Every finding on record at Rosewood Health Facility

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This failure resulted in ineffective infection surveillance (continuous method to collect, analyze, monitor and reduce infections) and antibiotic stewardship program (a program to monitor the use of antibiotics - medications used to treat infections in healthcare settings) and had the potential to increase the spread of infectious diseases to residents, staff, and visitors.Findings:During a concurrent interview and record review on 2/11/26 at 9:13 a.m. with IP, IP's training record was reviewed. IP stated she had not completed the specialized training in infection prevention and control. IP stated she started to work as a full-time IP (40 hours per week) at the end of October 2025. IP stated she does not hold any other role in the facility.During a review of the facility's Job Description - Infection Preventionist dated 7/8/20, the Job Description - Infection Preventionist indicated, Requirements: Specialty training in Infection Prevention and Control through accredited continuing education. Certificates: Must meet currently or have completed national training requirements for Infection Prevention and Control.

Based on observation, interview, and record review, the facility failed to ensure two of three laundry dryer filters were free of thick lint build up. This failure had the potential to increase the risk of a fire affecting residents' safety. Findings: During a concurrent observation and interview on 2/10/26 at 8:38 a.m. with Laundry Aide (LA) 1, in the laundry room, there were two dryers not in use. There was thick lint build up in each of the dryer's filters. LA 1 stated she has not gotten to clean it. During an interview on 2/12/26 at 11:23 a.m. with Housekeeping Supervisor (HS), HS stated, Honestly Monday [three days ago] was the last time I saw them cleaning the filter around 8:45 a.m. and 9 a.m. I don't go in there and clean the filter. During a review of the facility's policy and procedure (P&P) tilted, Cleaning Washers and Dryers, dated 11/14/23, the P&P indicated, Procedure to Clean the Outside: d. At the end of each shift, clean the filter and filter area. e. Check the burner area for lint build up. f. Wipe all areas that are easily accessible.

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a program to monitor the use of antibiotics - medications used to treat infections in healthcare settings) for four of five sampled residents (Resident 26, Resident 4, Resident 3, and Resident 24). This failure had the potential for residents to receive unnecessary antibiotics and to place them at risk for adverse health outcomes. Findings:During a concurrent interview and record review on 2/11/26 at 9:52 a.m., with Infection Preventionist (IP), the facility's Infection Control Prevention & Control Surveillance (ICPCS), dated 12/2025 was reviewed. The ICPCS indicated:a) On 12/5/25 to 12/12/25, Resident 26 had an order of Macrobid (antibiotic medication for bladder infection) 100 mg (milligram) PO (by mouth) BID (twice a day) x (times) 7 days for UTI (Urinary Tract Infection - bladder infection). There was no documentation of signs/symptoms and organism on culture (this test identifies the specific organism causing the illness, allowing for targeted antibiotic or treatment selection). IP stated she did not get to check if the urine was cultured (if laboratory tested to identify the specific organism of the infection to ensure correct antibiotic treatment). IP stated there was no documentation of signs/symptoms. IP stated the urinalysis (urine diagnostic test to identify infection) indicated it was not meeting the UTI criteria but not logged in the ICPCS. b) On 12/13/25 to 12/18/25, Resident 4 had an order of Cefuroxime Axetil (a strong antibiotic to treat infections, may cause serious side effects) 500 mg PO BID x 5 days for UTI. IP stated there are no documentation of signs/symptoms and organism on culture in the IPCS. c) On 12/18/25 to 12/27/28, Resident 3 had orders of Vancomycin HCL (strong antibiotic to treat infections) 125 mg QID (four times a day) x 10 days, Daptomycin (strong antibiotic to treat infections) 550 mg IV (intravenous-administered through the veins) Q Day (once a day) x 40 days, and Ertapenem sodium (strong antibiotic to treat infections) 1 g (gram) IV Q Day x 40 days. IP stated there are no documentation of signs/symptoms and organism on culture. IP stated Resident 3 had no symptoms but not logged in the ICPCS. d) On 12/16/25 to 12/21/25, Resident 24 had an order of Cephalexin (strong antibiotic medication) 500 mg PO QID x 5 days. On 12/20/25 to 12/27/25, Resident 24 had an order of Amoxicillin (antibiotic medication) 500 mg PO TID x 7 days for UTI. IP stated there was no documentation in the ICPCS why the antibiotic was changed. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes dated December 2016, the P&P indicated, Antibiotic usage and outcome data will be collected and documented using the facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 4. All antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: c. date symptoms appeared; f. pathogen identified; h. date of culture; k outcomes; l. adverse events.

