Every finding on record at Rocky Mountain Care- Clearfield

Based on observation, interview and record review it was determined that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for 7 out of 54 sampled residents, multiple residents complained of staffing shortages, long call light response times, and delays in assistance with Activities of Daily Living (ADLs). Additionally, resident council notes documented late medication administration. Resident identifiers: 1, 7, 9, 13, 31, 73, 86, 110, 113, 127, 129, and 156.Findings included:1. On 5/5/26 at 12:55 PM, an interview was conducted with resident 86. Resident 86 stated that when he pressed the call light it sometimes took forever to be answered. Resident 86 stated that he had therapy that was often delayed because he had to wait for staff assistance to get up. Resident 86 stated that he would push the call light and staff would give him a [NAME] excuse for not assisting him when he needed it. Why do they have a call light if they don't take care of the patient? Resident 86 stated that he was paying for services that he should be getting. Resident 86 stated that staff were always saying they were short staffed and they did not have enough time. Resident 86 stated that staff did not cut his fingernails so his wife had to come and do this for him. Resident 86 stated that his wife also had to help with incontinence care, cleaning feces and urine, because there was not enough staff to assist. Resident 86 stated that his wife was very upset about this and spoke with the Administration. The Administration came to speak with him and told him that they were working on fixing this but he had not seen any results yet. This is ridiculous. Resident 86 stated that he filed a grievance report with the Resident Advocate regarding these concerns.Resident 86 was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included aftercare following joint replacement surgery, fracture right femur, intervertebral disc disorders, type 2 diabetes mellitus, acquired absence of right leg below knee, morbid obesity, heart failure, presence of right artificial hip joint, hypertensive heart and chronic kidney disease. On 12/25/25, resident 86's Minimum Data Set (MDS) Assessment documented that the resident was a substantial/maximal assistance with toileting, showers, bed mobility; partial/moderate assistance for upper body dressing; and dependent for lower body dressing and transfers. Resident 86's Care Plan had a focus area for alterations in Activities of Daily Living (ADL) function secondary to Right femur fracture that was initiated on 11/3/25. The interventions identified on the care plan included: 2-person assist with transfers - up to extensive assistance, assist in completing ADL tasks each day, encourage participation in Physical Therapy, and encourage use of call lights when ADL assistance is needed.The grievance log was reviewed and no documentation could be found of any complaints/concerns filed by resident 86.On 5/13/26 at 3:24, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 86 used a urinal and was incontinent of bowel. CNA 1 stated that resident 86 only required one staff for incontinence care as he was able to roll independently. CNA 1 stated that some days the facility was staffed well and others not so much. CNA 1 stated that the hallway that resident 86 resided on required more staff and was more needy. CNA 1 stated that after 6:00 PM it was crazy in the hallway. CNA 1 stated that it was difficult to complete tasks, and sometimes showers did not get completed due to low staffing. Even with a shower aide they sometimes don't get done. CNA 1 stated that incontinence care was done during rounds every 2 hours or as needed, and when it is super hectic a call light may be on for 15 minutes. CNA 1 stated that on the 300 hallway there was a resident that required 2 staff for incontinence care and it took an hour to provide so call lights were on for a longer time there. 2. On 5/4/26 at 12:40 PM, an observation was made of the Minimum Data Set (MDS) Coordinator in the dining room serving drinks to residents when resident 110's family member asked for a food item. The MDS Coordinator stated she did not usually help with dining as much as she was that day and she did not know if she could get the food item.3. On 5/4/26 at 10:39 AM, an interview was conducted with resident 9. Resident 9 stated that staff sometimes took a long time to respond to call lights, and while she had some great nurses and CNAs, there was not enough staff to ensure quick responses. Resident 9 stated that she waited for over an hour for assistance with a brief change the previous night after activating the call light due to a bowel movement, because her CNA was assisting another resident with complex medical needs to prepare for bed.4. On 5/4/26 at 11:20 AM, an interview was conducted with resident 1. Resident 1 stated that she required assistance from staff and had waited over 2 hours for staff to come in and assist her. Resident 1 stated that she was waiting for staff to come in and boost her up in bed and had been waiting for approximately 10 minutes. On 5/4/26 at 11:35 AM, an observation was made of two CNAs entering resident 1's room to reposition her in bed. 5. On 5/4/26 at 11:39 AM, an interview was conducted with resident 31. Resident 31 stated that call light response times are horrendous. Resident 31 stated that the facility was always short -staffed on the weekends. Resident 31 stated that he had waited over one hour for staff to come and get him off of the toilet. Resident 31 stated the CNAs do not work together and if someone was busy and other lights turned on other CNAs just say it was not their hall and they don't respond.6. On 5/5/26 at 8:23 AM, an interview was conducted with resident 156. Resident 156 stated that his call light was not answered all the time and he sometimes had to wait over 20 minutes for staff to come into his room. 7.On 5/5/26 at 8:45 AM, an interview was conducted with resident 129. Resident 129 stated that call lights took about 60 minutes for staff to respond to. Resident 129 stated that CNAs come in and turn off the call light and say they will be back and they never come back. 8. On 5/5/26 at 9:09 AM, an interview was conducted with resident 13. Resident 13 stated that she was unable to walk and was non-weight bearing. Resident 13 stated that there were times that she really had to pee and had to wait a long time for staff to respond to her call light. Resident 13 stated that she had some incontinent episodes waiting for staff to respond. 9. On 5/5/26 at 12:46 PM, a confidential interview was conducted with a resident. The resident stated there were not enough staff and they had to wait for an hour for assistance. The resident stated they were unable to feel when they had a bowel movement and had to wait for long periods of time in a dirty brief. The resident stated there were a lot of CNAs that called out sick so the facility was short staffed a lot. 10. On 5/5/26 at 10:37 AM, an interview was conducted with resident 34. Resident 34 stated he was on the rehab side of the building and the call light wait time on the long term side was Horrendous. Resident 34 stated it made him feel not important. Resident 34 stated residents started to yell out for assistance because call lights were not answered. Resident 34 stated staff did not check on him throughout the shift. Resident 34 stated staff have been kind of mean in the long term care side by telling him if he got in his wheelchair he had to be up for longer than 2 hours. Resident 34 stated he could not stay up for 2 hours in his chair because of back pain caused by his herniated discs. 11. On 5/4/26 at 3:335 PM, an interview was conducted with resident 73. Resident 73 stated his hall needed at least another CNA for each shift. Resident 73 stated he had to wait up to an hour and a half for his call light to be answered. Resident 73 stated there were a lot of staff that called in sick and there should be 4 CNA's for his hallway but sometimes there are only 2. Resident 73 stated that he sometimes was not repositioned for over 12 hours because there were not enough staff. Resident 73 stated weekends and Mondays they were short staffed. Resident 73 stated sometimes he had to sit in a dirty brief for a long time because other residents need more assistance. Resident 73 stated staff worked their butts off. 12. On 5/4/26 at 2:53 PM, an interview was conducted with resident 110's family member. The family member stated there were not enough staff for 2 staff members to transfer residents who required a hoyer lift. The family member stated resident 110 had waited up to an hour for his call light to be answered. The family member stated resident 110 liked to get back in bed about 2:30 PM but that was the hardest time to get 2 staff members to transfer him with the hoyer lift. The family member stated she had been the second person assisting with the hoyer lift because there were not enough staff. 13. On 5/5/26 at 9:21 AM, an interview was conducted with resident 113. Resident 113 stated the agency staff were terrible. Resident 113 stated a nurse came and argued with her about taking medications one time and she refused. Resident 113 stated the nurse came back and said the resident was right. Resident 113 stated staff did not know how to empty her colostomy bag and there had been a few incidents when the bag exploded. Resident 113 stated she had to wait for 45 minutes in her bowel movement when her bag exploded. Resident 113 stated the staff do not look professional and smelled. 14. On 5/4/26 at 3:14 PM, an interview was conducted with resident 127. Resident 127 stated agency staff were not as diligent as facility staff. Resident 127 stated he had waited 30 to 60 minutes and had fallen out of bed waiting for staff. Resident 127 stated he felt frustrated and stated Don't I matter? 15. On 5/4/26 at 10:39 AM, an interview was conducted with resident 7. Resident 7 stated she just did not use her call light because the staff were very busy. On 5/13/26 at 9:43 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that staffing was based on the facility census and resident acuity. The ADON stated that the 300/400 currently had multiple residents that required Hoyer lifts and call light wait times were very long and residents had to wait for staff to be available. The ADON stated that there was primarily just agency staff on the 300/400 hallway and there had been resident complaints about staff sitting at the nurse's station and not answering call lights. The ADON stated that she was trying to identify why there were so many staffing issues in the 300/400 hall and that this was a work in progress. The ADON stated that weekend staffing was difficult because it was mainly just agency staff that were working in the facility. The ADON stated that she thought most of the CNAs were good, but some had some bad habits that she would like to get fixed.16. Resident Council notes were reviewed for April 2025. There were concerns that Certified Nursing Assistants (CNAs) were at the desk talking when call lights were on. Resident Council notes were reviewed for May 2025. There were concerns that medications were being delivered late to residents.Resident Council notes were reviewed for June 2025. There were concerns that agency staff were delivering medications late. Resident Council notes were reviewed for July 2025. There were concerns that agency staff were administering medications late. Newer CNAs were using their cell phones while providing care to residents.Resident Council notes were reviewed for August 2025. There were concerns about additional staff in the dining room to offer additional assistance to residents. CNAs assigned to other halls are not willing to assist each other.Resident Council notes were reviewed for September 2025. There were concerns that showers were offered late, extended call light times, and the need for shower aides.Resident Council notes were reviewed for October 2025. There were concerns with inconsistent nurses, CNAs not rounding and rushing through cares, and call light times. Resident Council notes were reviewed for November 2025. There were concerns with inconsistent medication routines, the need for improvement with follow-up and availability from staff, and shower aides.Resident Council notes were reviewed for January 2026. There were concerns with nighttime staffing.Resident Council notes were reviewed for February 2026. There were concerns that CNAs did not help covering halls not in their section.Resident Council notes were reviewed for March 2026. There were concerns that CNA availability in the dining room was causing late meals and CNAs were complaining about their jobs in front of residents.Resident Council notes were reviewed for April 2026. There were concerns with call lights being turned off without addressing the needs of residents.(Cross refer to F550, F676, F677, F684, F688)

Based on interview and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 3 out of 54 sampled residents, a resident's brief was the incorrect size and caused a wound, and another resident was unable to put his prosthetic arm on during the weekend because staff were not trained. These examples were cited at a harm level. Resident identifiers: 13, 22, and 63.Findings included:1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included aftercare following explantation of knee joint prosthesis, urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, and unspecified escherichia coli. On 5/5/26 at 9:09 AM, an interview was conducted with resident 13. Resident 13 stated that she was allergic to the briefs that the facility used. Resident 13 stated that she wore the briefs for a few days after she was admitted and got a rash to her peri area. Resident 13 stated that she was incontinent at times and stopped wearing the briefs due to the rash. On 5/7/26 at 10:51 AM, an interview was conducted with Certified Nursing Assistant (CNA) 7. CNA 7 stated that resident 13 required a Hoyer lift when she needed to use the bathroom because she was non-weight bearing. CNA 7 stated that resident 13 was becoming incontinent and was allergic to the briefs and would often request a female urinal. CNA 7 stated that resident 13 had a rash in between her legs that had spread to her buttocks. CNA 7 stated that resident 13 had started putting pillowcases in between her legs to help with the wetness. On 5/7/26 at 10:55 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that resident 13 was not being seen for any wound care at the facility. UM 1 stated that he was unable to find any progress notes or skin assessments about resident 13's rash. On 5/7/26 at 10:57 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he had not been informed of any skin conditions that resident 13 may have had. LPN 1 stated that he believed resident 13 wore briefs for incontinence and he had not heard of any allergy that may have caused a rash. On 5/7/26 at 2:11 PM, a follow-up interview was conducted with LPN 1. LPN 1 stated that a skin assessment had been performed on resident 13 earlier in the day where redness was noted to her buttocks. LPN 1 stated that resident 13 had informed the CNAs that she did not want to wear briefs due to the redness and this information had not been passed on to the nurses. On 5/11/26 at 9:01 AM, a follow-up interview was conducted with UM 1. UM 1 stated that resident 13 was not wearing a brief when the skin assessment was conducted on 5/7/26. UM 1 stated that an order for barrier cream was placed by LPN 1 on 5/7/26 after the skin assessment was documented. It should be noted that no order for barrier cream or a skin assessment was charted on 5/7/26. 2. Resident 63 was admitted to the facility on [DATE] with diagnoses which included other lack of coordination, weakness, blindness in right eye category 3, blindness in left eye category 3, and acquired absence of left upper limb above elbow. On 5/6/26 at 2:07 PM, resident 63 stated during a Resident Council meeting that he would like staff to be trained on how to put on his arm. Resident 63 stated that nurses have told him they do not know how to put on his prosthetic arm. Resident 63 stated that he was out of luck when there was no one at the facility to help him. On 05/11/2026 at 10:53 AM, resident 63 asked if this surveyor could help him put his arm on. Resident 63 stated that he had asked his nurse and she never came back to help him. On 5/11/26 at 10:56 AM, an observation was made of resident 63 asking the Infection Preventionist (IP) nurse to help him put his arm on. The IP was observed to wheel resident 63 to the therapy room without attaching the prosthetic arm. On 5/13/26 at 8:09 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated he was the nurse for resident 63. RN 1 stated that he had only been at the facility a couple of times and did not know how to put on resident 63's prosthetic arm. RN 1 stated that he thought that the therapy department put on resident 63's arm. On 5/13/26 at 8:13 AM, an interview was conducted with CNA 8. CNA 8 stated that he did not know how to put resident 63's prosthetic arm on. CNA 8 stated that resident 63 had to go to therapy to have them assist him with his arm. On 5/13/26 at 8:58 AM, an interview was conducted with the Physical Therapist (PT). The PT stated that the facility had an on-call therapist available on the weekends that could come into the facility if there was a new admission that needed an evaluation. The PT stated that resident 63 was not able to put on his prosthetic arm and therapy had been doing it for him. The PT stated that therapy should probably train some CNAs on how to put on resident 63's prosthetic arm. The PT stated that resident 63 probably did not wear his prosthetic arm on the weekends because no therapy staff were available to assist him. On 5/13/26 at 9:06 AM, a follow-up interview was conducted with resident 63. Resident 63 stated that he was not able to put his prosthetic arm on by himself. Resident 63 stated that he was unable to wear his arm on the weekend because there was no staff that could assist him with putting the prosthetic arm on. Resident 63 stated that he would like to discharge from the facility and go home, but he needed to know how to use his prosthetic arm and he cannot learn when he does not wear it. On 5/13/26 at 11:03 AM, an interview was conducted with the DON. The DON stated that resident 63 was participating in physical and occupational therapy. The DON stated that nursing staff and therapy staff assisted resident 63 with putting on his prosthetic arm. The DON stated that therapy was in the facility on the weekends and they placed resident 63's prosthetic arm on. 3. Resident 22 was admitted on [DATE] with diagnoses which included sepsis due to other specified staphylococcus, atrial fibrillation, type 2 diabetes mellitus and protein-calorie malnutrition. On 5/5/26 at 10:19 AM, an interview was conducted with resident 22. Resident 22 stated she had a bed sore on her bottom. A nursing progress note dated 4/25/826 at 12:59 AM revealed Wound found on 114b (R) buttock during brief change. Wound looks like it was caused from the brief being too tight. The wound is shallow & dry with reddened area along the brief edge. Provider notified and wound order put in [medical record system]. A physicians order 4/29/26 at 1:30 PM revealed Wound Location: Right buttock Cleanse with NS [normal saline]/wound cleanser, pat dry apply to wound bed; Calcium alginate cover with Cover dressing treatment Frequency: Daily and PRN [as needed] with brief changes. On 5/11/26 at 8:48 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated resident 22 had a wound on her right gluteus. RN 3 stated when staff were doing rounds and repositioned her she complained of pain. RN 3 stated from what she could see the wound looked like it was probably from a brief. RN 3 stated usually Certified Nursing Assistants (CNAs) asked the residents how the briefs feel or they can measure because there was also information on measuring briefs in the brief packaging instructions. On 5/11/26 at 9:11 AM, an interview was conducted with CNA 6. CNA 6 stated she had been employed with the facility for 3 months. CNA 6 stated she took mental note of the brief size in the residents room and then made sure they remained stocked in their room. CNA 6 stated she did not know how to size residents in briefs. CNA 6 stated there was no system to know what size briefs residents wore. On 5/11/26 at 9:25 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated there were tape measures for the briefs and CNAs could measure the resident. UM 2 stated If a resident's brief was too tight, then CNAs should do measurements. UM 2 stated if a resident developed a wound, then the wound team would be informed. A care plan dated 2/12/26 revealed that resident 22 was at risk for alteration to skin integrity secondary to impaired mobility, weakness, and decreased sensory awareness. An intervention was to provide skin and incontinence care assistance, as needed. On 5/11/26 at 3:51 PM, an interview was conducted with UM 1. UM 1 stated the wound was initially excoriation on the right buttock on 4/28/26. UM 1 stated he would look at the brief size to ensure the resident had the correct size. UM 1 stated he hoped CNAs were using correct size briefs.

