Every finding on record at Riverside Nursing Centre

Based on observation, interview, and record review, the facility failed to follow contact precautions for one of three resident's (Resident #104) reviewed for infection control practices.Findings:Resident #104 (R104)Review of a Face Sheet revealed R104 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of adult failure to thrive. During an observation on 04/16/26 at 9:31 AM, a contact precautions sign hung outside R104's room that directed staff .gown and gloves to be worn each time room entry is made. Review of a physician order summary for R104 reflected .contact precautions due to confirmed diagnoses of shingles. During an observation on 04/16/26 at 12:30 PM, certified nurse aide (CNA) C assisted R104 with lunch as the resident laid in bed. CNA C did not have on a gown or gloves nor any PPE (personal protection equipment). During an interview on 04/16/26 at 12:35 PM, Registered Nurse (RN) E indicated that the expectation for all staff was to follow posted contact precautions when entering R104's room for any reason.

This citation is related to intake #2973235Based on observation, interview, and record review, the facility failed to treat two of four residents (Resident # 103 and an unidentified resident) with dignity and respect when assisting them with breakfast. Findings:Resident #103 (R103)Review of a Face Sheet revealed R103 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of traumatic brain injury, quadriplegia, cognitive communication deficit, and need for assistance with personal care which included one staff person required to feed the resident. During an observation on 04/16/26 at 8:50 AM, certified nurse aide (CNA) D stood next to R103's left side of the bed and the breakfast tray and (presumably) CNA's D's cell phone sat on the overbed table. CNA D offered R103 a bite of food and then looked down at the cell phone and scrolled through the screen. At 8:51 AM, CNA D offered R103 another bite of food and then continued to scroll through the cell phone. At no time during the observation did CNA D engage in meaningful conversation with R103. Unidentified ResidentDuring an observation on 04/16/26 at 8:45 AM, a resident sat at a table in the dining room with her back to the doorway and CNA C sat at the same table and was observed assisting the unidentified resident with breakfast. CNA C lifted a utensil with food on it to the residents mouth and then began scrolling on a cell phone that sat on the dinning room table. There was no meaningful conversation or interaction observed between the resident and CNA C. During an interview on 04/16/26 at 8:55 AM, the ADON (assistant director of nursing) was made aware of the above-mentioned observations and stated that staff cell phone use when providing care and assistance to resident's was not an acceptable practice.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of premises and equipment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings Include:On 02/09/2026 at 11:46AM, food debris observed on base of a lift, stored in [NAME] hallway. Food debris consisted of food ground into the mat sitting in indented area of base and loose food particles. During facility walkthrough on 02/09/2026 at 2:00PM, with Maintenance Supervisor (MS) T, food debris was observed on matting at base of equipment. It appears this is the same food debris seen in the morning. MS T stated general cleaning of equipment was a responsibility for the hall's resident care staff, but housekeeping would clean the equipment if equipment could not be cleaned with the cleaning wipes provided for the equipment. On 02/09/2026 at 12:57PM, observed baseboard heater cover was not installed in room [ROOM NUMBER], leaving approximately 3 ft of the heaters metal fins exposed and accessible to residents. Residents' bed is partially blocking the remaining portion of the baseboard heater which also does not have a cover. Interview with MS T regarding the baseboard cover and work orders revealed they were aware of the issue and had made multiple repairs to baseboard heater, however the repairs had been short term as the cover would not remain on. MS T indicated they were considering vacating room during repairs as they may be extensive in nature. On 02/09/2026 at 1:55PM, observed in shared bathroom for rooms [ROOM NUMBERS], cobwebs and dust accumulated on vent cover. On 02/09/2026 at 2:05PM, observed in shower room, dust accumulation on vent cover. MS T was asked, at time of observation, who was responsible for cleaning of the ceilings and vents in the facility, MS T stated it was the responsibility of housekeeping personnel. On 02/09/2026 at 2:25PM, observed on East hallway, the wall covering under hallway mini-split unit was bubbling and peeling away from wall allowing exposure of the wall surface behind it. On 02/09/2026 at 3:00PM, cobwebs were observed on ceiling over the dry storage area in the kitchen. Spoke to Dietary [NAME] (DC) U about observed cobwebs, DC U indicated they were unaware of the cobwebs prior to our discussion. MS T indicated during interview regarding cleaning procedures housekeeping was not responsible for cleaning in the kitchen area.

Based on interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include:On 02/09/2026 at 2:30PM, during interview with Maintenance Supervisor (MS) T it was found that MS T had not participated in a Water Management Team meeting, a policy review or a risk assessment during employment at facility. MS T has been with the facility since October 2025. Review of the maintenance department's Water Management Plan Binder indicates there is no documentation for minutes from a Water Management Team meeting, policy review or risk assessment occurring within the past twelve months.

Based on interview and record review, the facility failed to formulate and complete advanced directives in a timely manner for 4 of 17 residents (R2, R4, R6, and R24) reviewed for advanced directives. Findings include: R2 A review of R2's Face Sheet, dated 2/11/26, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a compression fracture of the third thoracic vertebra, depression, and generalized muscle weakness. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/28/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R2 was cognitively intact. A review of R2's Electronic Medical Record (EMR), dated 1/13/26 to 2/9/26, failed to reveal if R2 had been offered to formulate an advanced directive and/or complete an advanced directive (i.e., there was not any completed advanced directive documentation in R2's EMR. A review of R2's Electronic Medical Record (EMR), dated 1/13/26 to 2/9/26, failed to reveal if R2 had been offered to formulate an advanced directive and/or had completed an advanced directive. A review of R2's undated Informed Health Care Decisions form in their admission Packet revealed the facility failed to determine if R2 wished to prepare an advanced directive during the admission process and/or what R2's wishes regarding medical treatment was as it applied to an advanced directive (the form was blank). During an interview on 02/10/2026 at 3:00 PM, a copy of R2's Advanced Directives was requested from the Director of Nursing (DON). On 02/10/2026 at 04:23 PM, R2's Advanced Directives was requested from the DON a second time and also from the Nursing Home Administrator (first request). A further review of R2's EMR on 2/11/26 revealed a Medical Treatment Decisions of Resident form, dated and signed 2/10/26 (almost a month after R2 had been admitted to the facility), that indicated R2 wished to formulate an advanced directive and that she wished to have treatments such as cardiopulmonary resuscitation and other treatments (e.g., artificial nutrition, antibiotics, hospitalization, and artificial hydration) as needed During an interview on 02/11/2026 at 08:40 AM, the DON verbally verified that she could not locate R2's advanced directives in her medical record. She stated the facility completed an advanced directives form (Medical Treatment Decisions of Resident form) for R2 yesterday when she could not locate a completed form. Resident #4 (R4) Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure, chronic kidney disease, type II diabetes mellitus, and weakness. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R4, with a reference date of 12-19-2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R4 was cognitively intact. Review of R4's Do Not Resuscitate Order and Medical Treatment Decisions of Residents dated 10-09-2024 indicated that R4 had requested that in the event her heart stopped beating that no person shall attempt to resuscitate R4. Review of R4's Physician Order dated 03-04-2025 revealed R4's code status as a Full Code, meaning R4 would receive full resuscitation in the event her heart stopped beating. In an interview on 02-10-2026 at 2:00 PM, Social Services (SS) A stated she was unsure how R4's resuscitation was changed to a full resuscitation. SS A revealed that R4 should be documented as do not resuscitate per R4's Medical Treatment Decisions of Residents form dated 10-9-2024. Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE] with pertinent diagnoses which included end stage renal disease with dependence on renal dialysis, acute kidney failure, and congestive heart failure. Review of a MDS assessment for R6, with a reference date of 12-22-2025 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R6 was cognitively intact. Review of R6's Do Not Resuscitate Order dated 05-01-2025 indicated that R6 had requested that in the event his heart stopped beating that no person shall attempt to resuscitate R6. Further review of the document revealed there was only one witness signature (form requires two witnesses) and no physician signature (required to activate a do not resuscitate order). In an interview on 2-11-26 at 7:47 AM with SS A revealed that she removed the Do Not Resuscitate Order dated 05-01-2025 from the electronic medical record (EMR) because it wasn't right. SS A stated that the document should have had two witnesses and a physician signature. Resident #24 (R24) Review of a Face Sheet revealed R24 admitted to the facility on [DATE] with pertinent diagnoses which included acute pancreatitis, respiratory failure, and chronic obstructive pulmonary disease. Review of an MDS assessment for R24, with a reference date of 01-21-2026 revealed score of 13, out of a total possible score of 15, which indicated R24 was cognitively intact. Review of Electronic Medical Record (EMR) indicated that R24 was a Full Code. Further review of the EMR revealed there was not a Do Not Resuscitate Order and there was not a Medical Treatment Decisions of Residents that indicated R24's decision for code status. In an interview on 2-11-2026 at 10:03 AM SS A revealed that R24 had a Medical Treatment Decisions of Residents dated 10-18-2025 that was not uploaded into the EMR. Medical Treatment Decisions of Residents was signed by R24 and was marked NO for cardiopulmonary resuscitation. When asked why R24's EMR was marked full code SS A stated she would correct R24's EMR. Review of facility/procedure Advanced Directive Planning, indicated that Advance Directive planning discussions are available with each resident.upon admission to the facility.care planning conferences will include the resident's preference for Advance Directive planning

Based on interview and record review, the facility failed to 1.) ensure medications and treatments were administered/completed following the physician order for 6 residents (Resident #21, #18, #6, #31, #17, and #5) out of 12 residents reviewed for nursing professional standards of practice.Findings:Resident #17 (R17) Review of a Face Sheet revealed R17 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes. Review of R17's Physicians Orders revealed an active order for insulin aspart U-100, before meals at 9:15AM, 12:15PM, and 5:00PM. During a medication administration observation on 02-10-2026 at 8:04 AM, Licensed Practical Nurse (LPN) B was observed preparing to administer insulin Aspart to R17. LPN B attached a new pen needle to the insulin pen, dialed the ordered insulin amount and administered the insulin to R17. LPN B did not dial a priming dose or expel insulin into the needle to ensure patency of the needle. In an Interview on 02-10-2026 at 8:10 AM, LPN B stated she did not know she had to prime the insulin needle prior to administration. LPN B stated she administers her own insulin and has never primed the insulin needle. LPN B revealed she was going to check facility policy. Resident #5 (R5) Review of a Face Sheet revealed R5 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes. Review of R5's Physicians Orders revealed an active order for Insulin Lispro 100 units per milliliter; 4 units to be given twice a day at 8:00 AM and 5:00 PM per insulin pen. Hold for blood sugar less than 120. Further review of R5's Physicians Orders revealed an active order for Lantus Solostar U-100 Insulin 15 units to be given once a morning per insulin pen. During a medication administration observation on 02-10-2026 at 8:14 AM and before checking facility policy, LPN B was observed preparing to administer insulin Lispro and insulin Lantus to R5. LPN B attached a new pen needle to the insulin pen for Insulin Lispro and Insulin Lantus, dialed the ordered insulin amounts and administered the insulin to R5. LPN B did not dial a priming dose or expel insulin into either of the needles to ensure patency of the needle. In an interview on 2-10-2026 at 10:00 AM with Regional Nurse (RN) E revealed standard of practice is to prime an insulin pen needle prior to dialing the ordered amount of insulin during an administration. Review of facility policy/procedure Injection Technique, Insulin pens should be primed prior to administering medications. Resident #21 (R21) Review of an admission Record revealed R21 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Chronic Diastolic Heart Failure. Review of R21's Order Summary dated 10/2/25 revealed, daily weight once a morning. Review of R21's January and February Weight Summary revealed a weight was not obtained on 1/1/26, 1/4/26, 1/7/26, 1/13/26, 1/19/26, 1/21/26, 1/22/26, 2/2/26, or 2/4/26, Review of R21's January and February Medication/Treatment Administration Record revealed: On 1/1/26 the entry was left blank. On 1/4/26 the entry was left blank. On 1/7/26 the weight from the previous day was reentered. On 1/13/26 the weight from the previous day was reentered. On 1/19/26 the entry was left blank. On 1/21/26 Other was documented but there was no corresponding progress note. On 1/22/26 the entry was left blank. On 2/2/26 the weight from the previous day was reentered. On 2/4/26 the weight from the previous day was reentered. Review of R21's Electronic Health Record revealed no documentation for a rationale for not obtaining R21's weights on the above dates. Resident #18 (R18) Review of an admission Record revealed R18 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 2 diabetes mellitus. Review of R18's Order Summary dated 8/26/25 revealed, Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/mL; amt: 8 units; subcutaneous Special Instructions: Hold if BS (blood sugar) less than 110.Three Times A Day. To be completed at 08:00 AM, 12:00 PM, and 05:00 PM Review of R18's Blood Sugar log revealed: On 1/9/26 no lunch blood sugar assessment (assessed at 4:25 AM and again at 4:13 PM.) On 1/16/26 no dinner assessment. (assessed at 1:00 PM and again at 7:43 PM.) On 1/22/26 no dinner assessment. (assessed at 1:00 PM and again at 7:18 PM.) On 1/29/26 no lunch assessment (assessed at 4:30 AM and again at 4:38 PM.) On 2/4/26 no dinner assessment (assessed at 12:44 PM again on 2/5/26.) Review of R18's January and February Medication Administration Record revealed: On 1/9/26 R18's lunchtime Humalog was administered despite no documented blood sugar assessment. On 1/12/26 R18's Humalog was held for BG (blood glucose) 121 Resident not eating much for lunch. (Held when blood sugar within parameters without an order from the provider). On 1/14/26 at 4:26 AM R18's blood sugar was 98 and the breakfast Humalog was administered. On 1/15/26 at 11:18 PM R18's blood sugar was 96 and the lunchtime Humalog was administered. On 1/16/26 R18's dinnertime Humalog was administered despite no documented blood sugar assessment. On 1/20/26 at 4:38 AM R18's blood sugar was 79 and the breakfast Humalog was administered. On 1/22/26 R18's dinnertime Humalog was administered despite no documented blood sugar assessment. On 1/24/26 at 4:37 AM R18's blood sugar was 97 and the breakfast Humalog was administered. On 1/27/26 at 5:02 AM R18's blood sugar was 96 and the breakfast Humalog was administered. On 1/29/26 R18's lunchtime Humalog was administered despite no documented blood sugar assessment. On 2/3/26 at 4:06 AM R18's blood sugar was 96 and the breakfast Humalog was administered. On 2/4/26 R18's dinnertime Humalog was administered despite no documented blood sugar assessment. Resident #6 (R6) Review of an admission Record revealed R6 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Hypertensive heart and chronic kidney disease with heart failure. Review of R6's Order Summary dated 9/5/25 revealed, metoprolol tartrate tablet; 25 mg; amt: 1; oral Special Instructions: hold for systolic blood pressure less than 100 or HR (heart rate) less than 60 Once A Day on Sun, Mon, Wed, Fri. Review of R6's December Medication Administration Record revealed: On 12/31/25 R6's metoprolol was held despite heart rate and blood pressure within acceptable range BP 101/79 and heart rate 61). Review of R6's Blood Pressure log and Heart Rate log revealed: On 1/18/26 there was no blood pressure or pulse assessment. On 1/19/26 there was no blood pressure or pulse assessment. Review of R6's January and February Medication Administration Record revealed: On 1/18/26 the blood pressure and pulse assessment obtained on 1/16/26 was utilized and the metoprolol was administered. On 1/19/26 R6 was not administered the metoprolol for drug/item unavailable. There was no corresponding progress note to indicate the provider or management were notified. Resident #31 (R31) Review of an admission Record revealed R31 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension and atrial fibrillation. Review of R31's Order Summary dated 1/20/26 revealed, metoprolol succinate tablet extended release 24 hr; 25 mg; amt: one; oral Special Instructions: HOLD for SBP (systolic blood pressure) < (less than) 110 and/or HR (heart rate) <60. Twice A Day To be administered in the morning and in the evening. Review of R31's Heart Rate and log revealed: On 1/21/26 there was no morning heart rate assessment. On 1/22/26 there was no morning assessment. On 1/23/26 there was no morning or evening assessment. On 1/24/26 there was no morning or evening assessment. On 1/25/26 there was no morning assessment. On 1/26/26 there was no morning assessment. On 1/29/26 at 9:09 AM R31's pulse was 53. On 1/29/26 at 11:12 PM R31's pulse was 56. Review of R31's Blood Pressure log revealed: On 1/21/26 there was no morning assessment. On 1/25/26 R31's evening blood pressure was 108/68. On 1/26/26 R31's evening blood pressure was 100/68. On 1/29/26 R31's evening blood pressure was 107/53. Review of R31's January Medication Administration Record revealed R31's metoprolol was administered on 1/21/26, 1/22/26, 1/23/26, 1/24/26, 1/25/26, 1/26/26, and 1/29/26 despite the lack of assessments or blood pressure and/or heart rates out of parameters. During an interview on 2/11/26 at 2:08 PM, The Director of Nursing (DON) confirmed the above medication administration errors and the lack of daily weights and reported that moving forward it would be required to input the vital signs into the electronic medication administration record to ensure assessments were completed. Additionally, all licensed nurses would receive education on administering medication following the providers ordered parameters. Review of the facility policy, General Dose Preparation and Medication Administration last revised 1/1/13 revealed, .4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following.If necessary, obtain vital signs. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to ensure assistance with Activities for Daily Living (ADL) care was consistently provided for 2 of 12 residents (Resident #17 and #18) and residents in attendance at the resident group meeting, reviewed for ADL care.Findings:Resident #17 (R17) Review of a Face Sheet revealed R17 originally admitted to the facility on [DATE] with pertinent diagnoses which included acute respiratory failure, chronic kidney disease, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, difficulty in walking, and need for assistance with personal care. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R17, with a reference date of 12/02/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R17 was cognitively intact. Review of a current (Activities of Daily Living) ADL Care Plan intervention for R17, initiated 06/14/2023, indicated: to keep R17 clean and dry as possible and to minimize skin exposure to moisture. In an interview on 02/09/2026 at 11:11 AM, R17 reported she had not received a shower in approximately two weeks. R17 stated the shower that was scheduled (2/5/26) they (staff) told R17 there was not enough time for her to shower. R17 indicated she liked getting showers and it made her feel clean. R17 reported no bed baths had been substituted for showers during the last 2 weeks. In an interview and record review on 02/10/2026 at 1:21 PM, Director of Nursing (DON) revealed Shower Sheets that R17 had received a shower on 01/05/26 and 02/04/26. R17 received two showers within a 5-week span. DON revealed a document Point of Care History for R17 indicating possible received showers. DON was unsure if this documentation was an actual shower or bed bath due to staff signing out twice a day or not at all and no signatures documented on R17's actual shower days. Resident #18 (R18) Review of an Face Sheet revealed R18 admitted to the facility on [DATE] with pertinent diagnoses parkinsonism, bipolar disorder, anxiety disorder, and need for assistance with personal care. Review of a MDS assessment for R18, with a reference date of 01/01/2026 revealed a BIMS score of 15, out of a total possible score of 15, which indicated R18 was cognitively intact. Review of the current Pressure Ulcer Care Plan intervention for R18, initiated 07/09/2021, indicated: to keep R18 clean and dry as possible and to minimize skin exposure to moisture. In an interview on 02/09/2026 at 11:50 AM, R18 stated that she is supposed to get two showers a week and usually only gets one. R18 reported it makes her feel grubby. R18 stated there was a basin in the bathroom that is used some days to wash up, but it doesn't help with washing her hair. R18 reported the last shower she received was on Tuesday (2/3/26). In an interview and record review on 02/10/2026 at 1:21 PM, DON revealed Shower Sheets that R18 had received a shower on 1/9/2026, 1/24/2026, and 2/6/2026. DON revealed a document Point of Care History for R18 indicating possible received shower on 1/27/26. R18 had received 4 showers in a 5-week span. DON reported the expectation for resident showers would be two showers a week or resident preference. Review of facility/procedure Resident Rights, revealed residents have the right to a dignified existence. During a confidential group meeting with 8 residents in attendance on 02/11/2026 at 10:30 AM until 02/11/2026 at 11:37 AM, the residents were queried on the frequency they received showers. 6 of 8 residents reported that when there were agency aides working then we get skipped for showers further reporting that it wasn't because the agency staff are so busy it was because they (agency staff) were good for skipping things. The residents reported that they frequently observed agency staff sitting at the front desk (nurses' station) BS'ing. One resident stated, we are on a (shower) list, and it should be followed with another resident stating they didn't feel that we should have to beg to get a shower.

