compliance (revised 8/6/24).Review of the July 2025 CPO revealed a physician's order that indicated for the staff to monitor the resident for behaviors of hitting, kicking, verbal aggression, and taunting behaviors, and if behaviors were observed, enter a progress note, ordered 6/9/25.The 6/10/25 nursing progress note revealed that Resident #2 was asked to eat her lunch in her room due to her behavior in the dining room, which included yelling and taunting other residents. Cross reference F603: failure to be free from involuntary seclusion. -The facility failed to implement appropriate person-centered interventions to address Resident #2's behaviors. The 7/4/25 nursing progress note revealed Resident #2 was redirected by staff for her behavior and told that if she was not nice, she had to go to her room. -The facility failed to implement appropriate person-centered interventions to address Resident #2's behaviors. 4. Resident interview and observationResident #2 was observed and interviewed on 7/24/25 at 1:22 p.m. in her room. Resident #2 sat in her recliner and held a needlepoint craft. Resident #2 said that she liked living in the facility and was happy. She said there were a few other residents who yelled a lot. Resident #2 said she loved playing Bingo and looked forward to playing it.Resident #2 said she recalled times she was told to return to her room, but she could not remember when or why. Resident #2 said she was offered another needlepoint craft to work on in her room. Resident #2 said she enjoyed the needlepoint but was concerned she might miss the bingo games.III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to another facility on 6/30/25. According to the June 2025 CPO, diagnoses included dementia with unspecified severity, with agitation and Alzheimer's disease.The 6/26/25 MDS assessment revealed Resident #1 was moderately impaired with daily decision making, had short and long-term memory problems, and was severely impaired with cognitive skills for daily decision making per staff assessment. During the look-back period, Resident #1 had short and long-term memory problems, inattention, and disorganized thinking were continuously present, and the resident wandered daily.The MDS assessment identified Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others during the look-back period. Resident #1 required moderate to substantial assistance from staff for activities of daily living, and required supervision or touching assistance for standing, transferring, and walking.B. Record reviewThe behavior and wandering care plan, initiated 3/27/25, revealed the resident had exit-seeking behaviors and wandered throughout the facility with no sense of direction. Pertinent interventions included monitoring Resident #1 for side effects and effectiveness of psychotropic medications (initiated 3/27/25), calmly approaching the resident and re-approaching the resident if she appeared frustrated, agitated, or if behavior escalated (initiated 3/27/25), monitoring the resident prevent the resident from getting too closed and/or touching other residents (initiated 3/27/25), monitoring the resident for going into other residents' rooms (initiated 3/27/25), giving the resident non-judemental support, keeping the resident safe during episodes of behavior and offering and providing activities of interest to keep the resident engaged in positive interactions (initiated 6/4/25).-Review of Resident #1's comprehensive care plan did not reveal documentation regarding Resident #1's behaviors of urinating and defecating in public places or interventions for the staff to implement to address the resident's behaviors (see interviews below).Review of the June 2025 CPO revealed the following physician's orders:Wander guard, ordered 3/21/25;Behavior monitoring for wandering around the facility and into other resident rooms, ordered 3/27/24;Offer non-pharmacological behavior interventions, to include providing a , calm, positive, one-on-one quiet environment, offering snacks and diversion activities, reorienting and redirecting the resident, ordered 6/4/25.-Review of Resident #1's electronic medical record (EMR) did not reveal documentation regarding Resident #1's behavior of urinating and defecating in public areas or interventions that were implemented to address the resident's fear of using her own restroom (see interviews below).IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 7/24/25 at 1:35 p.m. CNA #1 said she was provided dementia care training at staff meetings and during shift reports. She said she understood residents with dementia were frequently unable to communicate their needs. CNA #1 said she was not aware of specific interventions for Resident #1 and Resident #2's dementia behaviors. CNA #1 said she knew Resident #1 wandered around the facility and was challenging to monitor. CNA #1 said Resident #1 had behaviors of urinating and defecating in other residents' rooms and sometimes in common areas. -However, review of Resident #1's EMR did not reveal documentation of Resident #1's behaviors of urinating and defecating in other resident's rooms or common areas (see record review above).CNA #1 said the staff made attempts to redirect Resident #1 while she wandered and were sometimes unable to respond timely to prevent Resident #1's behavior. CNA #1 said she redirected residents when behaviors were disruptive during activities but did not know how to arrange alternate activities or how often to monitor residents when they had escalated behaviors. Licensed practical nurse (LPN) #1 was interviewed on 7/24/25 at 1:55 p.m. She said Resident #1 and Resident #2 had dementia and behavior issues. LPN #1 said Resident #1 wandered throughout the facility and into other residents' rooms. LPN #1 said the staff monitored Resident #1 when she wandered around the facility but could not always intervene promptly. She said she would tell the residents that they would be removed from the activity or returned to their room if they had behaviors. She said she made her decisions for behavior management based on what she thought was appropriate for each situation. The DON was interviewed on 7/22/25 at 3:10 p.m. The DON said Resident #1 had wandering behaviors while she was admitted to the facility. The DON said Resident #1 was fearful of using the bathroom in her room and wandered into other rooms or facility areas to urinate and/or defecate. The DON said the nurse should document behaviors urinating defecating in public areas in the resident chart. The DON said behavior documentation was important to monitor effectiveness of care provided by the facility staff. The DON was unable to locate documentation of staff interventions for Resident #1's wandering and touching other residents (see record review above). The DON said the facility did not have a policy for resident disciplinary action, that allowed staff to send residents to their rooms and cancel participation in future activities. The DON said when residents had disruptive behavior it was necessary to separate residents for the safety of others. The DON said if residents were redirected, the residents should have an alternate activity or intervention offered and not be sent to their room. The DON said Resident #2 had a history of behavior concerns of yelling at othersThe DON said she was unable to locate dementia plans of care for Resident #2that identified appropriate interventions to address Resident #2's behavior, rather than sending the resident to her room The DON said the facility recently had a staff turnover in the MDS coordinator position and the new MDS coordinator was learning how to write and develop plans of care for dementia care. The DON said she would work with the MDS coordinator to update care plans for dementia care residents.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #2 (hired on 5/24/19), CNA #3 (hired on 12/8/10), CNA #4 (hired on 7/22/10) and CNA #5 (hired on 4/29/14) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The nursing home administrator (NHA) was interviewed on 3/21/24 at 1:10 p.m. She said she could not locate the performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on record review and interviews, the facility failed to ensure three (#36, #40 and #49) of five residents were free from unnecessary psychotropic medications out of 23 sample residents. Specifically, the facility failed to: -Implement effective individualized behavior monitoring in the medical record to determine the efficacy of psychoactive medications for Residents #36, #40 and #49; and, -Ensure consents to review the risks versus benefits were in place prior to administration of psychotropic medications for Residents #40 and #49. Findings include: I. Facility policy The Psychopharmacological policy, dated July 2022, was provided by the nursing home administrator (NHA) on 3/25/24 at 11:57 a.m. It read in pertinent part: Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: -Anti-psychotics, antidepressants, anti-anxiety medications; and hypnotics. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes indications for use and adequate monitoring for efficacy and adverse consequences. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. II. Resident #36 A. Resident status Resident #36, age under 65, was admitted on [DATE]. According to the March 2024 computerized physician order (CPO), diagnoses included stroke, anxiety disorder and depressive disorder. The 2/4/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. No behaviors were indicated. B. Record review The psychosocial care plan, revised 8/3/23, revealed the resident took psychotropic medications (Amitriptyline and Seroquel) related to anxiety and depression. The resident had a psycho-social well being deficit related to anxiety and depression. He had a impaired psychiatric mood related to his stroke. Interventions included offering a non pharmacological behavior intervention prior to the behavior medication administration such as offering him fluids/snacks, toileting, one-on-one activities, repositioning, and to re approach him at a later time. Staff were to monitor for signs of mood changes or distress, observe and report any changes in mental status caused by situational stressors. Behavior monitoring initiated 1/18/24 for Amitriptyline (antidepressant) for crying and Seroquel (antipsychotic) for agitation. The March 2024 CPO revealed the following physician orders: Seroquel 50 milligram (MG)- give one tablet a day for other depressive episodes-ordered on 4/3/23; Amitriptyline150 MG- give two tablets a day for other depressive episodes-ordered on 5/4/23; Behavior monitoring for Amitriptyline for crying outbursts-ordered on 8/2/23; Offer non pharmacological behavior interventions prior to behavior medication administration. Non pharmacological behavior interventions that are effective include: offer fluids/snacks, toileting, one-on-one activity, repositioning, and to re approach at a later time-ordered on 8/4/23; and, Behavior monitoring for Seroquel for agitation-ordered on 1/4/24. -A review of the certified nurse aide (CNA) behavior monitoring from 1/1/24 to 3/24/24 failed to reveal any episodes of agitation or tearfulness. A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 1/1/24 to 3/24/24 revealed: Behaviors indicated related to Amitriptyline as occurring on 1/8/24. -No behaviors were indicated related to Seroquel in January, February, or March 2024. Non pharmacological interventions were tried on 1/1/24, 1/2/24, 1/8/24, 1/14/24, 1/15/24, 1/22/24, 1/23/24, 1/25/24, 1/26/24, 1/28/24, 1/29/24, 2/4/24, 2/5/24, 2/7/24-2/12/24, 2/18/24, 2/20/24 and 2/25/24. -However, the documentation failed to indicate what interventions were tried and what medication the interventions were associated with. -There were no behaviors observed indicated in the resident's progress notes from 1/1/24 to 3/24/24. Non pharmacological interventions indicated in the MAR and TAR were not documented in the progress notes. C. Staff interviews CNA #1 was interviewed on 3/25/24 at 10:22 a.m. She said the CNAs documented behaviors in the point of care (POC) system for CNA charting. If the behavior was not part of the generalized list of behaviors, the CNA would notify the charge nurse verbally for the charge nurse to document. If the social services director (SSD) wanted the staff to monitor for a specific behavior or use a specific intervention, the SSD would verbally let the staff know of the expectation. She said the behaviors the staff were monitoring for Resident #36 were tearfulness and emotional outbursts. The resident struggled with being young and having to live in a nursing home related to his stroke and causing him to become tearful. She was not aware of the non pharmacological interventions for the resident. Registered nurse (RN) #1 was interviewed on 3/25/24 at 11:40 a.m. She said the nurses documented the resident behaviors on the MAR in the resident's chart. The nurse made a progress note indicating the behavior and interventions tried. She said Resident #36 had behaviors of tearfulness. He struggled with adjustment to his deficits and placement. She used distractions when he was tearful by engaging him in stretching when he came to the nurses station. The SSD was interviewed on 3/25/24 at 1:42 p.m. She said the medical records director (MRD) entered the behaviors in an order for the nurses to document on the MARs. The non pharmacological interventions were a separate order entered by the MRD. Behavior tracking was pulled by the director of nursing (DON) for the psychotropic drug review meeting. Behavior tracking reports were used to determine the efficacy of medications and if the medications needed to be continued. If a resident did not display behaviors in a three month period, the medication associated with those behaviors would be reviewed for a dose reduction or to be discontinued. If the resident was taking multiple medications, a behavior tracker would be initiated for each medication. She did not know if there were separate non pharmacological intervention trackers for each medication. The non pharmacological trackers were used to determine if alternative interventions were successful for the resident. She did not know if the DON reviewed the behavior tracking from the CNA charting for the meeting. The SSD did not have a process for auditing if consents were in place for the medications. She said Resident #36 had behaviors of crying outbursts. The resident had a recent divorce after his stroke and randomly cried regarding the loss of his spouse and his independence. The staff were tracking agitation and crying outbursts. The resident would display agitation regarding having to live in a nursing facility. The SSD did not know if the resident had a dose reduction of any of his medications in the last three months. The MRD was interviewed on 3/25/24 at 2:58 p.m. He said residents taking psychotropic medications required a behavior tracker to be initiated on the MAR within a few days of starting the medication. The nurses gave him the behavior information to include on the tracker. The non pharmacological tracking was a separate order. There should be a non pharmacological tracker for each medication. The DON was interviewed on 3/26/24 at 11:39 a.m. She said the MRD would consult with the nurses regarding which behaviors needed to be included on the behavior tracker. The non pharmacological tracker did not allow the staff to enter what interventions were tried and successful, the nursing staff entered the interventions in the resident's progress notes. She said the staff were to use a non pharmacological intervention when the resident displayed behaviors to determine if the medication was necessary and if a least restrictive approach could be used. The CNAs were to document behaviors in the POC system but the behaviors on the CNA trackers were generalized and not resident specific. The DON said if the resident displayed a behavior not indicated on the tracker, the CNAs reported the behavior and the intervention to the nurse to document in the resident's progress notes. She said the behavior tracking was used to determine the efficacy of the psychotropic medication. If a resident had not displayed behaviors in a three month period, the medication should be reviewed for a dose reduction or to be discontinued. III. Resident #40 A. Resident status Resident #40, age under 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included mild cognitive impairment, anxiety, depression, obsessive compulsive disorder and mild intellectual disabilities. The 2/11/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. No behaviors were indicated. B. Record review The psychosocial care plan, revised 1/12/24, revealed the resident took psychotropic medications related to anxiety and depression. The resident had a psycho-social well being deficit related to anxiety and an intellectual disability. The resident exhibited behaviors of skin picking until the skin bled related to an obsessive compulsive disorder. Interventions included offering a non pharmacological behavior interventions prior to the behavior medication administration such as offering him a calm approach, positive reassurance, one-on-one, a quiet environment, fluids/snacks, diversion activities, re-orientation, and redirection. Behavior monitoring initiated 1/18/24 for Lexapro for crying outbursts and Seroquel for scratching skin. The March 2024 CPO revealed the following physician orders: Quetiapine (Seroquel) 50 MG- give two tablets for anxiety-ordered on 10/3/23; Lexapro (antidepressant) 10 MG- give one a day for depression- ordered on 10/24/23; Offer non pharmacological behavior interventions prior to behavior medication administration. Non pharmacological behavior interventions that are effective include: calm approach, positive reassurance, one-on-one, quiet environment, offering of fluids/snacks, diversion activities, reorientation, and redirection-ordered on 12/3/23; Behavior monitoring for Lexapro (antidepressant) for crying outbursts/losing, forgetting, or misplacing items-ordered on 1/16/24; Behavior monitoring for Seroquel for scratching skin until bleeding-ordered on 1/16/24; Lorazepam (Ativan) (antianxiety) 0.5 MG- give one tablet every 6 hours for 14 days PRN for anxiety- ordered on 3/2/24 and discontinued 3/16/24; and, Lorazepam 0.5 MG- give two tablets every 6 hours for 14 days PRN for anxiety-ordered on 3/17/24. -A review of the CNA behavior monitoring from 1/1/24 to 3/24/24 failed to reveal any episodes of frustration, anger at others or scratching and picking at self. A review of the resident's MAR and TAR from 1/1/24 to 3/24/24 revealed: Behaviors indicated related to Seroquel as occurring on 1/22/24, 1/29/24, 1/31/24, 2/25/24 and 3/4/24. Behaviors indicated related to Lorazepam as occurring on 1/2/24, 2/1/24, 2/3/24, 2/7/24, 2/8/24, 2/10/24, 2/14/23, 3/2/24, 3/3/24, 3/4/24, 3/15/24, 3/17/24, 3/21/24, 3/22/24 and 3/23/24. -No behaviors were indicated related to Lexapro in January to March 2024. Non pharmacological interventions were tried to 1/1/24, 1/14/24, 1/15/24, 1/22/24, 1/28/24, 1/29/24, 2/2/24, 2/3/24, 2/5/24, 2/9/24-2/12/24, 2/17/24, 2/19/24, 2/25/24, 3/4/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24-3/21/24 and 3/23/24-3/25/24. -However, the documentation failed to indicate what interventions were tried and what medication the interventions were associated with. Progress notes reviewed from 1/1/24 to 3/24/24 revealed: Behaviors marked as observed on 1/3/24, 1/7/24, 1/8/24, 1/17/24, 1/21/24, 1/22/24, 1/29/24, 1/31/24, 2/7/24-2/10/24, 2/18/24, 2/22/24, 2/25/24, 2/27/24, 2/28/24, 3/1/24, 3/4/24, 3/8/24, 3/15/24, 3/22/24 and 3/24/24. -However, no description of the behaviors were included in the note. Lorazepam PRN given on 3/2/24, 3/3/24, 3/4/24, 3/16/24, 3/17/24, 