Based on observation, interview, and record review, for 1 out of 54 sampled residents, the facility did not ensure each resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization was necessary. Specifically, the facility did not discontinue a resident's Foley catheter when ordered by a provider in a timely manner. This was cited at a harm level. Resident identifier: 34.Findings Included:Resident 34 was admitted on [DATE] with diagnosis that included acute kidney failure, obstructive and reflux uropathy, intracerebral hemorrhage, and encephalopathy. On 5/5/26 at 10:37 AM, an interview was conducted with resident 34, who stated that he had a Foley catheter since his admission to the facility. Resident 34 stated that his attempt to urinate upon admission was unsuccessful, requiring him to have a Foley catheter, and he had not been allowed to attempt again. On 2/13/26 at 2:43 PM, a progress note documented that resident 34 arrived at the facility with a Foley catheter in place and draining clear yellow urine. On 2/16/26, there was an order to discontinue the Foley catheter and Monitor urine output, bladder scan as indicated. Report concerns to provider. On 2/19/26, an order was created to Bladder scan q8 [every 8] hours check for retention. Strait [sic] cath [catheter] with 250ml [milliliters] or more. ***3 times in row of strait [sic] cath*** place foley and add all orders for foley placement. On 2/21/26 at 3:28 AM, a progress note documented The resident had not urinated for three days, bladder was scanned and 483ml of urine was noted in the bladder. 16 Fr [French] foley catheter was inserted per MD's [Medical Doctor] order with successful outcome. Straight catheter order for q6h [every 6 hours] is discontinued. A communication form titled Clinic Visit/Progress Note and Orders was located in resident 34's medical record. The form documented that on 5/7/26, resident 34 was seen at a rehabilitation clinic for a follow up visit. The form documented that the rehabilitation provider ordered trial foley out and obtain PVRs [Post-Void Residuals]. It should be noted that the form was uploaded to resident 34's medical record on 5/11/26 at 2:53 PM. The form did not contain a notation to indicate that it had been addressed by a nurse or provider. An order to discontinue the Foley catheter and obtain PVR could not be located in resident 34's medical record after the clinic visit. On 5/13/26 at 1:44 PM, an interview was obtained with Registered Nurse (RN) 1. RN 1 stated he was an agency nurse. RN 1 stated that he reviewed communication forms upon resident's return from an appointment, created a progress note detailing the information about the visit, updated the resident's primary provider, and entered any changed orders into the medical record. Additionally, RN 1 stated he would notify the primary provider if a resident was to express a desire to discontinue a Foley catheter. On 5/14/26 at 8:54 AM, an interview was conducted with the Assistant Director of Nursing (ADON) and Unit Manager (UM) 2. The ADON stated that staff sent a communication form with residents to all appointments for the provider to document any notes or new orders. The ADON stated that the floor nurse received the form when a resident returned to the facility, noted any notes or new orders, contacted the primary provider to approve the new orders, and created a progress note. The ADON stated that primary providers had to coordinate and approve orders from specialists. The ADON stated that if the floor nurse did not receive a communication form they contacted the clinic for further information. The ADON stated that sometimes the communication forms were misplaced during transport, or the provider gave the communication sheet to the resident instead of transportation. The ADON stated that the floor nurse or herself searched for the communication form if the resident returned without one, or they contacted the provider's office to obtain any information. The ADON stated that because resident 34's communication form did not contain the date it was noted by a nurse before being scanned into the medical record, it was possible the form was misplaced or an agency nurse did not know the proper process for communications forms. UM 2 stated that resident 34 told the facility that the rehabilitation provider had ordered to start him on baclofen for pain, so she called the clinic and got an order for the baclofen. UM 2 stated that she asked the clinic specifically about the baclofen order, and was not aware of the order to discontinue the Foley catheter and obtain PVR. The ADON stated she was unaware if resident 34 had expressed a desire to discontinue his foley catheter. UM 2 stated she would contact resident 34's primary provider to ensure he was aware of the rehabilitation provider's order documented on the Clinic Visit/Progress Note and Orders form. On 5/14/26 at 11:35 AM, an interview was conducted with resident 34. Resident 34 stated that he was just informed that his catheter was going to be removed. Resident 34 stated that he had constant pain in his penal tip due to the catheter. Resident 34 stated that he told the nurses about the pain when they came to check on him.The Medication Administration Record (MAR) documented that resident 38 reported a pain level of 3 or 4 five times between 5/8/26 and 5/12/26. On 5/14/26 at 1:03 PM, an interview was conducted with RN 8. RN 8 stated that resident 34 had complained of general pain at his catheter site, and they took steps to make sure it did not get infected. RN 8 stated that they were informed that day of orders received from the rehabilitation clinic to remove the catheter and see if resident 34 could urinate, and that should help with the pain. On 5/14/26, the following order was created May do trial d/c [discontinue] of foley catheter and obtain PVR's. Obtain first PVR after first spontaneous void, measure within 10-15 minutes after voiding. Check PVR q4-6 [every four to six] hours post void until PVR < [less than] 100-150, then stop. Contact MD if PVR > [greater than] 300ml. It should be noted that the order was created seven days after resident 34's appointment on 5/7/26, when his rehabilitation provider sent the order to discontinue the Foley catheter and obtain PVR.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, for 1 out of 54 sampled residents, a resident was not provided showers as scheduled. This example will be cited at a Harm level. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included morbid obesity, other lack of coordination, weakness, and other abnormalities of gait and mobility.On 5/4/26 at 2:35 PM, a concurrent observation and interview were conducted with resident 1. Resident 1 was observed wearing a hospital gown that had stains on the front of it and hair that appeared to be greasy and uncombed. Resident 1 stated that she had not received daily showers and required assistance with showers from staff. Resident 1 stated that she had to have her head shaved by the facility nurse because her hair had become matted from the lack of washing and she could not brush her own hair. Resident 1 was upset that she had to have her head shaved because her hair used to be long and in braids. Resident 1 stated that she had not had a shower in two weeks. Resident 1 stated she had been told several times that she would get a shower, but she just sits and waits. Resident 1 stated that she had not signed any forms that declined a shower.A care plan Focus initiated on 4/8/25, documented [Resident 1] has alterations in ADL [activities of daily living] secondary to incontinence, weakness.The interventions included assisting in completing ADL tasks each day. Provide dignity and respect, and encourage independence.The TASK revealed ADL documented that resident 1 received daily showers.The medical record and shower sheets were reviewed for April and May 2026. Resident 1 received showers on 4/7/26, 4/21/26, and 5/5/26. Resident 1 received a bed bath on 4/14/26 and 4/25/26.On 5/6/26 at 7:29 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated that resident 1 was to be showered daily. CNA 5 stated that CNAs received a schedule of the residents that required showers for the day. CNA 5 stated that if a resident refused a shower then staff respected that decision. CNA 5 stated that a resident was asked three times throughout the day if they wanted a shower and if they refused a shower, a shower refusal sheet was signed by the resident. CNA 5 stated that if a resident could not sign for themselves then the nurse and CNA had to sign the refusal sheet. On 5/6/26 at 7:33 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that shower refusal sheets were scanned into the resident's medical record. The ADON stated that the facility recently switched over to using shower aides for the facility and an agency CNA was performing showers for the long term care residents. The ADON stated that showers should be charted in the resident's medical record when they had been completed.On 5/13/26 at 11:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 1 was a substantial or maximum assist with showering or bathing herself. The DON stated that there had been some concerns in the facility regarding residents receiving showers as scheduled and that the facility had revamped their shower process by getting shower aides. The DON stated that if a resident refused, they were asked three times by staff and this was documented in the medical record. (Cross-refer F725)

Based on observation, interview, and record review the facility failed to ensure that a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 1 out of 54 sampled residents, a resident's range of motion decreased with restorative nursing services after the resident was discharged from physical therapy. This was cited at a harm level. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included other abnormalities of gait and mobility, other lack of coordination, and weakness.On 5/4/26 at 11:20 AM, an interview was conducted with resident 1. Resident 1 stated that she was unable to move herself in bed and was waiting for staff to come and boost her up in bed. A care plan Focus initiated on 2/28/25, documented [Resident 1] has a decrease in mobility and functional abilities secondary to respiratory failure, morbid obesity. [Resident 1] is currently participating in the AROM [active range of motion]/Transfers restorative nursing program.The interventions included, but were not limited to, encourage participation in Restorative Program and to notify the nurse of refusals, decline in status. A review of resident 1's physical therapy discharge note dated 11/8/25 revealed that resident 1 was able to transfer independently with supervision, could ambulate 5 feet with minimum assistance, and was independent with bed mobility.A review of resident 1's Restorative Nursing Program revealed that resident 1 would perform active range of motion exercises to upper and lower body 15 minutes a day for 3-6 days a week and transfer from the bed to the wheelchair and back to bed with assistance 3-6 days a week. On 5/11/26 at 8:21 AM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated that resident 1 was last seen for therapy in November 2025. The DOR stated that resident 1 was seen two times a week for 30 days. The DOR stated that resident 1 was discharged from therapy because she had met her therapy goals and was referred to the Restorative Nursing Program on 11/28/26. On 5/11/26 at 11:59 AM, an interview was conducted with Restorative Nursing Assistant (RNA) 1. RNA 1 stated that resident 1 was a heavy sleeper and he had a hard time waking her up to perform her active range of motion exercises and transfers. RNA 1 stated that if resident 1 was sleeping he would not perform exercises or transfers with her. RNA 1 stated that resident 1 had never refused doing her exercises and transfers but he did document that she refused or was not available when he was unable to wake her up if she was sleeping. RNA 1 stated that he would tell the RNA nurse that resident 1 felt sick or was sleeping and the nurse should be documenting the refusals and the reasons why. RNA 1 stated that he thought the last time he went in and performed exercises or transfers with resident 1 was maybe one month ago, but he could not recall. RNA 1 stated that resident 1 was unable to move herself in bed or perform transfers on her own.On 5/11/26 at 12:37 AM, a follow-up interview was conducted with resident 1. Resident 1 stated that the facility counted her showering as restorative because it was difficult for her to get up and out of bed. Resident 1 stated that when she had done physical therapy, she was able to get herself repositioned in bed and transferred to her wheelchair. On 5/13/26 at 11:03 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 1 typically required an extensive assist for repositioning and was dependent for transfers. The DON stated that resident 1 was placed in the RNA program after she was discharged from therapy for reaching her goals with transfers. The DON stated that based on current documentation, resident 1 needed a substantial/maximum assist for transfers and somewhere in between a partial to maximum assist with bed mobility. The DON stated that based on when resident 1 was discharged from physical therapy, resident 1 had declined in function with transfers and mobility.

Based on observation, interview, and record review, the facility did not treat each resident with respect, dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, for 5 out of 54 sampled residents, staff were not provided education on how to attach a resident's prosthetic arm, residents complained of having incontinent episodes while waiting for staff to answer call lights, when the staff member tried to empty the ostomy bag it detached, resulting in scattered stool everywhere, and a resident was seated at a table that was at her chin height for breakfast. The first example was cited at harm. Resident identifiers: 21, 34, 63, 86, and 113.Findings included:1. Resident 63 was admitted to the facility on [DATE] with diagnoses which included other lack of coordination, weakness, blindness in right eye category 3, blindness in left eye category 3, and acquired absence of left upper limb above elbow.On 5/6/26 at 2:07 PM, resident 63 stated during a Resident Council meeting that he would like staff to be trained on how to put on his arm. Resident 63 stated that facility nurses had told him they do not know how to put on his prosthetic arm. Resident 63 stated that he was out of luck when there was no one at the facility to help him.On 5/11/26 at 10:53 AM, resident 63 asked if the surveyor could help him put his arm on. Resident 63 stated that he had asked his nurse and she never came back to help him. On 5/11/26 at 10:56 AM, an observation was made of resident 63 asking the Infection Preventionist (IP) nurse to help him put his arm on. The IP was observed to wheel resident 63 to the therapy room without attaching his arm.On 5/13/26 at 8:09 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated he was the nurse for resident 63 that day. RN 1 stated that he had only been at the facility a couple of times and did not know how to put on resident 63's prosthetic arm. RN 1 stated that he thought that the therapy department put on resident 63's arm. On 5/13/26 at 8:13 AM, an interview was conducted with CNA 8. CNA 8 stated that he did not know how to put resident 63's prosthetic arm on. CNA 8 stated that resident 63 had to go to therapy to have them assist him with his arm.On 5/13/26 at 8:58 AM, an interview was conducted with the Physical Therapist (PT). The PT stated that the facility had an on-call therapist available on the weekends that could come into the facility if there was a new admission that needed an evaluation. The PT stated that resident 63 was not able to put on his prosthetic arm and therapy had been doing it for him. The PT stated that the therapy department should probably train some CNAs on how to put on resident 63's prosthetic arm. The PT stated that resident 63 probably did not wear his prosthetic arm on the weekends because no therapy staff were available to assist him.On 5/13/26 at 9:06 AM, an interview was conducted with resident 63. Resident 63 stated that he was not able to put his prosthetic arm on by himself. Resident 63 stated that he was unable to wear his arm on the weekends because there was not any staff that could assist him with putting the prosthetic arm on. Resident 63 stated that he would like to discharge from the facility and go home, but he needed to know how to use his prosthetic arm and he could not learn when he did not wear it. On 5/13/26 at 11:03 AM, an interview was conducted with theDirector of Nursing (DON). The DON stated that resident 63 was participating in physical and occupational therapy. The DON stated that he thought that nursing staff and therapy staff assisted resident 63 with putting on his prosthetic arm. The DON stated that he was under the impression that therapy was in the facility on the weekends and they placed resident 63's prosthetic arm on.2. On 5/5/26 at 10:37 AM, an interview was conducted with resident 34. Resident 34 stated the call light wait times was Horrendous, and he had to wait 45 minutes for his call light to be answered. Resident 34 stated it made him feel not important when he had to wait for his call light to be answered. Resident 34 stated other residents started yelling out to get assistance and they got faster assistance. Resident 34 stated they need more staff or more people. Resident 34 stated he had a Foley Catheter since admission. Resident 34 stated he felt like he should just go home because all he did was lay here. Resident 34 stated staff did not come in and check on them every 2 hours unless he used the call light. Resident 34 stated if he was transferred to his chair, then he had to stay in it for 2 hours but that hurt his back because of herniated discs in his back because he could not sit in the chair very long. (Cross refer to F690)3. Resident 86 was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included aftercare following joint replacement surgery, fracture right femur, intervertebral disc disorders, type 2 diabetes mellitus, acquired absence of right leg below knee, morbid obesity, heart failure, presence of right artificial hip joint, hypertensive heart and chronic kidney disease. On 5/5/26 at 12:55 PM, an interview was conducted with resident 86. Resident 86 stated that when he pressed the call light it sometimes took forever to be answered. Resident 86 stated that he had therapy that was often delayed because he had to wait for staff assistance to get up. Resident 86 stated that he would push the call light and staff would give him a [NAME] excuse for not assisting him when he needed it. Why do they have a call light if they don't take care of the patient? Resident 86 stated that he was paying for services that he should be getting. Resident 86 stated that staff were always saying they were short staffed and they did not have enough time. Resident 86 stated that staff did not cut his fingernails so his wife had to come and do this for him. Resident 86 stated that his wife also had to help with incontinence care, cleaning feces and urine, because there was not enough staff to assist. Resident 86 stated that his wife was very upset about this and spoke with the Administration. The Administration came to speak with him and told him that they were working on fixing this but he had not seen any results yet. This is ridiculous. Resident 86 stated that he filed a grievance report with the Resident Advocate regarding these concerns. On 12/25/25, resident 86's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10/15, which would indicate a moderate cognitive impairment. The assessment documented that the resident was a substantial/maximal assistance with toileting, showers, bed mobility; partial/moderate assistance for upper body dressing; and dependent for lower body dressing and transfers. Resident 86's Care Plan had a focus area for alterations in Activities of Daily Living (ADL) function secondary to Right femur fracture that was initiated on 11/3/25. The interventions identified on the care plan included: 2-person assist with transfers - up to extensive assistance, assist in completing ADL tasks each day, encourage participation in Physical Therapy, and encourage use of call lights when ADL assistance is needed.The grievance log was reviewed and no documentation could be found of any complaints/concerns filed by resident 86.On 5/13/26 at 3:24, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 86 used a urinal and was incontinent of bowel. CNA 1 stated that resident 86 only required one staff for incontinence care as he was able to roll independently. CNA 1 stated that some days the facility was staffed well and others not so much. CNA 1 stated that the hallway that resident 86 resided on required more staff and was more needy. CNA 1 stated that after 6:00 PM it was crazy in the hallway. CNA 1 stated that it was difficult to complete tasks, and sometimes showers did not get completed due to low staffing. Even with a shower aide they sometimes don't get done. CNA 1 stated that incontinence care was done during rounds every 2 hours or as needed, and when it is super hectic a call light may be on for 15 minutes. CNA 1 stated that on the 300 hallway there was a resident that required 2 staff for incontinence care and it took an hour to provide so call lights were on for a longer time there. 4. Resident 113 was admitted to the on 8/27/25 and readmitted on [DATE] with diagnoses which included Crohn's disease, encounter for attention to ileostomy, chronic obstructive pulmonary disease, stage 3 chronic kidney disease, and congestive heart failure. On 5/5/26 at 9:21 AM, an interview was conducted with resident 113. Resident 113 stated the agency staff were terrible. Resident 113 stated that on one occasion she requested staff assistance with her ostomy bag at 1:30 PM when the staff member tried to empty the ostomy bag it detached, resulting in scattered stool everywhere. Resident 113 stated the nurse left her room. Resident 113 stated she yelled for someone walking by and after that person searched for the nurse, they discovered that the nurse had gone home. Resident 113 stated she laid in her stool until 2:15 PM, despite the fact that her call light was activated. Resident 113 stated another occasion a staff member went to empty her ostomy and refused to follow her instructions to use a basin. Resident 113 stated the staff emptied the contents of her ostomy bag into a disposal bag, tied it, and upon lifting the bag burst stool all over the immediate area. Resident 113 stated the stool got in her mouth and the staff member started laughing. Resident 113 stated the staff were trying to put a dirty sheet on the dirty bed then handed her wipes to clean herself up. Resident 113 stated that when she requested a shower, the staff replied that it was too late for her to get one. On 5/13/26, a Daily Skilled Charting assessment documented that resident 113 required supervision or touching assistance for toilet hygiene. The assessment defined toilet hygiene as The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.Resident 113's Care Plan had a focus area for having an ostomy that was initiated on 1/19/26. The interventions initiated on the care plan included: Ostomy care every shift and as needed, monitor ostomy site every shift for signs and symptoms of infection or skin breakdown, and change ostomy site as prescribed. On 5/13/26 at 9:39 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 113 required assistance emptying her ostomy bag and the clean up involved, and that resident 113 would let CNAs know when she needed assistance. On 5/13/26 at 1:13 PM, an additional interview was conducted with resident 113. Resident 113 stated that she required assistance emptying her ostomy bag, especially when she received infusions, because the tubing hindered the process. Additionally, resident 113 stated that once a CNA had unintentionally detached the ostomy bag during the emptying process, spilling the contents onto her and the bed. Resident 113 stated that the CNA left to get a towel, but did not return, so she activated the call light. Resident 113 stated that she waited over an hour covered in stool before a different CNA assisted her. Resident 113 reported that the stool caused a burning sensation where it contacted her skin.5. On 5/5/26 at 12:46 PM, a confidential resident interview was conducted. The resident stated they had to wait an hour to have their call light answered especially during shift change. The resident stated there were usually a lot of staff that called out before their shifts and they were short staffed. The resident stated he needed more empathy from the staff who cared for them. There was a strong urine odor in the room. 6. Resident 21 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy, heart failure, weakness and convulsions. On 5/7/26 at 8:00 AM, an observation was made of resident 21. Resident 21 was placed at a table that was at chin height. CNA 3 stated It's okay, we help her. Unit Manager (UM) 1 was observed to laugh. CNA 3 was observed to lock resident 21's brakes. A care plan dated 5/2/25 revealed resident 21 had alterations in ADL function secondary to weakness and impaired mobility. An intervention was to praise all efforts at self care. On 5/7/26 at 2:38 PM, an interview was conducted with CNA 3. CNA 3 stated she was an agency CNA. CNA 3 stated resident 21 went to the dining room for meals because she had a hard time swallowing and leaned to the side in the wheelchair. CNA 3 stated she prefers to have resident 21 upright in her chair. CNA 3 stated resident 21 used one of her hands to pick up finger foods. CNA 3 stated the table was really high for resident 21 but she usually put resident 21 at the shorter tables. CNA 3 stated resident 21's feet needed to remain elevated in the wheelchair. CNA 3 stated resident 21 struggled to eat at an angle at the shorter tables. On 5/7/26 at 2:56 PM, an interview was conducted with UM 1. UM 1 stated resident 21 ate in the dining room and was able to feed herself but sometimes needed assistance. UM 1 was observed to laugh and stated he noticed the table was too high for resident 21. UM 1 stated there were adjustable tables in the rehab so she needed one of those to best accommodate resident 21's table height so she can feed herself. (Cross refer to F725)