This citation pertains to intake #2741552Based on interview and record review, the facility failed to 1.) ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, and 2.) ensure that controlled pain medications were administered following provider orders and the residents' goals and preferences for 4 of 12 residents (Resident #24, R6, R1, and R20) and residents in attendance at the resident group meeting, reviewed for pain management.Findings:Resident #24 (R24)Review of an admission Record revealed R24 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: acute and chronic respiratory failure with hypoxia, spinal stenosis, low back pain, and asthma.Review of a Minimum Data Set (MDS) assessment for R24, with a reference date of 1/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated R24 was cognitively intact. Review of R24's Order Summary dated 12/4/25 revealed, hydromorphone (dilaudid) tablet; 2 mg; Amount to Administer: 2mg; oral Every 6 Hours Take with methocarbamol. AND methocarbamol (muscle relaxer) tablet; 750 mg; Amount to Administer: 750mg; oral Four Times A Day Take with hydromorphone.During an interview on 02/11/2026 at 11:40 AM, R24 reported that a few weeks prior she had not received her scheduled pain medication when an agency nurse was working. R24 confirmed the nurse was Licensed Practical Nurse (LPN) F. R24 stated, Supposedly he came in at midnight and at 6AM to give me my medicine. He did not! R24 reported LPN F brought medications to her room (around 9:30 PM) but her dilaudid was missing. When she confronted LPN F about the missing dilaudid, he kept saying it was in there (in the medication cup). LPN F did not go through and identify each medication he provided in the medication cup with R24 to refute the allegation. R24 stated, I know my pills. I know what they look like and I know if they're there. R24 reported that she had filed a complaint with the Director of Nursing (DON) after speaking with Registered Nurse (RN) G about not receiving her scheduled midnight or 6:30 AM pain medication and the agency nurse was terminated.Review of the Social Services Note dated 01/15/2026 at 4:20 PM revealed, Social Work met with (R24) for a supportive visit, specifically regarding concerns reported on 1/15/2026. Inquiry was made as to what occurred that prompted her concerns. (R24) reports that the nurse last night did not provide her with her prescribed pain medication or muscle relaxer. She reports the nurse gave her other medications, but her pain medication and muscle relaxer were not included. She states, I hate to second guess what the nurse gives me, but I know what I am taking and what my medications look like. She further stated, I can't have my pain medication and muscle relaxer until 11:00pm and the nurse was in between 9:30pm-9:45pm, that is too early. (R24) reports the only effect from the reported concern was that she is experiencing increased pain. Indicating her dilaudid ordered for pain control had not been administered.Review of the Social Services Note dated 01/16/2026 revealed, Social Work met with (R24) for a supportive visit, specifically regarding concerns reported on 1/15/2026.She reports she still has lingering pain, from not getting her meds the night prior, but she said, it will be better once it builds up in my system again.Review of a Facility Incident Report received via online submission on 1/15/26 revealed, Resident reported to the DON that she (R24) strongly believes that she did not receive her pain medication last night or this morning form (sic) (LPN F). It is reported in the medication administration record that the medication was given at 0000 on 1/15/26 and at 0600 on 1/15/26 and proof of use sheets coincide with medication being given. There was no discrepancy in medication count. Resident states that she did not receive her pain medication at those times.Audit of other residents receiving pain medications and no discrepancies identified.A statement written by (DON) stated: At 3:28pm on January 15th, 2026, (R24) came into my office stating, I need to talk to you. Something's been on my mind all day. (R24) explained how she strongly believes she did not receive her pain medication (Dilaudid) last night or this morning from (LPN F) (agency LPN). DON informed (R24) that (LPN F) had charted that he gave her Dilaudid at (midnight) on 1/15/26 and (6:00AM on 1/15/26. (R24) shook her head no and said, THAT DID NOT HAPPEN. I know what my Dilaudid looks like. He was last in my room around 9:30pm last night and I never saw him again. She explained how she shook the med cup around after he gave her meds at 9:30pm and stated, There was no medicine in there, when referring to her Dilaudid.The dictated statement from (R24) stated: At 945pm last night, he (LPN F) brought me medicine. He told me my pain pill and muscle relaxer were and (in) it. I looked and no matter what I did, I could not find them. And I did look to the bottom of it looking for the little pill because the pain pill, it's very small and I couldn't see it, so I shook it around, looked in the top, shook it around some more, looked in the bottom: there was nothing there. He (LPN F) told me he was giving me my 12am pain medication and muscle relaxer because he didn't want to have to wake me up to give it to me, which is very unusual. And then he said he gave me my medicine at 6:00 this morning. There was no medicine in there. He never came in and I think I was reading between 4:00 and 6:00 this morning and I mean I was reading pretty early. But yeah. I just don't know what he did with my medication, but I know I wasn't given them. I'm worried he took them for himself. I know what my meds look like. And those weren't it.A statement by (RN G) who was the off-going nurse at the time of the alleged incident. She stated that she was nervous following him and that he was not a good communicator, possibly a language barrier. Truly I think he is a sloppy nurse. He told me that morning conflicting times when he locked his (med cart) keys in the med room. Once it was 1:00, then 3:30 am. He did tell me he prepped all his narcs. He did want everyone to know that. I think that he has poor practices. If you are thinking he's diverting, I don't think he is, I don't ever see any signs. He tried to leave that morning without counting, he signed out before I got him to count with me.A statement from (Regional Clinical Nurse [RCN] H) who spoke with (LPN F) the morning in question prior to his departure. The writer (RCN H) arrived at the facility on January 15, 2026, at 7:00 AM to conduct an in-service training for nurses regarding controlled substance policies, including record-keeping, shift to shift counts, and verification procedures for items such as fentanyl patches. Upon arrival, (RNC H) noticed confusion at the medication cart. (RNC H) approached two nurses identified as (LPN F and RN G) regarding the required controlled substance count. (LPN F) stated he had already completed and signed off on the count, while (RN G) indicated she had not participated and that he needed to complete the count with her before leaving, in accordance with policy. (RNC H) expressed concern that (LPN F) appeared not to understand or follow the policy, as he insisted he already completed the count but did not perform it with another nurse as required. (RNC H) instructed (LPN F) to complete an additional medication count, in which he did so. Also, (RNC H) also observed that (LPN F) did not complete the medication refrigerator count as required and admitted to not doing so, but ultimately completed the medication count as required and instructed.On January 15, 2026, (LPN F) notified the Director of Nursing at 4:53 AM that he had accidentally locked the narcotic and med-cart keys inside the medication room, preventing access to controlled medication. Access was restored at 6:40 AM when incoming nurse (RN G) obtained spare keys. After arriving around 6:45 AM, the DON spoke with (LPN F) who explained he mistakenly locked the keys in the med room while receiving an early morning medication delivery. As a result, some narcotics were not administered until 7:00 AM, after the narcotic box was opened and a proper nurse-to-nurse narcotic count was completed. After his shift, (LPN F) called the DON at 8:58 AM and made several unsolicited statements about medication administration, including giving medications overnight and that morning without proper documentation. He appeared distressed, repeatedly using profanity and speaking nervously. When asked for clarification he avoided the question. (LPN F) called again at 9:10 AM, but the DON informed him she was in a meeting. Later that day, at 6:12 PM, (LPN F) texted the DON asking for help correcting what he said (staffing agency) believed was a no-call/no-show for 1/14/2026. He made additional attempts to call the DON that evening and again the following morning (January 16) at 8:41 AM, but she did not answer. At 12:02 PM on January 16, (LPN F) arrived at the facility in person with several bottles that appeared to contain home medications. He attempted to discuss the prior events, but the DON and (RNC H) instructed him that he was not permitted on the property. He was escorted out and seen leaving at 12:03 PM.Conclusion Based on the information obtained, the investigation into the alleged incident involving (R24) and (LPN F) has yielded inconclusive results. (R24) alleges that she did not receive her pain medications on the night of 1/15/26 but an in-depth narcotic reconciliation of facility narcotic records showed that there was no diversion or missing medications.(LPN F) denies any diversion and states that he gave the medications to the resident. Given the lack of corroborating evidence and the conflicting accounts, the investigation cannot definitively substantiate a drug diversion. (The statements above were dated and signed by the referenced nurses).Although it was reported in the medication administration record that the medication was given at 0000 on 1/15/26 and at 0600 on 1/15/26 and proof of use sheets coincide with medication being given, LPN F reported to both the oncoming nurse (RN G) and the DON that he did not have access to the narcotic key during the 6:00 AM dilaudid administration. Additionally, he reported to RN G that he had prepped all his narcs (narcotics). Indicating LPN F removed 2 doses of R24's dilaudid and documented the administration on her Controlled Substance Proof of Use form at the beginning of his shift and not at the actual time the dilaudid was dispensed (for R24 and all other residents that were to receive controlled drugs throughout the entirety of his shift). Prepping R24's dilaudid would account for the correct count (number of remaining dilaudid tablets) on R24's Controlled Substance Proof of Use form. Prepping/presetting controlled drugs can lead to medication errors (wrong resident, wrong dose, wrong time, wrong medication), count discrepancies, and/or missed doses.LPN F confessed to the DON that he did not properly document medications that he administered throughout his shift and that narcotics were administered late (when he obtained access to the narcotic keys). He openly admitted to RNC H that he did not complete or follow the required controlled substance count procedures and RNC H expressed concerns of LPN F's inability to understand or follow controlled drug policies. LPN F was described as a sloppy nurse with poor (nursing) practices by a colleague. Resident Group MeetingDuring a confidential group meeting with 8 residents in attendance on 02/11/2026 at 10:30 AM until 02/11/2026 at 11:37 AM, the residents were queried about medication administration. 1 resident reported (with 5 other residents in agreement) that medications were not always administered and that staff were always confrontational if the concern was addressed. 1 resident reported that pain medications that are scheduled are passed late and as needed pain medications are not promptly administered when requested (greater than an hour).3 residents reported that they have not received pain medications in the past which they reported to management. 1 resident reported because they did not receive their as needed pain medication timely, they had to receive therapy services unmedicated, further reporting how difficult it was to participate in therapy when experiencing pain. The resident reported that he had had a problem with a male nurse they brought in not administering pain medication on time and sometimes not at all (3 other residents reported the same concerns with the male nurse). The residents reported resolution of the concerns with that nurse as he was no longer working at the facility.Resident #6 (R6)Review of an admission Record revealed R6 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Hypertensive heart and chronic kidney disease with heart failure.Review of R6's Order Summary dated 9/225 revealed, hydrocodone-acetaminophen (Norco)- tablet; 7.5-325 mg; amt 1 tab Three Times A Day. To be administered between 07:00 AM-11:00 AM, 01:00 PM-02:30 PM, and 07:00 PM-11:00 PM. Review of R6's Controlled Substance Proof of Use form revealed that on 2/6/26 the afternoon dose (1:00 PM-2:30 PM) was not dispensed. (Indicating the medication was not removed from the blister pack for administration).Review of R6's Medication Administration Record revealed that on 2/6/26 the afternoon dose of Norco was not administered (area left blank).Review of R6's Electronic Medical Record revealed no documentation for the withholding of the Norco.Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: lumbar inflammatory spondylopathy (inflammatory disease that typically causes lower back pain and stiffness).Review of R1's Order Summary dated 6/20/25 revealed, hydrocodone-acetaminophen (Norco) tablet; 10-325 mg; amt: 1 tab; oral Three Times A Day. To be administered between 07:00 AM-11:00 AM, 01:00 PM-02:30 PM, and 07:00 PM-11:00 PM.Review of R1's Controlled Substance Proof of Use form revealed that on 2/8/26 R1's morning dose of Norco was not dispensed.Review of R1's Medication Administration Record revealed that on 2/8/26 all 3 doses of R1's Norco was documented as administered.Review of R1's Electronic Medical Record revealed no documentation for the withholding of the Norco.Resident #20 (R20)Review of an admission Record revealed R20 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: neuropathy.Review of R20's Order Summary dated 1/23/26 revealed, pregabalin (Lyrica-used for nerve pain) capsule; 50 mg; amt: one capsule; oral Three Times A Day. To be administered between 07:00 AM-11:00 AM, 01:00 PM-02:30 PM, and 07:00 PM-11:00 PM.Review of R20's Controlled Substance Proof of Use form revealed that on 2/6/26 the afternoon dose of lyrica was not administered.Review of R20's Medication Administration Record revealed that on 2/6/26 R20's afternoon dose of Lyrica was not administered (area left blank).Review of R20's Electronic Medical Record revealed no documentation for the withholding of the Lyrica.Review of the facility policy, General Dose Preparation and Medication Administration last revised 1/1/13 revealed, .Facility staff should only prepare medications for one resident at a time.Review of the facility policy Controlled Substances Standards of Practice last reviewed 01/2025 revealed, Policy: In order to accurately account for all control substances through the process of ordering, receiving, storage, administration and destruction, the following procedures have been provided.Distribution and Record Keeping in FacilityNurses removing controlled substance from the narcotic storage require documentation on the Proof-of-Use Sheet the amount removed using a full last name signature. Nurse documentation of inventory balance on Proof-of Use sheet MUST be made as soon as the controlled substance is removed from the package/cart. Avoid waiting until the end of med pass or end of shift.Once the nurse completes the administration, then the nurse is to document on the MAR paper record or E-Mar electronic record. If PRN medication is administered, additional documentation regarding reason, result, time and initials are required. Note: If documentation is not provided on MAR or E-Mar, medication will be considered not given. MAR or E-Mar is record of administration NOT the proof-of-use sheet.Both on-going and off-going Nurses will count the number of containers and narcotic Proof-of-Use sheets to ensure accuracy reconciliation and provide signatures on the Narcotic Page and Card Count sheet.Both on-going and off-going nurses reconcile the Narcotic EDK and Narcotic Refrigerator EDK by checking and signing that the tag numbers on the boxes to ensure accuracy of safekeeping. Counts will occur with each change in ownership of narcotic keys, at shift change and change in assigned.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Never document that you have given a medication until you have actually given it. Document the name of the medication, the dose, the time of administration, and the route on the MAR. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 644). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the physician failed to address pharmacy recommendations, the facility failed to implement physician approved pharmacy recommendations, and/or the facility failed to implement physician approved pharmacy recommendations timely for 4 of 5 residents (R2, R3, R12, and R24) reviewed for monthly pharmacy medication regimen reviews. Findings include: R2 A review of R2's Face Sheet, dated 2/11/26, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a post-traumatic stress disorder (PTSD), depression, and anxiety. A review of R2's Consultation Report, dated 1/22/26, revealed the pharmacist recommended that the physician either discontinue the as needed (prn) alprazolam (a medication for anxiety) or add a stop date not to exceed 14 days from the time it was initiated. The physician signed on 1/27/26 that they accepted the recommendation. A review of R2's Physician Order Report, dated 1/11/26 to 2/11/26, failed to reveal that the physician discontinued and/or added a stop date for R2's as needed alprazolam. A review of R2's Medication Administration Record, dated 1/11/26 to 2/11/26, revealed R2 had been receiving alprazolam as needed from 1/22/26 (the day after the order was initiated) to 2/11/26 (21 days after the order was initiated and 15 days after the physician accepted the recommendation) and there was no stop date listed. R3 A review of R3's Face Sheet, dated 2/11/26, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Face Sheet revealed they had multiple diagnoses that included depression, psychotic disorder with delusions, insomnia, and anxiety. A review of R3's Consultation Report, dated 4/3/25, revealed the pharmacist recommended that the physician add a stop date for as needed lorazepam (a medication for anxiety and insomnia) that was no more than 14 days from initiation. However, the report was not signed and/or acknowledged by the physician and/or designee (except for a handwritten note without name or initials of the writer at the bottom of the form, dated 2/11/26, that indicated it was reviewed, no stop date was implemented, and the medication was discontinued on 1/6/26 and re-ordered with a stop date of 1/19/26). A review of R3's Consultation Report, dated 10/8/25, revealed the pharmacist recommended that the physician add a stop date for as needed lorazepam that was no more than 14 days from initiation (a repeat recommendation from 4/3/25) or discontinue the as needed lorazepam. The physician accepted the recommendation on 1/15/26 and noted to add a stop date. A review of R3's Physician Order Report for January 2026 revealed that R3 had consecutively written physicians orders (3/27/25 to 1/6/26 and 1/6/26 to 1/19/26) for Ativan (lorazepam) to be administered every eight (8) hours as needed. A review of R3's Medication Administration Record, dated 4/1/25 to 1/31/26, revealed R3 had received Ativan (lorazepam) as needed three times in April 2025, twice in May 2025, once in July 2025, once in August 2025, four times in September 2025, once in October 2025, once in November 2025, and twice in December 2025 before the original pharmacy recommendation on 4/3/25 was addressed and a stop date was initiated. A review of the facility's Medication Regimen Review policy and procedure, dated 11/28/26, revealed, 6. The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. 8. Facility should alert the Medical Director when MRRs are not addressed by the attending physician in a timely manner. 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. Resident #12 (R12) Review of an Face Sheet revealed R12 admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes mellitus, hypertension, chronic respiratory failure, and weakness. Review of a Pharmacist Monthly Medication Review for R12 revealed irregularities were noted in September 2025, October 2025, November 2025, and December 2025. A request was made to the Director of Nursing (DON) on 2/11/2026 at 9:29 AM to produce the four pharmacy reported medication irregularities and recommendations for R12. In an interview on 2/11/2026 at 2:45 PM, Regional Nurse (RN) E and DON revealed that September 2025, October 2025, and December 2025 Pharmacy medication reports for R12 could not be located. Resident #24 (R24) Review of an Face Sheet revealed R24 admitted to the facility on [DATE] with pertinent diagnoses which included depression, insomnia, and chronic respiratory failure. Review of a Pharmacist Monthly Medication Review for R24 revealed irregularities were noted in October 2025 and December 2025. A request was made to the DON on 2/11/2026 at 9:29 AM to produce the two pharmacy reported medication irregularities and recommendations for R24. Review of Irregularity Reports for R24 on 2/11/26 at 12:29 PM, document titled Consultation Report dated 10/15/2025 with recommendation to reduce Amitriptyline (used to treat depression) to 25 milligrams daily with the end goal of discontinuation. Further recommendations documented on 12/22/25 were again to taper Amitriptyline to 25 mg daily for 5 days and discontinue related to a fall. Both recommendations were not reviewed or signed. Review of R24's Physicians Orders on 2/11/26 at 1:00 PM revealed an active order for Amitriptyline 50 milligrams daily. In an interview on 2/11/26 at 1:15 PM, the DON revealed that the completed pharmacy consult reports for R24 were still trying to be located. The DON stated that pharmacy consult recommendations should be completed within 30 days. Review of facility policy/procedure Medication Regimen Review, revealed facility should independently review each resident's medication regimen directly from the resident's medical chart and with Interdisciplinary Care Team members. for those issues that require Physician/Prescriber intervention, facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the recommendation or reject all or some of the recommendations contained in the recommendation and provide an explanation as to why the recommendation was rejected. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days.

Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 2 (R17 and R5) of the 7 residents observed during the medication administration task. This resulted in a facility medication error rate of 10.34% (3 errors out of 29 opportunities).Findings include:Resident #17 (R17 Review of a Face Sheet revealed R17 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes. Review of R17's Physicians Orders revealed an active order for insulin aspart U-100, before meals at 9:15AM, 12:15PM, and 5:00PM.During a medication administration observation on 02-10-2026 at 8:04 AM, Licensed Practical Nurse (LPN) B was observed preparing to administer insulin Aspart to R17. LPN B attached a new pen needle to the insulin pen, dialed the ordered insulin amount and administered the insulin to R17. LPN B did not dial a priming dose or expel insulin into the needle to ensure patency of the needle. In an Interview on 02-10-2026 at 8:10 AM, LPN B stated she did not know she had to prime the insulin needle prior to administration. LPN B stated she administers her own insulin and has never primed the insulin needle. LPN B revealed she was going to check facility policy. Resident #5 (R5)Review of a Face Sheet revealed R5 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes.Review of R5's Physicians Orders revealed an active order for Insulin Lispro 100 units per milliliter; 4 units to be given twice a day at 8:00 AM and 5:00 PM per insulin pen. Hold for blood sugar less than 120. Further review of R5's Physicians Orders revealed an active order for Lantus Solostar U-100 Insulin 15 units to be given once a morning per insulin pen.During a medication administration observation on 02-10-2026 at 8:14 AM and before checking facility policy, LPN B was observed preparing to administer insulin Lispro and insulin Lantus to R5. LPN B attached a new pen needle to the insulin pen for Insulin Lispro and Insulin Lantus, dialed the ordered insulin amounts and administered the insulin to R5. LPN B did not dial a priming dose or expel insulin into the either of the needles to ensure patency of the needle. In an interview on 2-10-2026 at 10:00 AM with Regional Nurse (RN) E revealed standard of practice is to prime an insulin pen needle prior to dialing the ordered amount of insulin during an administration. Review of facility policy/procedure Injection Technique, Insulin pens should be primed prior to administering medications.

Based on observation, interview and record review, the facility failed to ensure there were no expired medications and ensure opened medications were dated in one of one medication cart and in one of one medication storage room. Findings include: During an observation on 2/10/2026 at 7:00 AM, the following were noted in the medication room: (a) an opened Tuberculin Purified Protein Derivative vial (used for skin testing to detect if a person has been infected with Mycobacterium tuberculosis or TB) vial was observed in the refrigerator opened and undated (Per Physician Desk Reference (PDR) recommend vial should be discarded 30 days after opened) and (b) four bottles of Famotidine 20mg (milligram) tablets with 300 tablets in each bottle that expired January 2026. During an observation on 2/10/2026 at 7:15 AM, the following were noted in the medication cart: (a) an opened Albuterol inhaler with 196 puffs remaining with no date indicating the date it was opened (Per PDR recommend inhaler should be discarded 90 days after opened), (b) Gas Relief 125 mg bottle with expiration date of 1/2026, and (c) an opened Wixela inhub inhaler with 39 puffs remaining with no date indicating the date it was opened (Per PDR recommend inhaler discarded 30 days from opened foil package).In an interview on 2/10/2026 at 7:15 AM, LPN B stated the expired meds should not be in the medication storage room and available for resident use.Review of facility policy/procedure General Dose Preparation and Medication Administration, Facility should.check the expiration date on the medication.facility staff should enter the date opened on the label of medications with shortened expiration dates.Review of facility policy/procedure House Stock Policy, facility should ensure that house stock medications are stored in the original manufacturer's container.the medication name, strength, expiration date, and lot number should be clearly visible.