3/22/24 and 3/24/24. Progress notes documented the PRN was effective. -However, no behaviors or non pharmacological interventions were documented. -No consents that reviewed the risks versus benefits associated with taking the medications were located for the Lorazapem. C. Staff interviews CNA #1 was interviewed on 3/25/24 at 10:22 a.m. She said Resident #40 had behaviors of scratching himself when he became anxious. The resident would perseverate on a concern and it was difficult to redirect him. She said the Lorazeam was effective when he would perseverate. RN #1 was interviewed on 3/25/24 at 11:40 a.m. She said the resident used PRN Lorazepam for anxiety and when he would scratch himself. He had a developmental delay and could be challenging to redirect. RN #1 said she did not use non pharmacological interventions with Resident #40 because his behaviors would get out of control. The SSD was interviewed on 3/25/24 at 1:42 p.m. The SSD said the resident took PRN Lorazepam for anxiety and the behavior and non pharmacological interventions needed to be documented to determine if the medication needed to be continued as a PRN or become scheduled. Lorazepam was a medication which required a consent from the resident or the resident's responsible party prior to administration. She gave the consent forms to the MRD to scan into the resident's medication record. The DON was interviewed on 3/26/24 at 11:39 a.m. The DON said the SSD was responsible for obtaining the consents prior to the administration of the medications but the DON did not have a process to check to ensure the consents were in place. When a PRN medication was used, behaviors needed to be documented along with the non pharmacological interventions tried before the administration of the medication. She said the documentation was entered into the resident's progress notes. If a resident was on multiple psychotropic medications then there should be multiple non pharmacological intervention trackers because each medication was given for specific behavior. The DON said if there were not coinciding intervention trackers, the facility would not be able to determine which interventions were effective with which behavior. IV. Resident #49 A. Resident status Resident #49, age 93, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included dementia with behavioral disturbances. The 1/7/24 MDS assessment documented the resident was severely cognitively impaired and unable to complete the assessment. The staff interview revealed the resident had severely impaired decision making. No behaviors were indicated. B. Record review The psychosocial care plan, revised 1/9/24, revealed the resident took psychotropic medications related to mood stabilization and insomnia. The resident had a psycho-social well being deficit related to acute onset of delirium and dementia. Behavior monitoring initiated 1/9/24 for Seroquel for yelling. The March 2024 CPO revealed the following physician orders: Seroquel 25 MG- give one tablet twice a day for dementia with behavioral disturbances-ordered on 1/22/24 and discontinued 3/18/24; Seroquel 50 MG- give one tablet twice a day for dementia with behavioral disturbances-ordered on 3/19/24. Offer non pharmacological behavior interventions prior to behavior medication administration. Non pharmacological behavior interventions that were effective included: calm approach, positive reassurance, one-on-one, quiet environment, offering of fluids/snacks, diversion activities, reorientation, and redirection- ordered on 12/3/23; and, Behavior monitoring for Seroquel for yelling- ordered on 8/31/23. -A review of the CNA behavior monitoring from 1/1/24 to 3/24/24 failed to reveal any episodes of frustration or anger at others. A review of the resident's MAR and TAR from 1/1/24 to 3/24/24 revealed: Behaviors indicated related to Seroquel as occurring on 1/3/24 and 3/4/24. Non pharmacological interventions were tried on 1/1/24, 1/3/24, 1/8/24, 1/14/24, 1/15/24, 1/28/24, 1/29/24, 2/5/24, 2/10/24, 2/11/24, 2/12/24, 2/19/24, 2/25/24, 3/4/24, 3/9/24, 3/10/24, 3/11/24, 3/18/24-3/21/24 and 3/23/24-3/25/24. Progress notes reviewed from 1/1/24 to 3/24/24 revealed: Behaviors marked as observed on 1/3/24. The resident was yelling out where am I. Staff told her where she was and took the resident to breakfast without complications. Behaviors marked as observed on 3/17/24. The resident was yelling she was hungry and going back and forth to her room. No non-pharmacological interventions were documented. -No consents to review the risks versus benefirs of the medication were located for Seroquel. C. Staff interviews CNA #1 was interviewed on 3/25/24 at 10:22 a.m. She said Resident #49 had advanced dementia and had behaviors of yelling out. She frequently yelled out for food even after eating due to her short term memory deficits. She could be redirected with food or to an activity. RN #1 was interviewed on 3/25/24 at 11:40 a.m. She said the resident had behaviors of yelling out for food and propelling herself in and out of her room. If the staff provided her with food or candy, the resident could be redirected. The SSD was interviewed on 3/25/24 at 1:42 p.m. She said the resident yelled out when she wanted food or wanted to lie down. The resident was taking Seroquel for her yelling out. The resident yelled out when she was anxious. The behavior tracker should specify what yelling out behavior was being tracked regarding the Seroquel. The SSD said sometimes a resident might be yelling out for an unmet need and an unmet need was not a behavior requiring medication. The staff should anticipate unmet needs to prevent yelling out. Seroquel was a medication which required a consent from the resident or the resident's responsible party prior to administration. The DON was interviewed on 3/26/24 at 11:39 a.m. She said if a resident's behavior tracker only indicated a behavior such as yelling out, the tracker failed to specify if the yelling was for an unmet need or an uncontrollable behavior. If a resident communicated by yelling, this would not be a behavior to administer an antipsychotic medication for.

Based on record review and interview, the facility failed to prevent neglect for one (#4) of three residents reviewed for injuries of nine sample residents. During Resident #4's rehabilitation stay, the resident suffered a hip dislocation of unknown origin. Resident #4 was admitted to the facility on [DATE] for rehabilitation after surgery to his left hip. He had severe cognitive impairment and required extensive two-person assistance for care. Eighteen days later he was transferred to the hospital with the same hip having been dislocated. The facility stated the hip became dislocated due to his movement while in bed. The hospital records documented the cause of the dislocation was unknown. Hospital records further documented the resident had a pressure injury on his left heel. Subsequently, the resident had to have a second procedure to have the hip repaired from the dislocation. The facility failures contributed to the resident suffering a pressure injury, dislocated hip, hospitalization and additional surgery to repair the dislocation. Findings include: I. Facility policy The Nursing Dept. Unexplained Injury policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 11:23 a.m. It included in pertinent part the following: Policy: An investigation of all unexplained injuries (including bruises and abrasions) is conducted by nursing administration to ensure that resident safety was not jeopardized. Procedure: 1. Licensed nursing personnel are responsible for the initiation and completion of accident/incident reports and clinical notes. 2. The charge nurse completes a list of all staff members who cared for the injured resident within the last 48 hours and submits it to the Director of Nursing along with the completed accident/incident report. 3. The charge nurse reviews the situation with the unit staff. 4. The Director of Nursing reviews each case, and identifies trends and methods to eliminate such occurrences. 5. Reported per occurrence reporting manual. 6. Update resident care plan. 7. Document in clinical notes. II. Hip dislocation [DATE] A. Resident #4 status Resident #4, age 77, was admitted on [DATE]. According to the [DATE] computerized physician order [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). He needed extensive assistance (two people) with bed mobility, transfers, locomotion off and on the unit, dressing, toilet use and personal hygiene. B. Record review The baseline care plan dated [DATE] identified: -Transfer with the assistance of two -Toileting with the assistance of two -Bed mobility was dependent on staff -Incontinent of bladder and bowel The care plan, dated [DATE], identified the risk for falls related to left [MEDICAL CONDITION] (diagnosed [DATE]), history of falls, the need for extensive assistance with activities of daily living (ADLs), and urinary incontinence. He has a [DIAGNOSES REDACTED]. -Assure call light is within reach, encourage to use call light and staff will answer promptly. -Ensure resident wears properly fitting non-skid soled footwear -Keep call light within arm's length and teach how to use call light to request assistance. -Maintain an environment free of clutter and safety hazards. -Report to the medical doctor (MD) any side effects associated with the resident's medication use. -Provide and monitor use of adaptive devices. -Remind residents and reinforce safety awareness. -Report falls to MD. The progress note dated [DATE] at 10:01 a.m. written by physical therapist (PT) #1 included, Certified nurse aide (CNA) reported bulge in left hip which was reported to charge nurse Monday. Nursing report no abnormal findings at that time. Upon reassessment today patient presents with leg length differential (left shorter than right) . Patient also showing difficulty with alignment even after re-positioning several times. After several attempts to standing with max(imum) assist with two persons, nursing re-assess and decided to send patient to hospital for x-ray. The progress note dated [DATE] at 3:08 p.m. included, It was noted during therapy this morning that resident's left leg was rotating inward. Resident sent to (nearby hospital) radiology for x-ray of hip and femur. Resident's wife was notified. It was discovered that hip was dislocated and the resident has been sent to (larger hospital). A handwritten note provided by the nursing home administrator (NHA) on [DATE] at 10:00 a.m. documented: [DATE]- Resident #4, a reported 'bulge'. X-ray completed, sent to (larger hospital). -9:00 a.m. called registered nurse (RN) #1. 'CNA reported bulge to me. He was up in chair when reported. I assessed, no bulge or abnormality noted. No grimacing or signs of pain.' -9:20 a.m. CNA #1, 'When I was getting him up his hip looked different like a ball or bulge. He didn't show signs of pain. I then got him ready for the day and reported to (the) charge nurse. She assessed him and didn't find anything.' Will continue to follow up with hospital. The note did not have a signature or a time documented to identify when the note was written. The facility did not have further information regarding the hip dislocation. (Cross-reference F610, failure to investigate.) Hospital records received [DATE] at 12:05 p.m. via facsimile dated [DATE] documented, Resident #4 was brought from the nursing home to (nearby hospital) emergency department (ED) after possible fall .Unclear if the patient had a fall or not .admitted to (larger hospital) for left hip dislocation. C. Interviews A family member was interviewed on [DATE] at 9:45 a.m. She said Resident #4 had been admitted to the facility for rehabilitation following hip surgery. He had previously lived at home with her. She said when she was notified of Resident #4 going to the hospital she had been told he had dislocated his hip. She said she asked how the dislocation happened. She said the facility had told her they were not sure and ended the conversation. The facility staff did not call her back, and she did not readmit the resident to the facility after his hospitalization and surgery. She said he died a month later. CNA #3 was interviewed on [DATE] at 10:50 a.m. She said if she noticed a change in positioning of limbs she would report it to the charge nurse for them to assess the resident. CNA #2 was interviewed on [DATE] at 11:08 a.m. She said she would report any unusual findings to the charge nurse immediately. RN #2 was interviewed on [DATE] at 11:01 a.m. She said if a change in condition was reported to her from a CNA, she would complete an assessment, report findings to the director of nursing (DON) and NHA. She said she would notify the provider to see if orders were needed. She said she would place the resident on alert charting and write a progress note. She said she would start an incident report. The DON was interviewed on [DATE] at 11:13 a.m. She said when a change of condition was reported to her she would follow up to make sure the provider and the family were notified. She said she would assess the care plan to see if revised interventions were necessary. She said as soon as the therapist reported the feet were at different levels the facility called the provider and sent Resident #4 to the emergency department for x-rays. She said the family and provider were notified right away. The NHA was interviewed on [DATE] at 1:45 p.m. She said the facility had not completed an investigation on the hip dislocation (cross-reference F610). On [DATE] at 12:46 p.m. the NHA said there were notes on the hip dislocation, and agreed they were not in a central location easily accessible. She said she would send them as soon as she could collect them. On [DATE] at 8:28 a.m. she said she had not reported the injury to the state. (cross-reference F609, failure to report.) The NHA said the facility had reached out to the hospital for more information on the injury and was denied information. She said after the hip dislocation the therapist provided information on transfers and how to report injuries of unknown origin. She said the hip may have popped out. She said the results of her investigation revealed no abuse, no harm, no abnormal transfers and no falls. D. Additional records On [DATE] at 3:12 p.m. the facility emailed a stand-up meeting form dated [DATE]. On the back side of the form a handwritten note documented, Resident #4-hip dislocation, on D3, history (h/x) of [MEDICAL CONDITION]? Low calcium. 11/ (incomplete date)- Monday day staff- zero signs or symptoms (s/s) of issues. Nocturnal (noc) zero s/s of issues- Social services director (SSD). Tuesday unable to bear weight, no issues, noted per prior RN assess-change notes-sent for x-ray . -All stated hip deductor pillow in place when in bed. Always used two person assist. 'He would rarely help so we always have at least two people.' CNA #1. A handwritten note, no date or time, with the resident's initials on the top of it documented, Occupational therapist (OT)- ,[DATE] talked to CNA and charge nurse and restorative CNA, noted change today. No falls, no reports of difficulty in transfers prior. They said no concerns overnight. Spoke with DON and provider x-ray ordered. [MEDICAL CONDITION] may have contributed-seen research on this. A handwritten note was emailed on [DATE] at 5:23 p.m. The note had no date, time, or signature, documented, OT- CNA #4 and CNA #1 both work B hall as CNA. RN #2 charge nurse. Restorative CNA #5. Spoke with all on ,[DATE] concerning Resident #4. ALL noted change today on ,[DATE]. A handwritten note was emailed on [DATE] at 5:26 p.m. At the top of the note was written SSD. The note did not have a signature, a date, or time it was written. The note included, ,[DATE] nurse aide (NA) #1 no concerns. Certified medication aide (CMA) #1 no concerns. RN #3 no concerns. All verified boots on, abductor pillow in place, no increase pain, transferred CNA and RN was normal transfer. No change in assessment. -,[DATE] CNA #6 no concerns, already in bed with boots and pillow. Did not transfer during night shift. CMA #1 no concerns, had boots and support between legs. RN #4 no concerns no noted changes, we didn't get him up, used log roll to change after incont. Had boots and support between legs. A handwritten note was emailed on [DATE] at 10:24 a.m. The note did not have a signature, a date, or time it was written. The top of the note was titled QA Review. The note documented, Summary of investigation: Resident #4 left hip dislocation [DATE]. Staff interviews and chart review completed ,[DATE]. No injury, no fall, no s/s of abuse. Abductor pillow in place when in bed, two person assist. Resident likely dislocated hip related to moving lower extremities in bed. The handwritten notes did not have a signature or a time documented to identify when the notes were written. III. Blister to left heel [DATE] A. Record review The care plan, dated [DATE], identified the potential for alteration in skin integrity related to left [MEDICAL CONDITION] and decrease in mobility, incontinence, and the need for extensive assist. Interventions included: -Skin check to be performed by a licensed nurse weekly. -Assist the resident to turn and reposition every two hours and as needed. -Apply heel protectors to bilateral feet while in bed related to heel blister. Float heels. The [DATE] MDS identified the resident was at risk for developing pressure injuries, and identified the resident did not have any pressure injuries at admission. A wound assessment report for Resident #4 dated [DATE] identified an intact blister on his left heel. The date the blister was identified was [DATE]. The cause was noted as unknown (Cross-reference F610 failure to investigate). The progress note dated [DATE] at 5:33 p.m written by RN #1 documented, Resident noted to have an intact blister to left heel 3 cm X 3 cm. Provider notified, new orders received for pressure relieving boots and float heels. Notified nurse practitioner (NP) of blister on Monday for further orders. Cross-reference F686 failure to prevent pressure injuries. B. Interviews CNA #3 was interviewed on [DATE] at 10:50 a.m. She said any changes in skin were reported immediately to the charge nurse. CNA #2 was interviewed on [DATE] at 11:08 a.m. She said every time cares were provided to a resident the skin was checked. She said if there were any changes to the skin it was reported to the charge nurse right away. RN #2 was interviewed on [DATE] at 11:01 a.m. She said if an aide reported any changes in the skin, she would complete an assessment and notify the DON, NHA, provider and the family. She would request orders from the provider for treatment to the affected area. The DON said there had not been an investigation on the cause of the injury. (Cross-reference F610 failure to investigate) The DON was interviewed on [DATE] at 11:13 a.m. She said when a change of condition was reported to her she would follow up to make sure the provider and the family were notified. The NHA was interviewed on [DATE] at 12:46 p.m. The NHA said there were notes on the heel blister, and agreed they were not in a central location easily accessible. She said she would send them as soon as she could collect them. On [DATE] at 8:28 a.m. she said the heel blister happened from the resident rubbing his heel against the mattress while in bed. C. Additional records On [DATE] at 3:12 p.m. the facility emailed a stand-up meeting form dated [DATE]. On the back side of the form a handwritten note documented, Resident #4 - orders: blister to left heel. Friction pressure, already on air pressure relieving mattress already repositioning. New boots/float heels- compliant with boots. CNA states, 'I usually find his left sock in the sheets when I get him up.' Monitor compliance with boots.