Based on observation, interview, and record review, for 1 out of 54 sampled residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not initiate orders for pain medication after it was ordered by a provider in a timely manner. This example will be cited at a harm level. Resident identifier: 34.Findings Included: Resident 34 was admitted on [DATE] with diagnosis that included acute kidney failure, obstructive and reflux uropathy, intracerebral hemorrhage, and encephalopathy. On 5/14/26 at 11:35, an interview was conducted with resident 34. Resident 34 stated that he had burning pain in his fingers and could not straighten them. Resident 34 stated that he also had pain in his lower back due to herniated discs, pain in his lower legs, and pain in his knee that he attributed to a meniscus tear. Resident 34 stated that his current pain level was a 7/10 and an acceptable level of pain was a 4/10. Resident 34 stated that the facility doctor just ordered Baclofen for him and it seemed to be helping his pain. Resident 34 stated that ice packs helped his knee pain but the facility would not give him that anymore because it needed a special order and involved monitoring. Resident 34 stated that he did not think they wanted to do the additional monitoring that would be needed with an ice pack. Resident 34 stated that his back pain could be very intense at times. Resident 34 stated that they only administered medication for pain and did not provide any other non-pharmological interventions for pain management. Resident 34 stated that he tells the nurse about his pain when they come to check on him.On 5/11/26 at 1:15 PM, a provider note documented that When asked how he is doing, [resident 34] reports that he is concerned about his pain. He states that his back doctor had planned to start him on baclofen, but unfortunately the order sheet was lost between the doctor's office and the facility. The provider will order baclofen today to address this gap in his care. When asked about any other changes or concerns, he expresses worry about long-term access to his medications and states that 'no one understands how much pain I am in.' On 5/11/26 at 3:00 PM, a progress note documented Resident c/o [complains of] left knee pain. Resident states hurting meniscus in the past prior to admission and it flaring up with pain at times. Resident requested to try anti-inflammatory like Voltaren gel. Provider notified. Provider gave new order for Voltaren 1% gel topical to left knee [4 times a day] PRN [as needed] for pain. Resident notified of new order.A communication form titled Clinic Visit/Progress Note and Orders was located in resident 34's medical record. The form documented that on 5/7/26, resident 34 was seen at a rehabilitation clinic for a follow up visit. The form documented that the rehabilitation provider ordered Increase Gabapentin to 600 mg [milligrams] TID [three times a day] and Start Baclofen 10 mg 2x [two times] per day It should be noted that the form was uploaded to resident 34's medical record on 5/11/26 at 2:53 PM. The form did not contain a notation to indicate that it had been addressed by a nurse or provider. Resident 34's medical record contained the following orders:a. Acetaminophen oral tablet 325 mg. Give 650 mg by mouth every 4 hours as needed for pain; Start date 2/13/26.b. Duloxetine Hydrochloride capsule delayed release particles 60 mg. Give 1 capsule by mouth one time a day for pain; Start date 3/31/26.c. Gabapentin (Neurontin) 100 mg. Give two capsules by mouth three times a day for pain; initial Start date 4/1/26.d. Baclofen oral tablet 10 mg. Give 10 mg by mouth every 12 hours as needed for muscle spasms; Start date 5/8/25.e. Voltaren External Gel 1 % (Diclofenac Sodium (Topical)). Apply to left knee topically as needed for pain four times daily PRN; Start date 5/11/26.The order to Increase Gabapentin to 600 mg TID was not located in resident 34's medical record.On 5/12/26 at 9:15 AM, a provider documented [resident 34] seen in an acute visit for increased arthritis pain. He has been started on Voltaren gel. He continues on gabapentin 200 mg by mouth three times a day for neuropathy. Continue acetaminophen for pain. Will monitor for improvement in pain. Continue to encourage activity. He feels he is doing well overall.On 5/13/26 at 1:44 PM, an interview was obtained with Registered Nurse (RN) 1. RN 1 stated he was an agency nurse. RN 1 stated that he reviewed the communication form upon a resident's return from an appointment, created a progress note detailing the information about the visit, updated the resident's primary provider, and entered any changed orders into the medical record. On 5/14/26 at 8:54 AM, an interview was conducted with the Assistant Director of Nursing (ADON) and Unit Manager (UM) 2. The ADON stated that staff sent a communication form with residents to all appointments for the provider to document any notes or new orders. The ADON stated that the floor nurse would receive the form when a resident returned to the facility, note any notes or new orders, contact the primary provider to approve the new orders, and create a progress note. The DON stated that primary providers had to coordinate and approve orders from specialists. The DON stated that if the floor nurse did not receive a communication form they contacted the clinic for further information. The ADON stated that sometimes the communication forms were misplaced during transport, or the provider gave the communication sheet to the resident instead of transportation. The ADON stated that the floor nurse or herself searched for the communication form if the resident returned without one, or they contacted the provider's office to obtain any information. The DON stated that because resident 34's communication form did not contain the date it was noted by a nurse before being scanned into the medical record, it was possible the form was misplaced or an agency nurse did not know the proper process for communications forms. UM 2 stated that resident 34 told the facility that the rehabilitation provider had ordered to start him on baclofen for pain, so she called the clinic and got an order for the baclofen. UM 2 stated that she asked the clinic specifically about the baclofen order, and was not aware of the order to increase Gabapentin to 600 mg TID. UM 2 stated she would contact resident 34's primary provider to ensure he was aware of the rehabilitation provider's order documented on the Clinic Visit/Progress Note and Orders form. On 5/14/26 at 1:03 PM, an interview was conducted with RN 8. RN 8 stated that resident 34 had complained of pain in his lower back. RN 8 stated that they would reposition resident 34 frequently to help relieve the pain. RN 8 stated they could administer Tylenol, Baclofen, and Voltaren gel to resident 34 as needed for the pain. On 5/14/26, the following order was created: Gabapentin Oral Tablet Give 600 mg by mouth three times a day for Pain management. It should be noted that the order was created seven days after resident 34's appointment on 5/7/26, when his rehabilitation provider sent the order to start 600 MG of Gabapentin TID.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were soiled, meat was being cut next to ready to eat foods and meal trays that were eaten from were placed in the same cart as meal trays that had not been served. Findings included:1. On 5/4/26 at 9:05 AM, an initial tour of the kitchen was conducted. The following was observed:a. The hand washing sink outside the kitchen had orange liquid splattered on the wall around it. b. Inside the ovens were soiled and there was a dried white and yellow substance on the side of it. c. There was a white substance of hard water build up on the dish machine. There were pieces flaking off of the white substance. 2. On 5/4/26 at 1:37 PM, an observation was made of the meal carts. There were meals that had not been served in the cart. A Certified Nursing Assistant (CNA) in the 300-400 hallway was observed to put a dirty tray from a resident room in the meal cart above the trays that had not been served. On 5/6/26 at 12:46 PM, an observation was made of the meal cart in the 700 hallway. Registered Nurse (RN) 7 was observed to remove a dirty tray from a resident room and place it in the meal cart above meal trays that had not been served. CNA 10 stated to RN 7 that dirty trays needed to be placed on top of the meal cart and not in it. 3. On 5/4/26 at 1:24 PM, an observation was made of the ice and water cart at the 300-400 hallway nurses station. The cart was observed to have hair and debris on the shelves underneath the water and ice. 4. On 5/7/26 at 7:51 AM, an observation was made of the dining room. The tables and floor were dirty. At 8:06 AM, an observation was made of the housekeeping staff with their cleaning carts in the dining room where residents were eating. 5. On 5/7/26 at 8:16 AM, an observation was made of the meal cart labeled R2. There was a dried liquid substance inside and on the bottom. There were meal trays that had not been delivered to residents inside . 6. On 5/11/26 at 12:33 PM, an observation was made of the dining room. The floor was sticky and dirty. 7. On 5/11/26 at 12:37 PM, a follow up kitchen tour was conducted. The following was observed:a. The handwashing sink outside of the dining room had dried liquids around the sink and on the walls and baseboards.b.The dish machine had large amounts of a white substance that was hard water build up. c. Behind the shelves that stored clean dishes in the dish room was a broken plate with debris. d. An observation was made of [NAME] 1 cutting raw pork tenderloin on a white cutting board with a black handled knife. On the same table next to the raw meat Dietary Aide (DA) 2 was observed to be putting brown sugar into small cups. [NAME] 1 was observed to be washing the meat off in the sink with ready to serve drinks in the same sink. A sign was observed on the refrigerator that revealed Prevent cross contamination Use CORRECT COLOUR CODED CHOPPING BOARDS & KNIVES Red was raw meat and white was bakery & (and) dairy. e. Under the 3 compartment sink near the trayline there was a brown colored dried substance that had dripped down the wall. There were crumbs and debris along the floor next to the wall. f. Behind the mixer, slicer, and toaster there was a window that had a brown substance on the window seal. In the window track there were dead bugs, crumbs, and debris. The wall next to the slicer had a dried liquid substance down the wall. There was dust on the wall above the window. g. At 1:23 PM, an observation was made of the Dietary Manager (DM) coughing. The DM was by the trayline and did not cover her mouth. On 5/11/26 at 2:21 PM, an interview was conducted with the DM. The DM stated the dining room had not been cleaned and she had been working with housekeeping to clean from the table top to the floor and dietary staff cleaned the top of the tables up. The DM stated the dining room needed to be cleaned. The DM stated the dish machine repair company had provided a chemical to remove the hard water from the dishmachine and it was used weekly and looked better. The DM stated meat should be cut on the red cutting board and not next to ready to eat foods. The DM stated that food trays needed to be delivered and then picked up and put back into the meal cart. The DM stated dirty meal trays should not be placed in carts with trays that had not been served.

Based on interview and record review the facility failed to follow their written policies and procedures for feedback, data collection systems, monitoring to develop and implement appropriate plans of action to correct identified deficiencies. Specifically, there were repeat deficiencies and systemic failures were not identified during the Quality Assurance and Performance improvement (QAPI). Findings included:On 5/4/26 through 5/14/26, it was identified residents were harmed in the following deficiencies F550, F684, F690, F697, and F745. Deficiencies cited on the previous survey on 4/17/24 and recited during the current survey included F550, F559, F584, F676, F677, F689, and F812. The facility provided a policy titled Quality Assurance and Performance Improvement that was last reviewed/revised on 4/2025. The policy stated It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The policy included the policy explanation and compliance guidelines and program development guidelines. On 5/14/26 at 11:17 AM, an interview was conducted with the Administrator. The Administrator stated QAPI meetings were scheduled monthly and the last meeting was 4/8/26. The Administrator stated the company had a structured format for QAPI that included department managers adding concerns to a QAPI document and then the QAPI team followed a lengthy list of how to address the identified concerns. The Administrator stated the QAPI had identified issues regarding staffing and the need for more permanent facility staff and less agency staff. The Administrator stated staffing was determined by 1.1 hours of nursing hours per patient ratio. The Administrator stated if there were heavy (higher acuity resident) hallways or one on one supervision of a resident, then staffing was adjusted. The Administrator stated QAPI had identified late meals, snacks not provided, and cleanliness of the facility. The Administrator stated he had been the Administrator for 6 weeks and had not been able to fully address all the identified issues in QAPI but was working on them. (Cross refer to F550, F559, F584, F676, F677, F689, and F812)

Based on observation, interview and record review, for 2 out of 54 sampled residents, the facility did not provide at least three meals daily with no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may lapse between a substantial evening meal and breakfast the following day if a resident group agreed to this meal span. Specifically, there was 15 hours between when dinner and breakfast was served and there was no substantial evening snack being offered. Resident Identifiers: 31 and 113. Findings included:The Meal Service Times were posted as breakfast at 8:00 AM - 9:00 AM, Lunch 12:00 PM - 1:00 PM and Dinner 5:00 PM - 6:00 PM. On 5/4/26 at 11:39 AM, an interview was conducted with resident 31. Resident 31 stated snacks were hit and miss if the staff remembered to bring out snacks. Resident 31 stated the snacks were usually saltines or club crackers and graham crackers. On 5/5/26 at 9:21 AM, an interview was conducted with resident 113. Resident 113 stated she was occasionally offered a snack at night. Resident 113 stated she was offered saltine crackers or a rice crispy treat last night. On 5/6/26 at 1:49 PM, during the Resident Council meeting multiple residents stated that they had not been receiving snacks. One resident voiced concerns over residents not receiving snacks with their names on them. Residents stated that staff members were eating resident snacks off of the cart.On 5/6/26 at 1:57 PM, the Dietary Manager (DM) stated that someone had been raiding the snack carts and all of the snacks were gone. The Dietary Manager stated that the snack cart got locked in the medication room and then staff were unavailable to open the medication room for residents to retrieve their snacks. The Dietary Manager stated that there had been a breakdown in communication between Certified Nursing Assistants (CNAs) and the kitchen staff with regards to snacks.On 5/11/26 at 2:21 PM, an interview was conducted with the DM. The DM stated the kitchen sent out a snack cart at 8:00 PM and started sending specific snacks to residents with weight issues. The DM stated the snack cart had cottage cheese, fruit, puddings, chips, crackers, and sandwiches. The DM stated she asked residents about snacks and learned they were not being provided. The DM stated a resident followed the dietary staff one night and took a picture of a staff member taking snacks from the cart. The DM stated she was working with nursing staff to have 1 person assigned to make sure the residents were served snacks. The DM stated usually there were greek yogurt, hardboiled eggs, and sandwiches. The DM stated residents should be offered more than crackers as a nightly snack.