Based on observation, interview and record review, the facility failed to maintain best practices for storage of foods brought to residents by family and other visitors. Findings include: On 02/09/2026 at 10:32AM, at time of interview Dietary Supervisor (DS) S states they do not have the key to the refrigerator and freezer; and DS S left to the nurse's station to obtain the key to open the doors of refrigerator and freezer. DS S, noted dietary staff is not responsible for dating food or discarding food from the residents' refrigerator. Observed the following items, in the resident's refrigerator, without a date of when food was received and placed in refrigerator: cream-based soup with room number only on container, opened jar of Tostitos cheese dip, oatmeal in kitchen dishware. Record review of the facility's policy, Foods Brought in to Resident Education Material, #5 Cooked food items will be labeled with the resident's name and date of delivery. If the food items need refrigeration/freezing, the items will be placed in a resident designated refrigerator/freezer.

This citation pertains to intake #s 2655849 and 2663547.Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 2 of 12 residents (Resident #10 and #17), and residents in attendance at the resident group meeting, reviewed for resident rights, dignity and respect.Findings: Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and hypertension Review of a Minimum Data Set (MDS) assessment for R10, with a reference date of 12/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R15 was cognitively intact. Review of a Facility Incident Report received via online submission on 10/24/25 revealed, (R10) made an allegation that a staff member took a long time to assist her to the bathroom and that the staff member said, I'm not doing this and left the resident there. The resident then stated that the staff member came back to assist her to the bathroom and after that she put her in bed, then stated, Don't ring that bell again for the rest of the night. The resident alleges that this took place around 1:30 am on the 10/24/25.There was a staff member fitting that description working during that time period named (Certified Nursing Assistant [CNA] C).When asked to give more clarification the event that took place, (R10) stated: (I) needed to get up and go to the bathroom and was having a hard time getting up. Rang the call light and she (CNA C) came and she (CNA C) said, I'm not doing that because you (R10) were having a hard time getting up. She (CNA C) left and came back in a short time and took me (R10) to the bathroom. She (CNA C) told me (R10) to put the call light on when I was done, so I did. She (CNA C) put me back in bed and said, Don't push the call light for the rest of the night . Review of a Complaint/Incident Investigation Report received by the State on 10/27/25 revealed, .On 10/24/2025, (R10) pressed her call light for assistance to use the bathroom. (CNA C) came in and told her that she couldn't assist her at the moment. (CNA C) did return to get her to the bathroom and put her back into bed again. Afterwards, (CNA C) told (R10) not to press the call light again. Review of CNA C's Personnel Action Form with an effective date of 11/4/25 revealed, .Investigation completed. Resident states employee told her not to push her call light the rest of the night. Employee says untrue. Resident alert + oriented. No reason to not believe resident.Termination of employment. During a confidential group meeting with 8 residents in attendance on 02/11/2026 at 10:30 AM until 02/11/2026 at 11:37 AM, the residents were queried on the staff attitudes and their right to be treated with dignity and respect. The residents unanimously agreed that the agency staff did not perform their work duties as they should reporting that they would often stand at the (nurses) station and talk, get real loud and goof around, don't know their a** from a hole in the ground, don't follow protocol at the facility. One resident reported that upon answering their call light an agency staff member impolitely stated, your lights on, what do you want. Another resident reported they would shut off their call light and would not return. They unanimously agreed that on nights with primarily agency staff, there were extensive call light wait times (up to an hour) and medications were administered later than their preferred time. The residents in the group meeting unanimously reported that the agency staff members were overall rude and disrespectful and need to be trained. Further discussion revealed dissatisfaction with the environment and the sound level. 5 of the 8 residents reported that at night the facility staff members were not careful about doors shutting and would allow them to slam which was terrifying at night. Review of the facility policy Resident Rights last reviewed 01/2025 revealed, It is the policy of this facility to ensure residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Resident #17 (R17) Review of an Face Sheet revealed R17 admitted to the facility on [DATE] with pertinent diagnoses which included acute respiratory failure, chronic kidney disease, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, difficulty in walking, and need for assistance with personal care. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R17, with a reference date of 12/02/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R17 was cognitively intact. Review of a current (Activities of Daily Living) ADL Care Plan intervention for R17, initiated 06/14/2023, revealed R17 required the assistance of two staff to go to the bathroom. Further review of ADL Care Plan indicated: to keep R17 clean and dry as possible and to minimize skin exposure to moisture. In an interview on 02/09/2026 at 11:11 AM, R17 reported she had been incontinent of bowel the previous night after waiting for her call light to be answered. R17 reported when staff answered her call light the Certified Nursing Assistant (CNA) stated you stink. R17 reported when the staff treat her like that she feels like I don't mean anything.

Based on interview and record review, the facility failed to ensure the provider was immediately notified of a change in resident medical condition for 4 of 12 residents (Resident #8, #10, #30, and #5), reviewed for notification of change.Findings:Resident #8 (R8)Review of an admission Record revealed R8 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: asthma and epilepsy.Review of the provider Concerns/Communication log with an entry dated 1/30/26 which revealed, (R8) Concern: saturations (oxygen level) for day shift were in the 50's.Team Action/Date: Oxygen was 50!!Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Pulse oximetry (SpO2) Normal: SpO2 95% (greater than or equal to 95%).Review of R8's Nursing Progress Note dated 02/03/2026 at 03:19 PM revealed, (nurse practitioner) in to see (R8) today per note in providers' book that O2 sat on 1/31/26 was in the 50s.Review of R8's provider Progress Note dated 02/03/2026 at 06:17 PM revealed, Nursing notes oxygen sat on 1/30 was in the 50's. No VS charted for 1/30, no call to provider, no nursing note. Confirming a delay in physician notification of an acute change of condition.Review of R8's O2 Saturation log revealed an oxygen assessment was documented on 1/27/26 and then again on 2/3/26. There was no reassessment of R8's oxygen saturation documented.Resident #10 (R10)Review of an admission Record revealed R10 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and hypertension (high blood pressure).Review of R10's Nursing Progress Note dated 01/02/2026 at 02:55 PM revealed, resident found to have manual BP of 70/42 with associated s/s (signs and symptoms) of lightheadedness and dizziness while standing. (nurse practitioner) informed (and) verbal instructions received to administer 1000ml (milliliters ) of 0.9 NS (normal saline) IV (intravenous fluids) 250ml/hr (milliliters and hour) now recheck BP (blood pressure) during and after infusion There was no documentation in the blood pressure log of vital signs during the infusion. There were no blood pressure assessment(s) documented in the blood pressure log on 1/2/26.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Hypotension is present when the systolic BP falls to 90 mm Hg or below.Review of R10's Nursing Progress Note dated 01/05/2026 at 5:04 PM revealed, At 1600 (4:00 PM): (R10) with manual 80/60 BP (blood pressure) with associated headache and fatigue.Review of the provider Concerns/Communication log with an entry dated 1/5/26 revealed (R10) hypotn (hypotension) 80s/60s manual-tx'd (treated) PO (oral) fluids 1600-2000 (4:00 PM through 8:00 PM)-planned to tx (treat) IVF (with intravenous fluids) if symp. (symptomatic)/ (or) SBP < 100 (systolic blood pressure less than 100) at 2000 (8:00 PM) 1/5.Review of R10's Blood Pressure log revealed that on 1/6/26 at 4:00 AM a blood pressure on 90/60 (SBP less than 100).Review of R10's Nursing Progress Note dated 01/06/2026 at 5:26AM revealed, Manual BP (blood pressure) checks completed at 2115 (9:15 PM), 0000 (midnight) and 0400 (4:00 AM). Resident continues to complain of fatigue and headache. Indicating R10 had a blood pressure of less than 100 systolically (top number) and continued to be symptomatic of low blood pressure, and the provider was not notified for further direction on treatment and or monitoring.R10's blood pressure was not reassessed until 1/6/26 at 5:20 PM. R10's Blood Pressure log revealed a blood pressure of 88/51. Indicating blood pressure assessments were not completed to ensure R10 was not in a hypotensive crisis.Review of R10's provider Progress Note dated 01/06/2026 at 2:32 PM revealed, .Nursing reports hypotension w/ (with) SBP (systolic blood pressure) in the 70's. Pt (patient) asymptomatic. Average BP runs in the 80-100 systolic. Medications reviewed, fluids encouraged.May consider Midodrine (medication to increase blood pressure) if she becomes symptomatic.Review of R10's Order Summary dated 07/01/2025 revealed, Vital Signs Weekly to be assessed on 1/6/26, 1/13/26, 1/20/26, and 1/27/26.Review of R10's Blood Pressure log revealed that on 1/6/26 at 5:20 PM a blood pressure of 88/51 was obtained. There was no blood pressure assessment again until 1/20/26 at 5:47 PM.Review of R10's January Medication/Treatment Administration Record revealed the entry for vital signs on 1/13/26 utilized the vital signs obtained on 1/6/26 despite the known symptomatic hypotensive incidents R10 experienced.Resident #30 (R30)Review of an admission Record revealed R30 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: down syndrome and anxiety disorder.Review of the provider Concerns/Communication log with an entry dated 1/14/26 revealed, (R3) Extra dose ativan 1/12 + 1/13.Review of R30's Order Summary and January Medication Administration Record revealed the following:Ativan (lorazepam) tablet; 0.5 mg; Amount to Administer: 1 tab; oral Every 4 Hours - PRN (as needed). dated 01/12/2026 and discontinued 01/16/2026.There was no documentation that the as needed Ativan was administered between 01/12/2026 and 01/16/2026.lorazepam (Ativan) tablet; 0.5 mg; Amount to Administer: 0.5mg; oral Three Times a Day dated 12/19/25 and discontinued 1/16/26.All 3 doses of the Ativan 0.5 mg were administered on 1/12/26 and 1/13/26.On 1/14/26 the morning dose was not administered Due to Condition.On 1/14/26 the afternoon dose was not administered due to lethargy.Ativan (lorazepam).tablet; 0.5 mg; Amount to Administer: 1 tab; oral Three Times a Day. Dated 1/12/26 and discontinued 1/13/26On 1/12/26 the evening dose of Ativan 0.5 mg was administered (along with the previous order for a total of 1mg of ativan and not 0.5 mg)On 1/13/26 the morning dose was not administered by Licensed Practical Nurse (LPN) D due to Duplicate order. There was no documentation that LPN D notified the provider or the Director of Nursing (DON) of the duplicate order.LPN D did not place the order on hold and on 1/13/26 the afternoon dose of Ativan 0.5 mg was administered (along with the previous order for a total of 1mg of ativan and not 0.5 mg).Review of R30's Blood Pressure log revealed that on 1/13/26 at 6:57 AM a blood pressure result of 73/45 (an excessive amount of Ativan can result in low blood pressures). There was no documentation that the provider was notified of the hypotension and change from R30's baseline blood pressures.Review of R30's Incident Report with an event date of 1/13/26 revealed, Duplicate order was entered for Ativan for 2 days. Resident received a double dose of Ativan on 01/12/26 and 01/13/2026. Duplicate order entered. Resident received 2 extra doses of Ativan, once on 1/12 and once on 1/13.Review of R30's Nursing Progress Note dated 1/15/2026 at 02:45PM revealed, Nurse on the floor notified this nurse of a duplicate order for Ativan in resident's chart. This nurse reviewed medications and found that resident did have a duplicate order of Ativan since 1/12/26. In reviewing residents medication administration record, it was found that resident had received 2 extra doses of Ativan 0.5mg, once on 1/12/26 and once on 1/13/25 due to the duplicate order. Resident was assessed and no negative outcomes were observed by this nurse. Vitals were stable. Resident was at baseline. Provider, guardian and hospice was notified. Order was corrected.Resident #5 (R5)Review of an admission Record revealed R5 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes.Review of R5's Order Summary dated 11/8/25 revealed, Notify physician for blood glucose readings less than 70 mg/dL or greater than 400 mg/dLReview of R5's January and February Blood Sugar log and Electronic Medical Record revealed:On 01/13/2026 at 11:26 AM R5's blood sugar was 500. There was no documentation that the provider was notified.On 01/15/2026 at 12:13 PM R5's blood sugar was High (greater than 600). There was no documentation that the provider was notified.On 01/19/2026 at 05:09 PM and 05:14 PM R5's blood sugar was High. There was no documentation that the provider was notified.On 01/20/2026 at 03:32 PM R5's blood sugar was High. There was no documentation that the provider was notified.On 01/27/2026 at 12:03 PM R5's blood sugar was High. There was no documentation that the provider was notified.On 01/29/2026 at 12:00 PM R5's blood sugar was 519. There was no documentation that the provider was notified.On 02/04/2026 at 12:56 PM R5's blood sugar was 447. There was no documentation that the provider was notified.On 02/06/2026 at 11:20 AM R5's blood sugar was 504. There was no documentation that the provider was notified.On 02/06/2026 at 04:31 PM R5's blood sugar was High. There was no documentation that the provider was notified.On 02/06/2026 at 06:13 PM R5's blood sugar was 511. There was no documentation that the provider was notified.On 02/07/2026 at 07:43 PM R5's blood sugar: 539. There was no documentation that the provider was notified.On 02/09/2026 at 11:49 AM R5's blood sugar was 456. There was no documentation that the provider was notified.During an interview on 02/12/2026 at 9:11 AM, the Director of Nursing and Regional Nurse (RN) E confirmed the nurse did not follow nursing standards of practice or facility policy regarding the notification of change for R8. The DON and RN E reported that LPN D should have immediately notified them of the duplicate order to ensure the subsequent double dose was not administered confirming the afternoon ativan medication error was preventable. The DON and RN E reported the licensed nurses should immediately report and change in resident condition and critical results directly to the provider and reported they would be completing education for all licensed nurses on what was appropriate to document in the provider communication log and what requires an immediate call to the provider. Additionally, they would be educating licensed nurses on appropriate timeframes for notification to the providers.Review of the facility policy, Notification of Change last reviewed 01/2025 revealed, The Residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition.Some physicians may require different notification parameters for conditions such as blood glucose or other conditions.The Licensed nurse will use professional judgement any time that in their opinion the resident requires immediate medical attention.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Vital Signs Acceptable Ranges for Adults-Temperature range Average temperature range: 36 to 38 C (96.8 to 100.4 F)Average oral/tympanic: 37 C (98.6 F)Average rectal: 37.5 C (99.5 F)Axillary: 36.5 C (97.7 F)Pulse 60 to 100 beats/min, strong and regularPulse oximetry (SpO2) Normal: SpO2 95%Respirations 12 to 20 breaths/min, deep and regularBlood pressure Systolic <120 mm Hg Diastolic <80 mm Hg.[NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Hypotension is present when the systolic BP falls to 90 mm Hg or below. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Blood glucose level is above or below target range. Continue to monitor patient. Check for any medication orders for deviations in glucose level. Notify health care provider. Administer insulin or carbohydrate source as ordered, depending on glucose level. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Maintaining normoglycemia or a glucose level of less than 180 mg/dL and reducing blood glucose variability are recommended as an evidence-based practice for safe and effective patient management ([NAME], 2020). [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation, interview, and record review, the facility failed to properly assess one resident (R9) out of twelve reviewed for self-administration of medications.Findings include:Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnosis which include type II diabetes mellitus, major depressive disorder, anxiety disorder, and cognitive communication deficit. In an observation on 2/10/2026 at 8:42 AM R9 was observed to have a bottle of Flonase nasal spray (24-hour nasal spray that treats allergy symptoms) at the bedside. Licensed Practical Nurse (LPN) B asked R9 if she had already administered the medication and R9 answered that she was unsure why the Flonase nasal spray was at bedside. LPN B administered the Flonase nasal spray as physician ordered and placed the Flonase into the medication cart.Review of a Physician Order dated 03/05/2025 Flonase Allergy Relief (fluticasone propionate) spray, 50 micrograms one spray each nostril every morning. Further review of physician order revealed that R9 had no diagnosis for use of Flonase.In an interview on 2/10/2026 at 8:45 AM LPN B stated the Flonase nasal spray for R9 should have been in the medication cart and not at bedside. LPN B was unsure how long the Flonase nasal spray was at R9's bedside. In an interview on 2/10/2026 at 11:00 AM Director of Nursing (DON) reported after reviewing R9's electronic medical record, R9 did not have a self-administration assessment completed to self-administer the Flonase nasal spray at bedside. Review of facility policy Self-Administration revealed residents may not exercise the right to self-administer medications until the interdisciplinary team (IDT) has determined if the resident is safe to self-administer medications and which medications may be self-administered. a care plan will be initiated for residents who can safely self-administer medications. a physician's order will be obtained for residents who can safely self-administer medications. medications will be stored in a secured location, in resident room in a locked area or with the medication cart until dispensed to the resident for self-administration.

Based on interview and record review, the facility failed to provide a resident with written notice of the facility's bed hold policy upon transfer to the hospital for 1 of 2 residents (R27) reviewed for hospital transfers. Findings include: A review of R27's Face Sheet, dated 2/12/26, revealed R27 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included obstruction of the bile duct and weakness, A review of R27's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/9/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R27 was cognitively intact.A review of an Interdisciplinary Team note, dated 1/24/26 for 1/19/26, revealed R27 had been transferred to the hospital emergency room on 1/18/26 for evaluation and treatment of excessive purulent drainage (thick, milky, or opaque fluid often having a foul odor that signifies an active infection) from R27's biliary drain (a thin tube that is inserted through the skin into the liver and that drains fluid into a bag). In addition, the Interdisciplinary Team note revealed R27 had been transferred to another hospital for treatment, management, and admission.A review of R27's electronic medical record, dated 1/6/26 to 2/12/26, failed to reveal that the facility had provided R27 with written notice of their bed hold policy when she was transferred to the hospital emergency room on 1/18/26.During an interview on 02/12/26 at 10:20 AM, the Director of Nursing (DON) was informed that the surveyor could not locate the written notice of the facility's bed hold policy that R27 should have received prior to, or soon after, her transfer on 1/18/26 to the hospital emergency room. The DON stated she would look and see if it was in a stack of unfiled paperwork in her office. A copy of the written notification was requested from the DON, if she could locate it. During a second interview on 02/12/26 at 10:30 AM, the DON stated the facility did not give R27written notification of the facility's bed hold policy when she went to the emergency room on 1/18/26. She stated they only gave her the bed hold policy when she was admitted to the facility. A review of the facility's Bed Hold policy and procedure, reviewed 01/25, revealed the bed hold policy will be provided to the resident or the resident's representative at the time of admission and again with any emergency transfer from the community. 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission and again prior to a transfer due to hospitalization or therapeutic leave. 2. The facility shall provide the bed hold policy acknowledgement to the resident or the resident representative with any resident initiated therapeutic leave or transfer to alternative healthcare community including a hospital admission. This acknowledgement will provide information to the resident and/or resident representative that explains the duration, the reserved bed payment policy and also facility permitting return of the resident to the next available bed.

Based on interview and record review, the facility failed to complete Preadmission Screening and Resident Review (PASARR) Level 1 Screenings timely for 2 of 2 residents reviewed (R2 and R12). Findings include:R12 Review of a Face Sheet revealed R12 admitted to the facility on [DATE] with pertinent diagnosis which include schizoaffective disorder, bipolar type, and type II diabetes. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R12, with a reference date of 12/22/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 04, out of a total possible score of 15, which indicated R12 had severe cognitive impairment. Further review of the MDS revealed R12 had received an antipsychotic and an antidepressant within the 7-day assessment period. Review of the electronic medical record revealed a PASARR Level 1 Screening dated 09/22/2025 marked hospital exemption discharge which meant that R12 was certified by a physician to admit to a long-term clinical facility after a hospital stay, required nursing facility service, and was likely to require less than 30 days of nursing service. Upon further review there was no completion of a new PASARR Level 1 screening after the 30-day exemption was passed the 30 days which would have initiated a level II evaluation with mental health services for R12. In an interview on 2/10/2026 at 2:42 PM with Social Services (SS) A reported she missed the 30-day exempt Level 1 PASARR screening review for R12. (SS) A reported the expectation would be to follow procedure for the PASARR process. Review of facility policy Pre-Admission-admission Process, Revised 10/2017 revealed Social Services will ensure that the referring party obtains a Level 2 PASARR screening, when indicated. A review of R2's Face Sheet, dated 2/11/26, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a post-traumatic stress disorder (PTSD), depression, anorexia nervosa- binge eating/purging type, and a personal history of other mental and behavioral disorders. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/28/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R2 was cognitively intact. A review of R2's electronic medical record (EMR), dated 1/13/26 to 2/9/26, failed to reveal if R2 had a Preadmission Screening and Resident Review (PASARR) Level 1 Screening (a screening that evaluates all applicants for serious mental illness and/or intellectual disability in order to ensure that they receive the appropriate care and services that they require) performed prior to admission. A review of R2's admission Packet Audit, undated, failed to indicate if facility staff had ensured that a PASARR Level 1 screening was completed prior to R2 being admitted to the facility (the Check Off and Initial boxes for this task/item were blank). During an interview on 02/10/2026 at 3:00 PM, the Director of Nursing (DON) was notified that a copy of R2's PASARR Level 1 screening could not be located in their medical record. The DON stated she would look and see if she could locate it within a stack of documents that were in her office that had not been scanned into residents' medical records. A copy of R2's PASARR Level 1 screening was requested from the DON, if one could be located. On 2/10/2026 at 4:48 PM, the facility provided an undated and unsigned copy of a PASARR Level 1 screening for R2. In addition, the PASARR Level 1 screening did not even have the name (typed or printed) or the title of the individual who allegedly completed the form. The PASARR Level 1 screening revealed R2 had current mental illness diagnoses and was being treated for mental illness. A second review of R2's EMR, dated 1/13/26 to 2/11/26, revealed the facility loaded R2's PASARR into the medical record on 2/10/26. During an interview on 02/11/2026 at 11:10 AM, Social Services (SS) A stated R2 did not have a PASARR Level 1 screening completed prior to her admission. SS A stated R2 came from an out of state hospital and they had requested that the facility do the PASARR Level 1 screening when R2 arrived. SS A further stated that R2's PASARR Level 1 screening had been completed on 2/10/26 by a Registered Nurse (RN) and presented the form to the surveyor with the RN's name typed on it (no signature) and the date the PASARR Level 1 screening was completed. SS A also confirmed that the PASARR Level 1 screening form that was in R2's EMR at the time of this conversation lacked the date and time the form was completed, typed/printed name and title of the individual who completed the form, and the signature of the individual who completed the form. A review of R2's PASARR Level 1 screening form that SS A presented to the surveyor confirmed that the form was completed by an RN and that the form had been completed on 2/10/26 at 3:39 PM (28 days after R2 was admitted to the facility and approximately 30 minutes after the form was requested from the DON). It also revealed that R2's PASARR Level 1 screening was unsigned by the person who completed the form. A review of the State Operations Manual, dated 08/08/24, revealed, The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities and related conditions. This initial screening is referred to as Level I Identification of individuals with MD (Mental Disorder) or ID (Intellectual Disability) ( 483.128) and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identify individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility.