Based on record review and interviews, the facility failed to ensure one (#1) of two sample residents was protected from abuse and ensure that concerning injuries of unknown origin were thoroughly investigated to prevent recurrence. The facility failed to prevent multiple, repeated injuries to Resident #1, who was non-interviewable and dependent on staff for care. Record review revealed the resident suffered a series of injuries that the facility failed to thoroughly investigate, assess and track, and failed to implement protective measures to prevent, although the injuries indicated rough treatment during care. The resident's injuries documented by the facility were: -On 2/12/2020, bruising to the resident's forehead, bruising to the right foot and a scratch on the right shin; -On 2/16/2020, bruising to the resident's left toe; -On 2/21/2020, bruising to the left upper pubic bone; -On 2/24/2020, redness and broken blood vessels to the right eye; -On 3/1/2020, bruising to the pubis and perineal area. According to hospital documentation after the resident was discharged to the hospital on [DATE] for a high fever and condition change, she had multiple bruises of different ages from unknown trauma, including injuries to her pubic area, labia, abdomen, forehead, eye, both legs, left thigh, right foot, and both hands. The facility's failure to investigate and protect the resident from abuse resulted in multiple recurring injuries. Findings include: I. Resident status Resident #1, age 69, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the February 2020 computerized physician orders [REDACTED]. The 12/29/19 minimum data set (MDS) assessment revealed the resident's cognitive status was not completed due to the resident was rarely/never understood. The resident had severe cognitive impairment. She required extensive two-person assistance with transfers, dressing, toilet use, and personal hygiene. She had other behavior symptoms not directed toward others, occurring one to three days from the past seven, and did not reject care during the assessment period. II. Record review A. Care plans The care plan, dated 9/25/19, identified the resident had the potential for alteration in skin integrity related to incontinence, decreased mobility, and [MEDICAL CONDITION]. Interventions included a skin check to be performed weekly. The care plan, dated 9/24/19 and revised on 3/30/2020, identified the resident's activity of daily living (ADL) status would be maintained at optimal level with all needs met on a daily basis. Interventions included to monitor skin condition during care and report to the nurse. The care plan did not identify the resident required two-person transfers, as indicated in the MDS assessment. The care plan was revised 30 days after the resident was discharged . The care plan, dated 9/26/19 and revised on 3/30/2020, identified the resident exhibited behaviors such as striking self and crying. Interventions included to monitor for behaviors of striking self and document per shift. The care plan was revised after the resident was discharged . The resident did not have a care plan identifying her at risk for abuse. B. Skin assessments The weekly wound assessment report, dated 2/12/2020, identified on the visual body map three areas: 1. A bruise to the forehead; 2. A bruise to the top of the right foot; 3. A scratch to the right lateral shin. The wound assessment report documented the right lateral shin scratch was caused by an accident, and the bruise on the top of the right foot was also caused by an accident. The facility provided no other skin assessments. The cause of the bruise to the resident's forehead was not documented or investigated. The facility failed to document weekly skin assessments for Resident #1 during February 2020. C. Investigative reports and progress notes 1. Injuries on 2/12/2020 - right foot and right calf The incident report dated 2/12/2020 documented, Certified nurse aide (CNA) came and reported that the resident has a bruise to top of right foot and scratch to back of right calf. Bruise top of right foot size 2 cm X 2 cm. Scratch to back of right calf size 4.5 cm in length. Immediate post incident action was, Remove foot pedals when transferring. Also put on derma leg protectors. Wear slippers to prevent rubbing on top of her foot. The narrative of investigation documented, Interdisciplinary team (IDT) - it is reasonable to conclude this resident was seen by the staff kicking her wheelchair with her right foot which resulted in a bruise on the top of her right foot. The resident is currently out of the facility at this time in the hospital and will be reassessed when she returns. There was no mention in the incident report of the bruise to the resident's forehead (see below). There was no corresponding nursing or behavioral note regarding the resident kicking her own wheelchair. 2. Injury on 2/12/2020 - bruise to forehead The nursing progress note dated 2/13/2020 at 1:54 p.m. documented, Resident had bruise on right side of forehead measuring 2 cm X 3.5 cm. Area is yellow and looks old. There was no evidence of an investigation into the cause of the bruise, and no prior documentation of the bruising other than the 2/12/2020 skin assessment. 3. Injury on 2/16/20 - bruising to left second toe The incident report dated 2/16/2020 documented, CNA came and reported to this nurse that the resident has a bruise to (the) second toe to the left foot. Bruise to second toe to left foot purplish discoloration size 2 cm X 2 cm. Immediate post-incident action was, Ensure resident wearing slippers when transferring. The narrative of investigation documented, IDT- It is reasonable to conclude this resident was seen by the staff kicking at her wheelchair with her feet. It is reasonable to conclude this resident's bruises on her feet were caused by the resident kicking her own wheelchair. The resident is currently out of the facility at this time and will be assessed upon her return from the hospital. There was no corresponding nursing or behavioral note regarding the resident being witnessed kicking her own wheelchair. There was no evidence of an investigation into the resident's new injury. 4. Injuries on 2/21/2020 - left upper pubic bone and right foot The nursing progress note dated 2/21/2020 at 5:53 p.m. noted, While giving care to the resident it was noted that resident had areas of concerns, resident demonstrates no signs or symptoms (s/sx) of fear. The incident report dated 2/21/2020 documented, During changing of brief it was noted that the resident had bruises to the left upper pubic bone. No pain, also has noted bruising to right foot. Bruise to pubic area 4.5 cm X 1 cm, bruise to foot 12.5 cm X 10 cm, and scab measures 2.5 cm X 1.2 cm to the top of mid right foot. Immediate post-incident action was, Re-educated nursing staff on the importance of using two person transfers. The narrative of investigation documented, IDT- investigation: staff interviews - noted bruises this afternoon, slight discoloration this early a.m. Resident denies fear and abuse, no s/sx of abuse or fear noted. Continued interview results, resident did participate on scenic drive in bus on 2/21/2020. Seatbelt matches with place of bruising and size correlates with belt buckle. Resident also noted to be kicking her feet while on drive. Resident does tend to kick her feet and/or swing her hands, hitting herself when agitated - see care plan. Chart review, labs low platelet count noted which can increase bruising. Reasonable to conclude bruising related to seatbelt and kicking her feet. Staff education to ensure proper placement of seat belt and foot pedals-cushion areas if needed. Ensure proper footwear to protect residents feet. There were no corresponding nursing notes in the resident's medical record regarding resident behaviors or staff actions that may have contributed to the resident's new injuries. There was no documentation on the medical record regarding self-injurious behavior. There was no evidence of a thorough investigation into the resident's injuries. 5. Injury on 2/24/2020 - right eye The nursing progress note dated 2/24/2020 at 2:19 a.m. documented, CNA came and reported that the resident has redness to right eye. This nurse went and checked eye. Noticed resident has a broken blood vessel to right eye. When asked resident if it hurt, the resident stated no. Asked the resident if she had rubbed her eye and she stated yeah. There was no evidence of an investigation of the resident's new injury. The care plan was never updated or reviewed after each of the above injuries to include interventions and assess for effectiveness of the interventions to prevent further injuries. Although staff surmised per IDT notes that the resident's injuries were from her striking herself, nursing progress notes, reviewed for the month of February 2020, did not include any documentation of the identified behavior of striking herself. Likewise, behavior tracking documentation during February 2020 revealed no evidence of the resident striking herself. Staff documented asking the resident if she had injured herself but failed to investigate further. Moreover, the resident had severe cognitive impairment and was unable to make herself understood. 6. Injuries on 3/1/2020 - pubis and perineal area The facility investigation from an incident on 3/1/2020 documented, Bruise noted to residents peri-area by a CNA #4, and reported to the charge nurse on 3/1/2020. Charge nurse (CN) states she had just contacted the power of attorney (POA) regarding transferring resident to a local hospital for evaluation for continued elevated temperature. CN notified nursing staff to get resident ready for transfer at about 3:35 p.m. At 3:50 p.m. CN assessed the resident just prior to transfer, noting dark purple bruise about 5 in X 2 in to pubis. Resident did not express fear or abuse, shaking her head no. Resident was not guarding, flinching, or expressing s/x of fear or abuse. Manager on duty (MOD) contacted the director of nursing (DON) notifying her of the bruising. MOD then transferred resident to emergency department (ED) via facility vehicle. MOD reported to ED staff that the facility was aware of bruising and will be conducting investigation as well. CNA #3 from the night shift on 2/29/2020 was placed on probation on 3/1/2020 until investigation completed. Nursing home administrator (NHA) notified of bruising on 3/1/2020 at 8:30 a.m. The Sheriff's office called, NHA told that case was open on resident and another case number would not be issued. Staff and residents interviewed by NHA and social services director (SSD) from 3/1/2020 and 3/5/2020. Results of interviews: CNA #3 stated she was giving the resident a bed bath on 2/29/2020 at about 8:30 p.m. Resident was noted to be scratching her peri-area vigorously. CNA #3 states resident was cooperative with bed bath. Licensed practical nurse (LPN) #1 stated he entered residents room about 8:45 p.m. to ask CNA #3 for assistance once she was done. LPN #1 stated resident appeared calm, no signs or symptoms of distress noted. CNA #3 stated the resident was 'very sweaty as her fever broke' about 4:00 a.m. on 3/1/2020. CNA #3 stated as she transferred the resident to her wheelchair, the resident sat forcefully on the pummel portion of her wheelchair cushion as it was not properly aligned in chair. CNA #3 then states she pushed the resident in her wheelchair to the tub room for a bath. CNA #3 had resident in whirlpool bath when residents 'bottom slid forward.' CNA #3 states she used her forearm forcefully to residents peri-area to keep resident from sliding further into tub as CNA #3 reached for the call light. Certified medication aide (CMA) #1 states she entered tub room and assisted CNA #3 to boost the resident up in the tub. CMA #1 states resident calm and did not appear to be in any distress. CNA #3 then used the call light again about 4:30 a.m., LPN #1 entered tub room and assisted resident to stand as CNA #3 pulled up residents attends and pajama bottoms. LPN #1 states resident was calm and cooperative with care and did not appear to be in any distress. CNA #3 then pushed the resident in a wheelchair back to the room and transferred the resident to bed. On 3/1/2020 CNA #4 states she noticed bruising to the peri-area and reported it to CN after breakfast. CNA #4 stated the resident was cooperative with care, but was feverish and not feeling well overall. Reasonable to conclude that bruising to the lower peri-area was caused by transferring the resident to sit forcefully to pummel portion of wheelchair cushion. Reasonable to conclude that bruising to pubis caused by CNA #3 forcefully using forearm to peri-area to keep the resident from slipping in the tub. Signed by the NHA on 3/5/2020. Handwritten notes on the bottom of the page included: Chart review-low platelets; two person assist, previous bruising, CNA #3 did not work with Resident #1 on or prior to bruising being noted. Interviews with residents on B and E hall completed on 3/2/2020 by NHA and SSD. No stated concerns. Interviews with residents on A and F halls completed on 3/3/2020 by NHA and SSD. No concerns stated. The incident report from 3/5/2020 was not clear if the resident had the assistance of two people for the transfer and the forceful sit or the forearm to peri-area was done with only one aide present. There was no documentation to show that additional facility staff were interviewed regarding the resident's multiple injuries. The resident's care plan did not identify two-person assistance, and the care plan was not updated. D. Hospital records The arrival nursing progress note dated 3/1/2020 at 3:41 p.m. included, She has a subconjunctival hemorrhage to the right eye that they (the facility) state has been there since last weekend and bruising to the right lower leg and foot of unknown time, and new bruising to the perineal area and the right hand. She has no history of, such as falling out of the chair or falling out of the bed, and the patient has a cognitive delay and is unable to give any history. She also has bruising to the forehead that they (the facility) state has been there since last week. Review of systems on admission noted, Abnormalities: decreased appetite and fever 24 hours and multiple bruises of different ages to her body from unknown trauma. Review of the hospital's photographs of the resident's injuries, dated 3/1 and 3/2/2020, revealed the following: On 3/1/2020: 1. A dark pink bruise to the posterior of the right hand. 2. A dark purple bruising and swelling to pubic area. 3. An old pink bruise to abdomen. 4. A dark pink bruise to anterior right hand. 5. Dark purple bruising and swelling to labia majora. 6. Pink bruising and old abrasion to lower right anterior leg. 7. A pink bruise and a red scab to the anterior of the lower left leg. 8. A pink bruise to the left upper leg on the back and left posterior thigh. 9. Dark purple bruising and a red scab to inner right foot. 10. A dark purple scab and wound to top of the right foot. On 3/2/2020: 1. A pink bruise to forehead. 2. Trauma to the right eye (a red sclera). 3. A red scab and red scrape to the right thumb. 4. Dark red scrapes and scabs to palm of right hand. 5. A pink scab/bruise to left pinky. III. Interviews CNA #1 was interviewed on 4/6/2020 at 9:15 a.m. She said any skin issues found while providing cares were reported to the charge nurse (CN). CNA #2 was interviewed on 4/6/2020 at 9:20 a.m. She said all skin issues were reported to the CN and the CN would do an assessment. CNAs #6, #7, and #8 could not be reached for an interview, and did not return messages. RN #1 was interviewed on 4/6/2020 at 9:30 a.m. She said when a CNA reported a new skin issue, she would assess the area, complete an investigation, notify the provider, family, DON and NHA. She said she would implement interventions to help prevent further injuries. The DON was interviewed on 4/6/2020 at 9:58 a.m. She said she expected the aides to report any new skin issues to the CN. She said the CN would then complete an incident report. She said any new interventions should be added to the care plan. She said the IDT team met to discuss the incident report and review the interventions. She said each resident received a skin assessment weekly. She said she did not know why there were not weekly skin assessments completed for Resident #1. She said labs were reported by the hospital that Resident #1 had a low platelet count and the low platelet count would be responsible for the bruising. The DON was interviewed a second time on 4/7/2020 at 12:18 p.m. She said the behaviors that were tracked in the Medication Administration Record [REDACTED]. She said the tracking of the behavior should have been done in the progress notes, and she acknowledged it was not documented. The DON said the big injuries were investigated and as a result the aide was terminated, and the nurse was written up. As far as the resident's other injuries, she said she was unable to answer why they were not investigated.