Based on observation, interview, and record review, the facility failed to implement infection prevention practices when: Three of three clean laundry bins had dirt-like debris at the bottom. This failure had the potential for contaminating clean laundry and spread of infectious diseases to the residents. Three of three personal laundry transport carts had thick dust-like debris along the bottom frame of the cart. This failure had the potential for contaminating personal laundry and spread of infection and diseases to the residents. The facility did not follow its policy and procedure (P&P) titled, Surveillance of Infections. This failure had the potential for unidentified increase and spread of infectious diseases to the residents. Findings: 1. During a concurrent observation and interview on 2/10/26 at 8:52 a.m. with Laundry Aide (LA) 1, in the laundry room, there were three clean laundry bins in front of the three dryers. The three clean laundry bins had dirt-like debris at the bottom with pieces of material. LA 1 stated she had not gotten to clean them. 2. During a concurrent observation and interview on 2/10/26 at 9:17 a.m. with LA 1 in the laundry room, there were three personal laundry transport carts. The personal laundry transport carts' bottom frame had a thick dust-like debris. LA 1 stated she would clean it right now. During an interview on 12/12/26 at 10:12 a.m. with Housekeeping Supervisor (HS), HS stated, I don't know how often they clean the personal laundry carts, but that's maintenance who power washes the carts to get dirt and debris out from the wheels and frame. Usually, a work order is given to the maintenance to clean the bottoms of the personal laundry carts. Maintenance doesn't have a record of work done on the carts. During an interview on 12/12/26 at 10:52 a.m. with Maintenance Technician (MT) 1, MT 1 stated, I don't do anything with the personal laundry carts, I don't do any regular work on them, if anything it would just be changing the wheels. During an interview on 12/12/26 at 11:01 a.m. with MT 2, MT 2 stated, As far as I know, we don't pressure wash the carts, unless they tell us to. Cleaning is done based on work orders or if asked. During a review of the facility's Simple Work Order Listing (SWOL - list of maintenance requests) dated 2/12/26, the SWOL indicated, Description: Check All Laundry Carts, Organize Resident Laundry. There was no documentation of cleaning the personal laundry transport carts. During a review of the facility's P&P titled, Laundry and Bedding, Soiled, dated 2001, the P&P indicated, Linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. 3. During a review of the facility's Surveillance Worksheet (SW-the continuous, systematic collection and analysis of data to identify, track, and reduce healthcare-associated infections (HAIs) among residents), dated September 2025, the SW indicated, Total Number of new HAIs: 10. There was no documentation of preventative measure to slow or stop the spread of infection. During a review of the facility's SW dated October 2025, the SW indicated, Total Number of new HAIs: 15 [increased by 5 from September 2025]. There was no documentation of preventative measures to slow or stop the spread of infection. During an interview on 2/11/26 at 11:10 a.m. with Infection Preventionist (IP), IP stated stated she did not review the SW to implement preventative measures to slow or stop the spread of infection. IP stated there was no documentation of what preventative measures were implemented in the SW. During a review of the facility's P&P titled, Surveillance for Infections dated September 2017, the P&P indicated, The infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiological significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the infection preventionist will collect data to help determine the effectiveness of such measures.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Obtaining a Fingerstick [using a small needle (lancet) to draw a few drops of blood from the fingertip for immediate analysis] Glucose [sugar that is the body's main energy source] Level for 15 of 15 sampled residents (Resident 16, Resident 5, Resident 75, Resident 83, Resident 60, Resident 35, Resident 47, Resident 53, Resident 87, Resident 81, Resident 57, Resident 88, Resident 4, Resident 1, and Resident 73). This failure resulted in nursing staff conducting procedures on residents without a physician's order.Findings:During a concurrent interview and record review on 2/12/26 at 8:46 a.m. with Minimum Data Set (MDS- resident assessment tool) Coordinator (MDSC) and Assistant MDSC (AMDSC), MDSC stated 15 facility residents received insulin (treatment to regulate blood sugar). Physician Order (PO) for insulin for Resident 16, Resident 5, Resident 75, Resident 83, Resident 60, Resident 35, Resident 47, Resident 53, Resident 87, Resident 81, Resident 88, Resident 4, Resident 1, and Resident 73 were reviewed. AMDSC stated there is no specific PO for finger stick blood sugars for any of the 15 residents who received insulin. During a review of Resident 16's PO, dated 2/4/26, the PO indicated, Insulin Glargine Subcutaneous Solution . Inject 32 unit subcutaneously [below the skin] at bedtime . hold if BS [blood sugar] less than 100. The PO dated 2/8/26 indicated, Insulin Lispro Injection Solution . Inject 14 unit subcutaneously before meals . hold if BS less than 100 and Insulin Lispro Injection Solution . Inject as per sliding scale: 0 - 99= 0 unit . subcutaneously before meals and at bedtime . If BS is more than 401 give 12 units and call MD [medical doctor]. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 5's PO, dated 1/31/26, the PO indicated, Insulin Glargine Solution .Inject 18 unit subcutaneously at bedtime . hold if BS is below 100. The PO, dated 1/31/26 indicated, Insulin Glargine Solution . Inject 20 unit subcutaneously one time a day . hold if BS less than 100. The PO dated 1/17/26 indicated, Insulin Glargine Solution . Inject as per sliding scale: If 0-99 = 0 units . 401+ = 12 units, subcutaneously before meals and at bedtime MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 75's PO, dated 2/6/26, the PO indicted, Insulin Lispro Injection Solution . Inject as per sliding scale: 0-150 = 0 units . subcutaneously before meals and at bedtime. If BS is more than 400 give 18 units and call MD. Semglee (yfgn) [type of insulin] Solution Pen-injector . Inject 30 unit subcutaneously at bedtime . Hold if BS < [less than] 100. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 83's PO, dated 2/5/26, the PO indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . subcutaneously before meals and at bedtime . if BS is more than 401 give 12 units and call MD. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 60's PO, dated 2/5/26, the PO indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . subcutaneously before meals and at bedtime. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 35's PO, dated 1/30/26, the PO indicated, Insulin Glargine Subcutaneous Solution . Inject 14 unit subcutaneously at bedtime . Hold if BS <90. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 47's PO, dated 1/30/26, the PO indicated, Insulin Glargine Subcutaneous Solution . Inject 10 unit subcutaneously one time a day . hold if BS <100. The PO, dated 1/16/26, indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . subcutaneously before meals and at bedtime . Notify MD for BS> [greater than] 400. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 53's PO, dated 1/24/26, the PO indicated, Lantus SoloStar [type of insulin] Subcutaneous Solution Pen-injector . Inject 40 unit subcutaneously at bedtime. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 87's PO, dated 1/30/26, the PO indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . subcutaneously before meals and at bedtime. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 81's PO, dated 2/7/26, the PO indicated, Insulin Glargine Subcutaneous Solution . Inject 10 unit subcutaneously in the morning. The PO, dated 2/7/26, indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . 401+ = 12 units, subcutaneously before meals and at bedtime. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 57's PO, dated 1/1/26, the PO indicated, Insulin Degludec . Inject 17 units subcutaneously at bedtime . Hold if BS <100. The PO, dated 12/14/25, indicated, NovoLOG [type of insulin] FlexPen Subcutaneous Solution Pen-injector . Inject as per sliding scale: if 150 - 200 = 2 units . if BS>400 USE 20 units q [every] 3 h [hours] until under 400., subcutaneously before meals and at bedtime. MAR for FSBS results dated February 2026 was reviewed. During a review of Resident 88's PO, dated 2/11/26, the PO indicated, Insulin Glargine Solution .Inject 28 unit subcutaneously at bedtime and Insulin Lispro Injection Solution . Inject 9 unit subcutaneously two times a day before breakfast and lunch hold if BS less than 100. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 4's PO, dated 1/18/26, the PO indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . 401+ = 12 units, subcutaneously before meals and at bedtime. The PO, dated 2/10/26, indicated, Semglee Subcutaneous Solution . Inject 21 unit subcutaneously one time a day . Hold if blood glucose <80. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 1's PO, dated 2/1/26, the PO indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . 401+ = 12 units, subcutaneously before meals and at bedtime. The PO, dated 1/20/26, indicated, Insulin NPH (Human) . Inject 13 units subcutaneously two times a day . hold for BS <90. MAR for FSBS results dated February 2026 was reviewed.During a review of Resident 73's PO, dated 2/3/26, the PO indicated, Insulin Lispro Injection Solution . Inject as per sliding scale: if 0 - 99 = 0 units . subcutaneously before meals and at bedtime . if BS is more than 401 give 12 units and call MD. MAR for FSBS results dated February 2026 was reviewed.During an interview on 2/12/26 at 8:58 a.m. with Director of Nursing (DON), DON stated that there should be a PO for FSBS checks.During an interview on 2/12/26 at 9:29 a.m. with AMDSC, AMDSC stated there were no POs for nurses to perform FSBS for any of the 15 residents receiving insulin.During a review of the facility's P&P titled, Obtaining a Fingerstick Glucose Level dated 2001, the P&P indicated, The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Preparation: 1. Verify that there is a physician's order for this procedure.