Based on interview and record review, the facility failed to implement the facility policy for pressure injury/wound management for 3 of 12 residents (Resident #21, #17, and #6) reviewed for alterations in skin integrity.Findings:Resident #21 (R21)Review of an admission Record revealed R21 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Chronic Diastolic Heart Failure.Review of R21's Order Summary dated 10/2/25 until 1/19/26 revealed, Skin Assessment Weekly.Review of R21's weekly Skin Body Assessment dated 12/18/25 revealed, LLE (left lower extremity) ulcer known finding treatment in place .There were no weekly Skin Body Assessment completed on 12/25/25 or on 1/1/26.Review of R21's Skin Body Assessment dated 1/8/26 revealed, .some excoriation on buttocks bilateral cream applied house stock barrier cream on open areas on buttock noted.Review of R21's Electronic Health Record revealed no documentation that the Director of Nursing, the provider, or the emergency contact were notified of the alteration in her skin integrity. R21's Care Plan was not updated to reflect the excoriation with implementation of new interventions to prevent the worsening of breakdown/injury. There were no new treatment orders implemented (house stock barrier cream on open areas as documented in the skin assessment.)Review of R21's Skin Body Assessment dated 1/14/26 revealed no follow up regarding the excoriation identified on 1/8/26.Review of R21's Interdisciplinary Progress Note 1/19/26 revealed, Weekly IDT (interdisciplinary team) Review of Wounds: (R21's) right medial lower leg wound has healed. Care plans/orders dc'd (discontinued) and resolved as of 1/16.Review of R21's Care Plan-Evaluation Notes dated 1/19/26 revealed, .Stable at this time with no new skin breakdown issues.Review of R21's Order Summary dated 1/19/26 revealed Skin Assessment Weekly-Sunday 1st shift. There was no weekly Skin Body Assessment documented for 1/19/26.There was no weekly Skin Body Assessment completed on 1/21/26.Review of R21's Skin Body Assessment dated 1/27/26 revealed, Sacrum/Coccyx - skin tears. (R) and (L) intergluteal cleft.Review of R21's Nursing Progress Note dated 1/27/26 [Recorded as Late Entry on 01/29/2026 02:37 PM] revealed, Moisture-associated skin tears found to RIGHT & LEFT intergluteal cleft. Wound NP (nurse practitioner) to eval at the bedside, January 30th.Orders/care plan initiated. Wounds added to Wound Manager.Review or R21's Order Summary revealed no treatment was initiated for the MASD/skin breakdown from the identification of the wound on 1/27/26.Review of R21's Medication/Treatment Administration Record revealed no documentation of treatments ordered or completed for R21 from 1/27/26-1/29/26.Review of R21's Nursing Progress Note dated 1/30/26 revealed, Wound Rounds: Skin tears to R/L intergluteal cleft correctly identified as MASD (moisture associated skin damage) to sacrum R/L (right/left) by (name omitted) NP during Wound Rounds; DON updated verbiage in Wound Manager. MASD R/L wounds evaluated at the bedside with (name omitted), NP. Initial evals for both areas. Measurements updated. Assessment attached in Wound Manager. Careplan/orders verified. Treatment for both sites: Cleanse with normal saline/wound cleanser. Apply hydrocolloid dressing MWF (Monday, Wednesday, and Friday) and as needed.Review of R21's Order Summary dated 1/30/26 revealed, Sacrum wound cleanse with NS (normal saline)/wound cleanser - apply hydrocolloid dressing. MWF (Monday, Wednesday, and Friday) and as needed.Review of R21's Nursing Progress Note dated 2/6/26 revealed, Wound Rounds w/ (with) NP: MASD to R/L sacrum assessed at bedside; MASD to R sacrum is improving; care plan/orders reviewed; measurements updated. MASD to L sacrum has healed as of 2/6/26.Review of R21's skin integrity Care Plan revealed, Problem Start Date: 01/27/2026 Category: *Skin Integrity-With active MASD to LEFT sacrum; had MASD to RIGHT sacrum--healed as of 2/6/26. Indicating a discrepancy in the healing of the wounds.Review of R21's Treatment Administration Record and Order Summary revealed the treatment for R21's sacrum wound was ongoing since the initial order on 1/30/26. There was no modification of the order with the change/resolution of the wound on 2/6/26 as of survey exit (2/12/26.)During an interview on 02/12/2026 at 9:11 AM, the Director of Nursing reported that she initiated treatment for R21 upon identification of the breakdown on 1/27/26 but confirmed it was not ordered in the Medication/Treatment Administration Record until 1/30/26 following the wound consultant's assessment.Review of the facility policy Pressure Injury Prevention and Care last revised 01/2025 revealed, Purpose: To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of pressure injuries to promote and facilitate resolution of pressure injuries.Procedure: 1. Nurses will complete the Skin Body Assessment Observation upon admission/readmission, then weekly and as needed.5. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution.6. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order. 7. Physicians and responsible parties will be notified of pressure injury upon identification and with change in status of pressure injury.9. Potential/suggested procedure with pressure injury identification: A. Notify the physician/provider and the resident's responsible party B. Initiate treatment in accordance with facility protocols, standing orders, or physician orders C. Document the appearance of the pressure injury (eg: size, location, appearance, odor (if any), drainage (if any), condition of peri-wound, wound edges, stage, etc.) D. Implement pressure-relieving or pressure-reducing interventions as appropriate E. Notify the Director of Nursing F. Update the resident care plan to address the area of pressure injury, and approaches initiated.

Based on interview and record review, the facility failed to maintain complete medical records for 3 of 12 sample residents (R2, R3, and R27). Findings include: R2 A review of R2's Face Sheet, dated 2/11/26, revealed R2 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a post-traumatic stress disorder (PTSD), depression, and anxiety. A review of R2's electronic medical record (EMR), dated 1/13/26 to 2/9/26, failed to reveal any advanced directive documentation that would indicate if R2 had been offered to formulate an advanced directive and/or complete an advanced directive. A second review of R2's EMR, dated 1/13/26 to 2/9/26, failed to reveal if R2 had a Preadmission Screening and Resident Review (PASARR) Level 1 Screening (a screening that evaluates all applicants for serious mental illness and/or intellectual disability in order to ensure that they receive the appropriate care and services that they require) performed prior to admission. During an interview on 02/10/2026 at 3:00 PM, the Director of Nursing (DON) was notified that the surveyor could not locate any documentation in R2's EMR that would indicate the facility addressed advanced directives with R2. The DON stated she would look in the file folders and boxes in her office to see if the facility had addressed advanced directives when R2 was admitted . A copy of R2's advanced directives documentation was requested from the DON, if any could be located. During the same interview on 02/10/2026 at 3:00 PM, the DON was notified that a copy of R2's PASARR Level 1 screening could not be located in their medical record. The DON stated she would look and see if she could locate it within a stack of documents that were in her office that had not been scanned into residents' medical records. She stated the facility has had some issues with getting resident documents scanned into the residents medical records. A copy of R2's PASARR Level 1 screening was requested from the DON, if one could be located. On 2/10/2026 at 4:48 PM, the facility provided an undated and unsigned copy of a PASARR Level 1 screening for R2. In addition, the PASARR Level 1 screening did not even have the name (typed or printed) or the title of the individual who allegedly completed the form. The PASARR Level 1 screening revealed R2 had current mental illness diagnoses and was being treated for mental illness. A second review of R2's EMR, dated 1/13/26 to 2/11/26, revealed the facility loaded R2's PASARR into the medical record on 2/10/26.During a second interview on 02/11/2026 at 08:40 AM, the DON verbally verified that she could not locate R2's advanced directives in her medical record. She stated the facility completed an advanced directives form (Medical Treatment Decisions of Resident form) for R2 yesterday (2/10/26) when she could not locate a completed form. During an interview on 02/11/2026 at 11:10 AM, Social Services (SS) A presented a PASARR Level 1 screening form to the surveyor that indicated the form had been completed by a Registered Nurse (RN) on 2/10/26 at 3:39 PM (28 days after R2 was admitted to the facility and approximately 30 minutes after the form was requested from the DON) with the name of the RN typed in. However, the RN had failed to sign the form. In addition, SS A confirmed that the PASARR Level 1 screening form that was in R2's EMR at the time of this conversation lacked the date and time the form was completed, typed/printed name and title of the individual who completed the form, and the signature of the individual who completed the form. R3 A review of R3's Face Sheet, dated 2/11/26, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Face Sheet revealed they had multiple diagnoses that included depression, psychotic disorder with delusions, insomnia, and anxiety. A review of R3's Pharmacist Drug Regimen Review forms, dated 12/4/24 to 2/10/26, revealed that the pharmacist had noted that a report was made for noted irregularities and/or recommendations on 3/13/25, 4/3/25, 10/13/25, 11/5/25 and 12/8/25. In addition, the Pharmacist Drug Regimen Review form for 5/19/25 did not indicate if R3's medications were reviewed on that visit (the bubbles for No Recommendations or Please take the following action directed below were not checked and the area for inputting actions was blank. A review of R3's electronic medical record (EMR), dated 1/13/26 to 2/10/26, failed to reveal any pharmacy Consultation Reports for 3/13/25, 4/3/25, 5/19/25, 10/13/25, 11/5/25, and/or 12/8/25 that would indicate what irregularities and/or recommendations were made by the pharmacist. During an interview on 2/11/26 at 11:00 AM, the DON confirmed that R3's pharmacy Consultation Reports for 3/13/25, 4/3/25, 5/19/25, 10/13/25, 11/5/25, and/or 12/8/25 were in boxes/file folders in her office and had not been scanned into R3's medical record. A review of the facility's Medication Regimen Review policy and procedure, dated 11/28/16, revealed, 12. Facility should maintain readily available copies of MRRs on file in Facility as part of the resident's permanent health record. R27A review of R27's Face Sheet, dated 2/12/26, revealed R27 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included obstruction of the bile duct and weakness, A review of an Interdisciplinary Team note, dated 1/24/26 for 1/19/26, revealed R27 had been transferred to the hospital emergency room on 1/18/26 for evaluation and treatment of excessive purulent drainage (thick, milky, or opaque fluid often having a foul odor that signifies an active infection) from R27's biliary drain (a thin tube that is inserted through the skin into the liver and that drains fluid into a bag). In addition, the Interdisciplinary Team note revealed R27 had been transferred to another hospital for treatment, management, and admission. A review of R27's electronic medical record (EMR), dated 1/6/26 to 2/12/26, failed to reveal that the facility had provided R27 with written notice of their bed hold policy when she was transferred to the hospital emergency room on 1/18/26. In addition, R27's EMR failed to reveal if the facility had provided written notice of their bed hold policy at any time after her admission. During an interview on 02/12/26 at 10:20 AM, the Director of Nursing (DON) was informed that the surveyor could not locate the written notice of the facility's bed hold policy that R27 should have received on admission and prior to, or soon after, her transfer on 1/18/26 to the hospital emergency room. The DON stated she would look and see if it was in a stack of unfiled paperwork in her office. A copy of the written notifications were requested from the DON, if she could locate them. During a second interview on 02/12/26 at 10:30 AM, the DON stated the facility did not give R27 written notification of the facility's bed hold policy when she went to the emergency room on 1/18/26. She stated they only gave her the bed hold policy when she was admitted to the facility. The DON was able to provide a copy of the bed hold policy that R27 was presented with on 1/6/26 and verified that it was not scanned into R27's medical record but had been in a box/file folder in her office. A review of the facility's Bed Hold policy and procedure, reviewed 01/25, revealed, 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission and again prior to a transfer due to hospitalization or therapeutic leave. The signed copies will be maintained in the resident's financial or personal file. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Timely documentation of the following types of information should be made and maintained in a patient's EHR to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments. Communications with other health care professionals regarding the patient; Communication with and education of the patient, family, and the patient's designated support person and other third parties. Order acknowledgement, implementation, and management. Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/27/25).