Based on interviews, observation and record review, the facility failed to ensure one of 29 sample residents (#42) received timely and comprehensive care and services to prevent the development and progression of pressure ulcers. Record review revealed the resident had several pressure ulcers (sacrum, ischium, hips), some of which developed after admission and several of which that worsened. Record review revealed the facility failed to ensure the resident's wounds were comprehensively assessed and monitored, and that interventions were timely implemented to promote healing and to prevent further decline. Review of the resident's wound assessments and interviews revealed all assessments were completed by a licensed practical nurse (LPN) without oversight by a registered nurse (RN) or the Director of Nurses (DON). Interviews revealed the LPN was not formally trained in wound care. Cross-reference F282; qualified staff. Documentation indicated that almost all of the wounds deteriorated after discovery and required treatment with a [DEVICE] as well as surgical debridement. The findings include: 1. Resident #42, a [AGE] year old male, was admitted to the facility originally on 3/5/13 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 9/9/13 Quarterly Minimum Data Set, the resident scored 4 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment. He required total assistance for all activities of daily living including bathing, dressing, grooming and toileting. He was totally dependent for bed mobility and transfers, requiring two-person assistance. He required supervision and cuing for eating. He was incontinent of bowel and had an indwelling Foley catheter. 2. Record Review a. Pressure ulcer care plan The resident's care plan, dated 3/5/13, addressed risk for alteration in skin integrity due to [MEDICAL CONDITION] and incontinence. It stated the resident had a pressure ulcer on his sacrum and ischium (side not specified). It also stated the resident had returned from the hospital with a debrided wound to the right hip that was then Stage III. -The goals were for no further alteration in skin integrity for 90 days, and that the wound would be healed in the next 90 days. -Approaches were: --Roho cushion to wheel chair and pressure relief mattress --toilet and reposition every two hours and as needed with peri-care with each toileting. --wound nurse to monitor wound weekly and document --place on dietary supplements --Family Nurse Practitioner/Wound Care Consultant following for wound care and will continue to follow --[DEVICE] as prescribed --wet to dry dressing twice daily to right hip --receiving dietary supplement for wound healing The interventions above were not dated and the care plan and goals were not updated with orders to turn and reposition hourly (see below). Moreover, the care plan was not updated to address the specific care and services to be provided to promote healing of the multiple pressure areas that developed on and after 5/15/13 (see below). b. History and Physical A history and physical, dated 6/26/13, noted a "significant decline in the resident's condition over the past few months." It recorded the resident had [MEDICAL CONDITIONS], had difficulty with urinary output due to a [DIAGNOSES REDACTED]. It stated the significant development of a Stage III over his sacrum as well as his right buttock. The skin assessment noted two areas of necrotic wounds Stage III decubiti. The coccyx wound was noted to be four by five cm with hard necrotic eschar. The right ischium was noted to be measured at 4 x 4 cm (cm). It also stated he had "some Stage II pressure ulcers to hips." c. Physician orders [REDACTED]. Record review revealed multiple orders for multiple wounds that worsened, that documented delays in acquiring equipment and supplies for treatment and orders for hospitalization and surgical intervention relating to wound deterioration. -5/22/13 Telephone order: Dressing change, cleanse two pressure ulcers from sacrum and ischium with ? strength [MEDICATION NAME], apply skin prep to peri-wound, cover with [MEDICATION NAME] dressing on Tuesday and Friday, and change dressing if falls off or gets soiled. Signed by physician. -5/31/13 Physician telephone order: Cleanse pressure ulcers with soap and water, pat dry, apply med honey to wound bed, cover with alginate and change every three days -6/10/13 Physician telephone order: Dressing change daily to sacrum, cleanse with ? strength [MEDICATION NAME], rinse, apply hydrogel to wound bed, cover with Vaseline gauze. Dressing to ischium, apply Santyl to eschar only, cover with Vaseline, secure and change daily. -6/19/13 Nurse Practitioner order: Coccyx and right ischium wounds, wet to dry dressing twice daily. Hips and left ischium, [MEDICATION NAME] dressing change every three days. Cleanse wounds prior to dressing with wound wash. -6/20/13 Telephone order Nurse Practitioner: Cleanse wound to Right ischium and sacral wounds, apply hydrogel to wound bed, cover with petroleum gauze, cover with moist gauze, cover with dry dressing and secure. -7/5/13 Physician Telephone order: [DEVICE] (vac) for treatment of [REDACTED]. -7/16/13 Note from facility to physician: Wound vac received and initiated. Will follow up with Nurse Practitioner tomorrow regarding frequency of changing. -7/17/13 Physician telephone order: Discontinue prior dressing changes to coccyx and ischium. [DEVICE] in play, verify working properly and dressing intact every shift. -8/22/13 Nurse Practitioner telephone order: Treat right lateral hip wound with Santyl ointment, cover with saline moistened gauze and change daily. Change [DEVICE] on coccyx and ischium to Monday, Wednesday and Friday. -8/27/13 Nurse Practitioner telephone order: Hold [DEVICE] until supplies arrive. Wet to dry dressing as follows twice daily. Cleanse wound with soap and water or wound wash, rinse well, lightly pack with saline moistened gauze, cover with dressing and secure with tape. Change dressing if it becomes soiled. -8/29/13 Nurse practitioner telephone order: Discontinue wet to dry (dressing). Resume [DEVICE] to coccyx and ischium. -10/8/13 Physician telephone order: Wet to dry dressing changes twice daily to right hip, coccyx and right ischium. Strict turn every one hour schedule. -10/14/13 Nurse practitioner telephone order: Refer to general surgery for [REDACTED]. -10/16/13 Physician telephone order: Wet - dry dressing to hip, coccyx and ischium twice daily until supplies for [DEVICE] arrive. -10/18/13 Physician telephone order: Resume [DEVICE] pressure 125 continues and change dressing Monday, Wednesday and Friday. Continue wet to dry dressing to right hip. -11/4/13 Obtain culture on right hip wound on 11/5/13. d. Wound Assessments (1) Right Ischium Pressure Ulcer Review of wound assessments revealed this wound worsened after discovery. No physician or nurse practitioner notes or assessments were present from 5/15/13 to 7/2/13, and treatment interventions to promote healing ([DEVICE]) were delayed. Specifically: Wound recorded as new on 5/15/13, Stage 2, measurements [MEDICAL CONDITION] cm., no drainage. -In June, assessments were recorded by licensed practical nurse (LPN) on 6/10/13, 6/12/13, 6/20/13 and 6/27/13. By the 6/27/13 assessment, this wound was Stage 3 and measured [MEDICAL CONDITION] cm with small amount of sero-sanguineous drainage. -On 7/3/13 Nurse Practitioner Progress note indicated necrotic tissue from sacrum and right ischium were removed, wound Stage 3. [DEVICE] treatment was being considered. -In July, assessments were recorded by the LPN on 7/5/13, 7/10/13, and 7/17/13. By the 7/17/13 assessment, the wound was assessed as improved with measurement of [MEDICAL CONDITION] cm. On 7/5/13, the LPN recorded a [DEVICE] had been ordered, on 7/10/13, she recorded awaiting [DEVICE] approval, and on 7/17/13, she recorded using [DEVICE]. -In August, assessments were recorded by the LPN on 8/7/13 and 8/29/13. On the 8/29/13 assessment, the wound was listed as unchanged. -On 8/22/13, a nurse practitioner note indicated the wound was improved with small area of necrosis. On 8/29/13, she noted loose necrotic tissue which she debrided and continued [DEVICE]. -In September, assessments were recorded by the LPN on 9/4/13, 9/11/13, and 9/26/13. The resident was hospitalized for [REDACTED]. Upon return on 9/26/13, the LPN assessed the wound as Stage 3, with measurements of 7.5x5x1 cm. The nurse practitioner did not evaluate the ulcer in September 2013 according to facility progress notes. -In October, assessments were recorded by the LPN on 10/2/13, 10/9/13, 10/16/13, 10/23/13 and 10/31/13. By 10/31/13, the wound was recorded as improving by the LPN and measured [MEDICAL CONDITION] cm. (2) Right Buttock/Trochanter Pressure Ulcer Record review revealed this wound developed after admission, worsened after discovery as a Stage I and was not consistently monitored. Deterioration discovered in October was not timely addressed. Specifically: The wound was recorded as new on 6/12/13, Stage 1, measurements 2x2x0 cm. The accompanying note revealed only pressure relieving measures were used to treat the wound. -In June, assessments were recorded by LPN one time on 6/12/13 (see above). -In July, assessments were recorded by the LPN on 7/5/13, 7/10/13, and 7/24/13. By 7/24/13, the wound was a Stage 2 and measured 1.2x1x1 cm. -In August, one assessment was recorded by the LPN on 8/29/13, when the wound was a Stage 2 and measured [MEDICAL CONDITION] and was 100% eschar. On 8/22/13, the nurse practitioner note indicated wound being treated with Santyl, treatment to continue. -In September, assessments were recorded by the LPN twice, on 9/4/13 and 9/26/13. (The resident was in the hospital for treatment of [REDACTED].) The nurse practitioner did not evaluate the ulcer in September 2013 according to the facility progress notes. -In October, assessments were recorded by the LPN five times, on 10/2/13, 10/9/13, 10/16/13, 10/23/13, and 10/31/13 with deterioration noted on each assessment. By 10/31/13, the wound measured 10x7x1.5 with large amounts of sero-sanganuinous drainage. On 10/9/13, the LPN noted "Wound is deteriorating with purulent drainage, increased dressing changes, nurse practitioner to re-evaluate in 5 days." The nurse practitioner evaluated the wound on 10/14/13 and noted "Right hip wound is 100% necrotic. There is hard brown necrotic eschar to edges and wound bed has soft foul smelling necrotic tissue." Plan was to resume [DEVICE] and refer to general surgery for [REDACTED]. (3) Sacral Pressure Ulcer Record review revealed this wound developed after admission, deteriorated after discovery as a Stage II, and was not consistently monitored after discovery or timely evaluated for treatment. Specifically: The wound was recorded as new on 5/15/13 at Stage 2 with measurements of 1.2x1.2x1 cm. -In May, assessments were completed by the LPN one time, on the date of discovery (see above). -In June, assessments were completed by the LPN three times, on 6/12/13, 6/20/13 and 6/27/13. By 6/27/13, the LPN noted the wound had deteriorated and was measured at [MEDICAL CONDITION] cm. The nurse practitioner did not evaluate the pressure ulcer during June 2013 according to the facility progress notes. -In July, assessments were recorded by the LPN three times, on 7/5/13, 7/10/13 and 7/17/13. On 7/5/13, the nurse practitioner evaluated the pressure ulcer and indicated necrotic tissue was present, and the wound was deep with exposed bone. She ordered a [DEVICE] for treatment. The LPN on her assessments, documented on 7/5/13, that the [DEVICE] had been ordered; on 7/10/13, that the [DEVICE] was in the process of being approved by insurance; and on 7/17/13, that the [DEVICE] was in place. -In August, assessments were recorded by the LPN twice, on 8/13/13 and on 8/29/13. On 8/13/13, the LPN noted minimal wound improvement and that she had requested a re-assessment by the nurse practitioner. By 8/29/13, the wound was a Stage 4, and measured [MEDICAL CONDITION] cm. On 8/22/13, nine days after the LPN's request, the nurse practitioner evaluated the wound. She noted some improvement, some granulated material and a new necrotic area the size of a quarter was present. On 8/29/13, the nurse practitioner noted the wound showed a 3x3 cm brown necrotic area had developed. She noted the [DEVICE] would continue. -In September, assessments were completed by the LPN three times, on 9/4/13, 9/11/13 and 9/26/13, upon the resident's return from hospitalization [DATE] to 9/26/13. The wound was noted to be a Stage 4, improved, with measurements of 10x6x1.4 with small amount of sero-sanguineous drainage. The nurse practitioner did not evaluate the pressure ulcer during September 2013 according to the facility progress notes. -In October, assessments were completed by the LPN four times, on 10/2/13, 10/15/13, 10/23/13 and 10/31/13. By 10/23/13, the wound was a Stage 4 and measured at 9.8x6.5 cm. The Nurse Practitioner recorded an assessment on 10/14/13 and noted the wound was pink and clean with open edges. Instruction was given to resume the [DEVICE]. (4) Left Buttock, Trochanter Pressure Wound Record review revealed this wound developed after admission. According to a Wound assessment dated [DATE], this wound was recorded as new, at Stage 2 with [MEDICAL CONDITION] cm measurements. Orders were written for [MEDICATION NAME] every three days according to the note section on the assessment. An assessment was recorded by the LPN on 6/27/13, at Stage 2 with measurement of [MEDICAL CONDITION] cm. The note on the assessment noted that the wound appeared healthy with no sign of infection and a [MEDICATION NAME] dressing was implemented. No further assessments of this wound were located in the record. (5) Left Buttock, Pressure Ulcer According to a Wound Assessment, dated 9/26/13 (re-admission), the wound was noted as new, at Stage 2, with measurements of [MEDICAL CONDITION] cm. The note on the assessment indicated the wound was a new pressure ulcer noted on admission back from the resident's hospital stay. It was covered with [MEDICATION NAME] dressings as physician ordered and the Nurse Practitioner was coming to assess. No further documentation was found in the medical record regarding this wound. e. Nutritional Interventions The resident was maintained on a regular diet with a Prostat diet ordered three times a day with meals. The resident had a care plan for weight loss, dated 3/13/13, targeting weight loss related to decreased appetite. -The plan's goal was for the resident to have a decrease or no further weight loss over the next 90 days. -Approaches included the resident was to be weighed weekly and the physician and family were to be informed of the resident's weight status. The resident was to receive [MEDICATION NAME] as ordered to help stimulate his appetite and was to be offered snacks of choice between meals. No indication of a care plan update was recorded. The resident's weights were recorded on a weekly basis March 2013 and April 2013. However, they were not recorded on a weekly basis beginning May 1, 2013 as follows: -3/4/13 105 pounds -5/8/13 92 pounds -5/21/13 94 pounds -5/28/13 94 pounds -6/5/13 95 pounds -6/18/13 96 pounds -6/24/13 97 pounds -7/08/13 97 pounds -8/05/13 97 pounds -8/19/13 97 pounds -9/9/13 100 pounds -9/16/13 100 pounds -9/26/13 97 pounds -9/30/13 97 pounds -10/8/13 96 pounds -10/21/13 95 pounds On 7/15/13, the physician ordered Vitamin C 500 mg daily for wound healing via telephone in accordance from a request from the dietician. On 7/19/13, the physician ordered Prostat three times daily to be administered by dietary. Nursing assessment recorded the resident's nutritional status as follows: -7/25/13 weight 97.6 pounds, leaves more than 25% of food uneaten at most meals. No change in nutritional status -8/11/13 weight at 97.4 pounds, leaves more than 25 percent of food uneaten at most meals -10/10/13 weight on 9/26/13 at 97.6 pounds and on 10/7/13 at 94.6 pounds, eats 75 percent or more Dietary notes read as follows -9/5/13 Resident was accepting Prostat and at times would take a health shake -9/6/13 Resident was receiving regular diet consuming 75 percent on average. The resident was also receiving 30 milliliters of Prostat three times daily and was consuming 75 percent on average. The resident wounds continued with [DEVICE] treatment. The resident also received [MEDICATION NAME], a multivitamin, Vitamin C, and [MEDICATION NAME]. Recommendations were for staff to encourage intake, encourage consumption of his supplements, and continue to monitor intakes. Record review revealed there were no notes prior to 9/5/13, although the resident had acquired more wounds and the wounds were not healing. 