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner for two of three sampled residents (Resident 24 and Resident 29). This failure resulted in Resident 24 and Resident 29 waiting up to one hour for staff to respond to their needs. Findings: During a group interview on 2/10/26 at 9:58 a.m. with Resident 24, Resident 24 stated, Regarding the call light system, staff is responding within five minutes, turning off the call light, and then tells us they [staff] will be back but never returns. During a review of Resident 24's Minimum Data Set (MDS - comprehensive assessment tool), dated 12/23/25, the MDS indicated Resident 24 had a Brief interview for Mental Status (BIMS - Cognitive assessment) score of 15 (score of 13 to 15 indicates cognitively intact). During a group interview on 2/10/26 at 10 a.m. with Resident 29, Resident 29 stated, I timed them [staff] and have waited an hour. One time, I waited so long and I had a soiled diaper. Resident 29 stated, Night time is the worst, nine out of 10 times they don't respond. I feel like it hits a wall and doesn't go high enough to get results. During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had a BIMS score of 14. During a review of Resident 29's Grievance Form dated 11/13/25, the Grievance Form indicated, Resident [29] states she waited about half an hour for her call light to be answered. During a review of the Call Light Response Time Log (CLRTL) for Resident 29, dated 11/13/25 at 3:14 a.m., the CLRTL indicated, Reset Time [length of time the call light was switched off and was answered]: 34 minutes and 33 seconds.During a review of the facility's Resident Council Minutes (RCM - the official written record of meetings held by a group of nursing home residents to discuss concerns, rights, and activities) dated 11/13/25, the RCM indicated, Call lights not answered in a timely manner. Residents stated they waited about half an hour for call light to be answered. During a review of the facility's RCM dated 12/10/25, the RCM indicated, Call lights are not answered in a timely manner. Residents stated CNA [Certified Nursing Assistant] turns call light off, states they will be back and do not return.During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, dated September 2022, the P&P indicated, Call for assistance are answered as soon as possible, within 0 to 15 minutes. Urgent requests for assistance are addressed immediately.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI - a program that monitors quality of care at the facility and addresses system deficits) committee failed to monitor and evaluate infection prevention and control performance data for two of 12 months (August and September) in 2025. This failure placed facility residents at risk for infectious diseases. Findings: During a concurrent interview and record review on 2/12/26 at 11 a.m. with Administrator, the facility's QAPI records were reviewed. Administrator stated the QAPI committee met quarterly and in 2025 met on 1/31/25, 4/23/25, 7/30/25, and 10/17/25. Administrator stated each QAPI meeting reviewed quality indicators (measures of facility performance) data going back three months. Administrator stated the 10/17/25 meeting reviewed quality indicators data from August, September and October 2025. Administrator provided the records of the 10/17/25 meeting which included the Infection Control Rounds (ICR) spreadsheet for August, September and October 2025. The ICR spreadsheet contained data for ten infection prevention and control quality indicators such as staff compliance with handwashing, putting on and removing personal protective equipment (gloves, gowns, masks, face shields, etc.), linen storage and other infection prevention and control indicators. There was no data for the infection prevention and control performance indicators in the ICR spreadsheets for August and September 2025. All the fields were blank. Administrator reviewed the QAPI records and did not find the infection prevention and control performance data for August and September 2025. Administrator stated she she would ask the Infection Preventionist (IP). During an interview on 2/12/26 at 11:33 a.m. with Administrator and IP, IP stated the infection prevention and control performance data for August and September 2025 had not been tallied. During a review of the facility's policy and procedure (P&P) titled, Health Center Quality Assurance and Performance Improvement Plan, updated 11/22, the P&P indicated, This Quality Assurance and Performance Improvement (QAPI) program has been developed to help us continually improve the way we care for and engage with our residents, team members, service partners, and the families of residents . This QAPI plan provides a framework by which organizational processes and outcomes are continuously accessed and improved through a systematic, comprehensive, data driven, and proactive approach to performance improvement .