This citation pertains to intakes 1275497 and 1275498. Based on observation, interview, and record review, the facility failed to: 1) operationalize policies and procedures, 2) provide services as documented, 3) notify physician of wounds with oversight, 3) timely interventions of wounds, and 4) implement care plan interventions of wounds for 3 residents (R5, R6, and R9) of 4 residents reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: Review of a policy titled Pressure Injury Prevention and Care, last reviewed 1/2025 revealed: 1. Nurses will complete the Skin Body Assessment Observation upon admission/readmission, then weekly and as needed. 2. Nurses will complete Braden Scale for residents on admission/readmission, weekly for 4 weeks, quarterly, at time of new pressure injury identification, and as needed. 5. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution. 6. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order. 7. Physicians and responsible parties will be notified of pressure injury upon identification and with change in status of pressure injury. 8. Physician/provider will be notified if pressure injury shows signs of deterioration, infection, or no improvement for further evaluation and recommendations regarding treatment and interventions. Resident #5 (R5) Review of a Face Sheet revealed R5 originally admitted to the facility on [DATE]. No diagnoses of pressure ulcers. Review of the Progress Notes for R5 revealed she died in the facility on [DATE]. Review of a Facility Reported Incident (FRI) dated [DATE] regarding an allegation of R5 not receiving a pressure ulcer dressing change in 5 days. The facility reported Registered Nurse (RN) G provided a dressing change on [DATE] for R5 and initialed and dated the dressing that day. RN G also provided care on [DATE] and noticed the same dressing with her initials was in place and dated [DATE]. The facility reported the pressure ulcer dressing changes were ordered to be done every day and acknowledged two different nurses documented the dressing changes were done [DATE] and [DATE] but did not actually provide the services. The Nursing Home Administrator (NHA) reported they identified like residents, reviewed dressing change orders and skin assessments to ensure dressing changes aligned with treatment documentation and did not find any concerns or discrepancies. The NHA concluded she could not substantiate the allegation. Review of the Electronic Medical Records (EMR) for R5 revealed some notes were in the nursing progress notes, some notes were in the Wound Summary, some notes were in the observations tab, and some were under the skin assessments. However, they did not correlate with one another. Review of an order dated [DATE] and discontinued on [DATE] for R5 revealed: Cleanse wound site with wound cleanser, apply triad wound dressing, cover with foam dressing, twice a day. This was documented as done on [DATE] between 7:00 AM and 11:00 PM, then the order changed. The exact wound is not identified. Review of the Nursing Progress notes for R5 revealed she went to the hospital on [DATE] at 8:00 PM and returned to the facility on [DATE] at 10:04 AM. Hospice admission was in progress upon her return. Review of a Nursing Progress Note for R5 dated [DATE] revealed: wound care provided to buttock (exact location not identified), wound bed 100% granulated tissue. Peri wound intact with discoloration from noted scar tissue. resident denies pain with wound cares. consulted with provider [Name] regarding ordered wound cares. new orders received. wound measuring 1.7cm x 3cm x 0.1 cm. DON (Director of Nursing) informed of findings. An order for R5 dated [DATE] and discontinued on [DATE] to be done at bedtime revealed: left upper buttock stage 2 pressure injury: 1. cleanse with normal saline 2. apply skin prep to intact peri wound. 3. allow skin prep to dry fully to air. 4. apply small amount of medihoney to wound bed. 5. place foam dressing over wound bed as secondary dressing 6. nursing to change daily and PRN (as needed). This is documented as done on 5/1 by RN G, 5/4 by LPN H, 5/5 by LPN F, and 5/6 by RN G. (Out to the hospital on 5/2 and 5/3). It was documented the dressing changes were done on [DATE] and on [DATE]; but not done per the facility's investigation. Review of an order dated [DATE] and discontinued on [DATE] for R5, once every 3 days, revealed: Left upper buttock: 1. Cleanse with soap and water. 2. Apply skin prep to area. 3. Cover with foam dressing. 4. Change every 3 days or prn (as needed) if soiled/dislodged. This is documented as done on [DATE].Review of a Nursing Progress Note for R5 dated [DATE] revealed: Coccyx wound resolved. Will continue to use foam dressing for protection. Change every 3 days or prn if soiled/dislodged. This progress note did not correlate with the wound care orders indicating there was still a wound. Review of a Wound Management report for R5 revealed the following: -Date identified: [DATE] -Unspecified Ulcer- Coccyx: 3.2 centimeters (cm) x 4.5 cm. On [DATE] it measured 11.5 x 13 (measurement standards not identified) with heavy seropurulent (yellow or tan, cloudy and thick) drainage with a foul odor. On [DATE] it measured 12 x 15 (measurement standards not identified.) Described as having a foul odor with necrotic tissue. -Date identified: [DATE]- Unspecified Ulcer- Right big toe pressure area: 0.7 x 1.4 cm. -Date identified: [DATE]- scab, right 2nd toe: 0.2 cm x 0.2 cm. On [DATE] it measured 0.2 x 0.2 and non-blanchable. -Date identified: [DATE]- Right hip- unstageable, deep tissue: 7 x 2.3 (measurement standards not identified). -Date identified: [DATE]- Pressure ulcer, right heel: 3.5 x 2.5 (measurement standards not identified). -Date identified: [DATE]- Right inner ankle: 2.5 x 2 (measurement standards not identified). -No wound assessment for the left upper buttock documented. Review of a Nursing Progress Noted for R5 dated [DATE] revealed: Placed new overlay mattress on resident's bed. Wound care done to coccyx, slight sheer noted on skin, no bleeding or drainage noted . Surrounding skin intact. Review of a Nursing Progress Note for R5 dated [DATE] revealed: RN (Registered Nurse) performed skin assessment. Stage 2 noted to coccyx region. Tx (treatment) in place and measurements recorded in event. SDTI (suspected deep tissue injury) to right great toe, measurements recorded in event. Second right toe reddened and blanchable. Tx (treatment) in place for both toes. Review of a Nursing Progress note dated [DATE] for R5 revealed: wound care provided per order no indication for infection noted at this time. wound on coccyx worsening. added to provider rounding book for review. DON notified of worsening wound. hospice also informed of wound decline. No documentation the physician assessed and addressed her wounds.An order dated [DATE] and discontinued on [DATE] for R5 revealed: Stage 2 coccyx pressure injury: cleanse with N/S (normal saline), pay (sic) dry. Apply sacral comfort foam to area, once a day every other day. This was documented as done on [DATE], [DATE] and [DATE]. (No dressing changes provided/documented from [DATE] to [DATE]). An order dated [DATE] and discontinued on [DATE] for R5 revealed: Stage 2 coccyx pressure injury: Cleanse with N/S, pay (sic) dry. Apply sacral comfort foam to area, once a day on Mon, Fri. This was documented as done on [DATE], [DATE], and [DATE]. An order dated [DATE] and discontinued on [DATE] for R5 revealed: Stage 2 coccyx pressure injury: Cleanse with N/S, pay (sic) dry, apply xeroform to wound bed, cover with sacral comfort foam to area, once a day on Mon, Fri. This is documented as done on [DATE], refused [DATE] with no reapproach or another attempt at another time documented, and 6/13. Review of a Nursing Progress note dated [DATE] with a late entry of [DATE] for R5 revealed: wound cares provided per provider order. wound significantly larger. Resident is currently actively EOL (sic) Hospice RN assisted with wound care wound identified as Kennedy ulcer per hospice rn. Daughter present for wound cares informed of decompensation and etiology of Kennedy ulcers. provider [name] also informed no new orders received at this time. No physician oversight or diagnoses of a new [NAME] Pressure Ulcer documented. Review of a Pressure Ulcer/Injury Care Plan for R5 initiated [DATE] revealed R5 was at risk for skin pressure and moisture associated skin damage. New Sacral stage 2 pressure ulcer and unstageable to Right great toe. (5-20-25) An intervention on [DATE] revealed: Nursing to provide wound care per physician's order. Report and (sic) decline or signs and symptoms of infection. On [DATE], a specialty mattress and a pressure reduction cushion for her wheelchair were implemented. On [DATE] (the year before) an intervention of SACRAL pressure ulcer developed (5-20-25). Assess for stage, presence/absence of granulation tissue and epithelization, and condition of surrounding skin with every treatment/dressing change. Measure weekly. Review of the Nursing Progress notes dated [DATE] revealed R5 passed away. In an interview on [DATE] at 4:00 PM, the DON reported the FRI with R5 happened before she started working at the facility but was aware that the nurse missed the admission skin assessment after R5 readmitted back to the facility from the hospital. When questioned about the Wound Audit from the FRI report with no dates of the audit, the DON reported it looked like the person who documented several residents on this form did a onetime audit of residents and identified residents who had wounds with no dressing orders in place or skin assessments. The DON was not aware of any ongoing audits for dressing changes and wounds at this time but does have a nurse who has been doing weekly wound rounds on residents and documenting them in the medical records. On [DATE] at 10:30 AM, a request was made to the DON for documentation that indicated R5's care was overseen by a physician. No documentation was provided by the end of this survey. In an interview on [DATE] at 8:09 AM, the DON reported physicians should be notified of any changes in conditions for residents. If it's not documented, then it's not done. The DON verified she could not find documentation from the practitioners that R5's care was overseen by a practitioner. The DON stated she expected care plan interventions to be updated and implemented. In an interview on [DATE] at 10:13 AM, the NHA was questioned about the FRI regarding R5 and the audit they did when they identified several other residents who had wounds that were not identified with treatments in place prior to this incident. The NHA confirmed they did a one-time audit of wounds since the FRI and have not done any monitoring for ongoing compliance to ensure dressing changes were being done as ordered and new wounds were being identified and treated timely. The NHA reported skin assessments and wound care has been a concern for a while and identified it as an area that needs improvement. The FRI documentation reflected R5's dressing changes were not done on 5/4, 5/5, 5/6 and on 5/7 it was acknowledged that the nurse identified the dressing for R5 still had her initials on it from [DATE]. The NHA reported that the nurse changed the dressing on [DATE] on the 3rd shift which technically was done on 5/7. The MAR shows R5 had a dressing change documented on [DATE] by another nurse. In an interview on [DATE] at 11:36 AM, Registered Nurse (RN) D and Licensed Practical Nurse (LPN) E reported wound management notes are sometimes in progress notes and was told as long as they get the notes in the EMR, it didn't matter where it was charted. Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE]. During an observation on [DATE] at 1:15 PM, R6 was observed in bed sleeping on her back. The facility matrix revealed she had an unstageable pressure ulcer. Review of the Wound Summary for R6 revealed the following: 1. Date identified: [DATE], Right heel, unstageable ulcer, right medial heel: 1 cm x 0.5 cm x eschar scant serious drainage treatment in place. On [DATE], it measured 1.8cm x 1.5 cm. 2. Date identified: [DATE], Coccyx, right medial coccyx (no initial measurements). On [DATE] it measured 0.3 cm x 0.3 cm. 3. Date identified: [DATE], Right big toe, tipoff right great toe: 0.5 cm x 0.5 cm x eschar. On [DATE], it measured 0.5 cm x 0.5 cm. 4. Date identified [DATE]: Coccyx, stage II pressure ulcer: 1.75 cm x 0.5 cm x 0.2 cm. On [DATE], it measured 2.4 cm x 1.5 cm. 5. During an observation on [DATE] at 3:12 PM, R6 was observed sleeping in her bed on her back in the same position as the last observation. 6. During an observation on [DATE] at 4:24 PM, R6 was observed sleeping in her bed on her back in the same position as the last observation. Review of a Nursing Progress noted dated [DATE] for R6 revealed: coccyx DTI (deep tissue injury) wound care provided, no drainage noted. wound bed 100% granulation healing appropriately. no concerns for infection at this time. recommend continuation of current plan of treatment. Review of the Practitioner Progress notes for R6 between [DATE] to [DATE] revealed no Practitioner oversight or acknowledgement of R6's wounds. Review of the Hospice IDG (Interdisciplinary Group) Meeting notes for R6 for the certification period of [DATE] to [DATE] revealed orders with an effective date of [DATE] for the resident's coccyx wound and another order with an effective date of [DATE] for the right heel. Both orders do not reflect the orders at the facility and no other documentation to indicate hospice is aware of the orders for wound care at the facility or that the facility contacted hospice for different/new orders. Hospice orders are as follows: 1. Coccyx- wash with soap and water, pat dry, apply barrier cream, apply mepliex (sic) (border foam dressing) dressing, change q3 (every 3) days and prn (as needed) if soiled or remove, effective [DATE]. (This does not indicate there are two coccyx wounds as the facility has identified). 2. Right big toe- clean with soap and water and pat dry, apply skin prep and leave open to air, complete daily, effective [DATE]. 3. Right heel, unstageable- clean with Dakin's (antiseptic solution) cover with hydrofera blue (a foam dressing with antibacterial properties and drainage absorption), cover with bordered dressing, facility nurse to change every other day and prn, effective [DATE]. Review of a Nursing Progress note dated [DATE] for R6 revealed: re-opened stage 2 pressure ulcer on coccyx discovered. irregular boarders. non blanching region measuring 3cm x2.5cm. blister intact and present on left side of coccyx measuring 1.5cm x1cm. reported findings to hospice provider, in house provider . notified. New treatment orders to be put in place. Review of the May, June, and [DATE] MAR for R6 revealed a new order dated [DATE] for a stage 2 pressure ulcer to coccyx region: 1. cleanse with NS or wound cleansing spray and clean 4x4 gauze 2. apply skin prep to intact peri wound and allow to dry 3. apply comfort foam dressing 4x4 over coccyx region. 4. nursing staff to change every other day and PRN. No dressing changes documented between [DATE] and [DATE]. The dressing is documented as not done on [DATE] stating the dressing was intact and the resident was screaming in a lot of pain. Another treatment was not documented as done on [DATE] and [DATE] with no supporting documentation. This does not match hospice orders and does not indicate it addresses both coccyx wounds and their exact locations. Review of the [DATE] MAR for R6 revealed a new order dated [DATE] and discontinued on [DATE] for un-stageable pressure injury right heel once a day on Tuesdays and Saturdays: 1. cleanse with normal saline and clean gauze 2. apply skin prep to adjacent intact skin and allow to dry 3. nursing to change twice weekly and PRN, discontinue order when resolved. No dressing documented as done on [DATE] with a comment stating it was completed by off going nurse.' Review of the [DATE] MAR for R6 revealed a new order dated [DATE] and discontinued on [DATE] for an unstageable pressure injury right heel once a day on Tuesdays and Saturdays: 1. cleanse with normal saline and clean gauze 2. apply skin prep to adjacent intact skin and allow to dry 3. apply comfort foam dressing 4. nursing to change twice weekly and PRN, discontinue order when resolved. Review of a Shower Sheet dated [DATE] for R6 revealed the Hospice Aide documented R6's right heel was wrapped with gauze. Review of a Pressure Ulcer/Injury Care Plan initiated on [DATE] for R6 revealed no new interventions since [DATE]. Review of an Activities of Daily Living (ADL) Care Plan initiated on [DATE] for R6 revealed she requires the assistance of 2 staff for bed mobility. Review of the June [DATE] for R6 revealed an order for a stage 2 pressure ulcer dressing change started on [DATE] to be done every other day. The dressing change was not done on [DATE]. No supporting documentation in the medical record why it was not done. In an interview on [DATE] at 8:09 AM, the DON reported if it's not documented, then it's not done. The DON verified she could not find documentation from the practitioners that R6's care was overseen by a practitioner. The DON expected care plan interventions to be updated and implemented. The DON acknowledged R6's care plan did not indicate she needed a repositioning schedule and reported if a resident is not mobile (like R6), she reported repositioning goes hand in hand with a resident who is not mobile. It is expected that even if it were not on the care plan, she would expect the CNAs to reposition every 2 hours. The DON reported she expects staff to notify hospice as well as the physicians of any changes in condition for R6. When asked about the hospice wound orders from the Hospice IDG notes for R6, the DON reported the facility physicians are to order wound care dressings and is not sure why the hospice information did not match the facility's and reported they should have communicated more effectively. Resident #9 (R9) Review of a Face Sheet revealed R9 originally admitted to the facility on [DATE]. Review of a Wound Summary for R9 revealed as follows:-Identified on [DATE]- right buttock pressure ulcer: measured 1 cm x 0.5 cm x 0.2 cm, on [DATE] (the most recent documentation) it measured 1.6 x 2 cm. No depth documented. -Identified on [DATE]- stage I on mid thoracic back: measured 4 cm x 3.5 cm, on [DATE] it measured 2.5 cm x 3 cm. No depth documented. - Identified on [DATE]- left buttock pressure ulcer. No measurements. Review of a Skin Body Assessment for R9 dated [DATE] revealed there were areas of skin impairment: bilateral buttock wound- treatment in place . lower lumbar pressure- treatment in place. No measurements. Review of a Skin Body Assessment for R9 dated [DATE] revealed: areas on bottom treatments in place. No measurements. Review of the June MAR for R9 revealed orders started on [DATE], once a day on Monday, Wednesday, and Friday, and discontinued on [DATE] for: Left and right side upper buttock wounds: 1. cleanse with normal saline and clean gauze2. 2. apply skin prep and allow to dry to intact skin 3. apply medihoney paste to wound bed 4. apply coccyx/ buttock optifoam over region 5. nursing to change three times weekly and PRNThe MAR revealed on [DATE] the dressing change was documented as not done done on 3rd. Resident didn't want done again. The MAR revealed on 6/21 it is documented as not done given night previous. No documentation to indicate this was done. Review of the June MAR for R9 revealed orders that started on [DATE], once a day on Fridays for: Lower lumbar pressure injury: 1. Cleanse with N/S-Pat dry 2. Apply skin prep to area 3. Cover with comfort foam. 4. nursing to change twice weekly and PRN DC (sic) Review of the Pressure Ulcer Care Plan for R9 revealed it was initiated on [DATE] for a pressure ulcer to buttock and lumbar region. This was initiated at least 30 days after the first pressure ulcer was identified. Review of a Nursing Progress note dated [DATE] for R9 revealed: wound cares provided to resident: R (right) buttock/ Coccyx region ulcer measurements 2cm x 2cmx 0.3cm wound bed compromised of 100% slough moderate amount of serosanguinous drainage present no concerns for infection noted. no odor present at this time. Mid thoracic back (middle of back), stage 1 pressure ulcer noted skin intact red non blanching 2.8cm x 3cm no drainage. Review of the EMR for R9 revealed there was no physician oversight of wound/assessment. In an interview on [DATE] at 8:09 AM, the DON reported skin assessments are to be done weekly to include all pertinent assessment information. The DON stated R9's lumbar wound was getting smaller, and his coccyx was a bit bigger. The DON was not certain of the cause of the pressure ulcers and verified R9 required two staff for repositioning. Even though it was not on the task list for the CNAs to reposition R9 every 2 hours, the standard of care was to do that.In an interview on [DATE] at 10:13 AM, the Nursing Home Administrator (NHA) reported the facility had identified areas needed for improvement and skin assessments and wound care was one of them. The NHA stated the facility had recognized it for a while but had not put a plan together yet. The NHA did acknowledge they needed to have physician oversight of resident care especially now that the contracted wound care specialists no longer came to the facility. Review of a policy titled Physician Services last reviewed 1/2025 revealed: The Administrator shall be responsible for assuring or promptly arranging for continuing medical care under the direction of a licensed physician. Arrangement of services from additional Ancillary services will also be arranged based on resident needs, including but not limited to Dentists, Podiatry, Audiology, and Vision Services.Primary Care Physician Procedure:1. A physician approves in writing the resident's admission2. Each resident is under the care of a qualified physician.3. The Physician should:a. See the resident within 30 days of initial admission to the facility.b. The resident must be seen at least once every 30 calendar days for the first 90calendar days after admission and at least every 60 days after that by a physician orphysician delegate as appropriate by State law.c. Review the resident's total care program, including medications and treatments ateach visit.d. Date, write, and sign a progress note for each visit. Review of a Standards of Nursing Practices policy last reviewed 1/2025 revealed: Responsibility with Medications and Physicians Orders1. The licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in achieve Matrix, on the MAR, TAR, ordering the medication from pharmacy, communicating order specifics to appropriate departments, i.e. dietary, therapy, etc. while a resident is determined to be receiving skilled services. Documentation when providing skilled level of care2. Monitoring of the residents' progress when skilled services are provided is essential to evaluate the ongoing benefits as well as need to make changes in the residents' plan of care. It is important to monitor the effectiveness of treatments, medications or rehabilitation services provided. Resident vital signs (temperature, pulse, respirations, blood pressure and pulse oximetry) will be required daily as a minimum nurses' responsibility to document a more detailed assessment when particular issues arise for a resident. Documentation should contribute to the identification and communication of the residents' problems, needs and strengths, providing a tracking of their condition on an on-going basis, recording residents' response to services provided is a matter of good clinical practice and is an expectation of trained and licensed health care professionals.Physical assessment and change of condition:3. Residents with changes in condition will be notified to the Director of Nursing or Clinical Leader to review the residents plan of care to ensure that appropriate care and services are being delivered until the condition is resolved. Residents with change in condition will be communicated during A.M. Clinical Review. Monitoring a change in condition requires the licensed nurse to include an entry in the progress notes. Communications to the physician will require a completion of a SBAR tool in the resident's medical record. The monitoring a resident's condition may have multiple entries in the residents' medical record that include progress notes, observations, and assessment tools.

This citation pertains to intake MI00- 4 Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview, and record review the facility failed to prevent the elopement of 1 of 3 residents reviewed for elopement (Resident #102) from a total of 3 sampled residents, resulting in an Immediate Jeopardy when (Resident #102) who had been assessed as an elopement risk and was observed attempting to exit the facility, eloped from the facility, unbeknownst to staff, on 06/10/22 at 7:00 PM and was brought back to the facility when a visitor notified facility staff and made them aware that the resident had eloped. This deficient practice placed Resident #102 and 3 other residents who were assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. Findings: Resident #102 (R102) was a [AGE] year old man admitted to the facility on [DATE] with diagnoses including: [CONDITION(S)], cognitive communication deficit, unsteadiness on feet, anxiety disorder, and history of a stroke due to an embolism (blot clot) of the left cerebellar artery. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #102 was severely cognitively impaired and ambulated independently. Review of an elopement risk assessment dated [DATE] indicated R102 was at risk for elopement. Review of a Care Plan for R102 indicated he was at risk for elopement, and initiated on 05/31/22, due to cognitive impairment and being observed by staff to push on doors. Review of a facility Incident Report dated 06/10/22 indicated R102 was noted missing at 7:05 PM by a visitor who alerted staff that R102 was seen across the street from the facility. Staff immediately returned the resident to the facility. The Nursing Home Administrator (NHA) was informed on 06/23/22 at 11:00 AM that Immediate Jeopardy (IJ) had been identified at F689 starting on 06/10/22 at 7:00 PM for the facility's failing to prevent the elopement of 1 resident (R102) who was a known elopement risk and who had been observed by staff attempting to push open doors to exit the facility, and still, unbeknownst to staff, eloped from the facility. This deficient practice has the potential to affect all 4 residents who are assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. On 06/23/22 the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: -On 06/10/22 at 7:05 PM, R102 was placed under constant staff observation (1:1). -On 06/10/22 the elopement book was reviewed and updated. -On 06/10/22 at 8:00 PM, the Maintenance Director was on-site and assessed exterior alarm systems to ensure all doors were working properly and were noted to be functioning appropriately. Two areas of possible concern were noted in the kitchen. -On 06/11/22 the NHA began education staff on elopement policy and procedure. -On 06/11/22 the company responsible for the door alarm systems was contacted and reviewed the alarm system to ensure all doors were working properly and recommended and provided for an additional coded alarm to be placed on the exterior kitchen door. -On 06/11/22 the facility contacted a locksmith to add an additional lock on the kitchen doors to prevent access to the kitchen area. On 06/23/22 this surveyor reviewed documentation, conducted interviews, and made observations to verify that the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency on 06/23/22 that the immediacy was removed on 06/11/22.

Based on interview and record review, the facility failed to immediately initiate CPR (cardiopulmonary resuscitation) for one pulseless resident (Resident #129) and failed to verify a code status and then initiate CPR for another pulseless resident (Resident #336), resulting in an immediate jeopardy when beginning on [DATE], the facility failed to initiate CPR for 2 residents who were found without a pulse and who were documented to be full code status. This deficient practice led to the death of 2 residents and placed all residents who were full code status at risk for not receiving CPR, if needed to sustain life. Findings: Resident #129 (R129) Review of a facility Face Sheet reflected R129 admitted to the facility on [DATE]. The Face Sheet specified in the section pertaining to Advanced Directives that R129 was a Full Code. Review of the entire Care Plan report did not reflect that R129's Advanced Directive and code status had been addressed in areas of focus. Review of a General Order created on [DATE] and signed by the physician on [DATE] reflected R129 was a Full Code/Give CPR. Review of Resident Progress Notes, documented by previous Director of Nursing #1 (DON1) R, dated [DATE] at 10:30 a.m. reflected 0808 (8:08 AM) [R129] was taken into the dining room in wheelchair. 0815 (8:15 AM) Staff noted resident's head was down with chin resting on chest. Nurse was notified. 0818 (8:18 AM, three minutes later) No pulse detected, staff took resident to her room and transferred her to bed. 0820 (8:20 AM) DON (Director of Nursing) arrived and was made aware of situation, called code. 0823 (8:23 AM six minutes after being discovered pulseless, eight minutes after being found unresponsive) DON initiated CPR with charge nurse assisting. 911 was called. 0835 (8:35 AM) EMS (Emergency Medical Services) arrived and took over code. 0850 (8:50 AM) EMS canceled code, pronounced death. 0855 (8:55 AM) DON called spouse to notify. 0900 (9:00 AM) DON notified Physician. Review of a Resident Progress Note, documented by Registered Nurse (RN) Q, dated [DATE] at 3:42 PM reflected, At approximately 0815 the staff notified this nurse that the resident (R129) was in the dining area not responding when they went to put her breakfast tray down. This nurse went to the resident and noticed that her eyes were wide open and fixated straight ahead, head was slumped down, face appeared bluish in color, mouth opened slightly with no sound coming from it. She would not respond to her name. She was wheeled out of the dining room and at approximately 0818 this nurse did not detect a pulse. Pulse ox was placed on finger and no oxygen rate was detected and no pulse rate detected. Staff took resident to her room and transferred her to bed. At approximately 0820 the DON arrived and was notified of the situation as the code was being called as the placed her in her bed. At approximately 0823 the charge nurse and the DON started CPR and 911 was notified. At approximately 0835 the EMS team cam and began to take over CPR. At 0850 the EMS team called off the code and at that time they pronounced her death. The DON notified family and physician. During a telephone interview on [DATE] at 10:20 AM, DON1 R reported that she first became aware R129 was unresponsive after arriving to the facility and observed RN Q trying to call the Medical Examiner (ME). According to DON1 R, RN Q appeared 'frantic' and told her she was calling the ME after having already spoken to the physician who advised her to do so because RN Q told the physician R129 was apparently deceased . DON1 R said she knew R129 was a Full Code and questioned why CPR had not been started and proceeded to initiate CPR for R129 who had by that time been transferred out of the dining room and into bed in her room. DON1 R said she thought they used the AED (Automatic External Defibrillator) but could not be sure. DON 1 R said she documented the timeline of events in a Resident Progress Note dated [DATE] at 10:30 AM based on what she was told and not entirely on what she had witnessed. During a telephone interview on [DATE] at 11:22 AM, RN Q reported that on [DATE], nurse aides told her R129 was not breathing. RN Q said she observed R129 in the dining room, apparently not breathing, her lips and face were blue, and she instructed the nurse aides to get vitals on R129 and bring her to her room for privacy. According to RN Q, R129 was literally stiff. RN Q explained that she had a hard time finding supplies and a pulse ox an when she was finally able to locate one, was unable to detect R129's oxygen saturation. RN Q said she did call the physician who instructed her to call the Medical Examiner (ME) because RN Q had reported R129 was already deceased . According to RN Q, Resident #129 had been sitting in the dining room from the time she started her shift at 6:30 AM on [DATE] until the nurse aides notified her of R129's condition at 8:15 AM. RN Q reported that she learned after the fact that R129 was not doing well but there was no documentation to explain what might have been going on prior to her death. RN Q said she did not know if R129 had choked and was unable to find her chart to verify R129's code status. Review of Resident Progress Notes for R129 from [DATE]-[DATE] did not reflect a progress note had been entered for R129 since [DATE]. Resident #336 (R336) Review of a Face Sheet revealed R336 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R336 admitted to the facility for short term rehabilitation services, with discharge plans to return to an assisted living setting. Review of a Brief Interview for Mental Status (BIMS), dated [DATE], reflected a score of 14 out of 15, which indicated that R336 was cognitively intact. During an interview on [DATE] at 12:27 P.M., Registered Nurse (RN) N reported the following information related to the events, involving R336, that occurred in the early morning of [DATE]: RN N (a) had worked the entire shift the morning of [DATE], (b) was alerted by certified nurse aide (CNA) G that R336 was unresponsive, (c) checked R336 for signs of life and found none, (d) believed R336 was a DNR (do not resuscitate), did not verify R336's code status, and did not initiate CPR, (e) later contacted EMS (emergency medical services) to have R336 pronounced (dead) and to remove the body, and (f) stated, not checking the code status was the biggest mistake I have ever made. Review of a police report, dated [DATE], reflected the following information, related to R336's death and RN N, that occurred the morning of [DATE]: RN N (a) advised Police Officer (PO) X there was confusion about whether or not R336 had DNR orders, (b) advised PO X that initially it was believed that R336 did have DNR orders and as a result, no attempts to resuscitate R336 occurred, (c) further advised being unsure of the facilities procedural policies when handling a deceased patient and called 911 in an attempt to get the Medical Examiner to respond, and (d) stated the belief that DNR orders existed for R336 and the lack of understanding of facility protocols led to the nearly one hour delay in finding R336 without a pulse and calling [DATE]. Additional review of the police report, dated [DATE], reflected the following information related to R336's and the acting Director of Nursing: Acting Director of Nursing (ADON) O arrived on the scene and believed the confusion arose as paperwork indicating R336's code status was buried in the resident's chart .(ADON) O was advised by police that the Medical Examiner's office had some concerns about the manner in which this incident was handled. ADON O suggested that perhaps the facility will go to a system where a sticky note is attached to the residents' charts indicating if a resident is DNR or not. Review of Social Service Admission Assessment for R336, dated [DATE] and written by Social Services Director (SSD) C, reflected: Code Status per the (facility) Policy was reviewed and the resident wishes: CPR. Review of a Care Conference note, dated [DATE], reflected .Code status was discussed and to continue to reflect a full code. Review of the facility policy and procedure Cardiopulmonary Resuscitation, last reviewed ,d+[DATE], reflected the following: PURPOSE- The purpose of this policy and procedure is to ensure the facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with residents physician orders, such as DNR/Full Code, and the residents advance directives .DEFINITIONS-Full Code: CPR will be initiated and [DATE] will be called for ALS (advanced life support). Do Not Resuscitate (DNR): DNR is a legal order provided by physicians to not provide CPR and/or other measure to prolong life in the event of loss of cardiac functioning. Families and friends may not initiate a DNR order verbally. In the absence of a legally executed DNR order, CPR will be initiated and [DATE] called. On [DATE], the Administrator was verbally notified and received written notification of the immediate jeopardy that began on [DATE], due to the facility's failure to provide quality care following professional standards of practice for residents in cardiac arrest. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. Review the medical records of all residents to identify treatment options choices in the medical chart. Started [DATE]. 2. Review all medical charts for clear identifiers in charts to reflect code status. Started [DATE]. 3. Review the plans of care for residents to ensure code status preferences are noted in the care plan. Started [DATE]. 4. Educate all staff on process to identify code status. Started [DATE]. 5. Review code status with residents to ensure code status listed on face sheets is correct. Started [DATE]. 6. Educate Social Work and MDS nurse to ensure code status and treatment options are reviewed at each care conference and updated as necessary. Started [DATE]. 7. Code Blue drills to be implemented on a regular basis to identify and areas of needed training and on-going education. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