3. Observations On 11/5/13 at 8:30 a.m., the resident was sitting at a table in the dining room, waiting for breakfast. He was sitting in his tilt chair, and appeared comfortable. On 11/6/13 at 8:15 a.m., the resident was observed in his room in his bed while a dressing change was being completed. The resident had been premedicated with as-needed pain medication and appeared to be comfortable. The resident's sacral and ischium wounds were cleansed and [DEVICE] was applied using a bridging technique. The LPN had difficulty getting the [DEVICE] to seal and repeatedly had to press on different areas of the dressings to achieve suction. The LPN left the room twice during the dressing change to obtain additional dressing materials. The resident's right hip wound was grey-colored with a moderate amount of green exudates and was foul-smelling. The dressing was reapplied. 4. Interviews On 11/4/13 at 4:25 p.m., the Licensed Practical Nurse (LPN) who had completed the wound assessments above was interviewed. She said she was the facility's wound nurse in charge of the care of resident #42's pressure ulcers. -She stated she had not had formal training or certification in wound care; she had learned how to care for wounds "on the job" at her previous place of employment. -She said she was caring for the first [DEVICE] on this resident that the facility had ever had. She said that she had not received formal training on the operation of a [DEVICE]. -She said that at the current time, resident #42 had five pressure ulcers; one on the coccyx, buttocks, both hips and left knee. She said the right hip wound had purulent green drainage and the resident had been on intravenous [MEDICATION NAME] for over a month. -She said the physician's assistant (nurse practitioner) was in charge of the resident's pressure wounds, and she was currently arranging for the resident to be transferred to an acute care hospital for treatment of [REDACTED]. On 11/5/13 at 10 a.m., the LPN was interviewed again. -She said the resident's pressure wounds had started in May 2013 after the resident had a bout with [MEDICAL CONDITION] with resulting diarrhea and that the resident's wounds had continued to deteriorate since that time. -She said the resident had been hospitalized in September 2013 for treatment of [REDACTED]. On 11/6/13 at 8 a.m., the LPN was interviewed again during a wound dressing change. -She said that she tried to measure and recorded the pressure wound measurements weekly. She said weekly wound rounds were not conducted with any other licensed facility staff; no other facility staff, including a registered nurse, evaluated the resident's wounds on a regular basis. -She said she could request input, stating the Director of Nursing (DON) would assess the wounds with her; however, to date, she had not requested input from the DON or any other registered nurse. -She said she contacts the nurse practitioner who was wound certified whenever the wounds were deteriorating or she thought a treatment change was in order; however, neither the nurse practitioner nor the physician routinely evaluated the resident's wounds. -She stated the physician delegated wound care to the nurse practitioner and she did not know when the physician had last examined the resident's pressure ulcers. -She said when a [DEVICE] was ordered, it took days before the apparatus could be obtained; she said that the delay was frustrating to her, but the medical supplier had told her that the delay was not unusual. -She said the resident's physician and medical power of attorney had agreed on 10/23/13, that the resident needed to be transferred to an acute care setting that specialized in wound care due to the deteriorating condition of the resident's pressure ulcers, but since that date, no arrangements had been made. On 11/6/13 at 10:00 a.m., the charge nurse was interviewed and said the resident was usually in bed in the morning until it was determined whether or not the wound nurse was going to do a dressing change that day. If no dressing change was completed, the resident went to the dining room for breakfast. She said he liked to stay in the day room where the other residents were. She said if he was in bed, he was to be turned every hour. On 11/6/13 at 10:30 a.m., the unit nurse aide said that she cared for the resident regularly. She said if he was in bed, he was to be turned every hour. If he was in his geri-chair, he was to be repositioned every hour. She said that sometimes it was difficult to accomplish this because the resident hated to go to his room; he frequently stayed out in the day room. She said he cannot move or reposition himself in bed. She said he was compliant was all of his care. On 11/6/13 at 11 a.m., the Director of Rehabilitation was interviewed. She said that the resident had been discharged from physical and occupational therapy in August 2013 because the resident had become non-compliant. "After he refuses, we really can't do anything." Asked if she periodically assessed the resident's positioning, she said "I put him in that chair (a tilt chair) with a Roho cushion because he was starting to slide out. He doesn't like therapists, so we try to stay out of his way." On 11/7/13 at 11:50 a.m., the DON was interviewed. -She said the LPN wound nurse was in charge of the resident's pressure ulcers and she confirmed she does not conduct wound rounds with the LPN. -She stated the facility was waiting for the physician to call and tell them where the resident was to be transferred for pressure wound care. She said she had called the physician's office "several times" with no response and it had been over two weeks. On 11/7/13 at 1:30 p.m., the LPN said that she had contacted two acute care facilities 'today' in an attempt to get the resident transferred out. On 11/13/13 at 10 a.m., the nurse practitioner was interviewed by telephone. -She said she was the wound care specialist for the facility's area and had been following the resident's pressure wounds during his stay in the facility. -She stated she does not go to the facility regularly or conduct wound rounds, but [MEDICATION NAME] the resident whenever the LPN calls her for a consultation or the resident's physician asks her to go look at the resident. -She said the only nurse at the facility she has had any contact with regarding the resident's care was the LPN. She does not have contact with the DON or any other RN at the facility. -She said her main concern was that every time she went to see the resident, he was lying flat on his back. She stated she has told the LPN and aides "repeatedly" that the resident needs to be off his back and his wounds, but in her experience, he had not consistently been positioned to aid the healing process. -She said the LPN told her that she (the LPN) had told nursing staff this week that she is not the only person that can change the resident's dressings; if a dressing change was necessary due to soiling or wetness, a licensed nurse should go ahead and change it. The LPN reported that prior to this week, she had been the only one changing the resident's dressing and if she was not available, they had not changed it but waited for her to do it. -She said the facility had asked her to give a presentation to all care staff regarding the care requirements of persons with pressure ulcers. She was going to the facility on [DATE] to give that presentation. -She said that as of 11/13/13, the resident still had not been transferred to an acute care facility.

Based on observation, record review and interview, the facility failed to ensure two of 13 sample residents (#7 and #12) and three supplemental sample residents (#16, #17 and #24) were provided the care and services necessary to attain and/or maintain their highest practicable level of well-being. Specifically: -For resident #12, the facility failed to provide timely follow-up and treatment, and adequate pain management for the resident's skin condition. The resident's skin condition worsened and caused the resident pain. -For residents #7 and #16, the facility failed to ensure medications were available and administered. -For residents #16 and #17, the facility failed to ensure the residents were appropriately placed on and then removed from a secure environment. -For resident #24, the facility failed to clarify and follow physician's orders. The findings include: 1. Resident #12 Resident #12, according to the facility face sheet, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Record Review Minimum Data Set (MDS) Assessment: The resident's most current MDS, dated [DATE], revealed the resident understood others and was understood by others, had no memory problems, and no behavior problems. The resident needed extensive assistance of one staff for bed-mobility, transfer, toilet use, and personal hygiene. She needed limited assistance of one person for walking in the room. She used a walker and wheelchair for mobility. The resident was frequently incontinent of urine, and always incontinent of bowel. She had a [DIAGNOSES REDACTED]. She had no risk of pressure ulcers, and no open [MEDICAL CONDITION]. She did have pressure reducing devices in her bed and chair. The resident had no pain, and received no treatment or medications for pain. Interdisciplinary Care Plan: (1) The resident's Interdisciplinary Care Plan (IDC), dated 5/28/10, with no revision dates, revealed the resident had potential for skin breakdown due to fragile and thin skin, and occasional urinary incontinence. The word "occasional" had a line drawn through it, and "frequent" was written in, but not dated. Interventions, dated 5/28/10, included anti-pressure device, foam mattress on bed and cushion on chair when up. Monitor skin every week for signs and symptoms of potential skin breakdown (redness/discoloration or open areas). Check for incontinence frequently. There was no revision to include the resident's current skin condition (see below). (2) The resident's IDC, dated 5/28/10, further revealed a care plan for potential for pain related to [DIAGNOSES REDACTED]. Interventions, dated 5/28/10, included to assist to reposition for comfort. There was no revision to include the resident's pain as it related to the resident's skin condition. (3) The resident's IDC, dated 5/28/10, revealed the resident had potential for uncontrolled status related to [DIAGNOSES REDACTED]. Interventions included check blood sugar and record. Administer Insulin as ordered. (4) The resident's IDC, dated 7/19/11, revealed the resident had attention seeking behaviors and manipulative behaviors as evidenced by history of numerous complaints to State surveyors, ombudsman, and people in authoritative positions, not previously brought to staff. Interventions included when the resident demands or wants things that are unreasonable, explain why they are unreasonable, and why the facility cannot do them and chart in nurses notes. Physician orders and progress notes: Physician orders, dated 12/15/11, revealed a telephone order to Cleanse open areas to buttocks with normal saline, apply [MEDICATION NAME], and cover with island dressing. Change daily. On 12/19/11 physician orders included: 1) Offload buttock area by turning patient every 2 hours. 2) Gel cushion when sitting (Rojo cushion). 3) Wound care nurse consult. The physician's progress note, dated 12/19/11, revealed the resident had told the physician she had a decubitus ulcer that was bothering her. The resident had declined for the physician to evaluate her buttocks. The physician's assessment included a decubitus ulcer and the prescribed cushion. Also included was a recommendation to offload the area and clean very well. Skin Assessments: Review of the facility's electronic skin assessments, dated 12/31/11, under rash location, checkmarks were made for the abdomen and perineum/genital area, and under swelling location, checkmarks were made for the right and left leg, feet, toes, and heels. Redness location was check-marked for the right and left buttock. Dry/flaky location areas were check-marked for the left and right leg. No areas were check-marked for the resident's buttocks. There was no corresponding nurses' note describing the measurement of the areas. Nurses' Notes: Electronic Departmental Notes for Nursing revealed the following: -11/29/11 at 9:50 a.m. This morning during the resident's bath the aide noticed some red irritation to the resident's buttocks. Upon assessment the resident did have some irritation possibly from the briefs. [MEDICATION NAME] was placed and will be placed several times throughout the day. The resident was encouraged with help of staff to have frequent brief changes and proper peri (perineal) care throughout the day. No measurements of the red irritated areas were documented. -12/28/11 at 5:17 p.m., resident has red excoriated area to buttocks. Left buttock has a 1.8 centimeter (cm) by 1.0 cm by 0.02 cm. Wound bed is beefy red. No odor noted. Surrounding tissue is dry and flakey. Wound care done as ordered. -12/29/11 at 5:38 p.m., wound care (was) done per MD orders but resident would like to have an appointment with MD to reassess wound on bottom. -12/30/11 at 12:27 p.m., (The resident) had shower today and wound dressing changed. -12/31/11 at 7:40 a.m., resident was administered 2 tablets of [MEDICATION NAME] 200 milligrams (mg) orally for complaint of pain to bottom due to skin damage. Pain level (was) 6 (pain scale of 1 to 10, 10 being the greatest pain). -1/1/12 at 5:36 p.m. Resident continued with complaint of pain and discomfort to bottom due to chafing of skin to buttocks. States was unable to sit upright because it put pressure to the area. Upon doing dressing change noted redness and peeling of skin. No drainage noted. Area cleaned with saline, [MEDICATION NAME] applied along with dressing. (Nurse) returned phone call to resident's family member in reference to this situation. Explained that (resident) refused to be assisted to the toilet at bedtime, even refuses to be cleaned up occasionally, and this was causing a lot of the breakdown. (Nurse) also explained that (resident) can position herself on her side (but see MDS above; the resident needed extensive assistance of one staff for bed mobility.) Over the counter medication (was) given orally for discomfort and did help. No measurements of affected areas were documented. Pain Assessments: Electronic pain assessments, dated 11/29/11 and 12/13/11, indicated the resident was not experiencing verbal or non-verbal pain. No more current assessments were provided. b. Observations/Interviews On 1/3/12 at 10:50 a.m., the resident was observed in her room sitting in her recliner. On 1/3/12 at 11:15 a.m., the resident was observed in her room sitting in her recliner. She stated that she has problems with pain. She stated she has sores on her (bottom) and they are really painful while sitting in the chair and lying in bed. The staff put cream on it and a bandage. Being incontinent of urine made the area burn. She said she asked for a pain pill last night, and it was given, but staff didn't offer, she had to ask. She stated it was painful when staff provided care and when they wipe her. She stated her pain was 10 out of 10, and had been for the last 3 weeks. Staff was notified of the resident's complaint of pain. On 1/3/12 at 1:00 p.m., the resident's skin was observed. The resident was in the bathroom attended by a Certified Nurse Aide (CNA). The Licensed Practical Nurse (LPN)/ MDS Coordinator/facility Wound Nurse cleaned and then dressed the wound area while the resident stood in the bathroom, using her walker for support. The skin of the right inner buttock was reddened and had peeling skin on the entire inner gluteal fold. The skin of the left buttock was similarly reddened and had peeling skin on approximately half the surface of the inner gluteal fold. When asked by the LPN before cleaning the area, the resident stated her pain was 10 out of 10, and had been for the last three weeks. No measurements were taken of the areas during this observation. The LPN/MDS Coordinator/Wound Nurse stated she had not taken care of the wound for about one week, and the area was larger than it had been. The last measurements were less than 2 centimeters around (approximately the size of a nickel). Now the redness and peeling skin covered a larger area. She thought the skin breakdown started as a urine burn. The resident had not been seen by the outside Nurse Practitioner wound nurse as ordered, on 12/19/11, but was scheduled to be seen today or tomorrow. On 1/3/12 at 1:30 p.m., the LPN/MDS Coordinator/Wound Nurse stated the care plan had not been updated regarding the resident's skin breakdown, offloading the area every 2 hours and the Rojo cushion as ordered, or regarding the resident's pain. On 1/3/12 at 1:50 p.m., the certified nurse aide (CNA) who stated she had been taking care of the resident that day stated she didn't think there was anything special about positioning for the resident. On 1/3/12 at 1:55 p.m., the resident stated no one came in to remind her or assist her to change position. She said she stayed in the same position for hours. She sat on her hands while in the chair to get pressure off when she was sitting in the chair. The pain may not be a 10 compared to someone who [MEDICAL CONDITION], but it was all she could stand. On 1/4/12 at 12:40 p.m., the Interim Director of Nursing (IDON) stated she had asked the resident about pain that day and was told by resident that she did not have pain. On 1/4/12 at 1:00 p.m., the Medical Director stated he would expect to be notified for a skin condition that was getting worse on current treatment. Review of the physician's progress note, written 1/4/12 during survey, revealed it read Excoriated (wound) on buttocks -OE: Diaper [MEDICAL CONDITION] secondary to patient not using BR (bathroom) but using diaper. -A: Diaper [MEDICAL CONDITION] with excoriation -P: Monostat cream TID [MEDICATION NAME] ointment TID (topical antibacterial for staph infection/impetigo) Zinc Oxide. 