Based on observation and interview, for 12 of 54 sampled residents, the facility did not provide each resident with food and drink that was palatable, attractive and at a safe and appetizing temperature. Specifically, residents complained of food quality and a test tray was not palatable. Resident identifiers: 1, 5, 9, 31, 34, 38, 74, 111, 113, 123, 129 and 156. Findings included:RESIDENT INTERVIEWS1. On 5/5/26 at 12:46 PM, an interview was conducted with resident 5. Resident 5 stated food needed to be worked on because he required gluten-free food. Resident 5 stated that the food supplier did not have gluten-free foods. Resident 5 stated when gluten was cross contaminated into his food he got a stomachache. Resident 5 stated he could not eat very much because of the food quality. 2. On 5/5/26 at 10:37 AM, an interview was conducted with resident 34. Resident 34 motioned a thumbs down when asked about the food. Resident 34 stated he had to order through the door dash 1 to 2 times per week because he could not eat the food. Resident 34 stated there needed to be more hispanic foods. Resident 34 stated that staff asked for his preferences but had not been provided his preferences. 3. On 5/4/26 at 2:34 PM, an interview was conducted with resident 38. Resident 38 stated the food was not the best and the kitchen was out of food items a lot. Resident 38 stated they offer sandwiches that were not edible. Resident 38 stated the food was stale or the brown sugar was hard as a rock and the oatmeal was a blob. 4. On 5/4/26 at 10:39 AM, an interview was conducted with resident 9. Resident 9 stated that the kitchen had a shoestring budget and frequently did not have items in stock, stating that there was no milk available the last two days. Resident 9 stated that the inconsistency of food availability had caused her to hoard non-perishable food in her room. Resident 9 stated that she frequently ordered off the alternative menu because scheduled entrees frequently had too much salt and pepper, but she found the alternative food menu limited and repetitive. Resident 9 stated that the alternative menu was similar to food that could be bought at a mini-market, such as corndogs, hot dogs, chicken tenders, and macaroni and cheese. Resident 9 stated she had requested to have some pasta noodles cooked for her so she could eat it with a small container of marinara dipping sauce she had in her room, but was told they could not accommodate that. Additionally, resident 9 stated that the kitchen will frequently go off the rails and send whatever. Resident 9 stated that last week she ordered macaroni and cheese, but she was served green beans, meatballs, potatoes, and marinara sauce. Resident 9 reported that when she requested corrections to her meals, kitchen staff told her and her Certified Nursing Assistants (CNAs) that they did not take food requests during meal time. Resident 9 stated that the kitchen required her to wait until they completed the meal service before they would address her requests. Resident 9 stated she would email the Dietary Manager (DM) with concerns and that the DM would reply to her emails, but other than that communication with the kitchen was poor. Resident 9 stated that it was difficult to talk directly to the DM because her office was located in the kitchen but the hallway to the kitchen was frequently blocked by the meal delivery carts.5. On 5/5/26 at 9:21 AM, an interview was conducted with resident 113. Resident 113 stated the food was terrible and her husband brought her food daily. Resident 113 stated she was so fed up by the food one day she went down to the kitchen because she was unable to eat certain foods because of her ostomy but the kitchen staff continued to send it. Resident 113 stated she had to decide to have the meals sent to her and she would eat what she could from the tray. Resident 113 stated she was served fried eggs that were not cooked and slimy. Resident 113 stated there was a corn rice mix served the day before and her husband took off the dome and said Good Lord what is that. Resident 113 stated it looked like a pile of vomit because it was pink, had lumps and was slimy. On 5/13/26 at 1:13 PM, an additional interview was conducted with resident 113. Resident 113 stated that for one meal, she ordered the chicken pot pie entree but she received a small pie with apple filling and uncooked oats on top. Resident 113 stated on another occasion she ordered a loaded hot dog, but she received a cold hot dog, a slice of bread, and no toppings or condiments. 6. On 5/4/26 at 9:54 AM, an interview was conducted with resident 123. Resident 123 stated the kitchen was always out of something and this morning there was no milk. Resident 123 stated they were always out of food alternatives . Resident 123 stated when ice cream was served it was half melted. Resident 123 stated the kitchen staff have not been very nice lately if you ask for additional food. 7. On 5/4/26 at 9:26 AM, an interview was conducted with resident 111. Resident 111 stated that the food varied with flavor. Resident 111 stated that the food was luke warm to cold by the time she received it and she ate in the dining room. 8. On 5/4/26 at 9:46 AM, an interview was conducted with resident 74. Resident 74 stated that he could not tell what kind of sandwich he was served the night before. Resident 74 stated the package had a date on it, but the meat was unidentifiable and he refused to eat it. 9. On 5/4/26 at 11:39 AM, an interview was conducted with resident 31. Resident 31 stated that the kitchen was out of milk this morning and this really irritated him. Resident 31 stated that the alternative menu always runs out and he was unable to have a hamburger. 10. On 5/4/26 at 2:35 PM, an interview was conducted with resident 1. Resident 1 stated that the food looked yucky. Resident 1 stated that her food was served to her warm and her soup was always cold. 11. On 5/5/26 at 8:23 AM, an interview was conducted with resident 156. Resident 156 stated that the food sucks and was just warm when he received it. 12. On 5/5/26 at 8:45 AM, an interview was conducted with resident 129. Resident 129 stated that the food had been awful and the alternative menu items were never available. On 5/4/26 at 9:05 AM, an interview was conducted with the DM. The DM stated they ran out of milk for breakfast because a staff member used the milk to make puddings. The DM stated pudding should have been made with heavy cream to make it fortified. The DM stated the milk delivery was scheduled for 5/5/26. The DM stated they served chocolate milk instead of regular milk. On 5/11/26 at 12:32 PM, the menu posted in the dining room was bacon cheeseburger on bun, crispy fries, lettuce/tomato/pickle, assorted juice, milk/beverage. A test tray was obtained from the kitchen. The cheeseburger was 122.1 degrees Fahrenheit and did not have bacon on it. There were onion rings 107.2 degrees Fahrenheit and had a soggy texture. The lettuce/tomato/pickles were warm. The cheeseburger was pressed meat and had a chewy texture. The chocolate milk was 45.6 degrees Fahrenheit. On 5/11/26 at 2:21 PM, an interview was conducted with the DM. The DM stated if a resident had complaints they were able to email her. The DM stated not a lot of residents had access to email so they were talking about installing a doorbell to the kitchen to get her attention because meal carts were in front of her door. The DM stated residents were also able to send their CNA or nurse to talk with the kitchen staff. The DM stated she cooked special meals, working with garnishing, and had sent pictures for marketing but they needed to work on quality. The DM stated the appearance of food was so important. The DM stated she sold out of all the new items on the alternative menu. The DM stated there was bacon on the last 3 cheeseburgers served.It should be noted the test tray was the last tray plated and there was no bacon on the burger.

Based on observation, interview, and record review, for 3 out of 54 sampled residents, the facility did not have menus that were prepared in advance and followed. Specifically, the menu listed potato salad was to be served, but residents were served chips. In addition, the menu had a bacon cheeseburger that did not have bacon served on it. Residents were served chocolate milk because the facility was out of milk. Resident identifiers: 4, 38, and 123.Findings included:On 5/4/26 at 9:05 AM, an observation was made of chocolate milk being placed on resident trays. There was no regular milk. An interview was conducted with the Dietary Manager (DM). The DM stated they ran out of milk because a staff member used the milk for pudding over the weekend. The DM stated chocolate milk was provided to residents. The menu on 5/4/26 listed breakfast as a choice of hot or cold cereal, scrambled eggs, iced mini cinnamon roll, tropical fruit, and assorted juice milk/beverage. The lunch was a meatball sub sandwich, homemade potato salad, pickled beets, assorted juice, and milk/beverage.On 5/4/26 at 9:54 AM, an interview was conducted with resident 123. Resident 123 stated the kitchen was always out of something. Resident 123 stated that he did not get milk for breakfast and he thought the residents were always supposed to get milk. Resident 123 stated the alternate menu was always out of something and not available.On 5/4/26 at 12:18 PM, an observation was made of the lunch meal. Residents with a mechanical soft diet order were served meatball sandwiches with marinara sauce, mashed potatoes and gravy with beets if they were a mechanical soft. If the resident had a regular diet texture they were served the sandwich, beets and chips. Resident 4 was observed to be served a meatball sandwich with no marinara sauce, mashed potatoes, and gravy with beets. Resident 4 was not provided a substitution for the marinara sauce. Resident 4's diet order was a liberal renal diet regular texture, thin consistency, for soft diet. It should be noted that the diet order was regular and soft. On 5/4/26 at 2:34 PM, an interview was conducted with resident 38. Resident 38 stated that it happened a lot that food items were not available. Resident 38 stated the kitchen would run out of hamburgers all the time. The menu for 5/11/26, at lunch was a bacon cheeseburger on a bun, crispy french fries, lettuce/tomato/pickle, assorted juice, and milk/beverage. A test tray was obtained on 5/11/26 at 1:30 PM, there was a cheeseburger with a bun, lettuce/pickle/tomato, onion rings and juice served. There was no bacon on the cheeseburger. On 5/11/26 at 2:21 PM, an interview was conducted with the DM. The DM stated when there was a meal substitution, the cook needed to contact the DM to determine the most accurate substitute. The DM stated they wrote the substitution in the book for the Registered Dietitian to approve monthly. The DM stated the potato salad was not prepared the day before and was not at the proper temperature to serve on 5/4/26. The DM stated chips were the closest substitute they had available.The DM stated they ran out of fries so they substituted onion rings at the end. The DM stated resident 4 should have been provided a substitution for the marinara sauce. The DM confirmed that residents' cheeseburgers should have included bacon on 5/11/26, stating she saw it being put on the last three meals plated. It should be noted the test tray was the last tray plated and there was no bacon on the cheeseburger.

Based on observation, interview, and record review, for 7 out of 54 sampled residents, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. In addition, the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, there were observations of late meals, residents had complaints regarding insufficient staff and late meals, and residents voiced complaints in the resident council meetings regarding late meals. Resident identifiers: 1, 9, 38, 82, 110, 123, and 127. Findings included:On 5/4/26 at 11:56 AM, the meal times were observed to be posted in the dining room. The meal times were breakfast service 8:00 AM - 9:00 AM, lunch service 12:00 PM - 1:00 PM, and dinner service 5:00 PM - 6:00 PM. On 5/4/26 at 12:40 PM, an observation was made of the Minimum Data Set (MDS) Coordinator in the dining room serving drinks to residents when resident 110's family member asked for a food item. The MDS Coordinator stated she did not usually help with dining as much as she was that day and she did not know if she could get the food item. On 5/4/26 at 1:10 PM, resident 82 in room [ROOM NUMBER] asked where his tray was. Certified Nursing Assistant (CNA) 6 stated his tray was coming. An interview was immediately conducted with CNA 6. CNA 6 stated resident 82 started asking for lunch about 10:00 AM. CNA 6 stated if there was something with wheels that went by in the hallway resident 82 would ask about a meal. CNA 6 stated he was redirected when that happened. Resident 82 received his meal tray at 1:21 PM. On 5/4/26 at 1:42 PM, the last hall tray was delivered to room [ROOM NUMBER].On 5/7/26 at 9:10 AM, the last hall tray was delivered to room [ROOM NUMBER]. On 5/11/26 at 1:25 PM, the last hall tray was delivered to room [ROOM NUMBER]. RESIDENT INTERVIEWS1. On 5/4/26 at 10:39 AM, an interview was conducted with resident 9. Resident 9 stated that when she addressed the kitchen staff about her meal concerns, they told her there was not enough staff or resources to accommodate her requests.2. On 5/4/26 at 3:14 PM, an interview was conducted with resident 127. Resident 127 stated meals were really late. Resident 127 stated he was served breakfast between 9:00 - 9:30 AM, and dinner was usually not served until 6:30 PM. Resident 127 stated that residents in the 500, 600, and 700 halls were able to get their meals sooner because they paid more. 3. On 5/4/26 at 2:35 PM, an interview was conducted with resident 1. Resident 1 stated she was not served lunch until 1:45 PM that day. Resident 1 stated dinner was not served until 7:30 PM and late meals had been going on for months. 4. On 5/4/26 at 2:34 PM, an interview was conducted with resident 38. Resident 38 stated that dinner was served sometimes at 8:00 PM and all meals were served really late. Resident 38 stated if she had an appointment scheduled she had to ask the kitchen to make her meal first so she was able to make her appointments because the meals were served late. 5. On 5/4/26 at 9:54 AM, an interview was conducted with resident 123. Resident 123 stated dinner was served late at 7:00 PM or 8:00 PM, and lunch was served at 2:00 PM because he was in the last hall to be served. Resident 123 stated he frequently had to pass on an activity because his lunch was not there. RESIDENT COUNCILResident Council notes were reviewed for March 2026. Concerns were noted for late meal deliveries.Resident Council notes were reviewed for April 2026. Concerns were noted for meal deliveries late at times and some items missed on requests.On 5/11/26 at 2:21 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the prior administrator stated that he wanted the residents who required one on one assistance to be plated and delivered first which was about 10 to 15 minutes before the dining room. The DM stated the dining room should be served at the scheduled meal times of 8:00 AM, 12:00 PM, and 5:00 PM. The DM stated after the dining room was served staff began working on the first rehab cart. The DM stated that 80% of the residents ate their meals in their room. The DM stated the kitchen staff had an additional 15 minutes past the posted meal times to serve the hall trays. The DM stated in October 2025 the meals were three hours late so the time had improved.

Based on observation, interview and record review, for 4 out of 54 sampled residents, the facility did not prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and naso-pharyngeal ulcers. Specifically, residents were observed to be laying flat while tube feedings were being infused. Resident identifiers: 8, 130, 155 and 166. Findings included:1. Resident 166 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, pneumonia due to klebsiella and protein-calorie malnutrition. On 5/6/26 at 10:50 AM, an observation was made of resident 166. Resident 166 was observed to be elevated at less than 30 degrees and had slid down in bed. There was no degree indicator on the bed. Resident 166's feet were against the footboard. Resident 166 had Peptamin AF infusing at 85 milliliters (mL) per hour and water 30 mL every 4 hours. A care plan dated 5/4/26 revealed resident 166 required a feeding tube which placed them at risk for medical complications. An intervention was to elevate the head of bed at least 30 degrees while the feeding tube was running and for at least 30 minutes after. On 5/6/26 at 11:55 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated prior to infusing a tube feeding he made sure the head of the bed was at least 30 degrees. RN 6 stated the resident's head of bed needed to be above a 30 degrees angle to prevent aspiration because if laying flat the formula could go into the resident's lungs. RN 6 stated he eyeballed the 30 degree angle. At 1:10 PM, RN 6 observed resident 166 and stated the head of the bed should be elevated more. RN 6 was observed to elevate the head of bed slightly. 2. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic respiratory failure, dysphagia following cerebral infarction, gastrointestinal hemorrhage, and tracheostomy status. On 5/4/26 8:10 AM, an observation was made of resident 8. Resident 8 was observed to be elevated less than 30 degrees while a tube feeding was actively infusing. A care plan dated 5/7/25 revealed resident 8 required a feeding tube which placed them at risk for medical complications. An intervention was to elevate the head of bed at least 30 degrees while the feeding tube was running and for at least 30 minutes after. 3. Resident 130 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, protein calorie malnutrition, dysphagia, metabolic encephalopathy, tracheostomy status, dependence on ventilator, and gastrostomy status, On 5/4/26 8:08 AM, an observation was made of resident 130. Resident 130 was observed to be laying flat in bed while a tube feeding was actively infusing. A care plan dated 6/5/25 revealed resident 130 required a feeding tube which placed them at risk for medical complications. An intervention was to elevate the head of bed at least 30 degrees while the feeding tube was running and for at least 30 minutes after. 4. Resident 155 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, chronic respiratory failure with hypoxia, lobar pneumonia, chronic obstructive pulmonary disease, irritable bowel syndrome, stage 4 chronic kidney disease, and epilepsy. On 5/6/26 at 10:11 AM, an observation was made of resident 155. Resident 155 was observed to be laying flat in bed while a tube feeding was actively infusing. On 5/6/26 at 11:11 AM, an observation was made of resident 155. Resident 155 was observed to be laying flat in bed. The bed's degree indicator was between 0 and 10 degrees. Resident 155 had Glucerna with Carbsteady infusing at 50 mL per hour and water 100 mL every 1 hour. A care plan dated 5/1/26 revealed resident 155 required a feeding tube which placed them at risk for medical complications. An intervention was to elevate the head of bed at least 30 degrees while the feeding tube was running and for at least 30 minutes after. On 5/6/26 at 12:08 PM, an interview was conducted with RN 7. RN 7 stated prior to starting a resident's tube feeding she made sure the resident was sitting up at about a 30 degrees angle. RN 7 stated if the resident was unable to tolerate a 30 degree angle then she notified the doctor. RN 7 stated she wanted to have the resident at a 30 degree angle to prevent aspiration. RN 7 stated she honestly did not know what a 30 degree angle was and she would just eyeball it. A concurrent observation was conducted of resident 155 in her bed with the bed laying flat. RN 7 stated resident 155 was laying flat because she moved around a lot and did not like to be at a 30 degree angle. RN 7 stated resident 155 should be checked on by staff every 1 to 2 hours for positioning. RN 7 stated she did not know if CNAs knew to adjust residents if the resident was laying less than 30 degree angle when a tube feeding was infusing. RN 7 stated she would expect CNAs to adjust residents to a 30 degree angle. On 5/6/26 at 12:54 PM, an interview was conducted with CNA 7. CNA 7 if a resident had a tube feeding infusing, they made sure the resident was at a 45 degree angle with the bed lowered to the floor. CNA 7 stated if a resident did not have a 45 degree angle, they would tell the nurse or adjust the resident. CNA 7 stated if a resident was laying flat, that it Would be bad, very bad they could aspirate and choking isn't fun. CNA 7 stated he had been to see resident 155 and she was confused. CNA 7 stated resident 155 would not be able to use the bed controls. CNA 7 observed resident 155 and resident's head of bed was elevated but resident was folded over in bed with her head at her waist. CNA 7 stated they kept the door open in order to watch resident 155's positioning while the tube feeding was infused. On 5/6/26 at 12:45 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that residents needed to be elevated between 30 and 90 degrees while a tube feeding was infused to prevent nausea, vomiting, and aspiration pneumonia. UM 1 stated that if a bed does not have a degree indicator on it staff will eyeball it to ensure the bed was elevated more than 30 degrees. UM 1 stated that he preferred the bed to be elevated closer to 90 degrees, but if the resident was sleeping the minimum the bed can be lowered was 30 degrees. UM 1 stated that agency staff were given a verbal reminder of tube feeding procedures and that an agency binder containing the tube feeding procedures were at every nurses station. UM 1 stated that he was unaware of any residents with tube feedings who have been treated or hospitalized with aspiration pneumonia in the last 4 years while he has worked at the facility. On 5/6/26 at approximately 1:00 PM, observations were made with UM 1 of the agency binders, which had no information on tube feeding procedures. UM 1 verified that the information was not located in the binders. On 5/6/26 at 2:48 PM, an additional interview was conducted with UM 1. UM 1 stated that the agency binder provided a website and password to the facility policies, including feeding tube procedures.

Based on observation, interview, and record review, the facility did not provide a safe, clean, comfortable and homelike environment. Specifically, for 2 out of 54 sampled residents, residents complained of a dirty environment, the handicap accessible door was broken to the courtyard, hallways were soiled, and the dining room was not cleaned between meals. Resident identifiers: 110 and 113. Findings included:1. On 5/5/26 at 9:21 AM, an interview was conducted with resident 113. Resident 113 stated her room was not cleaned for a week. Resident 113 stated her room was cleaned twice after the State Survey Agency entered the facility. 2. On 5/4/26 at 3:01 PM, an interview was conducted with resident 110's family member. The family member stated the window and blinds were dirty and had never been cleaned. The family member stated she left a kleenex under the bed on 4/30/26, and it was still there on 5/4/26. The family member stated there was no patio area for non-smokers to enjoy the outside. The family member stated there was a tiny courtyard off the rehab dining room but it was not handicap accessible. The family member stated the button did not work and once they went out they could not get back into the building. The family member stated she had told the Administrator multiple times. On 5/6/26 at 11:53 AM, an observation was made of the handicap exit into the courtyard from the rehab dining room. The button was pushed for the door to open and the door did not open. The door was unlocked. 3. On 5/4/26 at 9:40 AM, an observation was made of the 100 hallway. There were stains and debris on the floors. The side rails and molding next to the door frames were covered in dust and dirt. 4. On 5/7/26 at 8:46 AM, the 300 hallway was observed. There were stains and debris on the floor, side rails were dirty with stains, and the molding next to the door frames were covered in dust and dirt.5. On 5/7/26 at 7:32 AM, the dining room tables were observed with food debris on them and on the floor underneath them. On 5/11/26 at 7:51 AM, the dining room tables were observed to be soiled with debris, the floor was dirty, and there was an unidentified substance spilled on the floor. On 5/11/26 at 12:33 PM, the floor in the dining room was observed to be dirty. On 5/11/16 at 2:21 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she had been going back and forth with housekeeping on what needed to be cleaned in the dining room. The DM stated the dietary staff cleaned from the table top up and housekeeping cleaned from the table top down. The DM stated it was awful residents had to eat at dirty tables.