This citation pertains to intake # MI00- 3, #MI00- 7, MI00- 9 Based on interview and record review, the facility failed to assess, monitor, and prevent a pressure wound for one resident (Resident #29), resulting in an Immediate Jeopardy when beginning on 08/07/21, the facility failed to prevent a stage 4 pressure wound for Resident #29. This deficient practice led to Resident #29 being found unresponsive, in septic shock, requiring emergency medical intervention. Findings: Resident #29 (R29) Review of a Face Sheet revealed R29 was an [AGE] year-old male, originally admitted on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Assessment, completed 08/08/21, reflected skin comments: redness on peri-area (the perineum- the area between the anus and the scrotum) barrier cream applied. No documentation or comments related to any sacral skin concerns at admission were noted in the assessment. Review of a Baseline Care Plan and Skin Check for R29, dated 08/08/21, reflected no skin concerns in the sacral area and no interventions documented to reduce the risk of skin breakdown. Review of a Braden Scale (a tool used to predict the likelihood of a resident developing a pressure sore), dated 08/08/21, reflected R29 was at risk for developing a pressure ulcer. Review of a Resident Profile, date unknown, reflected R29 did not have any repositioning interventions in place. Review of lab reports for R29 revealed labs were drawn on 08/13/21, 08/17/21 and 08/20/21. WBC (white blood count), resulted 08/17/21, result=(16.9) High. (Normal Range-3.8 to 10.8). Review of a Braden Scale, dated 08/18/21, reflected R29 was at moderate risk for developing a pressure ulcer. Review of a Weekly Pressure Ulcer Progress Report, dated 08/31/21, reflected: (a) Date of Initial Discovery-08/29/21, (b) In House Acquired Pressure Ulcer, Buttocks, Stage 3, (c) measured 3cm (centimeters) x 3cm x 0.2cm, (d) turning schedule implemented-checked as non-applicable, (e) pressure relieving devices- checked yes for APM (alternating pressure mattress), (f) physician notified- 08/29/21,and (g) dietary notified-08/31/21. Review of an Initial Nutritional Assessment, written by Registered Dietician (RD) CC, due 08-07-21 and not completed until 09-02-21, reflected: Reason for Assessment- admission, Lab Values-no labs results from 08/13/21, 08/17/21, and 08/20/21 listed, Skin: Describe as Necessary- this section left blank, and Assessment Summary- no mention of any skin concerns that were identified on 08/29/21, and that had been documented as reported to dietary on 08/31/21. Review of a Care Plan reflected the following interventions and dates the interventions were implemented for R29's sacral pressure ulcer: (a) reposition every 2 hours as tolerated when in bed, implemented 09/21/21, (b) up in wheelchair for meals and therapy only, implemented 09/21/21, (c) pressure relieving mattress (APM), implemented 09/10/21, and (d) wounds to be measured weekly, implemented 09/10/21. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Weekly Pressure Ulcer Progress Report, dated 09/10/21, reflected: (a) Date of Initial Discovery-08/29/21, (b) In House Acquired Pressure Ulcer, Buttocks, Stage 3, (c) measured 3cm x 3cm x 0.2cm, (d) turning schedule implemented-checked as non-applicable, and (e) pressure relieving devices- checked yes for APM. Review of a signed Physician Order, dated 09/10/21, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was voided on 09/19/21. No documentation could be located in the medical record that discussed the referral to the wound clinic, if it had been scheduled, or why the order had been voided. Review of a Weekly Pressure Ulcer Progress Report, dated 09/17/21, reflected: (a) Date of Initial Discovery-08/29/21, (b) In House Acquired Pressure Ulcer, Buttocks, Stage 3, (c) measured 4cm x 4cm x 1cm, (d) turning schedule implemented-turn every 2 hours as allows, and (e) Wound Progress- coccyx deteriorated. Review of a signed Physician Order, dated 09/19/21, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R29's electronic medical record reflected that a Weekly Ulcer Progress Report, due on 09/24/21, had not been completed. During an interview on 10/27/21 at 9:35 A.M., Vice President of Clinical Operations (VPCO) Z indicated that (1) a Weekly Ulcer Progress Report for R29 could not be located in the record after 09/17/21, (2) a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Home to Hospital Transfer Form for R29, dated 09/29/21, reflected: Reason for Transfer-non responsive. Review of Nursing Progress Notes for R29 revealed the last nursing progress note that documented the alertness and overall functioning of R29 was dated 09/28/21 at 6:56 A.M. Review of hospital emergency department physician notes, dated 09/29/21, reflected the following information about R29, (a) temperature 102, blood pressure 94/80, respirations 42, and pulse 144, (b) had an extensive sacral decubitus ulceration that had eroded down through the soft tissue to the sacrum, some necrotic tissue noted, (photograph available) (c) appeared septic likely from the decubitus ulcer, (d) family was aware that (R29) had a severe infection and would likely pass away quite quickly without further intervention, and (e) plan was initially to get a plastic surgery consult for surgical intervention for the decubitus ulcer and wound and to admit patient through Internal Medicine. On 10/27/21, the Administrator was verbally notified and received written notification of the immediate jeopardy that that was identified on 10/27/21 and began on 08/07/21, due to the facility's failure to provide quality care following professional standards of practice to identify, assess, monitor, and prevent a pressure ulcer. A written plan for removal for the immediate jeopardy was received on 10/27/21 and the following was verified on 10/27/21: 1. Beginning on 10/27 - Educate all nursing staff on weekly skin assessments, skin inspection with cares, weekly wound log/measurements, completing observations, processing treatment orders. 2. Beginning on 10/27 - Skin sweep of all residents in facility to identify any skin concerns not documented/identified. 3. Beginning on 10/27 - Check all orders to verify for weekly skin observations. 4. Beginning on 10/27 - Check events/observations against skin sweep findings. 5. Beginning on 10/27 - Check resident with skin conditions or PI have treatment order and observation completed weekly. 6.Beginning on 10/27 - Assure preventive interventions are in place for healing and prevention. Although the immediate jeopardy was removed on 10/27/21, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on observations, interviews, and record reviews, the facility failed to monitor and assess for changes in condition for 2 residents (Resident #8 and Resident #26), resulting in an Immediate Jeopardy beginning on 9/17/21 when Resident #26 was hospitalized , and no assessments or physician notifications were documented; and on 10/26/21 Resident #8 was sent to the hospital after staff failed to competently assess, identify and report a change in condition to the physician. This deficient practice resulted in potentially avoidable hospitalization s and has the high likelihood to cause serious harm, injury and death for any residents who may experience a change in condition. Findings include: Resident #26 (R26) Review of a Face Sheet revealed R26 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed R26 had a BIMS indicating she is cognitively intact and required extensive assistance to totally dependence on staff for all ADL's. R26 Review of a progress note dated 9/16/21 for R26 revealed a new order for a foot dressing to be changed daily with a [MEDICATION(S)] blue wrap with gauze in a referral to one clinic is needed per nurse practitioner. this was not transcribed on the eMAR/TAR (elctronic medication administration record/electronic treatment administration record). Review of a nurse practitioners progress note dated 9/16/21 for R26 revealed: Patient seen on 9/12 for concerns regarding large wound of the foot which had been present for > than 2 weeks. Wound was noted to have significant amount of eschar with surrounding skin boggy, pink. Orders written for small amount of santal to be applied in referral to wound clinic . (R26) also has an abdominal wound which has been ongoing since prior to most recent hospitalization , anticipates (R26) will address this at wound clinic visit as well. Plan: cleanse wound daily. Apply [MEDICATION(S)] blue, cover with nonadherent gauze and wrap with kerlix. Staff to check on wound clinic appointment, schedule ASAP for an evaluation . Monitor closely, reevaluate PRN (as needed). No documentation located in the record that this order was transcribed and done. This document has a faxed date at the top of the document indicating it was faxed to the facility on [DATE]. Review of hospital records with an admitted [DATE] and a discharge date of [DATE] for R26 revealed she admitted with generalized weakness with new moderate to severe hypervolemic [CONDITION(S)], shortness of breath with acute [CONDITION(S)]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharged the resident with a list of medications and several wound care instructions. Review of the EMR (Electronical Medical Records) for R26 revealed no documentation, assessments or physician notifications prior to hospitalization on [DATE] to reflect the multiple wounds, weights, vital signs, shortness of breath, skin conditions, and screening for infections or COVID. During an observation on initial tour of the facility on 10/19/21, R26 was heading out to the hospital due to increased shortness of breath. Review of R26 list of weights revealed she had gained 41 pounds since her original admission to the facility from 7/10/21 to 10/20/21 and no documentation could be located indicating the physician was notified. The weights were not done daily as ordered. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/28/21, orders noted for a 2 liter fluid restriction for 24 hours, [MEDICATION(S)] (diuretic) 1 mg (milligram) ordered once daily (hospital recommended for 2 mg for 1 week post hospitalization on [DATE]), Several dressing changes ordered for her wounds noted, and the right foot dressing is not to be removed until her follow up visit with podiatry. There was no documentation indicating R26 went to a podiatrist the following week. The right foot dressing change orders conflicted with another order to clean the affected area of the right foot and apply Santyl ([MEDICATION(S)] [CONDITION(S)] histo.) ointment and then cover with a non-adherent dressing and Kerlix. [MEDICATION(S)] re ordered on 10/9/21 with a trough lab order to be done on 10/12/21, no trough lab results noted or indicated it was done. No orders for the Foley catheter maintenance/patency. Weekly skin assessments and vital signs ordered every shift and not done. No documentation indicating the physician was notified of any changes of treatments, medications, specialty physician visits, or changes in conditions as ordered. Review of the September and October 2021 Medication Administration and Treatment Administration Records (MARS/TARS) revealed R26 had several orders for multiple dressing changes, and some were not clear as to what wounds the dressing were for and R26 did not receive dressing changes as ordered. The resident was missing several blood sugar checks for September and October 2021, and [MEDICATION(S)] was not increased to 2 milligrams post hospitalization on [DATE]. Intravenous [MEDICATION(S)] was not started, as ordered post hospitalization , until 9/29/21 because it was not available. No documentation indicating the physician was notified when dressings were not done, blood sugars not completed, medications were missed, and post hospital recommendations/records were reviewed. Review of an Incident/Accident report dated 8/26/21 for R26 revealed she had a witnessed fall in the shower room. No follow up neurological assessments completed per policy. Review of the electronic medical records revealed no documentation for our R26's Fluid intake, daily weights, physical assessments, weekly wound/skin assessments, changes in conditions, and post fall assessments. No documentation could be located in the record indicating when/if appointments were made. Review of the paper chart for R26 revealed no assessments, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Nursing Home Administrator (NHA) T later provided physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a skin body assessment dated [DATE] revealed R26 had a large mass noted to her left side and was sent to the emergency room for an evaluation. No documentation or assessment describing the large mass is noted or any other health concerns. In an interview on 10/19/21 at 2:18 p.m., Licensed Practical Nurse (LPN) H reported R26 went to the hospital because there was a new mass that appeared overnight near her [CONDITION(S)], had blood in the urine and was lethargic, overall just not herself. Review of the Electronic Medical Records (EMR) for R26 revealed no assessments, progress notes or documentation regarding R26 wound observed near her [CONDITION(S)], shortness of breath, blood in her Foley catheter, the resident being transported to the hospital, or that the physician was notified. Review of emergency room documentation dated 10/19/21, reflected R26 complained of increased shortness of breath and blood in her Foley catheter. The facility told the hospital the residents oxygen saturation's were in the mid to low 90s on 2 liters nasal cannula. The hospital recommended increasing the resident's diuretic called [MEDICATION(S)] to two milligrams a day for one week, monitor her weight daily, and follow up with a primary care physician. In an interview on 10/20/21 at 8:19 A.M., R26 was in her room in bed and reported going to the hospital yesterday due to shortness of breath. The emergency room gave her different water pills and increased the dosage. R26 stated the blood in her urine resolved and there was nothing out of the ordinary wrong with the [CONDITION(S)] or aware of any mass near the [CONDITION(S)]. R26 was to go to the podiatrist yesterday but missed the appointment because of the trip to the hospital. R26 reported her foot was infected after falling in the shower. The foot had a huge blood blister and was not treated. R26 found out at the hospital she had an infected fracture in her foot ([CONDITION(S)]) and had to have her toe amputated and a bone in the foot removed. R26 reported after the fall she kept getting weaker and weaker, but the staff would not listen. In an interview on 10/20/21 at 8:53 a.m., LPN H reported she did not have any dressing change orders for R26 since she returned from the hospital and was to get the surveyor if she did do any dressing changes on this resident and never did. In an interview on 10/21/21 at 9:05 A.M., Vice President of Clinical Operations (VP) Z reported R26 was short of breath this morning but has anxiety in [CONDITION(S)]. VP Z reported they are having a hard time getting weights for the resident that are accurate and need to reeducate the staff on how to get accurate weights. The nurses were also not reviewing the weights that were reported. In an interview on 10/21/21 at 12:06 p.m., Nurse Practitioner (NP) EE reported using another computer system off site to document the visits and then faxes the documents to the facility. NP EE acknowledged all R26's physician and practitioner notes were not in the chart. NP EE reported questioning the accuracy of R26's weights and other factors that can affect the accuracy of her weights. NP EE was unaware of R26 complaining of any shortness of breath and said other practitioners visit the resident as well who may have addressed any concerns that she is unaware of. In an interview on 10/26/21 at 10:19 a.m., the Director of Nursing (DON) FF reported skin assessments are to be done once a week. She expects the CNAs to inform the nurse if anything different is noticed on a resident. when questioned about R26's weights, DON FF reported the weight scales are not appropriate for this resident and are looking into getting a bed that has a scale on it. The DON acknowledged the order was for calling the physician with a 2 pound weight difference had not been completed. Resident #8 (R8) Review of a Face Sheet revealed R8 was admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed R8 had a Brief Interview for Mental Status (BIMS) indicating R8 was moderately cognitively intact and required limited assistance of one staff for Activities of Daily Living (ADL) care. R8 During an interview on 10/21/21 at approximately 8:00 A.M., facility staff reported R8 had a fever and cold symptoms, and was in COVID observation/isolation pending PCR (polymerase chain reaction) COVID test results after testing negative for a COVID rapid test. The resident was on a 1:1 observation while in isolation with the door closed. Review of a Nursing Progress Note dated 10/21/21 at 5:11 P.M. for R8 revealed the facility notified his son they were ordering a chest x-ray since his COVID test was negative. Review of a Nursing Progress Note dated 10/22/21 at 3:08 a.m. for R8 revealed they were awaiting the chest x-ray results. R8 had a temperature of 102 at 10 p.m recheck of temp and oxygen level showed a decrease in temp to 99.2 and a O2 (oxygen) level of 78% (normal is 92-100%) bumped oxygen up to 4L due to resident sleeping with his mouth open, when mouth is closed resident is at 91-92%, around 3 am a gurgled rattle noted with exhaling. No documentation noting the physician was notified. Review of a Nursing Progress Note dated 10/22/21 for R8 revealed the health department was notified of a negative COVID test and chest x-ray and instructed to monitor the resident for high fever. The family and physician were documented as notified and no instructions from the physician or what physician was notified. No progress notes or assessments done on R8 after 10/22/21 at 9:12 a.m. until 10/26/21 at 8:18 a.m. and the facility was unable to locate or provide a copy of the chest x-ray results. Review of a Nursing Progress Note dated 10/26/21 at 8:18 a.m. revealed R8 had diminished lung sounds and labored breathing. His oxygen saturations (O2) were at 90-90%/O2 @ 3L/NC (3 liters nasal canula). No documentation indicating the physician was notified. During an observation on 10/26/21 at 10:00 a.m., R8 was in bed with eyes closed and receiving 2 liters (L) oxygen via nasal cannula. R8 was no longer on 1:1 observation or in isolation and his COVID test was negative. R8 was mouth breathing with irregular breathing noted. R8 did not wake up or respond to verbal cues. At 11:43 a.m. R8 was prepped to be sent out to the hospital. Review of a Nursing Progress Note dated 10/26/21 at 11:14 a.m. revealed the Nurse Practitioner (NP) saw R8 and the O2 saturations were at 83% on 3L nasal canula with labored breathing and complaints of abdominal pain. The family requested R8 be sent out to the hospital for an evaluation. During an interview on 10/26/21 at approximately 1:10 p.m. Licensed Practical Nurse (LPN) U reported she came in around 8:00 a.m. this day and was told in report R8's oxygen saturations were decreasing, and he was declining. When she took care of him the day before he was just not himself and more lethargic. LPN U reported the NP saw R8 this morning and his oxygen saturations were at 70% on 3L NC. LPN U reported R8's son was notified and asked about the laboratory results, but the NP could not find the lab results he had done a couple weeks ago and had to look all over for them. When queried about Certified Nursing Assistants (CNA's) notifying nurses when they notice a change in the residents, LPN U reported the CNAs won't always approach the nurses because of the attitude and backlash from the nurses when they do report concerns and reported the Administration is aware of this problem. During an interview on 10/26/21 at 1:50 p.m., LPN H reported R8's oxygen saturation's decreased into the low 90s this morning and she increased his oxygen to three liters LPN H reported her shift started today at 6:00 a.m. and was told in report R8 had oxygen saturation's that decreased into the 70s that night. LPN H reported she did not assess R8 this morning. LPN H reported she wanted LPN U to take over care of R8 when she came in to work at 8:00 a.m. so she could get her medication pass done. LPN U was there to help the facility during the survey and was an extra set of hands. LPN H reported she took R8's medications to him between 9:30 and 9:45 a.m. and noticed his breathing was a little more labored and would not wake up to take his medications. LPN H reported she did not do an assessment at that time or notify the physician. Review of hospital records dated 10/26/21 for R8 revealed the family told the hospital they think R8 has been getting sick over the last five days but not aware of the specifics. R8 was diagnosed with respiratory failure and aspiration pneumonia and is expected to stay in the hospital greater than two nights. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated 6/29/04). The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). In Legal and Ethical Issues in Nursing by G. [NAME] (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete. (pg. 171) It states that A [NAME] can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient. (pg. 171) A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. ([NAME] & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article.) The professional standard of quality for performing complete respiratory assessments is to assess respiration rate, rhythm, and depth, increased, decreased, or irregular respirations, lung sounds, oxygen saturation level, hypoxemia (low oxygen saturation level), labored or painful breathing, using accessory/chest muscles to breathe, the color of skin, nail beds, lips or mouth, restlessness, irritability, confusion, reduced level of consciousness, color and consistency of sputum, and the assessment of labs. (Mosby Sixth Edition Medical-Surgical Nursing Concepts and Clinical Practice, [NAME], [NAME], [NAME]) Review of a Director of Nursing (DON) job description revealed: Is responsible in accountable for the overall management of the nursing department. Coordinates with other disciplines to provide quality care to all residents. Supports in practice is the philosophy, policies, and objectives of the company. Monitors the outcome of nursing services activity by coordinating facility committees an using the quality assurance program to implement efficient and effective nursing interventions. Ensures that the highest degree of quality care is maintained at all times. Performs all duties using independent judgment and discretion to implement regulations and policy. Review of a Registered Nurse (RN)/Licensed Practical Nurse (LPN) supervisor job description revealed: General Purpose: responsible for the independent supervision of the delivery of care to a group of residents on a nursing unit with guidance from the Director of Nursing Services. assess resident needs, provides nursing care, evaluates nursing care, administers medications, and completes treatments. directly supervises the nursing assistants and the delivery of nursing care. Interviews, councils and evaluates the performance of nursing assistance. Review of a Nursing Assistant job description revealed: Under the supervision and direct RN/LPN Supervisor, to provide non licensed nursing care and services to residents in a long term care facility maintains a health physical and psychosocial environment for the residents. Duties: assist residents with activities of daily living . Report skin problems and any other changes in resident condition to the RN/LPN Supervisor . Read and follow daily care plans, in document care provided as required. Work with other members of the resident care team to provide quality resident care. On 10/29/21 at 2:00 PM, the administrator was verbally notified and received a written notification of the immediate jeopardy that was identified on 10/29/21 and began on 9/17/21, due to the facility's failure to monitor, assess and notified the physician for changes in conditions resulting in hospitalization s and the liklihood for serious harm, injury or death. A written plan for removal for the immediate jeopardy was received on 10/28/21 and the following was verified on 10/29/21: 1. On 10/28/21, began educating all nursing staff on assessment of residents with change of condition and notification to physician with change in condition in a timely manner. 2. Education to CNAs to include use of the Stop and Watch Tool began on 10/28/21. 3. Review of all residents in facility to identify any change in condition or significant change in weights beginning on 10/28/2021. 4. Review all residents with change in condition, assessment, physician notification or significant weight change to ensure timely notification to physician. Started 10/28/2021 5. Check resident with change in condition to ensure timely assessment and timely notification to the physician beginning on 10/28/2021 6. Staff competency audits in place for change in condition identification, assessment and reporting beginning 10/28/21. 7. Review of Change in Condition Policy completed 10/28/2021. Although the immediate jeopardy was removed on 10/28/21, the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on observation, interview and record review, the facility failed to ensure its Quality Assessment Process Improvement (QAPI) committee addressed known, self-identified deficiencies meaningfully and effectively, resulting in repeated failings related to the delivery of care and services at the facility that caused serious harm, serious injury and death and has the potential to impact all residents at the facility. Findings: Review of a facility policy QAPI Policy/Procedure last reviewed ,d+[DATE] reflected Each facility will ensure development of a plan that describes the process for conducting QAPI activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of their residents, through continuous attention to quality of care, quality of life, resident choice preferences and resident safety. The policy specified the facility QAPI process included elements related to Identifying and prioritizing quality deficiencies; Systemically analyzing underlying causes of systemic quality deficiencies; Developing and implementing corrective action or performance improvement activities; and Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed to meet set goals. Review of a facility policy QAPI Governance & Leadership last reviewed ,d+[DATE] reflected The facilities governing body is ultimately responsible for overseeing the QAPI committee. The facility Administrator had direct oversight of the facility's QAPI program with the responsibility for reporting to regional and corporate leaders of all functions of the QAPI committee. The Regional and Corporate Leadership will report directly to the governing body. The facility QAPI committee, will include the Medical Director, to collaborate to assure compliance with federal and state requirement, as well as continuous improvement in quality of care and customer satisfaction. Review of a document produced upon request for the date range [DATE]-[DATE] revealed a complete history of Nursing Home Administrators (NHA) and Directors of Nursing (DONs) who had been employed by the facility in the preceding year. The list reflected that ten (10) NHAs had been in place since [DATE] and 10 DONs held the role. The list of Director's of Nursing was not complete because one Director of Nursing was not named. According to the Regional Nursing Home Administrator (RNHA) T, she did not know who oversaw the nursing department from [DATE]-[DATE]. Review of a Terminated Employees report for the date range [DATE] to [DATE] reflected that over the course of one year, a total of 74 people of various disciplines (Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, housekeeping staff, laundry staff, dietary staff, administrative assistants) separated from the facility. Observations, interviews and records reviewed during the unannounced, on-site annual recertification survey and complaint investigation conducted from [DATE]-[DATE] the following was identified: (A) On [DATE], staff did not provide CPR in a timely manner to Resident #129, who was a full code due to lack of facility staff orientation and awareness of code status information. Resident #129 was pronounced dead on [DATE] at 8:50 AM. (B) On [DATE] Resident #336, who was a full code, was not given CPR due to staff being unaware of the resident's code status. Resident #336 was pronounced dead by EMS on [DATE] at 6:47 AM. Facility administrative staff were aware of both issues and failed to implement meaningful interventions to correct the deficient practice after Resident #129, who was a full code and was not provided with CPR in a timely fashion and died , followed by Resident #336 passing away from the same deficient practice 3 months later. On [DATE], the acting NHA reviewed the QAPI meeting documents for the previous year and was not able to locate evidence a review of Code Status and the prevision of CPR and related activities had been discussed. On [DATE] at 4:30 PM, the State Agency issued an IJ (Immediate Jeopardy) Template related to non-compliance at F-678, Cardio-pulmonary Resuscitation (CPR). C) The facility failed to prevent, monitor, and properly treat a stage IV pressure sore for Resident #29 (R29). On [DATE] R29 was admitted to the facility without any sacral skin concerns. The baseline care plan did not have any interventions to address a known risk for wound development. Documentation first identified a preventable sacral skin concern on [DATE] and a comprehensive wound assessment was not completed until ,d+[DATE] /21. The Admission Nutrition Assessment, due [DATE], was not completed until [DATE] and did not include any interventions for, nor discuss any sacral wound concerns. Care Plan interventions to monitor and treat a pressure wound were not implemented until [DATE] and not re-assessed and updated until ,d+[DATE] /21. A physician ordered referral to a wound clinic was not carried out. A wound care assessment was not completed for R29 after [DATE]. Hospital documentation and photo dated [DATE] reflected R29 arrived to the ED with a large sacral decubitus ulcer that included a photograph of a large decubitus ulcer with brown fully saturated dressings In the malodorous wound (that had tunneled to the sacrum) and a large area of probable Moisture Associated Skin Damage (MASD). On [DATE] at 12:30 PM, the State Agency issued an IJ Template related to non-compliance at F-686, Treatment/Services to Prevent/Heal Pressure Ulcers. D) Resident #26 has a history of [CONDITION(S)] and has had a weight gain of 41 pounds from [DATE] to [DATE]. The physician is to be notified of 2-pound weight change and was not notified. Resident #26 lacks documented assessments and was sent to the hospital on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the resident went back to the hospital with shortness of breath and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] E) Resident #8 has had trouble breathing and chest x-ray and COVID test ordered on [DATE]. No documentation indicating the resident was physically assessed from [DATE] to [DATE]. On [DATE], this surveyor saw the resident in bed at 10:00 a.m. with eyes closed and on 2 liters of oxygen via nasal cannula with some agonal breathing and did not respond to verbal stimuli. LPN H reported she learned in report that Resident #8's oxygen saturations decreased to the 70's the night before, however, LPN H did not assess Resident #8 because she was busy passing medications and was not physically assessed until 8:00 a.m. when LPN U arrived to the facility. At 11:43 a.m. resident was sent to the hospital where he was diagnosed of respiratory failure, aspiration pneumonia, and CHF. On [DATE] at 2:00 PM, the State Agency issued an IJ Template related to non-compliance at F-726, Competent Nursing Staff. During an interview on [DATE] at 11:45 AM, the acting Nursing Home Administrator (NHA) and Vice President of Clinical Operations (VPCO) Z reported that the facility is expected to hold monthly or more frequent Ad Hoc QAPI meetings. The acting NHA explained that she just started her role at the facility on [DATE] and had not participated in a QAPI meeting yet and did not plan to continue in her role as NHA at the facility after the conclusion of the current survey. VPCO Z reported that she was not aware of staffing difficulties at the facility because no calls pertaining to staffing reached her. During an interview on [DATE] at 3:00 PM, VPCO Z reported the facility had a procedure for evaluating residents who return to the hospital and said that facility administrative staff and QAPI committee were simply not doing it.