2. Resident #24 Resident #24, according to the facility face sheet, was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. a. Record Review Physician telephone orders revealed, on 12/21/11, a telephone order was given for [MEDICATION NAME] Iso-Osm 2.25 grams (gm) every 8 hours for 7-10 days. The total number of doses was not clarified, and the route was not given. (For every 8 hour dosing for 7 days, 21 doses would be administered. For every 8 hour dosing for 10 days, 30 doses would be administered.) The electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. b. Interviews On 1/4/12 at 10:30 a.m., the pharmacy technologist stated by phone that the pharmacy had received the order, on 12/20/11, not 12/21/11, as the facility order indicated. The pharmacy had sent 6 doses that day, a 2 day supply, and the total doses sent were 12 doses, then the order was discontinued, but she would check for sure, and would fax the information to the facility. On 1/4/12 at approximately 12:30 p.m., the facility received a fax stating the physician had concerns about the intramuscular route, and that was why the medication was sent for intravenous administration. Six doses were sent on 12/20/11 from one pharmacy, and a second location pharmacy sent nine more doses on 12/21/11, nine doses on 12/23/11, and six doses on 12/27/11, for a total of 30 doses. On 1/4/12 at approximately 2:00 p.m., the IDON was interviewed. She stated she did not know why the MAR indicated [REDACTED]. She expected nurses to call the MD to clarify if a range of doses were ordered, and a route should be included in a written order. 3. Resident #7 Resident #7, age 85, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her most recent Minimum Data Set (MDS), a quarterly assessment done, on 10/30/11, the resident required the assistance of one to two (staff) for activities of daily living (ADLs) which included bed mobility, transfers, ambulation, dressing, toileting and personal hygiene. Her cognitive status was moderately impaired. Record Review: Electronic record review revealed that resident #7 missed several doses of insulin, a regularly scheduled medication; one time for several consecutive days. The resident's [MEDICATION NAME], as needed for pain from hemorrhoids, also was missed. On a number of occasions the missed doses were due to unavailability of the medications. There was no evidence that the facility had notified the physician or the family of the missed doses (cross-reference F157). There was no evidence the Director of Nursing (DON) had been informed which was confirmed on interview. (Cross-reference F333; significant medication errors) Specifically: Resident #7 did not receive her Insulin ([MEDICATION NAME] or [MEDICATION NAME]) as ordered on the following occasions: -[MEDICATION NAME] 5 mcg for 7 a.m. on 11/25/11 was refused. -[MEDICATION NAME] 5 mcg for 7 p.m. on 11/24/11 was refused. -[MEDICATION NAME] 5 mcg for 7:30 a.m. on 11/25/11 not available, pharmacy notified. -[MEDICATION NAME] 5 mcg for 4:30 p.m. on 9/4/11 was refused. -[MEDICATION NAME] 5 mcg for 4:30 p.m. on 9/3/11 was not available. -[MEDICATION NAME] 5 mcg for 4:30 p.m. on 9/2/11 was refused. -[MEDICATION NAME] 5 mcg for 7:30 a.m. on 8/27/11 needles not available, not given. -[MEDICATION NAME] 5 mcg for 4:30 p.m. on 8/26/11 needles not available, not given. -[MEDICATION NAME] 5 mcg for 7:30 a.m. on 8/26/11 needles not available, not given. -[MEDICATION NAME] 5 mcg for 4:30 p.m. on 8/25/11 needles not available, not given. -[MEDICATION NAME] 5 mcg for 7:30 a.m. on 8/25/11 needles not available, not given. -[MEDICATION NAME] 5 mcg for 4:30 .m. on 8/24/11 needles not available, not given. -[MEDICATION NAME] 5 mcg for 7:30 a.m. on 8/24/11 needles not available, not given. -[MEDICATION NAME] R 100 Unit Insulin for 4:00 p.m. on 8/18/11 refused. -[MEDICATION NAME] R 100 Unit Insulin for 4:00 p.m. on 8/9/11 refused. -[MEDICATION NAME] R 100 Unit Insulin for 11:00 a.m. on 8/8/11 refused. -[MEDICATION NAME] R 100 Unit Insulin for 4:00 p.m. on 8/7/11 refused. -[MEDICATION NAME] Hemorrhoid Cream for 2:00 p.m. on 8/18/11 not available* -[MEDICATION NAME] Hemorrhoid Cream for 2:00 p.m. on 5/30/11 not available* Record review on 3/14/11 revealed the following Nurse's Note: "Resident noted with large amount of rectal bleeding during bath. Blood is bright red and large hemorrhoids noted. Pad placed with pressure over rectal areas. Bleeding continued heavy for 1 hr then decreases and becomes scant by 2400 ... " The physician ordered the [MEDICATION NAME] Suppository (7/11/11) for management of ongoing bleeding and pain issues for the resident. It was to be used, one suppository every 12 hours, as needed. Staff Interview: The Interim Director of Nursing (IDON) was interviewed on 1/3/12 at approximately 4:15 p.m. She was asked what her expectation was regarding resident #7 being out of medications. -She said she was very concerned that no one in nursing had advised her they had any trouble securing the appropriate medications for resident #7. She stated she recalled one time in August 2011 when she was told they did not have enough of the needles for the [MEDICATION NAME] syringes (they come separately and are a different type of needle than normally used for insulin administration). She stated she remembered having gone to a local pharmacy (could not recall which one) and stated she obtained two boxes and brought them to the nurses. -She stated no one ever told her they had run out of syringes, insulin or [MEDICATION NAME] for that resident. She stated she was not aware that the resident had missed so many doses of regularly scheduled medication. She also acknowledged the facility had not documented the nursing staff had notified either the physician or the family regarding the ongoing omissions. 4. Resident #16 Resident #16, age 95, was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. According to her most recent Minimum Data Set (MDS), a quarterly assessment, dated 12/25/11, she required the assistance of one to two staff for all activities of daily living (ADLs), which included transfers, bed mobility and ambulation. She required extensive assistance with dressing, personal hygiene and bathing. Her cognitive abilities were significantly impaired. Record Review Revealed: Medications Not Available: -[MEDICATION NAME] 24 mcg 8/31/11, 10/24, 10/27/ 10/29 and 11/8/11. Medications Refused: -[MEDICATION NAME] eye ointment, [MEDICATION NAME], Oyster Shell Calcium, Amitzia and [MEDICATION NAME] refused 12/4/11. -[MEDICATION NAME] eye ointment refused 12/10/11. -Amitza, Oyster Shell Calcium, [MEDICATION NAME] eye ointment and [MEDICATION NAME] refused 12/18/11. -[MEDICATION NAME] eye ointment, Amitza, [MEDICATION NAME] and [MEDICATION NAME] refused on 12/21/11. -[MEDICATION NAME] eye ointment refused 12/31/11. -[MEDICATION NAME] and [MEDICATION NAME] refused on 10/17/11. -[MEDICATION NAME], Protonox and [MEDICATION NAME] refused 9/22/11. -Amitzia and Oyster Shell Calcium refused 9/3/11. -[MEDICATION NAME] 40 mg refused 8/15/11 ...refused ALL a.m. meds. -Keflex 500 mg. Oyster Shell Calcium, [MEDICATION NAME] and [MEDICATION NAME] eye ointment refused 8/13/11. -Keflex 500 mg refused on 8/9/11. -[MEDICATION NAME] 24 mcg; [MEDICATION NAME]; [MEDICATION NAME] eye ointment, [MEDICATION NAME] and Oyster Shell Calcium refused on 8/8/11. -[MEDICATION NAME] 125 mcg refused 6/8 and 6/7/11. -[MEDICATION NAME] 150 mg refused 6/8 and 6/7/11. The resident missed at least 40 doses of various medications from April 2011 through December 2011. There was only one instance where it was documented that a family member was notified of the resident's missed medications. There was no evidence staff had ever informed the physician. Further Record Review Revealed: -On 4/27/11 it was documented in the Nurse's Notes that the results of a TSH and T3 levels were abnormal and the [MEDICATION NAME] was increased to 125 mcg daily. It also said "Ensure that med is being taken." (Family was notified) Staff Interviews: The Interim Nursing Home Administrator (INHA) and Regional Nurse Consultant (RNC) were in attendance in the interview with IDON, on 1/3/12 at approximately 4:15 p.m. They both stated they were not aware of the missing medications. They also confirmed that the nurses should have informed the DON, the physician and the family of any resident not receiving medications as ordered. 5. Residents #16 and #17 During electronic record review, on 1/3/12, there were references to residents #16 and #17 having been in a secure unit. The INHA and the RNC were asked on 1/2/12 (survey entry) if the facility had a secure unit. The response was no; however, when asked again on 1/3/12 at approximately 4:00 p.m. (because of the references in residents #16 and #17's records of placement in a secure unit), the INHA and RNC revealed the facility had a secure unit from 11/10 until 8/11. The INHA and RNC were not present when the secure unit closed nor when it opened in 11/10. During an interview, on 1/3/12 at approximately 4:30 p.m., the INHA and RNC stated that the facility used to have a "Dementia Placement Team" that met, went through a questionnaire and determined whether or not someone was appropriate for the Special Care Unit (secure unit). The NHA and RNC stated the facility had "notified" the State of their plan to close the secure unit via a letter. In checking with the Department of Health (DOH) on 11/21/11, the DOH had no record of such notification. Review of residents #16 and #17's electronic records revealed the residents had no physician orders with rationale for the residents' placement on the secure unit or signed consents for secure unit placement from the responsible parties. And, upon closing the secure unit, there was no documentation of physician orders with rationale explaining why the residents no longer needed to be in secure environment or signed consents from responsible parties for the residents movement to an open unit. a. Resident #16 Resident #16, age 95, was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. See MDS data above. Review of resident #16's electronic record revealed the following: The resident's care plan, dated 3/19/11, read the resident had ". . . behaviors related to dementia .... (She) gets agitated at the staff. She is resistive to care and has the potential to become combative. (name) requires secure unit placement r/t (related to) behaviors." The questionnaire for resident #16's placement in secure unit, dated 11/23/10, read, in pertinent part: -"Can this resident be managed in the regular unit of the facility with the appropriate approach and behavior management techniques? YES/NO Explain." It was marked, "No" with no explanation. -"What unmanageable behaviors does the resident exhibit? 1. Resistive to care. 2. Combative. 3. Strikes out at others. 4. Low frustration tolerance. 5. Low impulse control." -"Does resident have significant behaviors that seriously disrupt the rights of the other residents? Yes/No Explain. Yes as above." -"Is the resident a danger to him/herself?" "No, although has injured self while attempting to injure others." -"Is the resident a danger to others? How? Yes-staff only when doing personal care." The document read that the resident would benefit from increased one-to-one; structured programming and decreased stimulation. The questionnaire also asked if any medication therapy had been attempted to avert this transition? There was no answer. The signatures on the form of the "Dementia Placement Team" were of the former NHA, the former Director of Nursing (DON), the former Activities Director and the Dietary Director. There was no family participation, no physician participation, and it was marked approved. There was a telephone order corresponding to the resident's placement on the secure unit 11/30/10. It read, "May place resident in Special Care Unit." It was written by the Nurse Practitioner for the resident's physician. There was no documented reason for the resident's placement, no specific orders and no assessment by the physician. A 30 day re-evaluation was completed, dated 12/21/10. It read that all behaviors were the same and was signed by the facility staff, without physician and family signatures. A 90 day re-evaluation was completed dated 3/22/11. It read the same as the 30 day re-evaluation, as did the 180 day re-evaluation dated 6/22/11. None of these re-evaluations contained physician or family signatures. Further review of the 180 day re-evaluation dated 6/22/11 revealed at the bottom of the front page, in a section that asked whether or not the resident was still a candidate for appropriate placement in the secure unit, it read, "Placement is no longer appropriate - plans will be made to change placement." However, according to the resident's care plan, the resident remained in the secure unit until it was closed on 8/1/11. The resident's behavior care plan indicating her need for the secure unit (see above) documented the need for secure placement was "resolved" 8/1/11, two months after the 180 day re-evaluation indicated the resident was no longer appropriate for the unit. Further record review revealed no physician order with rationale to move the resident from the secure unit 8/1/11. There was no documentation, other than on the 180 day assessment dated [DATE], that indicated the resident should be removed from the unit at that time. b. Resident #17 Resident #17, age 86, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her most recent MDS, a quarterly assessment dated [DATE], she required the assistance of one to two staff for all ADLs, which included transfers, bed mobility and ambulation. She required extensive assistance with dressing, personal hygiene and bathing. Her cognitive abilities were significantly impaired. Review of resident #17's electronic record revealed the following: The initial Nurse's Note stated, "... (name of nursing home resident transferred from) stated that resident can have aggressive behavior, especially with changing clothes or Depends. Sometimes is up all night. At times will kick, scream and bite. Has good appetite, pushes self in wheelchair using her feet. Has several bruise(s) noted on left arm, no open skin areas noted. Nursing home (where she transferred from) stated bruises were from aggressive behavior - Incontinent of B&B (bowel and bladder)." There was further documentation of days when resident #17 was aggressive with cares and other days when she was cooperative and easily re-directed. Review of the resident's care plan, dated 11/30/10, showed she had " ...behaviors related to Alzheimer's ....she has the potential to wander, becoming intrusive. (resident name) requires secure unit placement R/T (related to) behaviors." (Resident #17 scored a zero on her Wandering assessment dated [DATE]). On 11/30/10 Nurse's Notes read, "Received orders: May place resident in special care unit." Further review of notes revealed her behaviors remained the same. She often refused cares and especially assistance with personal hygiene. There was a telephone order written 11/3/10 that read, "May place resident in Special Care Unit." It was written by the Nurse Practitioner for the resident's PCP. There was no documented reason for placement, no specific orders and no assessment by the physician. The questionnaire for resident #17's placement in secure unit, dated 11/23/10, read, in pertinent part: -"Can this resident be managed in the regular unit of the facility with the appropriate approach and behavior management techniques? YES/NO Explain." It was marked, "No" with no explanation. -"What unmanageable behaviors does the resident exhibit? 