Based on observation, interview, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADLs- routine daily self-care tasks to maintain basic physical health, hygiene, and independence) was provided to one of two sampled dependent residents (Resident 53). This failure had the potential for Resident 53's current level of bowel continence to decrease.Findings:During a concurrent observation and interview on 2/9/26 at 2:58 p.m. with Resident 53, in her room, Resident 53 sat in her wheelchair. Resident 53 stated could not use the left side of her body because she had a stroke (lack of blood flow to the brain leading to sudden loss of function). Resident 53 stated she can still feel the sensation of having to have a bowel movement (BM), but she needed assistance from the staff to get into the bathroom. Resident 53 stated if the staff do not respond to her call for assistance, she will have to have a BM in her brief. Resident 53 stated yesterday she pressed her call light for assistance to go to the bathroom to have a BM, a staff member answered the call light and asked what she needed. Resident 53 stated when she told the staff member she needed help with going to the bathroom, the staff member said she would be right back but never returned. Resident 53 stated she ended up having a BM in her brief. Resident 53 stated she was embarrassed when she had a BM in her brief because it made her room smell and then the staff had to clean her.During a review of Resident 53's admission Record (AR), the AR indicated a diagnosis of hemiplegia [paralysis of one side of the body] and hemiparesis [reduced voluntary muscle control affecting one entire side of the body] following cerebral infarction [death of brain tissue due to lack of blood supply] affecting left non-dominant [indicated resident was right-handed] side.During an interview on 2/11/26 at 11:15 a.m. with Director of Nursing (DON), DON stated that when residents need assistance, the staff should help the residents right away.During a concurrent interview and record review on 2/11/26 at 11:02 a.m. with Assistant Minimum Data Set (resident assessment tool) Coordinator (AMDSC), Resident 53's Care Plan, dated 3/19/25, was reviewed. The Care Plan indicated, Focus: The resident has an ADL self-care performance deficit r/t [related to HEMIPLEGIA AND HEMIPARESIS. Goal: The resident will maintain current level of function through the review date. Intervention . TOILET USE; The resident requires substantial/maximal assistance by 1 staff for toileting. Resident 53's MDS Section H - Bladder and Bowel, dated 1/16/26, indicated, H0400 Bowel Continence 1. Occasionally incontinent (one episode of bowel incontinence [during a seven-day look back]). Resident 53's Bowel elimination Task documentation indicated Resident 53 was incontinent on:November 2025: 11/3/25 day shift, 11/1/25 afternoon shift, 11/7/25 day shift, 11/7/25 afternoon shift, 11/22/25 night shift, and 11/26/25 night shiftDecember 2025: 12/4/25 day shiftJanuary 2026: 1/13/26 day shiftFebruary 2026: 2/5/26 afternoon shift, 2/6/26 afternoon shift, 2/7/26 day shift, and 2/8/26 afternoon shift. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 2001, the P&P indicated, Residents are provided with care, treatment, and service as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . 1. Residents are provided with care, treatment, and services to ensure their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate diminishing ADLs are unavoidable . 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with . c. elimination (toileting).