Based on observation, interview, and record review, for 3 of 54 sampled residents, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, Enhanced Barrier Precautions (EBP) were not implemented for a resident receiving wound care, and an observation was made of cross-contamination between residents during meals. Additionally, a resident's tube feeding formula was not capped when disconnected from the resident. Resident identifier: 2, 4, and 8. Finding Included:1. Resident 2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included neutropenia due to infection, cellulitis of right lower limb, cellulitis of left axilla, unspecified open wound right lower leg, and non-pressure chronic ulcer of other part of right foot with fat layer exposed. On 5/4/26 at 8:50 AM, an observation was made of resident 2's room. There was no EBP signage on the door and no Personal Protective Equipment (PPE) available for use. On 5/4/26 at 3:04 PM, an interview was conducted with resident 2. Resident 2 stated that her right leg had cellulitis and required daily bandage changes. Resident 2 stated that she wore briefs because she was not able to make it to the bathroom. Resident 2 stated that nursing staff do not come in and change her briefs and that she had to do that herself. On 5/5/26 at 8:10 AM, an observation was made of resident 2's room. There was no Enhanced Barrier Precaution signage on the door and no Personal Protective Equipment (PPE) available for use. On 5/5/26 at 3:15 PM, an observation was made of resident 2's room. There was no Enhanced Barrier Precaution signage on the door and no PPE available for use. On 5/6/26 at 7:54 AM, an observation was made of resident 2's room. There was an Enhanced Barrier Precautions sign and PPE was available for use. A review of resident 2's physician orders revealed an order on 3/8/26 for Enhanced Barrier Precautions- Related to wound care. On 5/6/26 at 11:11 AM, an interview was conducted with Certified Nursing Assistant (CNA) 9. CNA 9 stated that she was the CNA for resident 2 and that she did not know that resident 2 was on Enhanced Barrier Precautions and did not know why she would need them. CNA 9 stated that she believed that resident 2 was continent. On 5/6/26 at 1:07 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 2's Enhanced Barrier Precautions were lifted 2 weeks ago. LPN 2 stated that staff only needed Enhanced Barrier Precautions if a resident had COVID, catheters, or wounds. LPN 2 stated that resident 2 did have a wound on her leg and that might possibly be why she was on Enhanced Barrier Precautions. On 5/11/26 10:33 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated a resident was placed on Enhanced Barrier Precautions upon if they had an increased infection risk, such as a wound or an invasive line, including a PICC line, a catheter, or an open system dialysis port. The IP stated that Enhanced Barrier Precautions signs and instructions were posted on the outside the resident's door and PPE would be placed in an over the door storage hanger or in a chest of drawers right next to the resident's door. The IP stated that infection control protocols require staff to wear PPE if they are going to provide intimate contact with a resident on Enhanced Barrier Precautions. On 5/13/26 at 11:03 AM, an interview was conducted with the Director of Nursing. The DON stated that resident 2 was on Enhanced Barrier Precautions related to chronic wounds. The DON stated that resident 2 had an order for Enhanced Barrier Precautions. The DON stated that the infection nurse was overseeing the infection control program and should have posted signage and provided PPE. 2. Resident 4 was admitted to the on 1/16/26 with diagnoses which included category 5 blindness to the right and left eyes, stage 5 chronic kidney disease with heart failure, and type 2 diabetes mellitus. On 5/4/26 at 12:29 PM, an observation was made in the dining room while a meal was being served. After resident 4's tray had been served a female resident, seated next to resident 4, was observed opening a packet of butter and using a fork that she had used to feed herself to mix the butter into resident 4's mashed potatoes. On 5/14/26 at 11:48 AM, an interview was conducted with the DON. The DON also stated that infection control protocols require staff to perform hand hygiene between assisting each resident during meal time and to provide any assistance a resident might need during meals. 3. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic respiratory failure, dysphagia following cerebral infarction, gastrointestinal hemorrhage, and tracheostomy status. On 2/25/26, the following orders were started: a. Enteral Feed Order every shift Glucerna 1.2 at 63 ml/hr [milliliters per hour] and water flushes at 30 ml/hr x 20 hours (off at 1300 [1:00 PM], on at 1700 [5:00 PM]) via pump. b. Enteral Feed Order in the afternoon ***Disconnect tube feeding c. Enteral Feed Order in the evening ***Reconnect tube feeding On 5/4/26 at 10:32 AM, an observation was made of resident 8 with her tube feeding disconnected and the feeding bag, which still contained formula, uncapped. On 5/6/26 at 3:45 PM, an observation was made of resident 8 with her tube feeding disconnected and the feeding bag, which still contained formula, uncapped. On 5/6/26 at 3:47 PM, an interview was conducted with Registered Nurse (RN) 9. RN 9 stated that he would resume resident 8's tube feeding during his final rounds using the same formula in the feeding bag. RN 9 stated that once a feeding was complete he flushed the tubing with water, disconnected it from resident 8's gastrostomy tube, and then clipped the feeding bag tube to the pump. RN 9 stated that they did not normally cap the feeding bag tube after it was unhooked from a resident. RN 9 stated that the feeding bag and tubing would be changed every 24 hours during the night shift. On 5/7/26 at 2:22 PM, an observation was made of resident 8 with her tube feeding disconnected and the feeding bag, which still contained formula, uncapped. On 5/14/26 at 11:43 AM an interview was conducted with the DON. The DON stated that infection control protocols require staff to cap and hang disconnected feeding bag tubing on the pump.

Based on observation, interview, and record review, for 2 of 54 sampled residents, the facility did not ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs), including hygiene and dining. Specifically, a resident with visual impairment was not provided assistance with dining and another resident was not provided assistance with bathing. Resident identifiers: 4 and 38.Findings included:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included category 5 blindness to the right and left eyes, stage 5 chronic kidney disease with heart failure, and type 2 diabetes mellitus.On 5/4/26 at 12:25 PM, an observation was made in the dining room while a meal was being served. Dietary Aide (DA) 1 placed resident 4's meal tray down in front of him and walked away without assisting with set up. A female resident, who was seated next to resident 4, was observed opening up the mustard packets and squeezing the mustard onto resident 4's plate. Additionally, the female resident was observed opening up resident 4's milk carton for resident 4 to pour into his two-handled mug. On 5/4/26 at 12:29 PM, an additional observation was made of DA 1 serving resident 4's food and walking away without assisting with set up. The female resident was observed opening a packet of butter and using a fork that she had used to feed herself to mix the butter into resident 4's mashed potatoes. On 5/2/26, a Daily Skilled Charting assessment documented that resident 4 required setup or clean-up assistance for eating. Eating was defined as the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Resident 4's care plan had a focus area for being at risk for nutritional deficits related to end-stage renal disease, dialysis, diabetes mellitus, anemia, heart failure, and anxiety that was initiated on 1/18/26. Interventions initiated on the care plan included: provide assistance with meals as needed and provide diet and snacks as prescribed. Additionally, the care plan had a focus area for impaired vision secondary to diabetic retinopathy and macular edema initiated on 1/18/26. Interventions initiated on the care plan included: assist with visual appliances and provide an environment free of clutter. On 5/13/26 at 10:20 AM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that resident 4 needed assistance with getting to the dining room because he could not see well. CNA 4 stated that while all residents should have received assistance setting up their meals in the dining room, resident 4 needed help opening some items. On 5/14/26 at 9:45 AM, an interview was conducted with resident 4, who stated that his poor vision required staff to orient him to the items on his meal tray and where the items were located. Resident 4 stated that he needed staff to open containers and serve the contents due to limited strength and dexterity in his fingers. Resident 4 stated that staff typically placed his tray down and then ran off before he had time to request assistance. Resident 4 stated that the experience was frustrating, and while he did not want to be impatient, staff did not take any time to assist him. Resident 4 stated that occasionally friends, who were also residents at the facility, assisted him at mealtimes, but that he was uncomfortable relying on those friends. Resident 4 stated that if his friends were unable, he had to raise his hand and wait until staff members noticed him. Resident 4 stated that staff would eventually help him, but he had to wait a long time. On 5/14/26 at 11:47 AM, an interview was conducted with the Director of Nursing (DON), who stated that the facility expected staff to identify the plate's contents, open all containers, and provide any necessary assistance when serving resident meal trays. 2. Resident 38 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of medial malleolus of right tibia, displaced fracture of neck of left radius, person injured in unspecified vehicle accident, encounter for other orthopedic aftercare, other lack of coordination, abnormalities of gait and mobility, and pain disorder. On 5/4/26 at 2:34 PM, an interview was conducted with resident 38. Resident 38 stated she had been at the facility since December 2025. Resident 38 stated she has had three showers and a bed bath since she was admitted . Resident 38 stated the facility was trying to fix the resident showers and they had shower days. Resident 38 stated that she showered on Saturday and Wednesday. Resident 38 stated that staff were supposed to ask three times in the day if you needed a shower and sign a form if you refused the shower. Resident 38 stated that one night the staff asked her after 9:30 PM, and she refused to sign the form because she was sleeping. Resident 38 stated that she was not asked on Saturday, 5/2/26, if she wanted to shower. A care plan Focus initiated on 12/24/25, documented [Resident 38] has alterations in ADL function secondary to recent multiple fractures that required an ORIF [open reduction and internal fixation], increase in assistance with ADLS, increase in weakness. The interventions included, but were not limited to, assist in completing ADL tasks each day. Weight bearing as tolerated to the right lower extremity and left upper extremity no weight more than 5 pounds. The TASK: ADL documented that resident 38 received bathing on Wednesday and Saturday. The medical record and shower sheets were reviewed for April and May 2026. Resident 38 did not receive a shower as scheduled on 4/8/2026, 4/15/2026, 4/22/2026, and 5/2/2026. On 5/11/26 at 8:36 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated that resident 38 did not require much assistance with ADLs and resident 38 was pretty independent. UM 2 stated that all residents received assistance with showers even if they were a supervision or set up. UM 2 stated that showers were charted in the medical record and were assigned to a certain day. UM 2 stated if the shower was skipped or missed the CNA could use the as needed button in the electronic charting system for a different day. UM 2 stated the shower sheets were used with every shower and the Assistant Director of Nursing would track the shower sheets and refusals in her office. On 5/11/2026 8:43 AM, an interview was conducted with CNA 5. CNA 5 stated that she would complete a shower sheet for every shower and there was a separate sheet for the refusals. CNA 5 stated that the showers would be documented in the medical record. CNA 5 stated there were shower CNAs for the 100/200 hallway, 300/400 hallway, and the rehab side of the facility. CNA 5 stated there was not enough staff to complete showers. On 5/14/26 at 1:28 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there were days that resident 38 would shower herself and resident 38 would not let the staff know. The DON stated that staff would offer resident 38 a shower and resident 38 would ask the staff to come back another time until resident 38 would completely refuse for the day. The DON stated that resident 38 required supervision to partial assistance for ADLs. The DON stated that resident 38 may have a shower in her room but there was a communal shower in that hallway. The DON stated if resident 38 attempted to access the communal shower staff would have to assist her because the communal shower was locked. The DON stated that a partial assist would consist of staff setting up everything for the resident and providing at least 25% of assistance. The DON stated that supervision would consist of staff standing by and being present. The DON stated that staff would document in the medical record if resident 38 showered herself and she was independent. The DON stated if the documentation was blank the shower either did not happen or the documentation was missed. The DON stated that Not Applicable would be marked in the electronic charting system if the resident was out of the facility. The DON stated resident 38 should sign a refusal form if she refused a shower. (Cross-refer F725)

Based on interview and record review, the facility did not ensure that each resident who was given a psychotropic drug had adequate monitoring of that drug. Specifically, for 1 out of 54 sampled residents, a resident receiving an antidepressant did not receive that medication on dialysis days. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, post traumatic stress disorder, and dependence on renal dialysis.A physician's order started on 1/17/26, documented Sertraline HCl [hydrochloride] Tablet 100 MG [milligrams] Give 200 mg by mouth one time a day for depression.The May 2026 Medication Administration Record was reviewed. On 5/1/26, 5/6/26, 5/8/26, 5/11/26, and 5/13/26, the sertraline was not administered due to the resident being out of the facility at dialysis.An Orders - Administration Note dated 5/1/26 at 8:30 AM, documented At dialysis.An Orders - Administration Note dated 5/6/26 at 7:15 AM, documented Patient is at dialysis. Provider and family aware.On 5/14/26 at 11:18 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 4 usually returned from dialysis at 1:00 PM or 2:00 PM, and RN 2 would code the medications as resident out of the facility. RN 2 stated that resident 4 left the facility at 4:00 AM, for dialysis. RN 2 stated with the other halls and his experience with dialysis residents was to send the medications with the resident. RN 2 stated that he had not been administering the missed medications when resident 4 returned from dialysis because he was not sure the time specifications with those medications. RN 2 stated that he would check resident 4's blood glucose when he returned from dialysis. RN 2 stated that a lot of resident 4's medications stacked on each other and came later in the afternoon. RN 2 stated that he was not sure of the process of asking the provider about moving the administration times. On 5/14/26 at 12:22 PM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated she would have to check and see if the medications that were not sent with resident 4 were wash out medications or if resident 4 had already gone to dialysis before the medications were administered. UM 2 stated that dialysis may be administering the medications also. UM 2 stated that she would have to research the situation. On 5/14/26 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 4 went to dialysis at 4:00 AM or 5:00 AM. The DON stated that morning medications started at 6:00 AM, unless they were gastrointestinal medications because those were administered earlier. The DON stated if the medication was administered daily resident 4 could receive the medications when he returned from dialysis. The DON stated if the medication was twice daily or a timed medication and the doctor wanted resident 4 to receive those medications prior to dialysis then it would need to be stated on the physician order or to hold until resident 4 returned. The DON stated that resident 4 returned from dialysis around 10:00 AM. The DON stated it would be a general physician order to give the medications when resident 4 returned from dialysis.

Based on observation, interview, and record review, for 2 out of 54 sampled residents, the facility did not immediately inform the resident; consult with the resident's physician; and notify, when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, the physician was not notified when a resident had an abnormal Urine Analysis (UA) and a physician was not notified when a resident's blood pressure medication was administered with a recorded low pressure reading. Resident identifiers: 22 and 127. Findings included:1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included sepsis due to other specified staphylococcus, atrial fibrillation, type 2 diabetes mellitus, protein-calorie malnutrition and severe sepsis. On 5/5/26 at 10:19 AM, an interview was conducted with resident 22. Resident 22 stated she had been sick for the last few weeks with nausea, vomiting, headaches and was a little dizzy. Resident 22 stated she asked a nurse to perform a urine analysis test because she thought she had a UTI (urinary tract infection) and the nurse told her to talk to the doctor about it. Resident 22 stated those were the same symptoms she had in the past with a UTI. A care plan dated 2/12/26 revealed that resident 22 was at risk for infection. The goal was to not have untreated signs and symptoms of an infection through the next review. The interventions were to monitor labs as prescribed and notify physician of s/s (signs and symptoms) of infection. On 5/6/26 at 3:03 PM, a nurse practitioner note revealed . Will monitor her labs and check a urinalysis first. If she is having significant nausea or vomiting or her blood pressure becomes low, would consider some IV [intravenous] fluids. A nurses note dated 5/7/26 revealed a UA was collected at 4:30 AM. The laboratory results dated [DATE] revealed the appearance was slightly cloudy, a trace of hemoglobin, Leukocyte Esterase was 500 which was large, white blood cells 23, red blood cells were 3, epithelial cells were 17 and bacteria was 1+. All of the results were outside of normal parameters. There was no documentation that the physician had seen or reviewed the results. On 5/11/26 at 8:49 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated she did not know if there were laboratory results pending the physician's review. RN 3 stated if she received the above UA results she would notify the physician. RN 3 was observed to notify the Nurse Practitioner (NP) 1 of resident 22's 5/7/26 lab results on 5/11/26 at 9:11 AM. NP 1 was observed to ask RN 3 if resident 22 continued to have symptoms and if she did, then draw another UA. It should be noted the results were sent to the facility on 5/7/26 and the physician was notified of the abnormal labs on 5/11/26. On 5/11/26 at 9:17 AM, an interview was conducted with NP 1. NP 1 stated the provider on call should have been notified of resident 22's 5/7/26, lab results. NP 1 stated the nurses should document if the provider was notified of the results. On 5/11/26 at 9:20 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated nursing staff needed to contact the provider with any lab results. UM 2 stated the nurse needed to document that the provider was notified in a nurses note. UM 2 stated if the results were abnormal, then the provider should be notified right away. UM 2 stated there might have been an agency nurse on duty when the results were provided to the facility. UM 2 stated agency nurses did not have access to tiger text which is how nurses communicated with the physician. 2. Resident 127 was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral palsy, chronic respiratory failure, parkinsonism, morbid obesity, peripheral vascular disease, and hypertension. On 1/2/26, resident 127's physician ordered Hydrochlorothiazide (HCTZ) Tablet 12.5 milligrams (mg) by mouth one time a day for hypertension, and Lisinopril Tablet 20 mg by mouth one time a day for hypertension.Resident 127's May 2026 Medication Administration Record (MAR) was reviewed. The HCTZ and Lisinopril were held on 5/4/26 for a blood pressure (BP) of 91/45 but were administered on 5/11/26 for a BP of 98/58. The order did not have parameters to hold the medication. No documentation could be found that the Medical Doctor (MD) was informed of the low BP and subsequent medication administration. On 5/13/26 at 9:11 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that he would monitor BP and pulse prior to administering medication to treat hypertension. RN 1 stated that usually the orders had hold parameters but if not he would use his nursing judgement and contact the MD to see if they wanted to still administer or hold the medication. RN 1 stated that documentation for contacting the MD was in a progress note or tiger text. RN 1 stated that he also noticed resident 127's medication administration with a low BP. On 5/13/26 at 9:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the providers did not put hold parameters on the orders and would rather be notified if a medication needed to be adjusted. The DON stated that the nurse should have called the provider to see if it was okay to administer the HCTZ and Lisinopril and then documented in a progress note that the MD was notified. The DON stated that he did not see documentation that the provider was notified of resident 127's low BP prior to medication administration.