1. Goes into others rooms. 2. Has no ability to recognize appropriate boundaries. 3. Picks up things that don't belong to her and is resistive to giving them back. 4. Low frustration tolerance. 5. Low impulse control." -"Does resident have significant behaviors that seriously disrupt the rights of the other residents? Yes/No Explain. Yes as above." -"Is the resident a danger to him/herself?" No -"Is the resident a danger to others? How? Possible - she will strike out at others if she is angry." The questionnaire further read the resident could benefit from the secured unit placement because she would do better with shorter activities, the increased staffing, the increase of one to one and decreased interaction with other, more alert residents. The document asked if any medication therapy had been tried to avert this transition and to explain. It read "No" without explanation. The signatures on the form of the "Dementia Placement Team" were of the former NHA, a Registered Nurse, the former Activities Director and the Dietary Director. There was no family participation, no physician participation and it was marked approved. A 30 day re-evaluation was completed, dated 12/21/10. It read that all behaviors were the same and was again signed by the facility staff, but not the physician and family. A 90 day re-evaluation was completed, dated 3/22/11, and read as above, as did the 180 day re-evaluation, dated 6/22/11. None of these assessments were signed by the physician or family and none indicated the resident was no longer appropriate for the unit. However, a review of the resident's care plan documenting the resident's placement on the secure unit (see above) indicated the placement was "resolved" 8/1/11. There was no explanation why the resident no longer required the secure unit; she continued to exhibit the same behaviors after 8/1/11, which was the day the Special Care Unit was closed. Further record review revealed no physician order or rationale to move the resident off the secure unit. c. Staff Interview The INHA and RNC, interviewed on 1/4/12 at approximately 11:30 a.m., confirmed there were no signed assessments that included physician and family involvement, no physician orders regarding residents' placement on and off the secure unit, and no family consents regarding the residents' placement on and then off the unit. They both also stated they were not assigned to the building when the opening of the Special Care Unit took place. The INHA, however, stated she was aware of the history. None of the administrative staff were aware that the same procedure required to place a resident on a secure unit (assessment, consents and detailed physician's orders) needed to be followed when closing a unit, if the residents are not being transferred.

Based on record review, and resident, family, staff interviews, the facility failed to ensure one of seven sample residents (#2) maintained adequate hydration. Specifically, the facility failed to monitor and assess the resident's hydration status. The resident was at risk for dehydration due to fever and vomiting and exhibited signs and symptoms of impending dehydration including a mental status change. The facility's failure to adequately monitor the residents' hydration status contributed to the resident being subsequently hospitalized with [DIAGNOSES REDACTED]. Findings include: 1. Facility policy The facility policy entitled "Hydration and Nutrition" was requested and received on 2/24/11 at 10:30 a.m. from the Director of Nursing. The policy stated in pertinent part: "Policy: The nutrition and hydration status of each resident is maintained as close to optimal level as possible, and the prevention of dehydration. -Baseline nutrition and hydration information is obtained by a registered nurse on admission. -The Inter disciplinary Health Care team will assess and identify, by the initial assessments, and the MDS (Minimum Data Set), those residents at risk for dehydration. Residents will be assessed at admission, quarterly and upon any change of condition. . . -Fluids will be offered frequently: when turning, positioning, toileting or visiting with residents." 2. Professional References - Mosby's Clinical Nursing, 5th Edition 2002, pp 1440-1443, reads, in pertinent part: "Deficient fluid volume is the state in which an individual experiences decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without changes in sodium. "Related Factors: Diarrhea, fever with poor intake, vomiting. Defining Characteristics: Changes in mental status, decreased pulse or pressure, decreased urine output. Nursing Interventions: Measure vital signs; Measure intake and output; Monitor electrolytes, especially potassium, sodium, calcium, and magnesium; Assess skin turgor; Administer intravenous or oral fluids as ordered by physician; (Assess) Cause and how to prevent recurrence." - "Healthy adults estimated daily fluid needs are 30 ml per kilogram. . . In addition, adults with diarrhea, trauma, diuresis, fever, and in sensible losses may require additional fluids. Insensible losses are the result of respiration, fecal loss evaporation, and fever. Replace diarrhea output volume per volume with normal saline, [MEDICAL CONDITION] or fistulous output with 1/2 normal saline, and evaporation due to fever (250 ml/day for each oC above 37oC) with sterile water or D5W." ('Fluid Physiology' by Kerry Brandis -from <http://www.AnaesthesiaMCQ.com> and Clinical Nutrition A Resource Book for Delivering Enteral and [MEDICATION NAME] Nutrition for Adults, University of Washington Academic Medical Centers, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington, 1997. - "How is dehydration diagnosed ?" by Benjamin C. Wedro MD, FACEP, FAAEM <http://answers.webmd.com/experts/ /Benjamin-C-Wedro-MD-FACEP-FAAEM> www.yesanswer.de/med/1935.html "Dehydration is often a clinical diagnosis. Aside from diagnosing the reason for dehydration, the health care practitioner's examination of the patient will assess the level of dehydration. Initial evaluations may include: ? Mental status tests to evaluate whether the patient is awake, alert, and oriented. ? Vital signs may include postural readings (blood pressure and pulse rate are taken lying down and standing). With dehydration, the pulse rate may increase and the blood pressure may drop because the intravascular space is depleted of fluid. People taking beta blocker medications for high blood pressure, [MEDICAL CONDITION], or other indications, occasionally lose the ability to increase their heart rate as a compensation mechanism since these medications block the [MEDICATION NAME] receptors in the body. ? Temperature may be measured to assess fever. ? Skin may be checked to see if sweat is present and to assess the degree of elasticity (turgor). As dehydration progresses, the skin loses its water content and becomes less elastic. . ." 3. Resident #2 Closed medical record review revealed [AGE] year-old sample resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. There was no evidence of a completed Minimum Data Set (MDS). The care plan only addressed "Scheduled Care Routine Tasks." The goal and target date were "Scheduled Care Tasks." The approaches listed were: -Sleep monitoring, -Bowel movement, -Voiding, -Record meal, -AM/PM care, -Behavior noticed, -Skin check, -Snack, and -Repositioning The facility failed to adequately monitor the resident's hydration status from 1/13/11 to 1/19/11 and from 1/20/11 to 1/31/11. The resident experienced episodes of fluid volume deficit/dehydration. (1) Review of the facility's Nutritional Progress Review dated 1/16/11, completed shortly after admission by the Dietary Manager, indicated the resident was on a low purine diet, his average food consumption was 51% to 75%, he was independent in eating, had no skin issues, and his serum [MEDICATION NAME] level was unknown. The assessment revealed the estimated calorie needs for the resident were 2400 kcal per day based on 30 kcal/ kilogram. The resident required 58-71 g/day of protein and the resident's estimated fluid needs were 1740 mL per day. According to the 1/8/11 hospital records in the medical record reviewed on 2/27/11, the resident was on an antibiotic for the left elbow infection and his [MEDICATION NAME] level was low at 2.4 mg/dL. The normal range was between 3.3 through 4.5 mg/dL. Cross reference F325 Weight Loss. There were no documented measurable interventions demonstrating staff monitored the amount of fluids the resident consumed to ensure adequate hydration. Review of fluid intake records revealed no documentation to show fluid intakes were totaled or analyzed in relation to calculated daily fluid needs. There was no documented output to ensure the acutely ill resident had a positive balance of hydration. (2) Review of nurses' notes revealed a lack of documentation that nursing comprehensively monitored the resident for fluid volume deficit/dehydration, even though the resident presented with risk factors (poor oral intake, diarrhea, vomiting, and fever) as follows: - 1/13/11 at 7:50 p.m. ". . . Vitals 98/54 98.9 p 98 reg. 24. . . [MEDICAL CONDITION] present at certain joints: elbows, bunion areas and @ + @ ankles. . .Requires assist of two for transfers, 1 assist for ADL's. He propels himself in wheelchair. He feeds himself. His pain gets to 9. Pain occurs @ joints named above. . ." - 1/14/11 at 10:38 a.m., ". . . He is weak and needs some restorative therapy. . ." - 1/14/11 at 8:59 p.m., ". . .To continue Keflex 500 mg qid po (four times a day orally) for left elbow infection and to dress area as needed for drainage. Area draining small amount of light yellow fluid. . ." - 1/16/11 Vital signs documented on this date included a pulse of 95, a temperature of 97.5?F, a blood pressure (laying down) of 115/80 and a blood pressure (sitting) of 90/60. - 1/17/11 Vital signs documented on this date at 5:52 p.m. included a pulse of 105, a temperature of 97.9?F, a blood pressure (sitting) of 104/58. At 9:06 p.m. pulse was documented as 103, a temperature as 98.4 and a blood pressure laying down a 116/58. - 1/17/11 at 1:57 a.m. ". . .on abx (antibiotic) for elbow infection. . ." - 1/19/11 at 3:25 a.m. ". . .Noted at times resident yelling for staff to help him, staff explained to him that he needs to use his call light and it was inappropriate for him to yell." - 1/19/11 at 5:30 p.m. the vital signs were documented as a pulse of 108, a temperature of 99.0 and a blood pressure (lying down) 116/58. - 1/19/11 at 8:21 p.m. "At 1730 (5:30 p.m.) was noted by the CNA (Certified Nursing Aide) that resident had been "different all day." He noted change in mental status stated resident had refused meds and meals. Was noncompliant with care. I asked charge nurse (name of charge nurse) if she was aware. She stated kinda (kind of). I had charge nurse place call to (the physician's name) office. MD not in office. Nurse that returned call stated if we were that worried about resident condition to send to ER. Call placed to (physician's name) who was on call for (name of physician). Notified Dr. of resident elevated temp and change in mental status. Received orders to send to ER for eval (evaluation) and TX (treatment)." (3) Hospital Record Review Review of the 1/19/11 hospital record on 3/8/11, indicated the admitting [DIAGNOSES REDACTED]. The laboratory tests revealed a BUN (Blood Urea Nitrogen) of 27, a creatinine level of 1.3, and low levels of hemoglobin at 12.2 and a hematocrit of 37.1. The temperature was documented as 100.2 and the pulse was 117. The resident was hydrated with IVs and discharged back to the facility on [DATE]. (4) Declining intake According to the facility's "Nutritional Progress Review dated 1/16/11, the estimated fluid need was over 1740 mL per day. The documented daily intake levels were totaled (taken from the Meal and Snack computerized form received on 2/22/11) and revealed the declining oral intake. However, resident #2's needs would have been higher than the estimated 1740 cc, given fluid loss from nausea, vomiting, fever and infection. On 3/7/11 at approximately 1 p.m., the Nursing Home Administrator (NHA) gave the surveyor another form entitled "Intake and Output Roster" stating the facility tracked additional fluids (other than with meals and snacks) offered to the resident during the day; however, these intake totals were identical to the meal and snack documented totals and were not included in these daily totals below. There was no evidence of documented output totals. The documented daily total intakes included (deficits noted in parentheses): - 1/13/11 the total documented was 552 cc (admission day) - 1/14/11 the total documented was 1475 cc (1740 cc -1475 cc =265 cc deficit) - 1/15/11 the total documented was 975 cc (-765 cc) - 1/16/11 the total documented was 1300 cc (-440 cc) - 1/17/11 the total documented was 300 cc (-1440 cc) - 1/18/11 the total documented was 150 cc (-1590 cc) - 1/19/11 the total documented was 225 cc (-1515 cc) The resident was admitted to the hospital for acute dehydration on 1/19/11 and returned to the facility on [DATE] at 2 p.m. with orders to encourage fluids. - 1/20/11 there was no evidence of any fluids offered upon return to the facility - 1/21/11 the total documented was 975 cc (-785 cc) - 1/22/11 the total documented was 325 cc (-1435 cc) - 1/23/11 the total documented was 875 cc (-865 cc) - 1/24/11 the total documented was 225 cc (-1515 cc) - 1/25/11 the total documented was 325 cc (-1415 cc) - 1/26/11 the total documented was 1001 cc (-739 cc) - 1/27/11 the total documented was 1026 cc (-714 cc) - 1/28/11 the total documented was 1125 cc (-615 cc) - 1/29/11 the total documented was 650 cc (-1090 cc) - 1/30/11 the total documented was 400 cc (-1340 cc) - 1/31/11 the total documented was 325 cc (-1415 cc) The resident insisted on being discharged on [DATE]. A nurse's note dated 1/31/11 at 5:47 p.m. documented that the resident was discharged home (Cross Reference F204 Discharge) and then called at home to report to the ER per the physician's request after the physician read the 1/28/11 laboratory results. Review of the hospital records dated 2/1/11 indicated the resident was admitted for [MEDICAL CONDITION]. Interviews The Director of Nursing (DON) and a corporate consultant were interviewed on 2/23/11 at 3:15 p.m. The DON stated the nurses had access to meal and fluid intakes and it was her expectation for the nurses to monitor them. The resident was interviewed on 2/24/11 at approximately 12:36 p.m. He stated he had nausea and vomiting and ate little at the facility. The resident's wife was also interviewed at the same time. She added that the physician ordered Ensure; however, the facility didn't provide it. She stated she had taken the resident home a few times to encourage nutrition and had to buy the Ensure herself. She also stated the resident had vomited multiple times and lost weight at the facility. She stated she was disappointed with the care and resident's weight loss.