Based on observation, interview, and record review, the facility failed to ensure assistance with Activities of Daily Living (ADLs- routine daily self-care tasks to maintain basic physical health, hygiene, and independence) was provided to one of two sampled dependent residents (Resident 53). This failure resulted in Resident 53 being embarrassed due to not receiving assistance with her toileting needs and had the potential for her current level of bowel continence to decrease.Findings:During a concurrent observation and interview on 2/9/26 at 2:58 p.m. with Resident 53, in her room, Resident 53 sat in her wheelchair. Resident 53 stated could not use of her left side because she had a stroke. Resident 53 stated she still can feel the sensation of having to have a bowel movement (BM), but she needed assistance from the staff to get into the bathroom. Resident 53 stated if the staff do not respond to her call for assistance, she will have to have a BM in her brief. Resident 53 stated yesterday she pressed her call light for assistance to go to the bathroom to have a BM, a staff member answered the call light and asked what she needed. Resident 53 stated when she told the staff member, she needed help with going to the bathroom, the staff member said she would be right back but never returned. Resident 53 stated she ended up having a BM in her brief. Resident 53 stated she was embarrassed when she had a BM in her brief because it made her room smell and then the staff had to clean her.During a review of Resident 53's admission Record (AR), the AR indicated a diagnosis of hemiplegia [paralysis of one side of the body] and hemiparesis [reduced voluntary muscle control affecting one entire side of the body] following cerebral infarction [death of brain tissue due to lack of blood supply] affecting left non-dominant side.During an interview on 2/11/26 at 11:15 a.m. with Director of Nursing (DON), DON stated that when residents need assistance, the staff should help the residents right away.During a concurrent interview and record review on 2/11/26 at 11:02 a.m. with Assistant Minimum Data Set (resident assessment tool) Coordinator (AMDSC), Resident 53's Care Plan, dated 3/19/25, was reviewed. The Care Plan indicated, Focus: The resident has an ADL self-care performance deficit r/t [related to HEMIPLEGIA AND HEMIPARESIS. Goal: The resident will maintain current level of function through the review date. Intervention . TOILET USE; The resident requires substantial/maximal assistance by 1 staff for toileting. Resident 53's MDS Section H - Bladder and Bowel, dated 1/16/26, indicated, H0400 Bowel Continence 1. Occasionally incontinent (one episode of bowel incontinence [during a seven-day look back]). Resident 53's Bowel elimination Task documentation indicated Resident 53 was incontinent on:November 2025: 11/3/25 day shift, 11/1/25 afternoon shift, 11/7/25 day shift, 11/7/25 afternoon shift, 11/22/25 night shift, and 11/26/25 night shiftDecember 2025: 12/4/25 day shiftJanuary 2026: 1/13/26 day shiftFebruary 2026: 2/5/26 afternoon shift, 2/6/26 afternoon shift, 2/7/26 day shift, and 2/8/26 afternoon shift.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 2001, the P&P indicated, Residents are provided with care, treatment, and service as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . 1. Residents are provided with care, treatment, and services to ensure their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate diminishing ADLs are unavoidable . 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with . c. elimination (toileting).During a review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedures, dated 2010, the P&P indicated, Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including . b. Resident dignity and respect.

Based on observation, interview, and record review, the facility failed to develop and implement a noncompliance care plan (CP- documents the resident's needs based on an identified problem, documents interventions necessary to be implemented by the whole healthcare team to meet the established goal) for one of three sampled residents (Resident 1) identified as a high risk for developing pressure injuries (PI-is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure resulted in Resident 1 developing an unstageable pressure injury (obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the PI cannot be confirmed because it is obscured by slough [yellow or white material consisting of dead cells which attaches to the wound bed] or eschar [dead tissue that forms over healthy skin]. If slough or eschar is removed, a Stage 3 [Full-thickness loss of skin, in which adipose (fat) is visible] or Stage 4 [Full-thickness skin and tissue loss with exposed muscle, tendon [flexible tissue, similar to a rope], ligament [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects joints and bones] or bone are visible in the pressure injury] are revealed) to the coccyx (tailbone) and a deep tissue injury (DTI - intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) to the right heel. Findings: During a review of Resident 1's admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included wedge compression fracture of T-9 and T-10 vertebra (is a break in a vertebra [bones in your spine]) and end stage renal disease (kidney disease that progresses to a point where the kidneys lose nearly all their ability to filter waste from the body). During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 8/11/25, the MDS indicated, Resident 1' s BIMS (Brief Interview for Mental Status-standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness) The MDS indicated Resident 1 was dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), and sit to lying (the ability to move from sitting on side of bed to lying flat on the bed). The MDS indicated Resident 1 did not have pressure injuries upon admission. The MDS indicated Resident 1 was at risk for developing pressure injuries. During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, (Braden) dated 8/26/25, the Braden indicated Resident 1 scored a 11 (score of 10-12 indicated resident 1 was at a high risk for developing a pressure injury). During a review of Resident 