Based on observation, interview and record review, the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, for 2 out of 54 sampled residents, there was no documentation that a resident was notified of a room change. Resident identifiers: 52 and 121. Findings included:Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypertension, protein calorie malnutrition, depression and anxiety. On 5/7/26 at 7:58 AM, an observation was made of room [ROOM NUMBER]. Resident 121's name was on the door but he had been observed in room [ROOM NUMBER] on 5/6/26. There was no documentation in resident 52's medical record regarding the room change. There was no documentation in resident 121's medical record that he was receiving a new roommate. On 5/11/26 at 3:37 PM, an interview was conducted with the Resident Advocate (RA). The RA stated residents were notified of room changes prior to a room change. The RA stated resident 121 was notified and had paperwork that he signed. The RA was observed to look through a box of papers under her desk. At 4:01 PM, the RA stated resident 52 was notified verbally by staff regarding a roommate. The RA stated it was the company policy to do a verbal notification and not provide written notice when there was a room change. The RA provided a form for resident 52's room change, but there was no information on why there was a room move.

Based on interview and record review it was determined that for 1 of 55 residents that the facility did not ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. Specifically, a staff member documented a problem with a resident's toe, and it was not addressed by a doctor for 27 days, at which point the toe had become necrotic and surgery was required. Resident identifier: 19. Findings include: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, lack of coordination, abnormalities of gait and mobility, protein-calorie malnutrition, dysfunction of bladder, retention of urine, muscle weakness, glaucoma, essential hypertension, anxiety disorder, bipolar disorder, hyperlipidemia, insomnia, dementia, long term use of aspirin, and chronic obstructive pulmonary disease. An interview was unable to be conducted with the resident due to the resident's low cognitive status and diagnoses of dementia. On 4/8/24 at 2:27 PM an interview with resident 19's family member was conducted. Resident 19's family member stated that resident 19 got an infected toe, and it went unnoticed by the staff for so long that it nearly went gangrene. Resident 19's family member stated that he believed the staff could have addressed the infected toe sooner. Resident 19's medical records were reviewed. A document titled Observation Detail List Report dated 3/25/24 documented resident 19's Brief Interview for Mental Status (BIMS) score as a 3, which indicated severe cognitive impairment. Resident 19's Care Plan was reviewed. Resident 19 had a care plan initiated 4/8/24 that documented, DIABETES: [resident 19] has Diabetes type 2. The goal, initiated on 4/8/24, documented, [Resident 19 will have no unaddressed complication r/t DM [diabetes mellitus] through next review. The interventions stated, [Resident 19] referred to Podiatrist as needed. Created 11/11/21, Nurse to administer DM medication to [resident 19] per MD [medical director] orders. Created 9/3/20., Nurse to monitor [resident 19's] BG [blood glucose] level per MD orders and PRN [as needed]. Resident 19 had a care plan initiated 3/16/21 that documented, [Resident 19] is at risk for alteration in skin impairment R/T dx chronic obstructive pulmonary disease, DM II, and Vitamin D deficiency. The goal stated, [resident 19]'s skin will have no unaddressed skin impairment . The intervention created 3/16/21 documented, Keep clean and dry as possible. Minimize skin exposure to moisture. A Progress Note from 1/23/24 at 1:47 PM documented, Some pain in R [Right] 1st & 2nd toe during cares. Toe nails are long and need to be cut. SW [Social Work] notified of podiatry need. A documented titled Observation Detail List Report from 2/3/24 documented, No wound present in the Skin Integrity section. A documented titled Observation Detail List Report from 2/8/24 documented, No wound present in the Skin Integrity section. A Physician Assistant note from 2/9/24 at 5:55 AM was reviewed and the Physician Assistant did not address the pain in the right 1st and 2nd toe as reported by a nurse in the progress note from 1/23/24. A documented titled Observation Detail List Report from 2/15/24 documented, No wound present in the Skin Integrity section. A Physician Assistant note from 2/19/24 at 8:27 AM documented, Nurse concerned about her toe. Right great toe very red and sore, 2nd toe now with redness. [Resident 19] seems sore when this area is examined. Has had a referral for podiatry pending for several weeks. Replaced this. No fever. Some honey colored crusting noted. A Progress Note from 2/19/24 at 4:17 PM documented, Provider orders podiatry referral (transport notified); Keflex 500mg [milligram] Po [by mouth] QID [four times a day] x 7 days (medication administered now), Wound care daily with Bactroban (Wound care performed). Orders placed . 2nd toe appears to have integument alteration but is difficult to fully assess d/t [due to] pain and [resident 19]'s inability to provide any hx [history] . A Progress Note from 2/20/24 at 3:43 PM documented, Appt [appointment] with podiatry . Provider writes: Significant R>L food PAD w/ [with] R 2nd toe necrosis and rubor on dependency. URGENT: recommend arterial vascular studies to the BLE's [bilateral lower extremities] before any procedures/debridement. Provider orders refer to vascular consult . A Progress Note from 2/22/24 at 6:33 PM documented, 2nd toe is getting deeper coloration today. Otherwise s/s [signs and symptoms] are the same. Wound care performed with great difficulty but dressing in place a [sic] this time. A Progress Note from 2/26/24 at 11:05 AM documented, 2nd toe vascular appt scheduled 3/8. She is taking IM [intermuscular] Rocephin QD currently. RN [registered nurse] concerned about [resident 19]'s abilities, comfort, and desires. She may endure a lot of distress and an extended process of appointments, surgery, and wound care should her toe need to be amputated. [Resident 19] may be candidate to return to hospice. ADON [Assistant director of nursing]/provider/hospice notified . A Progress Note from 3/4/24 at 12:43 documented, Wound care performed, Deep purple area on plantar and mesial aspect of 2nd toe, and beneath the toenail of the hallux . A Progress Note from 3/7/24 at 6:01 PM documented, Pt [patient] saw vascular specialist today. Progress note from vascular physician stated: I attempted to call and speak with [resident 19]'s nurse, but no one would answer the phone. I am a previous provider for [resident 19] as I was a rounding nurse practitioner there at one time, so I am familiar with her past medical history. She has dementia, and is unable to give me info. I cannot feel good pulses in her bilateral feet unsure how long. Wound, but she expressed discomfort during evaluation and scans. Dx [diagnosis] PVD she is in need of bilateral angiogram for revascularization starting on the right side due to wounds her left lower extremity will follow a week later. A documented titled Observation Detail List Report from 3/7/24 documented, No wound present in the Skin Integrity section. A Progress Note from 3/27/24 at 2:24 PM documented, . Provider writes: angiogram of R leg - successful revascularization of occluded rt [related to] femoral & popular arteries. Also, successful angioplasty of RT anterior tibial artery. Now patient direct art [arterial] supply to foot . On 4/17/24 at 1:34 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that if a resident required to be seen by a podiatrist, she was responsible for adding the resident to a list that was then sent to the podiatrist. The DON stated that she had recently taken over responsibility for this roll, and at the time of resident 19's infected toe, social work would have been responsible for it. The DON stated that all residents had weekly skin checks, and she would have expected staff to be looking at the residents fingernails and toenails as part of the skin check. The DON stated that she cannot speak for the nurses, and she stated maybe nurses were not including toenails as part of the weekly skin checks. The DON stated that she was not the nurse conducting the skin checks for resident 19 so she cannot speak to how resident 19's toe looked. The DON stated that she did not believe that anything was missed with resident 19's toe. On 4/17/24 at 1:55 an interview with the Resident Advocate (RA) was conducted. The RA stated that the old social worker used to be responsible for making podiatry referrals. The RA stated that staff often told her about the need for referrals to be made, and she would have passed that information along to the DON. The RA stated that at the time of resident 19's infected toe, the nurse informed her about it and the RA passed the information along to the DON, who would have made the referral.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and each resident received adequate supervision and assistance to prevent accidents. Specifically, for 4 of 55 sampled residents, a resident was left unsupervised with a damaged bedside table and the resident was observed pulling on the broken plastic with sharp edges; a resident bed was not locked in place resulting in a fall with a finger injury; a resident was being assisted with a transfer by a family member outside, resulting in the resident falling and dislocating a shoulder; and a resident with a history of falls was injured. These findings resulted in a citing of harm for 2 residents. Resident identifiers: 20, 60, 80, and 166. Findings include: HARM 46232 1. Resident 166 was initially admitted to the facility on [DATE] and readmit to the facility on [DATE] with the diagnoses of periprosthetic fracture around internal prosthetic right hip joint, acute kidney failure, neoplasm of unspecified behavior of bladder, fall on same level from slipping, tripping and stumbling without subsequent striking against object, subsequent encounter, Human immunodeficiency virus [HIV] disease. Resident 166 medical records were reviewed on 4/15/24. On 2/1/24, a Minimum Data Set (MDS) documented resident 166 had a Brief Interview for Mental Status (BIMS) score of 15. The activities of daily living section documented resident 166's bed mobility as partial/ moderate assist. A care plan problem area initiated on 10/31/23 documented, [Resident 166] is at risk for falls secondary to impaired mobility, generalized weakness, multiple wounds, total hip sx, hx GLF [ground level fall], rhabdomyolysis, new environment. Documented interventions included: Lab review. 2. Frequent rounding. 3. Encourage the use of the call light. 4. Keep room free of clutter and tripping hazards. On 1/22/24 at 12:11 PM, a TELS work order #2693 was created for resident 166's call light not working. The work order documented that call light had been fixed on 1/23 at 10:09 AM. [Note: resident had a fall on the night of 1/22, which resulted in a hip fracture.] Resident 166's progress notes and incident reports were reviewed and revealed the resident had fallen on 1/21 and 1/22 and documented the following fall notes: a. On 1/22/24 at 2:04 PM, a nurse note stated, Resident continues on neuro check r/t fall on 1/21 .dressing changed to left knee abrasion, knee cleaned with NS [normal saline], applied bacitracin and covered with bordered foam dressing. Resident tolerated changed of dressing with minimal discomfort, call light within reach, resident reminded to call for transfers and any other needs. Pt [patient] verbalized understanding. b. An incident report dated 1/21/24 with a recorded time of 10:57 AM, documented resident 166 had an unwitnessed fall on 1/21/24 at 6:51 AM. The following description was documented, Pt was found on the floor and called 911, so paramedics found him on the floor. It is unknown for how long pt was on the floor but he stated 'for an hour'. Pt was assisted back to bed. He stated he wanted to go back to bed from the wheel chair and fell . Not able to describe why he didn't try to call facility staff by yelling, or asking his room mate to push the call light. Pt is A&O [alert and oriented] X4, skin check performed. Pt has skin abrasions to both knees, and right wrist. Nurse applied Bacitracin to affected areas, covered w [with]/bordered foam. MD [medical doctor] on call notified. Family wasn't responding, VM [voice mail] left for sister to call back. Neuro check initiated, v/s [vital signs] being taken. PRN [as needed] pain medication administered. Education provided for pt to use call light for help with transfers. Pt verballized (sic) understanding. The incident report documented contributing factors to resident 166's fall. Those factors included ambulating without assistance, a change in mental cognition, gait imbalance and a current urinary tract infection. c. On 1/23/24 at 4:33 AM, a nurse note stated, At 1155 resident fell while attempting to just get out of bed and walk around. States he was restless. Resident fell while very close to other residents bed. Sustained skin tear injury to right forearm and right lateral eyebrow. Skin tear is from elbow to outer wrist and apx [approximately] 1 in [inch] open at its widest. Cleaned with wound cleaner, applied non stick fil and kerlix. Residents oxygen sats [saturation] during early part of neuro exams were noted at 84-87. Deep breathing attempted but resident didn't respond well. O2 [oxygen] delivered at 3 liters for about 2 hours. Resident has recovered a satisfacgory (sic) o2 saturation level. Notified NP [nurse practitioner] around 0145 and have not received orders or indication of what he would like do and no new orders at this time. [Resident 166] was given his prn [as needed] oxy [oxycodone] for a pain the right hip he remarks is at a 10/10. No bruising noted in are (sic). WCTM [will continue to monitor] d. An incident report dated 1/23/24 with a recorded time of 2:43 AM, documented resident 166 had a witness fall due to their roommate observing the fall. The MD was notified of the fall on 1/23/24 at 1 AM. The nursing description stated resident 166 had fallen in their roommate's room and it had taken 4 staff members to move resident 166 back into bed. The Incident report documented resident 166 had experience 8/10 pain to their right hip and leg. The contributing factors to the fall included confusion, weakness, and gait imbalance, and ambulating without assistance. e. On 1/24/24 at 2:02 AM, a nurse note stated, . While preparing resident for transport, radiology called stating that a mildly displaced fracture of greater trochanter. f. On 1/25/24 at 9:58 AM, a Nurse Practitioner note documented, .Xray showed femur fracture and he was sent to the ER [emergency room ]. He returned 1/25/24 after being deemed not a surgical candidate. He is allowed TTWB [toe touch weight bearing] on the RLE [right lower extremity]. He continues weak and deconditioned and admitted here for ongoing care and therapy and management of his multiple medical conditions. On 4/17/24 at 9:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident fell , an assessment was done, vitals were taken, and family and providers were notified of the fall. The DON stated a fall event was opened and filled out. The DON stated a fall was only considered witnessed if it had been seen by staff. The DON stated when a resident fell , they were monitored by the nurse for 3 days. The DON stated after every fall, they tried to determine the root cause of the fall to prevent future falls from occurring. The DON stated if a resident's call light was not working then it was considered a high emergency and maintenance was called. The DON stated they did not want a resident to go without a call light since the resident would not be able to call for help. The DON stated the call light was a resident's lifeline. The DON stated on the day that resident 166 fell , they were confused and wanted to ambulate on their own. The DON stated resident 166 needed stand by assistance. The DON stated resident 166 had two fall very close to each other. The DON stated that with the first fall, resident 166 was reminded to call for help. The DON stated resident 166 was able to use the call light if they needed any assistance. The DON was made aware that resident 166's call light was not working on the night that the resident fell and fractured their hip. 47432 2. Resident 60 was admitted [DATE] with diagnoses including end stage renal disease, insomnia unspecified, essential (primary) hypertension, peripheral vascular disease unspecified, other intervertebral disc degeneration lumbosacral region, dependence on renal dialysis, displaced avulsion fracture (chip fracture) of left talus, subsequent encounter for fracture with routine healing, type 2 diabetes mellitus with diabetic polyneuropathy, and dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident 60's medical record was reviewed from 4/8/24 through 4/17/24. Resident 60's most recent Brief Interview for Mental Status (BIMS) Score from her most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] was a 15, indicating no cognitive impairment. Resident 60's quarterly MDS also indicated that Resident 60 is a limited assistance, one person assist for transfers. Resident 60's Care Plan was reviewed. A focus dated 7/3/23 revealed Problem: [Resident 60] is at risk for falls secondary to ESRD [end-stage renal disease] - (HTN [hypertension] potential with dialysis), weakness, impaired mobility, disc degeneration. This focus was last revised on 4/8/24. The goal listed for this focus was, [Resident 60] will have no untreated injuries r/t [related to] falls, through next review. The target date for this goal was listed as 4/30/24. The interventions listed for this goal were: Encourage the use of the call light. This intervention was initiated on 7/3/23. Keep room free of clutter and tripping hazards. This intervention was initiated on 7/3/23. A focus dated 7/3/23 revealed, [Resident 60] is at risk for altered ADL [activities of daily living] function secondary to ESRD, impaired mobility, morbid obesity, vision impairment. This focus was last revised on 4/8/24. The goal listed for this focus was, .will not have any unaddressed complications secondary to decreased ADL self-performance, through next review. The target date for this goal was listed as 4/30/24. The interventions listed for this goal were: Requests medications at bedside to promote independence. This intervention was initiated on 2/6/24. Assist in completing ADL tasks each day. Provide dignity and respect, and encourage independence. This intervention was initiated on 7/3/23. Encourage use of call lights when ADL assistance is needed. This intervention was initiated on 7/3/23. Encourage PT/OT [physical therapy/occupational therapy] services as prescribed. This intervention was initiated on 7/3/23. A progress note dated 2/19/24 at 5:44 PM revealed, Residents [sic] husband was attempting to help transfer her from her wheel chair [sic] to her bed. He slipped and lost his grip. He attempted to prevent her from falling by grabbing her left shoulder. She states she felt it pop and it is out of socket. She has very little movement in any direction without excruciating pain. Physical therapy in to evaluate. Xray [sic] ordered stat. Resident had a bout of nausea and was given zofran and her pain pill. WCTM [will continue to monitor]. An incident report dated 2/19/24 revealed, See PN [progress note]. Husband attempted to assist in transfer, LUE [left upper-extremity] shoulder pain, immobility after incident. Complains of pain with movement. Therapy assessed, assisted resident back into bed. Awaiting XR [x-ray]. A progress note dated 2/20/24 at 4:21 AM revealed, Pt [patient] reports left shoulder pain. Husband was trying to avoid pt to fall last night and grabbed her by left arm. today pt reports pain with ROM [range of motion]. Xray ordered. does not look dislocated. Pt needs refill on her norco for pain. A progress note dated 2/21/24 at 3:05 AM revealed, Resident returned from Hospital at around 8pm. She has Left shoulder strain and Rib fx [fracture]. N/O [new order] for Hydrocodone 7.5-325mg [milligram] tab Q [every] 6 hrs PRN [as needed] for pain. Review of an emergency department note from the hospital dated 2/20/24 revealed The x-ray of her ribs showed that she has an acute fracture of the left 3rd and 4th rib. On 4/8/24 at 2:44 PM, an interview was conducted with Resident 60. Resident 60 stated that on the day of the incident, her husband was attempting to help her transfer from her chair, and he slipped and dropped her to the floor. Resident 60 stated that she hurt her ribs during the fall. Resident 60 stated that her husband attempted to help her transfer because no staff were available to assist. On 4/16/24 at 12:17 PM, an interview was conducted with Resident 60's husband. Resident 60's husband stated that on the night of the incident he slipped while trying to help Resident 60 move from her chair. Resident 60's husband stated that he tried to help Resident 60 transfer because Resident 60 needed to use the restroom, there were no staff around, and the two of them had waited for over an hour for staff after pushing Resident 60's call light. On 4/16/24 at 1:16 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that Resident 60 requires limited one person assistance to transfer. On 4/16/24 at 12:55 PM, an interview was conducted with Registered Nurse (RN) 8. RN 8 stated that from what she was told, when Resident 60's husband was attempting to transfer Resident 60, his foot slipped and he lost his grip on Resident 60 and tried to re-establish his grip by grabbing her shoulder. RN 8 stated that Resident 60's husband then dropped Resident 60 to the floor. RN 8 stated that Resident 60 requires assistance to complete transfers and that Resident 60 has declined since September of 2023. On 4/16/24 at 2:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that ideally staff should answer call lights within 5 minutes and if the issue cannot be resolved, the call light should be left on. The DON stated that she would not expect a family member to help a resident transfer from their chair to their bed. The DON stated that it is not acceptable for a resident to wait an hour for staff to assist with a transfer. 43212 POTENTIAL FOR HARM 3. Resident 20 was admitted to the facility on [DATE] with diagnoses that included [NAME] Sachs disease, pseudobulbar affect, anxiety disorder, dysphagia, abnormality of gait and mobility, lack of coordination, and bipolar disorder. Resident 20's medical record was reviewed between 4/8/24 and 4/17/24. On 4/10/24 at 8:55 AM, an observation was made of resident 20 sitting in her wheelchair across from the 300-400 hallway nurses station. The staff had placed a bedside table across her lap while the breakfast trays were being passed. While resident 20 sat there, she was observed to be pulling at the plastic covering to the bedside table that was cracked and broken in multiple places on the table. The plastic was rigid and jagged with sharp edges. On 4/17/24 at 11:56 AM, the damaged bedside table was still in the hallway near the 300-400 nurses station. 4. Resident 80 was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare, unspecified fracture of upper end of right tibia, dementia, unspecified fracture of upper end of left tibia, unspecified fracture of shaft of right fibula, unspecified fracture of shaft of left fibula, chronic obstructive pulmonary disease, chronic respiratory failure, type 2 diabetes mellitus, weakness, abnormalities of gait and mobility, depression, and insomnia. On 4/8/24 at 10:48 AM an interview with resident 80 was conducted. Resident 80 stated that he had a fall at the facility when he was transferring from the bed to the chair, and his bed had slipped out from underneath him. Resident 80 stated that he bed locks were not locked. Resident 80 stated that he had smashed his finger. An observation of resident 80's right ring finger was made. Resident 80's right ring finger was missing the right half of the nail. The skin appeared to be healed. Resident 80 stated that after he fell and smashed his finger, there was no bleeding, but part of the nail turned black and fell off. Resident 80's medical records were reviewed. An incident report with an Event Date of 3/8/24 documented, Residents bed was not locked, bed rolled while he was sitting on edge of bed and he fell . The resident description of the fall was documented as, sitting on side of bed, wheels not locked, bed rolled and I fell on my bottom. The incident report documented that there were no injuries noted. A Progress Note from 3/8/23 at 10:24 PM documented, This LN [Licensed Nurse] was doing med pass when I was informed by CNA that resident was on the floor, on arrival in residents room I observed him lying on floor in supine position with a pillow under his head, I assessed him for injuries, no apparent injury noted, he was A/O [alert and oriented] x 4, able to tell this writer what happened, he stated, I was sitting up on bed with my feet on floor, CNA was assisting me, she observed me fall, my bed doesn't lock and it rolled causing me to fall and I did not hit my head, just fell on my bottom. CNA [name redacted] stated the same, I saw him fall, he did not hit his head, he fell on his bottom, I helped him lie down and put pillow under his head for comfort. ROM [range of motion] was at baseline, staff assisted resident up off the floor and back into bed . A Progress Note from 3/9/24 at 2:46 PM stated, Patient encouraged to use call light for transferring assistance this shift. Patient tolerates well and is observed using call light and waiting for staff to assist him. On 4/17/24 at 2:38 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that staff should be checking that the breaks are working every time prior to transferring a resident in or out of their bed. The DON stated that all of the beds have wheels and have breaks, and that the breaks should always be locked. The DON stated that the locking mechanism was broken on resident 80's bed when he fell . The DON stated that nobody had noticed that the locking mechanism was broken until resident 80 had fallen. The DON stated that maintenance immediately fixed the breaks on resident 80's bed. The DON stated that there were no routine checks completed by maintenance to ensure that the beds were safe. On 4/17/24 at 2:46 PM an interview with the Assistant Director of Maintenance (ADOM) was conducted. The ADOM stated that there were no routine checks on residents' beds. The ADOM stated that he could not recall if he had fixed resident 80's bed. The ADOM stated that maintenance only looked at the beds if there was a work order placed.