Based on observation, interview, and record review, the facility failed to provide meaningful interventions, root causes, and follow professional standards of practice for accidents and falls for 3 residents (Resident #8, Resident #16, and Resident #329), resulting in actual harm to Resident #8 and the potential for repeated falls with injuries to all residents at risk for falls. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 was admitted to the facility on [DATE] with pertinent diagnoses of dementia, fractured femur, and [CONDITION(S)]. Review of the Minimum Data Set (MDS) dated [DATE] revealed R8 had a Brief Interview for Mental Status (BIMS) indicating he was moderately cognitively intact and required limited assistance from one staff for Activities of Daily Living (ADL) care. Review of a Physician Progress Note dated 5/30/21 for R8 revealed the resident had a history of frequent falls. From previous falls he had a skull fracture, subarachnoid hemorrhage . (R8) was seen sitting in his wheelchair . hair is unkept . is unshaven. Review of an Incident Report dated 7/31/21 at 5:00 p.m. revealed R8 had an unwitnessed fall when the resident self-transferred to the bathroom and was found with pants around the ankles, on the floor. R8 sustained a contusion to the right side of the head. The facility's root cause/conclusion was: (R8) will exercise his right to self determination and self transfer. (R8) has dementia and confusion. The resident will attempt to complete independent surface to surface transfer without realizing when his movements exceed the functional capabilities. (R8) was assessed for injury timely. (R8) was relaxed. It is reasonable to conclude the dementia and the need to void enhanced this behavior and intervention were put into place. No allegations of abuse or neglect were made. (sic) No meaningful interventions noted and no statements from staff were obtained/provided. Review of a Nursing Progress Note dated 7/31/21 at 5:00 p.m. for R8 revealed the resident attempted to self transfer to the bathroom and fell and hit his head resulting in a very large gash to the right side of the head. Pressure was applied, 911 arrived, and the resident was sent out to the hospital. Review of hospital records dated 7/31/21 for R8 revealed, R8 had a painful large scalp laceration with a hematoma and required 13 staples to close it. Review of a Nursing Progress Note dated 8/1/21 for R8 revealed the resident returned to the facility from the hospital and now has 13 staples in his head. Review of an Incident Report dated 9/18/21 at 3:43 a.m. revealed R8 had an unwitnessed fall on 9/17/21 at 10:15 p.m. when Staff heard a thud, and observed (R8) on floor beside bed. R8 sustained a laceration to the bridge of the nose. Review of staff statements revealed R8 was not seen for at least 2 hours prior to the fall. Evaluation notes: (R8) will exercise the right to self determination and will self transfer. R8 will attempt to complete surface to surface transfer without realizing when his movements exceed his functional capabilities. He was assessed for injury timely. He was calm and relaxed. An intervention of body pillow on exit side of bed was put into place. No allegations of abuse or neglect were made, therefore this does not meet (State Agency) reporting criteria. Neurological assessments completed until 11:45 p.m. when R8 went to the hospital. Review of Nursing Progress Notes dated 9/17/21 for R8 revealed no documentation regarding the resident falling out of bed, the laceration to the bridge of the nose, no indication the physician was contacted or that R8 received first aid treatment. No documentation located in the record regarding when the resident left to go to the hospital or how R8 got there. Review of Hospital Records dated 9/18/21 for R8 revealed he fell at the nursing facility and had a laceration to the bridge of the nose, there was evidence of cervical spine tenderness from C3 - C7. R8 received 3 sutures for the laceration. Review of the Care Plan for R8 revealed on 1/28/21 a risk for falling care plan was initiated, and no interventions post fall on 7/31/21. A fall intervention was initiated on 9/20/21 to use a body pillow on exit side of bed when occupied. On 1/28/21 an intervention was initiated for of the resident requiring a one assist for toileting and transfers. Review of a Fall Policy last reviewed 7/2021 revealed: Purpose: (Facility) has established a standardized policy with guidelines that assigns responsibility and provides procedures for identifying residents at risk for falls, to systematically assess fall risk factors, providing guidelines for fall and repeat fall preventive interventions, outlines procedures for documentation and procedures for communication. this program includes 3 primary approaches to the management of falls in injuries. the second approach is through a systematic process of applying Root Cause Analysis (RCA) following a fall event. the goal is to understand the problem in sufficient depth two effectively eliminate the risk of possible future falls or injury. RCA is to use to analyze a single fall as well as to look at multiple falls so that patterns or trends can be identified, and changes can be made to systems, routines and residents plan of care Post Fall Event Investigation and Action Plan: The facility will utilize a post fall investigation process that utilizes a set of guides and tools to gather vital information. The nurse will complete a series of post fall assessments, interviews and investigative reports to gather information that will be used to determine contributing factors and root causes to the fall event. Documents include; Incident Report form, Post Fall Assessment & Initial Investigation, Staff Interviews (fall statements) form, Living Space Inspection form, Fall SBAR, Post Fall Assessment, skin Assessment (if skin injury has occurred), Neurological Checklist Tool (if indicated). Resident #16 Review of a Face Sheet revealed Resident #16 (R16) was an [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, cognitive communication deficit, muscle weakness, and unsteadiness on feet. During an observation on 10/19/21 at 12:12 P.M., R16 sat in a wheelchair next to the bed, the over bed table was pulled up to the resident, and the call light was wrapped around the right side bed rail near the head of the bed, out of reach of R16. R16 stated, should I stand up? During an observation on 10/26/21 at 10:07 A.M., Social Service Director (SSD) C pushed R16 in a wheelchair from outside room 8 to R16's room at the end of the hall. R16 had no footrests on the wheelchair at that time. During an interview on 10/26/21 at 10:27 A.M., Certified Nurse Aide (CNA) V stated that the standard of practice for pushing a resident in a wheelchair was to always use footrests for safety reasons. Resident #329 (R329) Review of a Resident Face Sheet reflected R329 admitted to the facility 5/23/2020 with diagnoses that included Covid-19, pneumonia, acute on chronic diastolic [CONDITION(S)], cognitive communication deficit, a urinary tract infection, non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity-bilateral lower extremities. Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] reflected R329 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 and was independent with locomotion on the unit where he lived. Review of a Care Plan initiated on 5/26/2020 reflected (R329) at risk for falling R/T (related to) weakness, restless leg syndrome, acute on chronic heart failure. The Goal of the care plan was for R329 to remain free from injury with approaches that included verbal reminders and environmental considerations for preventing falls including ensuring R329 was wearing properly fitting footwear and ensuring the floor is free of glare liquids or foreign objects. Review of an Event Report dated 10/9/2020 at 11:10 PM reflected R329 sustained injury after a witnessed fall in a shower room. According to the report, R329 was not wearing shoes, the floor was slippery and R329 slid off a shower chair sustaining a bruise to his left inner buttock and a skin tear to upper butt crack, left side of butt (sic). The description in the Event Report indicated Resident (R329) had liquid stools all day was shaking from being in the shower and sitting on the commode most of the day and was agitated. Interventions after the fall were described as follows: Had to place resident on 1:1 care and place him on bedside commode in hallway to monitor while he continued to have loose stools, due to replacing his chair and bed alarm finding it was not working either. Review of Resident Progress Notes dated 10/10/2020 at 2:06 AM reflected (R329) had diarrhea all of second shift and most of 3rd shift, finally petered out. The CNA on 3rd shift went down to get more towels and I was looking in on resident when was picking up a wash cloth he was trying to move and slid down, did not hit his head, though ended up with 2 skin tears on his bottom, a small one on his upper butt crack, put a durafoam on that one, and another open area on his left buttock. That I applied a padded 4 x 4 dressing on that one. Then he had a small bruise on the inner buttock. Incident report filled out.