Based on record review, family interview, and staff interview, the facility failed to ensure three of seven sample residents (#1, #2, #4) received proper respiratory treatment and care. Specifically, the facility failed to adequately assess/address and monitor the residents' respiratory needs. This contributed to resident #1's respiratory distress, brain [MEDICAL CONDITION] and subsequent death on [DATE]. The findings include: 1. Reference - Oxygen saturation According to "Medical Surgical Nursing," by Lewis & Collier, 3rd Edition, pages 445 and 814: "The SaO2 is expressed as a percentage. For example, if the SaO2 is 90%, then 90% of the hemoglobin attachments for oxygen have oxygen attached to them." Refer to the following: "SaO2 (%) Considerations a. >94 Adequate unless client is hemodynamically (refers to the monitoring of blood flow and pressure within the cardiovascular system) unstable. b. 90 Adequate in almost all clients. c. 88 Adequate for clients with chronic hypoxemia (refers to a blood oxygen level that is lower than normal) if no cardiac problems occur. d. <75 Inadequate: Tissue [MEDICAL CONDITION] (refers to a deficiency in tissue oxygenation and is associated with symptoms that reflect inadequate oxygen delivery to vital organs, such as the heart and brain) and cardiac [MEDICAL CONDITION] (irregular heart beat) can be expected." 2. Resident #1 Closed medical chart review revealed [AGE] year-old sample resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], revealed the resident had impaired vision, minimal difficulty with hearing, no memory impairments, and was independent in the cognitive skills needed for daily decision-making. The comprehensive care plan last updated on [DATE] indicated the resident required the use of oxygen and nebulizer treatments due to his [DIAGNOSES REDACTED]. The interventions listed were: - Apply oxygen to the resident via nasal cannula on 3 L per minute and titrate as needed, - Monitor the resident's oxygen saturation levels (SAO2). The care plan also read that the resident carried a portable SaO2 machine that he used to monitor his own saturation levels. The resident was to be reminded to notify nursing if his saturation levels were below 88%. - Give the resident [MEDICATION NAME] 0.083% solution four times as needed for [MEDICAL CONDITION]. - Give Duo Neb inhaler two puffs four times a day as needed. - Give [MEDICATION NAME] inhaler ,[DATE] diskus one puff twice daily and have the resident rinse his mouth after the use. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This order was written on [DATE] and there was a notation beside the entry that read may keep at bedside. (Cross reference F176 Self Administration of Medications) a. Facility Failures - Review of the Resident Council minutes dated [DATE] indicated under the topic "Nursing" that resident #1 "was concerned that his oxygen tank was not hooked up properly and this was a concern. A training on oxygen tanks was suggested for all nursing staff." The Director of Nursing (DON) was questioned about the most recent training on oxygen tanks and oxygen therapy. On [DATE] at 3:45 p.m. information was received from the DON dated [DATE] pertaining to the last in-service on oxygen tanks and oxygen therapy. - The facility had allowed the resident to use and administer his own nebulizer treatments and inhalers without an assessment to ensure the resident was able to administer these safely and correctly. There was no evidence that the resident was monitored when the nebulizer treatments and inhalers were used, (Cross reference F 176 Self Administration of Medications) even though the nursing staff documented these treatments were completed. b. History of pneumonia According to the hospital history and physical dated [DATE], the physician included under [DIAGNOSES REDACTED]." According to the nurse practitioner's notes dated [DATE], the resident had returned from the hospital to the facility on [DATE] due to an "acute exacerbation of [MEDICAL CONDITION] and pneumonia." The resident was on [MEDICATION NAME] antibiotic [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) of the sputum. c. Lack of facility monitoring - A nurse documented on [DATE] at 2:14 p.m., "Resident noted at 8:00 a.m. this a.m. to be very dusky when the RN entered the room. He was checking his 02 stats which was 55% and this RN noticed he did not have his cannula on. Resident was assisted to put his cannula back on and after five minutes his 02 stats was 91% on 4 L. Resident had not eaten his breakfast though it was taken to him at 7:15 a.m. After O2 sat came back up to normal he ate 90%. Despite incident, he has been very pleasant all day. He took his meds this a.m. and has been taking all his respiratory inhalers and treatments. VS (Vital signs): 97.6 100, 28, ,[DATE]. He received his lunch on time but vomited all his lunch, saying it was too rich. O2 sat remains at 93% on 4 L. Will continue to monitor." - On [DATE] at 8:26 a.m. a nurse documented at 4 a.m. that the resident's roommate had alerted staff that resident was having trouble breathing. "Resident leaning forward SPO2 83% with O2 on 4 L. [MEDICATION NAME] HHN tx (treatment) started. 4:03 a.m. 02 increased to 5 L. At 4:15 AM SpO2 86 to 88% O2 increased to 6 L. Resident c/o moist, nonproductive cough awakening him q1 hour. T/C (telephone call) to (name of nurse practitioner) see orders. 4:35 a.m. Gave [MEDICATION NAME] 20 mg and [MEDICATION NAME] 0.5 mg PO (orally). 5 a.m. resident asleep with the occasional cough." - On [DATE] at 11:46 a.m. a nurse documented that the resident complained of not feeling well and was noted to have increased shortness of breath. The nurse also documented the resident's oxygen saturations were in the low 80's on 4 L. The nurse documented the resident had a moist productive cough and rhonchi and rales were noted. The resident had 2+ [MEDICAL CONDITION] to the lower extremities according to the nurse. The nurse practitioner was notified. Per physician's, orders a second dose of [MEDICATION NAME] 20 mg was given and then [MEDICATION NAME] 0.25 mg was to be given every four hours for three doses. According to the nurse's documentation, the resident was given both [MEDICATION NAME] and [MEDICATION NAME] as ordered. "Will watch closely for any acute changes." - However there was no evidence that the resident was monitored closely during the night, for the next nurse's note was not documented until [DATE] at 1:59 p.m. This nurse documented, "Resident found with O2 cannula off at 9:55 a.m. Resident mostly unresponsive but does open eyes slightly when name called. He does not grip to command. He does nod slightly, shakes head slightly at times to question. VS's 96.2-P,[DATE]. Resp (respirations) deep and not of Cheyne Stoke quality. BP ,[DATE]. O2 sat with 73%. O2 cannula was replaced on patient and resident was given [MEDICATION NAME] treatment. His last one had been at 6 a.m. Pulses strong. O2 sat came up to 86% on 4 L but he remains barely responsive and skin dusky, warm and slightly moist. (Name of nurse practitioner) was notified of resident's condition. Order obtained to send to ER. Ambulance called per 911 at 1020 and they arrived and left for (name of hospital) ER at 1020. - Review of the ER record reveals a CAT scan was completed, a Foley catheter was placed, and hospice was ordered. The ER physician documented the resident was lethargic but responded. The clinical impression documented on the ER record was [MEDICAL CONDITIONS] and [MEDICAL CONDITION] with [MEDICAL CONDITION]. - The resident returned to the facility on [DATE] at 6:07 p.m. According to the nurse's note the resident was on clear liquids as tolerated; however review of the Meal and Snack record and the Intake and Output record revealed no documented evidence that the resident received any fluids on ,[DATE] and [DATE]. The Foley catheter output was documented as 900 cc on [DATE] at 10:35 a.m. - On [DATE] at 8:50 a.m. the nurse documented the resident responded to verbal stimuli and the Foley catheter was draining dark yellow urine. According to the night nurse's documentation the resident's roommate called for assistance at 2:45 a.m. and the resident was found on the floor. "Apparently hit forehead on overhead table. Large amount of blood. Return to bed. Assessed, family notified vital signs taken, taking large amounts of fluids." There was no documented evidence of neuro checks being completed. (Cross reference F323 Supervision to Prevent Accidents.) - On [DATE] at 8:55 a.m. a nurse documented that she was notified by a visiting family member that the resident was short of breath and agitated. According to the documentation the resident was in bed with respirations very labored with the SpO2 in the 60's on 5 L. The nurse documented the resident was confused and attempting to remove the catheter. The nurse documented that the morning medications had been given (although there was no documented evidence on the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the nurse's documentation, the family requested comfort care only. The nurse documented that the nurse practitioner discovered the resident with a weak thready heartbeat and without respirations at 4:40 p.m. The resident expired at 4:50 p.m. on [DATE]. Interviews A family member was interviewed on [DATE] at 12:30 p.m. and approximately 5:30 p.m. The family member reported the facility reported to them the resident was without oxygen anywhere from 40 minutes to four hours. The family member stated this was neglect. The family member also stated several family members were with the resident from approximately 8:30 a.m. to approximately 1 p.m. on [DATE]. During that time no staff member came in the room to reposition the resident, do neuro checks, or take vital signs, according to the family member. The family member questioned the facility's monitoring of the resident when the resident fell after his return from the emergency room stating he was lethargic and responsive only to verbal and pain stimuli. The resident's roommate was interviewed on [DATE] at approximately 6 p.m. and again on [DATE] at 5 p.m. The roommate stated the resident was confused upon return from the emergency room and forgot he had a Foley catheter. The roommate continued to say the resident attempted to get out of bed and fell to the floor. The roommate continued that the resident attempted to get out of bed again at 5 a.m. and staff brought a commode into the room. The registered nurse (RN) on duty the day the resident was found without his oxygen on was interviewed on [DATE] at 3:10 p.m. The RN stated she was not assigned to the hall upon which resident #1 resided. The RN stated she had been summoned by the other nurse to check the resident. She stated the resident "was cyanotic" and "responded a little" and "was unable to speak." The RN continued that the resident had his oxygen on at that time and his O2 stats were at 73%. The RN continued that the resident had his last nebulizer treatment at 6 a.m. and she decided to give him another treatment to help shortness of breath. The RN went on to say the resident would not have taken his oxygen off on purpose. She stated she then sent him to the emergency room per physician order. The RN went on to say that a family member arrived at the facility before the ambulance, hearing it on the scanner. She stated she was relieved the family member had arrived and could be with the resident. The Licensed Practical Nurse (LPN) that discovered the resident without his oxygen was interviewed on [DATE] at 2:05 p.m. The LPN stated she found resident #1 without his oxygen on, holding the oxygen cannula in his hand. She stated his O2 sats were in the 50%. The LPN stated he just didn't look right, was motionless, and not verbal. 3. Resident #4 Medical chart review revealed [AGE] year-old resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan last updated on [DATE], indicated the resident had the potential for weight loss, had a [DIAGNOSES REDACTED]. Interventions listed for the use of oxygen included: - Administer oxygen and 2 L per minute via nasal cannula as ordered, - Check O2 sats daily and as needed to maintain stats greater than 90%, - Nurse may titrate to keep SAO2 greater than 90% in. 1 L increments. Notify physician of need to titrate. Observations were made of resident #4 on [DATE] beginning at 7:51 a.m. The resident was seated at the assistive table in the dining room. She was observed with a personal alarm attached to her shirt. A portable oxygen canister was supported in a holder on the back of her wheelchair. The dial was observed turned to "0" indicating the canister was in off position; however the resident was wearing an oxygen nasal cannula. At 8:23 a.m. resident was removed from the dining room and taken to her room by a CNA. The portable oxygen canister was still in the off position. At 8:36 a.m. the resident was taken to the restroom by a CNA and returned to the TV room. The portable oxygen canister was now dialed to "2". The Nursing Home Administrator (NHA) was informed of the above observations at approximately 9:20 a.m. The resident oxygen sats were taken at this time and were 97% to 98%. 4. Resident #2 Closed medical record review revealed [AGE] year-old sample resident #2 was admitted to the facility on [DATE] for physical rehabilitation with [DIAGNOSES REDACTED]. The resident discharged home on [DATE]. There was no evidence of a completed Minimum Data Set (MDS). The care plan only addressed "Scheduled Care Routine Tasks." The goal and target date were "Scheduled Care Tasks." The approaches listed were: -Sleep Monitoring, -Bowel Movement, -Voiding, -Record meal, -AM/PM care, -Behavior noticed, -Skin check, -Snack, and -Repositioning Review of the physician's admission orders [REDACTED]. The O2 sats were to be checked daily and as needed. Review of the ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Days" and in the entries labeled "Nocs." Beside the entry labeled "Result" there was no documentation other than checkmarks in the dated squares on days ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE] and a "0" on [DATE] at Nocs. There was no documented evidence the resident's oxygen saturation levels were tracked and titrated at or above 90% as per physician order. The DON was informed of the above observations on [DATE] at approximately 3:15 p.m. On [DATE] the DON stated she had been monitoring the MARs and TARs for incomplete documentation.