Based on interview and record review it was determined, for 2 of 10 sampled residents, that the facility did not ensure that residents were free of significant medication errors. Specifically, one resident was inadvertently administered her roommates medications, and another resident was administered the incorrect insulin dosage. Resident identifiers: 1 and 4. Findings include: 1. Resident 1 was admitted to the facility [DATE] and readmitted on [DATE] with diagnoses which included unspecified atrial fibrillation, unilateral primary osteoarthritis, abnormalities of gait and mobility, muscle weakness, pain in left hip, hypothyroidism, essential hypertension, systolic congestive heart failure, pain, insomnia, neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, gout, depression, obstructive sleep apnea, morbid obesity, and chronic respiratory failure. On [DATE] resident 1's medical record was reviewed. A Nursing Note dated [DATE] at 6:52 AM written by Licensed Practical Nurse (LPN) 1 stated, Resident complained of SOB (shortness of breath) around 0510 (5:10 AM). This nurse checked VS (vital signs) BP (blood pressure) = ,d+[DATE], P (Pulse) = 42, T (temperature) = 97.7, SpO2 (Oxygen saturation) = 95% on RA (room air), RR (respiratory rate) = 20, noted on the face, resident was swetting (sic), labored breathing and lethargic. Responsive to stimuli. Called the on call provider, no answer. Called 911, EMT (Emergency Medical Technicians) team arrived and transferred resident to [name redacted] hospital. Notified the family and notified the facility thru (sic) the on call nurse. A Nursing Note dated [DATE] at 7:59 AM was recorded as Late Entry on [DATE] 8:15AM written by Registered Nurse (RN) 1 stated, Last evening this nurse inadvertently administered verapamil ER (extended release) 180mg (milligrams) tablet along with residents scheduled medications (amiodarone and Eliquis) at 2100 (9:00 PM). Notified [name redacted], manager on call of [name of facility]. Monitored resident closely and she felt well during the night. Vital signs at 0000 (12:00 AM): BP ,d+[DATE], HR (heart rate) 82, RR = 18, O2 (Oxygen) 96% on 3 LMP (liters per minute) O2. Temp 97.9. Resident was alert and oriented x 4, asymptomatic. Vital signs at 0300 (3:00 AM): BP ,d+[DATE], HR 75, RR 20, Temp 98.0. Resident was alert and oriented x4, asymptomatic. Them started feeling ill and c/o (complained of) SOB (shorness of breath) this morning around 0500 (5:00 AM). Pt (patient) started to get diaphoretic. Vital signs at 0505 (5:05 AM): HR was between ,d+[DATE], RR 20, BP ,d+[DATE], oxygen 95% on 3 LPM O2. Called EMS (Emergency Medical Services), they transported resident to [name redacted] Emergency Department. This nurse called and informed ED [Emergency Department] physician at [name redacted] hospital that Verapamil ER 180mg, Amiodarone 200mg, and Eliquis 5mg tablets were given last night. A document titled Event Report created [DATE] for resident 1 was reviewed. The document contained a description of the medication error from [DATE]. The documented reported that resident 1 had taken her roommates medications which included Verapamil, Tylenol, Buspirone, memantine, Senna Plus, and simvastatin. The document reported that resident 1 was notified of the error on [DATE]. The immediate measures taken reported in the documented stated, Provider attempted to be notified, vitals observes, EMS contacted and transported to hospital. According to resident 1's Medication Administration Report (MAR) for [DATE], on the evening of [DATE] resident 1 recieved her own medications which included; a. Amiodarone 200 mg b. Eliquis 5 mg c. Melatonin 3 mg In addition to resident 1's own medication, resident 1 also recieved her roommates which included; a. Tylenol 650 mg b. Buspirone 10 mg c. Mematine 10 mg d. Senna Plus e. Simvastatin 10 mg f. Verapamil ER (extended release) 180 mg On [DATE] at 1:14 PM, an interview with RN 1 was conducted. RN 1 stated she had a shift on [DATE] was from 6:00 PM to 6:00 AM. RN 1 stated that it was her second time working at this facility through a temporary staffing agency and she did not have an assigned area to work. RN 1 stated that she was assisting CNA's (Certified Nursing Assistants) and nurses. RN 1 stated that around 8:30 PM on [DATE] she began assisting LPN 1 with medication administration. RN 1 stated that LPN 1 was behind on medication administration and LPN 1 decided to pull the medications, hand them to RN 1, and RN 1 would deliver them to the residents. RN 1 stated at around 9:00 PM, RN 1 and LPN 1 got to resident 1's room. RN 1 stated resident 1 had a roommate. RN 1 stated that LPN 1 stated, I'm going to give you both the cups for this room and LPN 1 explained that one cup was for resident 1 and one cup was for the roommate. RN 1 stated that the roommate's medication included a nutritional supplement called Boost. LPN 1 stated that resident 1 was alert and oriented and the roommate was confused. RN 1 stated that when she went to resident 1's bedside, RN 1 had accidentally switched the cups of medication and attempted to give resident 1 medication that was meant to be for the roommate. RN 1 stated resident 1 told RN 1 that she did not drink boost. RN 1 stated that she left the room to let LPN 1 know that resident 1 was unsure about the medications. LPN 1 stated that the resident was confused and to let the resident know that those were the doctor's orders. RN 1 stated she returned to resident 1's room, believing it was the roommate, and told resident 1 to take the medications. RN 1 stated resident 1 swallowed the medications that belonged to her roommate. RN 1 stated that she then realized that she mistakenly administered the medications to the wrong resident. RN 1 stated that she administered Tylenol, Buspirone, memantine, Senna Plus, simvastatin, and verapamil ER. RN 1 stated that she reported the mistake to LPN 1, and LPN 1 told her, It's okay it happens sometimes and then LPN 1 administered resident 1's correct medications which included amiodarone and Eliquis. RN 1 stated that after the incident, she did CNA cares due to the facility being short on CNA's that night. RN 1 stated that she did not know if LPN 1 called a physician or the on-call nurse manager to report the medication error. RN 1 stated that her and LPN 1 monitored resident 1 throughout the night and resident 1 was stable until around 5:00 AM on [DATE]. RN 1 stated that once resident 1's vitals became unstable, resident 1 was send to the emergency department. RN 1 stated that she called the physician at the emergency department to inform them of the medication error. RN 1 stated that the right thing to do would have been to notify a physician immediately after the medication error, contact the nurse manager, hold all other medications and wait for orders from a physician. On [DATE] at 1:38 PM, an interview with LPN 1 was conducted. LPN 1 stated that she was 9 weeks into her 13-week contract with the facility. LPN 1 was working a 6:00 PM to 6:00 AM shift on [DATE]. LPN 1 stated that she was extremely busy on the night of [DATE] and did not have any CNA's on her hallway. LPN 1 stated that RN 1 was a float nurse and offered to help LPN 1 with passing medications. LPN 1 stated that at resident 1's room, LPN 1 handed RN 1 the medications for that room and RN 1 accidentally gave resident 1 the medications that should have been given to her roommate. LPN 1 stated that after the medication error, LPN 1 gave resident 1 her correct medications, which included amiodarone and Eliquis. LPN 1 stated that she attempted to call the on-call physician on her personal cellphone, but the call would not go through. LPN 1 stated that she was unable to send picture evidence of the attempted phone call because it was accidentally deleted. LPN 1 stated that she did not attempt to call anyone else because she was too busy assisting other residents. LPN 1 stated that she monitored resident 1 throughout the night and took vitals. LPN 1 stated around 5:30 AM resident 1's blood pressure and pulse were dropping, so she attempted to call the on-call physician. LPN 1 stated that the on-call physician did not answer so LPN 1 sent resident 1 to the ER. The hospital records titled Emergency Department Document from [DATE] for resident 1 was reviewed. The hospital records stated, Shortly after the patient arrived the nurse from the skilled nursing facility called and indicated that the night nurse had accidentally given the patient 180 mg of verapamil extended release. Prior to this a septic workup had been started. The chest x-ray did no show any acute infiltrate. The CBC and CMP were reassuring. The patient was given aggressive IV (intervenous) hydration and despite this her blood pressure continued to drop. Her oxygen saturation was inconsistent The patient became pulseless and CPR (Cardiopulmonary Resuscitation) was started .the patient was admitted to [doctors name redacted] service in the ICU (Intensive Care Unit). The hospital records titled Death Discharge Summary from [DATE] for resident 1 stated, According to ER physician, patient was short of breath and very agitated. She was very bradycardic. I was told that patient may have received 180 mg of extended [release] verapamil yesterday by mistake .She was given calcium gluconate. As she was altered, they decided to intubate her. I was called to this patient to the ICU .Code blue was called . Patient was found to be extremely acidotic due to lactic acid. We did not pursue dialysis per family request . Patient ultimately expired on [DATE] at 13:52. The hospital records reported that the immediate cause of death is severe bradycardia due to possible accidental overdose, complicated by cardiac arrest and severe acidosis with renal failure. On [DATE] at 12:37 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that if a medication error occurs, the nurses should stop administering other medications immediately, notify the physician of that error, follow the physician's orders, and assess the resident. The ADON stated that he was on-call the night of [DATE] and was notified the following morning of the medication error, which was approximately 10 hours after resident 1 had taken the wrong medications. The ADON stated that he should have been notified of the medication error immediately and he would have instructed LPN 1 to stop what she was doing, assess the resident, and to not proceed with that patient until there were instructions from the physician. On [DATE] at 1:00 PM, an interview with the Administrator (ADMIN) was conducted. The ADMIN stated that the facility conducted an investigation after the medication error. The ADMIN stated that the facility ended the work contract with LNP 1. The ADMIN stated that the facility created a four-step action plan, identified a problem, conducted education with all the nurses, and the facility was working on completing medication administration audits with all the nurses. On [DATE] at 3:09 PM, an email from the ADMIN reported that the ADMIN reviewed the on call provider call log from the physician group and no calls were made on behalf of resident 1 on the night of [DATE]. 30563 2. Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiparesis following cerebral infarction affecting, bipolar, borderline personality, and type 2 diabetes. A list of resident with medication errors was provided. Resident 4 was listed as having a medication error on [DATE]. An Medication Error/Treatment Error Event was reviewed. The from was created on [DATE] at 2:39 PM. The medication error was on [DATE] at 7:50 PM. The description was Incorrect Lantus dosage given at NOC (night) by RN, AM (morning) RN was given report of Pt (patient) getting an increased dose of Lantus as stated by NOC RN, NOC RN stated the Pt MD (medical doctor) has increased the dose when questioned by Pt. The medication error was NOC administered 100 units of Lantus at Bedtime, when Pt questioned the amount the NOC RN stated it had been increased by MD to 100 unit. The physician was notified on [DATE] at 2:35 PM. Resident 4's medical record was reviewed on [DATE] and [DATE]. Resident 4's physician's order dated [DATE] revealed to following: a. Lantus 100 unit/mL (milliliter) solution to administer 25 units subcutaneously at bedtime for type 2 diabetes mellitus b. Insulin Lispro 100 unit/ml solution; 100 unit/mL; Amount to Administer: Per Sliding Scale; If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 350, give 8 Units. If Blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Resident 4's [DATE] Medication Administration Record (MAR) revealed Lantus was administered: a. On [DATE] resident 4 was administered 8 units by LPN 2. b. On [DATE] resident 4 was administered 100 units by Licensed Nurse (LN) 1. c. On [DATE] resident 4 was administered 10 units by LPN 2. Resident 4's [DATE] MAR further revealed resident 4's blood glucose was 415 on [DATE] and resident 4 was not administered Insulin Lispro sliding scale insulin and 10 units of Lantus. On [DATE] at 10:49 AM, an interview was conducted with resident 4. Resident 4 stated not to long ago, a nurse came into her room and told her that a nurse had administered 100 units of her long acting insulin the night before. Resident 4 stated the next day she felt horrible, sick, nauseated, and sweaty. Resident 4 stated that she was not sure if her blood sugar had been checked throughout the night. Resident 4 stated that staff tell her there were not enough help at night all the time. Resident 4 stated she was always getting new nurses because they were all agency nurses. Resident 4 stated that agency staff just don't care. On [DATE] at 3:14 PM, an interview was conducted with LN 2. LN 2 stated she was an agency nurse and started her shift on [DATE] at 6:00 AM. LN 2 stated the previous nurse had told her during report that the physician increased resident 4's Lantus to 100 units. LN 2 stated that amount did not make sense. LN 2 stated resident 4's blood sugar was really low the next morning. LN 2 stated she did not want to administer the short acting insulin because of resident 4's blood sugar. LN 2 stated she checked the order and it was for 25 units not 100 units. LN 2 stated she got another nurse to confirm the physician's order. LN 2 stated as an agency staff member she did not know how to maneuver through the physician's orders in the electronic medical record. LN 2 stated she reviewed the nursing progress notes and there was no information that the 100 units had been ordered. LN 2 stated she then notified the Unit Manager (UM). LN 2 stated she did not know the time that the Lantus was administered. LN 2 stated that resident 4's blood sugar was low but not low enough to report to MD. LN 2 stated that the UM reported the medication error to the physician and the UM did not inform her of any new physician's orders. LN 2 stated that by dinner her blood sugar was with in normal range. LN 2 stated that resident 4's blood sugar was 81 at breakfast and 84 at noon, so that was why LN 2 started to question the 100 units. LN 2 stated resident 4's blood sugar was usually not below ,d+[DATE]. On [DATE] at 2:00 PM, an interview was conducted with LPN 2. LPN 2 stated she was an agency nurse. LPN 2 stated that resident 4 had a physician's order for Lantus 25 units every night. LPN 2 stated that she must have accidentally put the short acting insulin in as the long acting. LPN 2 stated she always went into resident 4's room and let her know she was administering 25 units. LPN 2 stated that she was able to remember the medication dosage that she administered to a resident over two weeks ago. LPN 2 stated she had a lot of patients in that hallway and was asked questions while charting and was distracted. LPN 2 stated she was frequently interrupted by family members, residents were high acuity, there was a high census, and there was not a short shift nurse, so she had to have the 300 hall and 400 hall. LPN 2 stated she had told management that there were too many residents for one nurse and had a text message to management about how it was too much for one nurse. LPN 2 stated the 300 and 400 hallway was a little too much, patients are too acute for the amount of time we have, under too much pressure for time, quality of care lacking, not able to give any quality of care on this unit. LPN 2 stated she felt really bad for the residents, behaviors of patients were too much, everybody had behavioral issues, residents were rolling into nurses with their wheelchairs because they were so angry, radical outburst of patients, it was difficult to be timely and administer medications properly. LPN 2 stated she had not made medication errors. LPN 2 stated she worked the night shift and had 20 to 25 residents until 10:00 PM when she then had about 48 residents. LPN 2 stated if any incident happened, it took a lot of time, writing notes, monitoring, sending residents to the emergency room , no way to fully monitor all of these patients, cannot actually give quality care with layout and number of patients. LPN 2 stated CNAs were overburdened with the hallway. LPN 2 stated she had reported the staffing concerns to the facility. LPN 2 stated she remember resident 4's blood sugar was 415 on [DATE]. LPN 2 stated that she documented in the doctor's log at the nurses station. LPN 2 stated she called doctor later after resident 4's blood sugar had decreased. LPN 2 stated she documented in the doctors log what had happened. LPN 2 states she administered 25 units of Lantus and 10 units of the short acting insulin. LPN 2 stated she should have documented in a progress note what happened. On [DATE], the Staff Development Coordinator (SDC) provided an physician's on call log. Resident 4's name was on the log with a blood sugar of 422. The log had multiple resident names on it and there was no additional information that the physician had been contacted. On [DATE] at 1:41 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 4 received 100 units of Lantus instead of 25 units. The ADON stated resident 4's blood sugar was in the 80s the next morning. The ADON stated he was not sure who discovered the medication error. The ADON stated there was an event form created the next day by LN 2. The ADON stated the nurse from the night before did not document anything. The ADON stated he was not aware of any other information regarding the Lantus doses on [DATE] and [DATE]. On [DATE] at 11:23 AM, an interview was conducted with the Minimum Data Set (MDS) coordinator. The MDS coordinator stated when a nurse had a medication error, the nurse was to immediately ensure patient safety, vital signs were normal at baseline and notify the physician right away. The MDS coordinator stated the nurse was to follow physician's orders. The MDS coordinator stated there was a step by step guide for medication errors for nurses and new protocols and policies had been implemented. The MDS coordinator stated nurses were re-educated within the last month or two. The MDS coordinator stated she did not know why there was an updated policy and education provided to nurses. On [DATE] at 11:57 AM, an interview was conducted with Unit Manager (UM) 1 and the Director of Nursing (DON). UM 1 stated when there was a medication error nurses should notify the physician, family and resident, and administration staff. UM 1 stated the nurse was to follow any orders that the physician gave based on the medications. UM 1 stated the nurse needed to start alert charting and monitoring for a few days to make sure there were no side effects. The DON stated the SDC was instructed to provide a guide for nurses of what to do after a medication error. The DON stated the guide had on it to notify the physician, follow orders given, notify the resident or family and follow the guideline of steps. The DON stated the SDC was working on it and put the guide in binders at the nurses station. The DON was asked to show where the binder and guide were at. The DON was observed to look for a binder at the rehab nurses station. The DON opened a binder and there was no information regarding medication errors. The DON stated the SDC would be able to show where the guide was. On [DATE] at 12:13 PM, an interview was conducted with the SDC. The SDC stated there was an in-serves for the nurses regarding medication errors. The SDC stated he was instructed to provide education regarding medication errors. The SDC stated the facility Quality Assurance and Performance Improvement (QAPI) was monitoring medication errors because they were more frequent. The SDC stated he also watched medication passes to monitor for errors. The SDC stated there was a Performance Improvement Plan and 2 in-services created. The SDC stated the in-service included the 5 rights of administration which were how to administer medications and the common techniques to avoid med errors. The SDC was unable to find the in-serve and guide in the binder for agency staff. The SDC provided an in-service form with 16 nurses signatures on it. The SDC stated there were 16 nurses for the facility. On [DATE] at 2:28 PM, an interview was conducted with the SDC. The SDC stated that he provided 2 in-services for nurses regarding medication errors. The SDC stated that there was a post test for medication errors that all nurses were going to complete by the end of the week. The SDC stated he was following each nurse on medication pass with in the next couple of weeks. The SDC stated he had completed 90% of facility nurses with following medication pass. The SDC stated when he was done following the facility employed nurses on medication pass, then he would start with agency nurses. The SDC stated that when an employee started there was a skills check off upon orientation and then a day of orientation was completed. The SDC stated the orientation included the medication pass. The SDC stated there was a provider log at each nurses station, in a folder. The SDC stated after the provider log was reviewed by the doctor then it went to medical records. The SDC stated they were not scanned into each residents medical record because there were multiple names on the same form.