Based on observation, interview, and record review, the facility failed to provide quality care based on professional standards and resident assessments in a consistent and timely manner for three residents (Resident #8, Resident #26 and Resident #329), resulting in the potential for, and actual harm, from avoidable declines in health status. Findings: Resident #8 (R8) Review of a Face Sheet revealed R8 was admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed R8 had a Brief Interview for Mental Status (BIMS) indicating he was moderately cognitively intact and required limited assistance of one staff for Activities of Daily Living (ADL) care. During an interview on 10/21/21 at approximately 8:00 a.m., the facility staff reported R8 had a fever and had cold symptoms and is in COVID observation/isolation pending PCR (polymerase chain reaction) COVID test results after testing negative for a COVID rapid test. The resident was on a 1:1 observation while in isolation with the door closed. Review of a Nursing Progress Note dated 10/21/21 at 5:11 p.m. for R8 revealed the facility notified his son they were ordering a chest x-ray since his COVID test was negative. Review of a Nursing Progress Note dated 10/22/21 at 3:08 a.m. for R8 revealed they were awaiting the chest x-ray results. R8 had a temperature of 102 at 10 p.m Recheck of temp and oxygen level showed a decrease in temp to 99.2 and a O2 (oxygen) level of 78% (normal is 92-100%) bumped oxygen up to 4L due to resident sleeping with his mouth open, when mouth is closed resident is at 91-92%, around 3 am a gurgled rattle noted with exhaling. No documentation noting the physician was notified. Review of a Nursing Progress Note dated 10/22/21 for R8 revealed the health department was notified of a negative COVID test and chest x-ray and instructed to monitor the resident for high fever. The family and physician were documented as notified and no instructions from the physician or what physician was notified. No progress notes or assessments done on R8 after 10/22/21 at 9:12 a.m. until 10/26/21 at 8:18 a.m. and the facility was unable to locate or provide a copy of the chest x-ray results. Review of a Nursing Progress Note dated 10/26/21 at 8:18 a.m. revealed R8 had diminished lung sounds and labored breathing. His oxygen saturations (O2) were at 90-90%/O2 @ 3L/NC (3 liters nasal canula). No documentation indicating the physician was notified. During an observation on 10/26/21 at 10:00 a.m., R8 was in bed with eyes closed and receiving 2 liters (L) oxygen via nasal cannula. R8 was no longer on 1:1 observation or in isolation and his COVID test was negative. R8 was mouth breathing with irregular breathing noted. R8 did not wake up or respond to verbal cues. At 11:43 a.m. R8 was prepped to be sent out to the hospital. Review of a Nursing Progress Note dated 10/26/21 at 11:14 a.m. revealed the Nurse Practitioner (NP) saw R8 and his O2 saturations were at 83% on 3L nasal canula with labored breathing and complaints of abdominal pain. The family requested R8 be sent out to the hospital for an evaluation. During an interview on 10/26/21 at approximately 1:10 p.m. Licensed Practical Nurse (LPN) U reported she came in around 8:00 a.m. this day and was told in report R8's oxygen saturations were decreasing, and he was declining. When she took care of him the day before he was just not himself and more lethargic. LPN U reported the NP saw R8 this morning and his oxygen saturations were at 70% on 3L NC. LPN U reported R8's son was notified and asked about the laboratory results, but the NP could not find the lab results he had done a couple weeks ago and had to look all over for them. When queried about Certified Nursing Assistants (CNA's) notifying nurses when they notice a change in the residents, LPN U reported the CNAs won't always approach the nurses because of the attitude and backlash from the nurses when they do report concerns and reported the Administration is aware of this problem. During an interview on 10/26/21 at 1:50 p.m., LPN H reported R8's oxygen saturation's decreased into the low 90s this morning and she increased his oxygen to three liters LPN H reported her shift started today at 6:00 a.m. and was told in report R8 had oxygen saturation's that decreased into the 70s that night. LPN H reported she did not assess R8 this morning. LPN H reported she wanted LPN U to take over care of R8 when she came in to work at 8:00 a.m. so she could get her medication pass done. LPN U was there to help the facility during the survey and was an extra set of hands. LPN H reported she took R8's medications to him between 9:30 and 9:45 a.m. and noticed his breathing was a little more labored and would not wake up to take his medications. LPN H reported she did not do an assessment at that time or notify the physician. Review of hospital records dated 10/26/21 for R8 revealed the family told the hospital they think R8 has been getting sick over the last five days but not aware of the specifics. R8 was diagnosed with respiratory failure and aspiration pneumonia and is expected to stay in the hospital greater than two nights. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated 6/29/04). The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). In Legal and Ethical Issues in Nursing by G. [NAME] (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete. (pg. 171) It states that A [NAME] can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient. (pg. 171) A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. ([NAME] & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article.) Review of a Director of Nursing (DON) job description revealed: Is responsible and accountable for the overall management of the nursing department. Coordinates with other disciplines to provide quality care to all residents. Supports in practice the philosophy, policies, and objectives of the company. Monitors the outcome of nursing services activity by coordinating facility committees an using the quality assurance program to implement efficient and effective nursing interventions. Ensures that the highest degree of quality care is maintained at all times. Performs all duties using independent judgment and discretion to implement regulations and policy. Review of a Registered Nurse (RN)/Licensed Practical Nurse (LPN) supervisor job description revealed: General Purpose: responsible for the independent supervision of the delivery of care to a group of residents on a nursing unit with guidance from the Director of Nursing Services, assess resident needs, provides nursing care, evaluates nursing care, administers medications, and completes treatments. Directly supervises the nursing assistants and the delivery of nursing care. Interviews, councils and evaluates the performance of nursing assistants. Review of a Nursing Assistant job description revealed: Under the supervision and direct RN/LPN Supervisor, to provide non licensed nursing care and services to residents in a long term care facility maintains a health physical and psychosocial environment for the residents. Duties: assist residents with activities of daily living . Report skin problems and any other changes in resident condition to the RN/LPN Supervisor . Read and follow daily care plans, document care provided as required. Work with other members of the resident care team to provide quality resident care. Resident #26 (R26) Review of a Face Sheet revealed R26 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed R26 had a BIMS indicating she is cognitively intact and requires extensive assistance to totally dependence on staff for ADL's. Review of a progress note dated 9/16/21 for R26 revealed a new order for residents foot dressing to be changed daily with a [MEDICATION(S)] blue wrap with gauze and a referral to one clinic is needed per nurse practitioner. this was not transcribed on the MAR/TAR. Review of a nurse practitioners progress note dated 9/16/21 for R26 revealed: Patient seen on 9/12 for concerns regarding large wound of the foot which had been present for > than 2 weeks. Wound was noted to have significant amount of eschar with surrounding skin boggy, pink. Orders written for small amount of santyl to be applied in referral to wound clinic . She also has an abdominal wound which has been ongoing since prior to most recent hospitalization , anticipates she will address this at wound clinic visit as well. Plan: cleanse wound daily. Apply [MEDICATION(S)] blue, cover with nonadherent gauze and wrap with kerlix. Staff to check on wound clinic appointment, schedule ASAP for an evaluation . Monitor closely, reevaluate PRN (as needed). No documentation this order was transcribed and done. This document has a faxed date at the top of the document indicating it was faxed to the facility on [DATE]. Review of hospital records with an admitted [DATE] and a discharge date of [DATE] for R26 revealed she admitted with generalized weakness with new moderate to severe hypervolemic [CONDITION(S)], shortness of breath with acute [CONDITION(S)]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharged the resident with a list of medications and several wound care instructions. Review of the EMR (Electronical Medical Records) for R26 revealed no documentation, assessments or physician notifications prior to hospitalization on [DATE] to reflect the multiple wounds, weights, vital signs, shortness of breath, skin conditions, and screening for infections or COVID. During an observation on initial tour of the facility on 10/19/21, R26 was heading out to the hospital due to increased shortness of breath. Review of R26 list of weights revealed she had gained 41 pounds since her original admission to the facility from 7/10/21 to 10/20/21 and no documentation showing the physician was notified. The weights were not done daily as ordered. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/28/21, orders noted for a 2 liter fluid restriction for 24 hours, [MEDICATION(S)] (diuretic) 1 mg (milligram) ordered once daily (hospital recommended for 2 mg for 1 week post hospitalization on [DATE]), Several dressing changes ordered for her wounds noted, and the right foot dressing is not to be removed until her follow up visit with podiatry. There is no documentation indicating she went to a podiatrist the following week. The right foot dressing change orders conflicted with another order to clean the affected area of the right foot and apply Santyl ([MEDICATION(S)] [CONDITION(S)] histo.) ointment and then cover with a non-adherent dressing and Kerlix. [MEDICATION(S)] reordered on 10/9/21 with a trough lab order to be done on 10/12/21, no trough lab results noted or indicated it was done. No orders for the Foley catheter maintenance/patency. Weekly skin assessments and vital signs ordered every shift and not done. No documentation indicating the physician was notified of any changes of treatments, medications, specialty physician visits, or changes in conditions as ordered. Review of the September and October 2021 Medication Administration and Treatment Administration Records (MARS/TARS) revealed R26 had several orders for multiple dressing changes, and some are not clear as to what wounds the dressing were for and did not receive dressing changes as ordered. The resident is missing several blood sugar checks for both months, and [MEDICATION(S)] was not increased to 2 milligrams post hospitalization on [DATE]. Intravenous [MEDICATION(S)] not started as ordered post hospitalization until 9/29/21 because it was not available. No documentation indicating the physician was notified when dressings were not done, blood sugars not completed, medications were missed, and post hospital recommendations/records were reviewed. Review of an Incident/Accident report dated 8/26/21 for R26 revealed she had a witnessed fall in the shower room. No follow up neurological assessments completed per policy. Review of the electronic medical records revealed no documentation for our R26's fluid intake, daily weights, physical assessments, weekly wound/skin assessments, changes in conditions, post fall assessments. No documentation indicating when/if appointments were made. Review of the paper chart for R26 revealed no assessments, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Nursing Home Administrator (NHA) T later provided physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a skin body assessment dated [DATE] revealed R26 had a large mass noted to her left side and was sent to the emergency room for an evaluation. No documentation or assessment describing the large mass is noted or any other health concerns. In an interview on 10/19/21 at 2:18 p.m., Licensed Practical Nurse (LPN) H reported R26 went to the hospital because there was a new mass that appeared overnight near her [CONDITION(S)], she had blood in her urine and was lethargic, overall just not herself. Review of the Electronic Medical Records (EMR) for R26 revealed no assessments, progress notes or documentation regarding R26 wound observed near her [CONDITION(S)], shortness of breath, blood in her Foley catheter, the resident being transported to the hospital, or that the physician was notified. Review of emergency room documentation dated 10/19/21, R26 Complained of increased shortness of breath and blood in her Foley catheter. The facility told the hospital the resident's oxygen saturation's we're in the mid to low 90s on 2 liters nasal cannula. the hospital recommended increasing the resident's diuretic called [MEDICATION(S)] to two milligrams a day for one week monitor her weight daily and follow up with a primary care physician. In an interview on 10/20/21 at 8:19 a.m., R26 was in her room in bed and reported she went to the hospital yesterday because she was short of breath. The emergency room gave her different water pills and increased the dosage. R26 said the blood in her urine resolved and said there was nothing out of the ordinary wrong with her [CONDITION(S)] or aware of any mass near her [CONDITION(S)]. She was to go to the podiatrist yesterday but missed the appointment because of the trip to the hospital. R26 reported her foot was infected after she fell in the shower. Her foot had a huge blood blister and was not treated. She found out at the hospital she had an infected fracture in her foot ([CONDITION(S)]) and had to have her toe amputated and a bone in her foot removed. She reported after her fall she kept getting weaker and weaker, but the staff would not listen to her. In an interview on 10/20/21 at 8:53 a.m., LPN H reported she did not have any dressing change orders for R26 since she returned from the hospital and was to get the surveyor if she did do any dressing changes on this resident and never did. In an interview on 10/21/21 at 9:05 a.m., Vice President of Clinical Operations (VP) Z reported R26 was short of breath this morning but has anxiety in [CONDITION(S)]. VP Z reported they are having a hard time getting weights for the resident that are accurate and need to reeducate the staff on how to get accurate weights. The nurses were also not overlooking the weights reported. In an interview on 10/21/21 at 12:06 p.m., Nurse Practitioner (NP) EE reported she uses another computer system off site to document her visits and then faxes the documents to the facility. NP EE acknowledged all R26's physician and practitioner notes are not in her chart. NP EE reported this day they were questioning the accuracy of R26's weights and other factors that can affect the accuracy of her weights. NP EE is unaware of R26 complaining of any shortness of breath and said other practitioners visit the resident as well who may have addressed any concerns that she is unaware of. In an interview on 10/26/21 at 10:19 a.m., the Director of Nursing (DON) FF reported skin assessments are to be done once a week. She expects the CNAs to inform the nurse if anything different is noticed on a resident. When questioned about R26's weights, DON FF reported the weight scales are not appropriate for this resident and are looking into getting a bed that has a scale on it. The DON acknowledged the order is for calling the physician with a 2 pound weight difference has not been done. Resident #329 (R329) Review of a Resident Face Sheet reflected R329 admitted to the facility 5/23/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] reflected R329 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 and was independent with locomotion on the unit where he lived. Review of a Care Plan initiated on 5/26/2020 reflected (R329) at risk for falling R/T (related to) weakness, restless leg syndrome, acute on chronic heart failure. The Goal of the care plan was for R329 to remain free from injury with approaches that included verbal reminders and environmental considerations for preventing falls including ensuring R329 was wearing properly fitting footwear and ensuring the floor is free of glare liquids or foreign objects. The care plan did not specify assessment approaches to monitor for injury after falling. Review of an Event Report dated 10/9/2020 at 11:10 PM reflected R329 sustained injury after a witnessed fall in a shower room. According to the report, R329 was not wearing shoes, the floor was slippery and R329 slid off a shower chair sustaining a bruise to his left inner buttock and a skin tear to upper butt crack, left side of butt (sic). The description in the Event Report indicated Resident (R329) had liquid stools all day was shaking from being in the shower and sitting on the commode most of the day and was agitated. Interventions after the fall were described as follows: Had to place resident on 1:1 care and place him on bedside commode in hallway to monitor while he continued to have loose stools, due to replacing his chair and bed alarm finding it was not working either. Review of Resident Progress Notes dated 10/10/2020 at 2:06 AM reflected (R329) had diarrhea all of second shift and most of 3rd shift, finally petered out. The CNA on 3rd shift went down to get more towels and I was looking in on resident when was picking up a wash cloth he was trying to move and slid down, did not hit his head, though ended up with 2 skin tears on his bottom, a small one on his upper butt crack, put a durafoam on that one, and another open area on his left buttock. That I applied a padded 4 x 4 dressing on that one. Then he had a small bruise on the inner buttock. Incident report filled out. The progress note does not indicate a physician was notified of the ongoing diarrhea or indicate R329 was placed on contact precautions for an unknown [MEDICATION(S)] illness that had the potential for sickening other residents or staff who did not take appropriate infection control precautions. Review of a Progress Note dated 10/20/2020 at 11:51 AM reflected, (R329) was going in various different rooms when he went into one resident's room, and she kicked him in the right shin. Neither resident was hurt or remembered the incident after re-evaluated. (R329's wife) called and notified. She was relieved that he wasn't the one kicking people. Will continue to monitor. The progress note did not specify whether or not staff intervened as R329 was wandering into and out of other resident's rooms before he was kicked by another resident. Review of Intake Information reported to the State Agency on 10/20/2020 reflected (R331) kicked (R329) in the right lower leg .Investigation: It was reported that (R329) had wandered into (R331's) room and that (R331) kicked (R329) in the lower right leg leaving an open area. This was reported by Certified Nurse Aide (CNA) GG who witnessed the interaction. In her statement she states that she heard (R331) yell 'Nurse! Nurse!' and she ran down to see what was going on. When she got to the room, (R329) was in (R331's) room and she entered to remove him. Before she could remove him (R331) came around the curtain and kicked (R329) in the right leg leaving an open abrasion . Review of an Event Report dated 10/28/2020 at 6:10 PM reflected R329 had an unwitnessed fall in his room. According to the report, R329 attempted to self-transfer from his wheelchair to bed. The report included one assessment of R329's neurological status. Review of the entire Electronic Medical Record and the paper chart did not reflect ongoing assessment of R329's neurological status after the unwitnessed fall on 10/28/2020. Review of a facility policy Fall Prevention Toolkit last reviewed 7/2021 reflected that a Neurological Checklist is to be implemented with any fall event that was unwitnessed or a head injury is suspected or has occurred. Review of an Event Report dated 11/8/2020 at 4:28 PM reflected that R329 was discovered with a Skin Tear to his right lower extremity measuring 6 cm (centimeters) by 7 cm. The report reflects that the resident (who was severely cognitively impaired) reported he bumped it on his wheelchair when self propelling, however the report does not indicate the injury was witnessed. Review of Resident Progress Notes dated 11/08/2020 at 3:24 PM reflected (R329) alert with confusion. No complaints of pain or discomfort. Resident states he bumped his right outer leg on wheelchair when ambulating. Skin tear noted to area. Cleaned and dressed. Doctor aware. Resident currently resting in wheelchair in bedroom at this time. During an interview on 10/28/2021 at 11:45 a.m., the acting Nursing Home Administrator (NHA) and the Vice President of Clinical Operations (VPCO) Z reported that it is the expectation that staff document resident behaviors when they occur. VPCO Z also reported that there was no documentation available in the paper medical record or electronic medical record to reflect the wounds sustained by R329 on 10/09/2020, 10/20/2020 or 11/08/2020 was accurately documented and monitored for healing. VPCO Z reported that an incident report and physical assessment pertaining to R329's wound was not created after the resident-to-resident altercation on 10/20/2020, making it unclear if the skin tear sustained by R329 on 11/08/2020 was a new wound or a re-injury of the wound sustained after the R331 kicked R329 in the right shin on 10/20/2020.

Deficiency Practice Statement B Based on observation, interview, and record review the facility failed to ensure facility staff consistently followed Standard Precautions for infection control during a medication administration observation for 6 of 9 residents (Resident #7, Resident #8, Resident #9, Resident #11, Resident #12 and Resident #10) reviewed during medication pass, from a total of 20 residents, resulting in an Immediate Jeopardy when on 8/7/17 beginning at approximately 12:05 p.m., Licensed Practical Nurse (LPN) F failed to consistently use gloves, wash hands, and disinfect blood glucose monitors increasing the potential for cross-contamination of equipment, transmission of disease, and growth of infectious microorganisms. This deficient practice placed all 28 residents in the facility at risk for serious harm or impairment due to having only one nurse who passed medications. Findings include: Review of the Policy and Procedure titled Glucometer Cleaning dated 1/2017, revealed Policy: To prevent the transmission of infections the facility requires disinfecting Blood Glucose Meters between resident uses. 1. Before and after using a Blood Glucose Meter, disinfect the meter by cleaning the outside by using a commercially available EPA-registered disinfectant detergent or germicide wipe. Review of policy Infection Control and Medication Administration undated, revealed Do not store personal food or fluids on the medication cart, do not eat or drink while passing medications .if you contaminate your hands by touching your mouth, nose or eyes you must wash your hands. Review of policy Hand Washing/Hand Hygiene with date 10/2015 revealed hand hygiene is to be performed 1. After immediate contamination with blood, other body fluids or potentially contaminated articles; 2. After removing gloves or other personal protective equipment; 3. After care of each resident; 4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.) 5. After handling urinals, bedpans, catheters, sputum, or any other body fluid; 6. After sneezing or coughing; 7. Before eating, preparing or handling food; 8. After using the restroom. Supplemental Resident #7 Review of a Face Sheet revealed Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 7/19/17, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated moderate cognitive impairment. Supplemental Resident #8 Review of a Face Sheet revealed Resident #8 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment for Resident #8 not yet completed. Supplemental Resident #9 Review of a Face Sheet revealed Resident #9 originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 8/1/17, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated that the resident was cognitively intact. Supplemental Resident #11 Review of a Face Sheet revealed Resident #11 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/11/17, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated moderate cognitive impairment. Resident #12 Review of a Face Sheet revealed Resident #12 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 7/14/17, revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated severe cognitive impairment. In an observation on 8/7/17 at approximately 12:05 p.m., LPN F was noted to prepare medications for Resident #11, when removing applesauce from a cooler on top of the medication cart, her right unwashed thumb dipped into the previously opened applesauce. LPN F proceeded to lick the applesauce off of her thumb, grabbed a spoon, used spoon to remove applesauce from container and placed it into a medication cup. LPN F touched the foil cover of the applesauce to cover the applesauce and placed it back into the cooler. LPN F then took the medication (medication cup with pills, applesauce, and spoon) into the dining room where Resident #11 was seated and administered medication without washing her hands. In an observation on 8/7/17 at 12:40 p.m., LPN F was noted to draw up Humalog (insulin) 25 units for Resident #7 at the medication cart. LPN F then put on gloves without performing hand hygiene (hand washing), entered Resident #7's room, administered the insulin, engaged the safety cap on the insulin syringe, removed her gloves, and left the room without performing hand hygiene. In an observation on 8/7/17 at 12:45 p.m., LPN F, immediately following the insulin administration for Resident #7, proceeded to Resident #8's room without performing hand hygiene. LPN F did not put on gloves, she then placed the used insulin syringe on Resident #8's bedside table and removed a 2x2 gauze from Resident #8's anticubital (elbow crease) that had blood on it, all without gloves or hand hygiene. LPN F then left Resident #8's room with the syringe without performing hand hygiene. LPN F then went back to the medication cart, put the used syringe in the sharps container and began to prepare the next resident's medication without performing hand hygiene. LPN F had no gloves on during the entire encounter. In an observation on 8/7/17 at 12:48 p.m., LPN F prepared Resident #9's medications without performing hand hygiene or using hand sanitizer. In an observation on 8/7/17 at 12:50 p.m., LPN F was observed taking a clear plastic disposable cup atop medication cart, using the pitcher of ice water to fill cup, drinking from cup, and setting cup back atop medication cart without performing hand hygiene. This cup was left atop the only medication cart in the facility while LPN F prepared Resident #12's medication. In an interview on 8/7/17 at 2:15 p.m., LPN F reported that she had cleaned the glucometer when it was returned to the medication cart, despite two surveyors having not witness this occur. LPN F stated, I should not have licked my finger after the applesauce was on it, then stated, I did wash my hands after that. The stated hand washing was not witness by the surveyor who accompanied LPN F when Resident #11's medications were administered. LPN F reported that she had been sick over the weekend and had diarrhea on from 8/5/17 through 8/6/17 and had called into work sick on 8/6/17. LPN F did come in as scheduled on 8/7/17. LPN F reported having continued neck pain, generalized body aches, and generalized fatigue on 8/7/17 during her shift. LPN F reported that she is supposed to wash her hands before and after every resident medication administration. LPN F reported that the glucometers are to be cleaned after each use with manufacturer recommended Sani-wipe. In an interview on 8/7/17 at 2:37 p.m. Director of Nursing (DON) B and Administrator A, DON B reported that the glucometer was to be cleaned by the nurse with a Sani-wipe for 2 minutes and allowed to dry for 2 minutes after each use and prior to putting away into the medication cart. Administrator A reported that it was unacceptable for nurses to lick their fingers and administer medications without first completing hand hygiene. During an observation on 8/7/17 at 11:50 a.m., LPN F was noted to be seated at Supplemental Resident #10's bedside checking her blood sugar. LPN F did not have gloves on while completing the procedure and was not visualized to remove gloves once the procedure was completed. LPN F exited the room after checking Supplemental Resident #10's blood sugar without gloves on and without washing her hands. LPN F proceeded to the medication cart with the dirty glucometer, opened the medication drawer, placed the glucometer into the medication cart, without cleaning it, and closed the cart and prepared to begin medication administration for residents. On 8/7/17 at approximately 5:15 pm, Administrator A was verbally notified of an immediate jeopardy situation and on 8/8/17 at approximately 4:00 p.m., Administrator A was notified in writing of an immediate jeopardy that began on 8/7/17 when facility staff failed to consistently implement standard precautions to prevent the spread of infection. On 8/9/17, this surveyor verified the following was implemented to remove the immediate jeopardy: 1. On 8/7/17, the facility glucometer was cleaned, the drawer for the glucometer on the medication cart was cleaned, the top of the medication cart was cleaned and all cups and spoons were disposed of by the Director of Nursing. 2. On 8/7/17, LPN F was placed on suspension pending education. 3. On 8/7/17, the Director of Nursing and Administrator review the policies titled Infection Control During Medication Administration, Hand Washing, and Glucometer cleaning. They were found to be accurate and up to date. 4. On 8/7/17, the Regional Clinical Director re-educated the Director of Nursing who then began re-educating licensed nurses on policies including Infection Control During Medication Administration, Hand Washing, and Glucometer cleaning. One nurse was allowed to work on the 3rd shift from 8/7/17 to 8/8/17 until morning when the Director of Nursing then educated the nurse on the above information. All other licensed nurses will not return to work without receiving the education. 5. On 8/7/17, the Director of Nursing reviewed infection control data for the past three months to identify trends or patterns of infections. None were identified. 6. On 8/7/17 and 8/8/17, all 28 residents in the facility were assessed for indicators of infection. No residents has any signs of symptoms of an infection. 7. On 8/7/17, the Medical Director and physician were notified of a potential cross contamination with the resident during medication administration. No new orders were recieved at this time. Although the Immediate Jeopardy was removed on 8/8/17, the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for minimal harm that is not Immediate Jeopardy due to the fact that the facility had not yet educated all staff and sustained compliance had not yet been verified by the State Agency. Deficiency Practice Statement B Based on observation and interview, the facility failed to ensure facility staff follow standard infection control practices for glove use and hand washing for 1 of 20 sampled residents (Resident #13) reviewed for infection control, from a total of 20 residents, resulting in the potential for transmission of disease, and growth of infectious microorganisms. Findings include: During an observation on 8/9/17 at 10:43 p.m., Resident #13 was assisted to the shower room to a sit-to-stand lift, shown how to hold her hands on the lift, assisted to stand, Certified Nursing Assistant (CNA) O and Activity CNA N assisted her to stand removed her brief and noted a large loose stool that was to the upper part of the back of her brief., the brief was also very wet and had strong urine odor. CNA O was gloved and used wipes to clean the stool, ACNA N wet a washcloth and put soap from the wall dispenser on it to cleanse some of the stool and used a wet washcloth to rinse the area, placing the soiled washcloths in a bag, CNA O completed the rest of the cleaning. Resident #13 was lowered to the toilet to see if she had to go to the bathroom, a brief was placed around her to be pulled up when she was stood, the control of the lift was touched, and Resident #13 was assisted to used the sit-to-stand. With the same gloves used for care Resident #13 was lifted, her wheelchair was put in place, her brief put in place, pants were pulled back up. Resident #13 was placed in the wheelchair and the lift was pushed out of the way. Resident #13's feet were positioned by ACNA N, who removed her gloves but did not wash her hands, then pushed Resident #13 to therapy. ACNA N brought Resident #13 back to the nursing station hallway because no one was in the therapy room and went to the another resident room touching the tray table assisting with care (helping put on a residents shoes). ACNA N then went into another resident room assisted with a gait belt transfer touching the railing while walking the resident to the activity bus waiting outside the front door, pressing the code in to open the door. ACNA N turned back to the facility pushed Resident #13 back to room [ROOM NUMBER] and assisted another resident by carrying her coat and holding her right arm to the front door, opening the front door then assisting the resident by holding her left arm, then went back and pushed a resident with a wheelchair to the front door. During an interview on 8/9/17 at 11:13 a.m. ACNA N reported that she had washed her hands 3 times while she was doing care for Resident #13, but said she had gone into residents rooms and assisted them with care and had not washed her hands.