Based on interview and record review, it was determined the facility did not ensure that the resident environment remained as free of accident hazards as possible and did not have an adequate assistive device to prevent accidents for 1 of 50 sample residents. Specifically, a malfunctioning electric wheelchair was in use which ran into the resident's femur after the resident sustained [REDACTED]. Findings include: Resident 122 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/8/16 at 9:00 AM, an interview was conducted with resident 122. Resident 122 stated that his wheelchair arm rest had broken off his electric wheelchair. Resident 122 stated that he was assisted to the bathroom by a Certified Nursing Assistant (CNA) when he lost his balance and was lowered to the floor. Resident 122 stated that his knee and back where pinned between the toilet and the wall. Resident 122 stated that the CNA picked up his wheelchair arm rest to move the wheelchair back but picked the arm rest up wrong and pushed the chair forward instead of in reverse. Resident 122 stated that the chair hit his leg and fractured his femur. Resident 122 stated that he was transported to the hospital and had surgery to repair his femur. Resident 122 stated that facility staff were aware that the wheelchair arm rest was broken at the time of the fall. Resident 122's medical record was reviewed on 6/8/16. Review of the quarterly Minimum Data Set (MDS) assessment completed by the facility staff on 12/25/15 revealed that resident 122 was alert and oriented with a BIMS (Brief Interview for Mental Status) score of 13. The facility staffed assessed resident 122 as requiring extensive assistance of two or more people for transfers and toileting. Review of the Falls care plan that was developed by facility staff on 6/25/15 revealed an outcome that (resident 122) would be free from injury after falls. The interventions that were developed to achieve the outcome included: (1) Intervene for Unsafe Behaviors Effecting Fall Risk; (2) 2 person assist for transfers r/t (related to) fall 10/30/15; and (3) Re-educated staff to use 2 person assist with all transfers on 1/17/16. On 1/20/16 at 11:50 PM, a licensed nurse documented, 1-20-16 2000 (8:00 PM): This nurse was called to room 104. Upon entering the bathroom found resident on the floor in front of the toilet laying on his right side facing the door. CNA stated that as she was transferring resident from the toilet to the electric wheelchair, that was previously broken and that he is non-compliant with non use of broken w/c (wheelchair) and continued to use anyways (sic), wheelchair malfunctioned and ran into resident making him fall to the floor. Resident assessed. Resident alert and oriented at this time. Resident stated that he could move extremities and that he did not hit his head. Resident able to move upper extremities as prior to fall. CNA and RN (Registered Nurse) attempted to slide resident so that this nurse could assess lower extremities. Resident left leg straight however right femur was in a 'L shape'. Pillow placed under head to keep him comfortable and instructed CNA to stay with resident until this nurse was able to get EMS (Emergency Medical Services) to transport resident to the hospital. VS (Vital Signs) (blood pressure) 172/102 t (temperature):96.1 P (Pulse) 77 r (respirations):24 O2 (oxygen saturation) 85% RA (room air). When asked if he was in pain he stated he had just had pain medication so he was okay. MD (Medical Doctor), EMS, and (local hospital) called. Resident refused to have family notified. Resident taken to (local hospital) at 2100 (9:00 PM) via EMS. Review of the x-ray of the femur obtained on 1/20/16 at 9:11 PM documented .Comminuted fracture of the distal diaphysis of the femur is impacted and displaced posterior 2 cm (centimeters). On 6/8/16 at approximately 9:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 122 was impatient with staff when getting on and off the toilet. The DON stated that one CNA assisted resident 122 while transferring off the toilet when resident 122 lost his balance. The DON stated that when the CNA went to move the wheelchair out of the way, the wheelchair went forward and hit him in his leg which resulted in a femur fracture. The DON stated that the wheelchair was broken and that the mechanism to move the electric wheelchair forward and backward had malfunctioned. On 6/8/16 at 11:00 AM, an interview was conducted with CNA 9, who was with resident 122 at the time he sustained the fall and fracture. CNA 9 stated that resident 122 required the assistance of at least 2 staff members during transfers, but often refused to have more than one person help him. CNA 9 stated that often the resident would insist on staff members only transferring him by themselves, because he did not like to wait for multiple staff members to become available. CNA 9 stated that resident 122 was alert and oriented, but got angry when staff members used more than one person to help him. When asked about the incident in January 2016, CNA 9 stated that resident 122 had asked for her assistance in getting to the bathroom. CNA 9 stated that after resident 122 had used the bathroom, she assisted him to stand up but that the resident could not stand very good and subsequently fell down, and became pinned between the wall and the wheelchair. CNA 9 stated that she had tried to move the electric wheelchair out of the way in the bathroom to make more room to assist the resident, but when she pushed the button to move it, the wheelchair moved forward instead of backward, and the wheelchair ran into resident 122's leg at nearly full speed. CNA 9 stated that she knew the wheelchair was malfunctioning at the time, because resident 122 had stated he was waiting for a repair company to fix it earlier that day.

Based on observation, interview and record review it was determined the facility did not ensure each resident's drug regimen was free from unnecessary drugs. Specifically, 1 of 12 sample residents did not have adequate lab value monitoring for medications. Resident identifiers: 1 and 2. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 2/27/12. Review of resident 2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A physician's progress note for resident 2 dated 1/3/12 documented that "The patient developed significant nose bleed. She has had some rectal bleeding, bright red, but she denies any particular particular problems. Her nose has some drainage of blood . . . INR (International Normalized Ratio) is 2.0 . . ASSESSMENT: Epistaxis and rectal bleeding. I think she needs a reverse of her [MEDICATION NAME], likely some fresh frozen plasma. Although her overall prognosis is rather poor, I do no think continued bleeding at this facility would be the appropriate thing to do. She is being transferred to the hospital." A facility "Hospital Discharge Summary" dated 1/3/12 documented that resident 2 was sent to a local acute care hospital after experiencing bloody emesis, bleeding from the rectum, and epistaxis. An acute care hospital discharge summary dated 1/6/12 documented that resident 2 arrived in the emergency room with an INR of 10. Resident 2 was admitted to the hospital and given 10 milligrams of Vitamin K as well as fresh frozen plasma to reverse the effects of the [MEDICATION NAME]. (Note: Normal INR value is 2.0-3.0 according to the hospital report). On 2/27/12 an interview was conducted with the facility Administrator and Director of Nursing (DON) regarding resident 2. The Administrator and DON stated that they had changed to a new PT ([MEDICATION NAME] time)/INR meter at the end of December 2011. The DON and Administrator stated that when resident 2 was admitted to the hospital with [REDACTED]. The Administrator and DON provided the surveyors with a copy of the Quality Improvement (QI) Process minutes. A review of the facility QI minutes revealed the facility had identified the inaccurate PT/INR values from the facility PT/INR machine on 1/3/12 with regard to resident 2. The QI minutes also stated that "According to the Medical Director, in the ER Resident (2) was found to have elevated PT/INR levels, above the levels that (the facility) had." As a result of the questioned accuracy of the machine the facility implemented a policy that "NO PT/INRs were to be done in house. All PT/INRs were to be done by the lab, until further notice." On 1/9/12 the facility allowed for PT/INRs to be done in the facility along with local lab to "compare accuracy." A review of multiple other residents' medical records was conducted on 2/27/12 to ensure the safety of other residents who had been receiving [MEDICATION NAME], including resident 1. Resident 1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1's nurses notes revealed the following: a) On 1/18/12 resident 1 had "drsg (dressing) to skin tear on L (left) hand saturated with blood. Changed drsg.., res (resident) is on [MEDICATION NAME] therapy STAT (immediate) PT/INR ordered. INR results: 11 . . . Res sent to (local) hospital @ (at) 11:30..." (Note: Normal PT level is 9.0-13.0 and INR value is 2.0-3.0 according to the laboratory report). b) On 1/18/12 "Res returned to (facility name) from (hospital) @ 1430 (2:30 PM) NO (new order) Vit (Vitamin) K (.)10 mg (milligrams) IM (intramuscular) x (times) 1 when received from pharmacy. Hospital out of vit K. D/C (discontinue) [MEDICATION NAME] until Monday 1/23/12, recheck PT/INR 1/23/12." c) On 1/19/12 6:30 AM "Vit K 10 mg IM given last night per night nurse report r/t (related to) high INR results yesterday; 0930 (9:30 AM) stat PT/INR done c/o (care of) lab, AM meds held r/t decreased LOC (loss of consciousness)..... 1030 (10:30 AM) Notified DA (daughter) of Resident's condition, DA stated she will try to call MD (Medical Doctor) et (and) will also ask why her mom is on [MEDICATION NAME] because she thought it was stopped long ago; 1130 Received call from (Name) with (Medical Doctor), explained Res status et (and) voiced concern that Res 'might be having internal bleeding'; (Name) ordered Guiaic test et to call her with results; 1140 Guiaic test done with positive results 1150 notified (name) then talk to MD re: Res condition, (positive) Guiaic test, etc;.....MD then ordered to send out Res to hosp (hospital) for eval (evaluation) and tx (treatment).....1500 (3:00 PM) Received PT/INR result today > (greater than) 97/>11.0 respectively....." Resident 1's physician telephone orders revealed the following: a) There was no date on the telephone order which revealed "[MEDICATION NAME] 4 mg po (by mouth) QD (once daily) on M (Monday), W (Wednesday), F (Friday), Sat (Saturday), Sun (Sunday) [MEDICATION NAME] 5 mg po QD on Tues (Tuesday) (and) Thurs (Thursday) Re(check) PT/INR in 2 wks (weeks) 1/18/12" b) On 1/18/12 "Send Res to (local hospital) per (Doctor) d/t (due to) INR:11" c) On 1/18/12 at 1400 "Vitamin K 10 mg IM x 1 D/C [MEDICATION NAME] till Monday 1/23/12 Dx (Diagnosis): [MEDICATION NAME] tx Re (check) PT/INR Monday 1/23/12 d) On 1/18/12 "re(check) PT/INR 1/19/12" e) On 1/19/12 "Guiaic test today..." f) On 1/19/12 "May sent to ER (emergency room ) (local hospital) for eval and tx." g) On 1/24/12 at 0850 "D/C [MEDICATION NAME] et [MEDICATION NAME] Con't (continue) to hold [MEDICATION NAME] until further orders from MD" On 1/18/12 the QI minutes revealed resident 2 "had a PT/INR in house with results of PT 40.6 and INR 4.1. (Local) lab with PT (greater than) 97 and INR (greater than) 11." Resident 1 was admitted to local hospital on [DATE]. Resident 1's hospital History and Physical was reviewed on 2/27/12. The History and Physical revealed, "Yesterday, the nurses noted that her mental status was altered. In addition, she had a cut on her left hand and bleeding from the wound was unable to be stopped. She was sent to (another local) Hospital Emergency Department and I (medical doctor) am told her INR there was 11.0. Apparently, vitamin K was not available at (the local hospital) and she was sent back to (the facility), where vitamin k was available. She was given an injection of vitamin k yesterday evening. Today, her nurse again noted her mental status to be altered. Her daughter came to evaluate and (the doctor's name) was contacted. Due to her high INR, combined with altered mental status, it was decided that she should go back to the emergency department for an evaluation. She came to (local hospital), where she was found to have an INR of 14.4. She has a [MEDICAL CONDITION] and she had black stool that was guaiac-positive in the bag......." The physician's plan for treatment was "the patient is receiving FFP (Fresh Frozen Plasma). I am also going to continue vitamin K. She was given 1 dose of vitamin k yesterday. We will follow her INR. I discussed the possibility of spontaneous bleeding which might be fatal." On 2/27/12 at 3:10 PM an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she has been employed with the facility for 1 year. RN 1 was stated resident 1 had a skin tear on her hand and the bleeding would not stop. RN 1 stated she "figured her (resident 1's) INR was increased because the blood was not clotting." RN 1 stated she checked resident 1's PT/INR on the facility machine. RN 1 further stated the INR was high, but could not remember the exact number. RN 1 stated the lab was contacted to recheck the PT/INR. RN 1 stated she notified resident 1's doctor and the on call doctor called back with orders to admit to the hospital. RN 1 stated there was no vitamin K available at the hospital, so resident 1 was returned to the facility for a vitamin K shot. A form entitled "In House PT/INR Lab Comparison" revealed on 1/18/12 at 9:00 AM resident 1 had her PT/INR tested with the facility machine and the lab. The facility machine values indicated the PT was 40.6 and the INR was 4.1. On 1/18/12 at 10:00 AM the lab values for resident 1 was her PT was greater than 97 and INR was greater than 11. On 2/27/12 at approximately 5:00 PM an additional interview was conducted with the facility Administrator and DON. The Administrator and DON comfirmed that the facility's plan of correction with regard to the malfunctioning PT/INR meters did not include an immediate re-check of all PT/INR levels of residents receiving [MEDICATION NAME], thus resulting in resident 1 being sent to the hospital.