1's Clinical admission (CA), dated 8/26/25, the CA indicated, Skin: Skin warm & dry, Skin color WNL (within normal limits) and turgor (the skin's elasticity and its ability to return to normal after being gently pinched, serving as a key indicator for assessing hydration) is normal. Skin note: open scabs to R (right) lateral (towards the side of the body or away from the middle) thigh, scabs to BLE (bilateral [both sides] lower extremities [arms and legs]) and BUE (bilateral upper extremities), skin peeling to R (right) foot, old amputation (surgical removal of a limb or body part) of all digits (toes) to R (right) and L (left) foot. During a review of Resident 1's care plan (is a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on The resident has an ADL self-care performance deficit r/t (related to) Limited Mobility, Limited ROM, Musculoskeletal impairment . , initiated 8/21/25, The care plan indicated a few of the interventions were Bed Mobility: The resident is totally dependent on 1-2 staff for repositioning and turning in bed 3-4 times a shift and as necessary, The resident is bedfast all or most of the time, and Personal Hygiene/Oral Care: The resident is totally dependent on 1 staff for personal hygiene and oral care. During a review of Resident 1's care plan with the focus on The resident has risk of potential for pressure injury development r/t immobility, initiated 8/22/25. The care plan indicated a few of the interventions were to The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested, Monitor nutritional status. Serve diet as ordered. Monitor intake and record. and Treat pain as per orders prior to treatment/turning. to ensure The [sic] resident's comfort. During a review of Resident 1's Documentation Survey Report, (DSR) for September 2025, the DSR indicated the following: On 9/2/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/2/25 at 11 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/2/25 at 11 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/3/25 at 1 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/3/25 at 3 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/3/25 at 5 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/4/25 at 3 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/4/25 at 5 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 9 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 5 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 7 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/5/25 at 9 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/6/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/6/25 at 9 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/7/25 at 7 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 1 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 3 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 5 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/8/25 at 11 p.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/9/25 at 1 a.m. the DSR indicated Resident 1 refused to turn and reposition.On 9/1/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/1/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/2/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/3/25 at 8 a.m. the DSR indicated Resident 1 refused breakfast.On 9/3/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/3/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/4/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/5/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/5/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner.On 9/7/25 at 8 a.m. the DSR indicated Resident 1 ate 26-50% of his breakfast.On 9/7/25 at 12 p.m. the DSR indicated Resident 1 ate 26-50% of his lunch.On 9/7/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of his dinner.On 9/8/25 at 12 p.m. the DSR indicated Resident 1 was unavailable for lunch.On 9/8/25 at 5 p.m. the DSR indicated Resident 1 ate 0-25% of dinner. During a review of Resident 1's Health Status Note, (HSN) dated 8/29/25 at 1:15 p.m. the HSN indicated, Resident refused turning and refused nail care notified to the nurse. Educate resident for hygiene and importance of turning to avoid pressure wounds. During a review of Resident 1's HSN, dated 8/29/25 at 10:27 p.m. the HSN indicated, Resident refused turning and nail care and change brief last round notify the nurse. Explained risk and benefits x [times] 3. During a review of Resident 1's HSN, dated 8/30/25 at 9:30 p.m. the HSN indicated, Resident refused bath Explained risk and benefits x3. During a review of Resident 1's HSN, dated 9/3/25 at 10:45 p.m. the HSN indicated, Ate 50%or less for 2 or more meals in the day. During a review of Resident 1's HSN, dated 9/4/25 at 9:06 a.m. the HSN indicated, During Night shift, resident had large BM [bowel movement] but refusing to change brief from CNA. CNA notified (sic) to CN [charge nurse]. Writer with 2 CNA go to resident. Explained resident to get brief change for hygienic purpose. Resident showing Aggressive behavior and don't want change anyway. Notified to MD [medical doctor]. Family made aware. Endorse to morning shift. During a review of Resident 1's HSN, dated 9/5/25 at 10:19 p.m. the HSN indicated, Ate 50% or less for 2 or more meals in the day. During a review of Resident 1's SBAR (situation background, appearance, review and notify- structured communication tool used in healthcare to convey critical patient information clearly and concisely) Communication Form, (SBAR) dated 9/6/25, the SBAR indicated, Other change in condition: open area on (Resident 1) scrotum (a pouch of skin containing testicles) and coccyx (tailbone) area wound unstageable . upon assessment noted pressure ulcer on coccyx . During a review of Resident 1's SBAR, dated 9/9/25, the SBAR indicated, Resident 1 had a right heel deep tissue injury (DTI - intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]). During a review of Resident 1's Skin & Wound Evaluation, (SWE) dated 9/9/25, the SWE indicated Resident 1 had an unstageable pressure injury to the sacrococcygeal, acquired in-house. The SWE indicated Resident 1's unstageable pressure injury to the sacrococcygeal measures area 1.9 cm2, length 2.5 cm, and width 1.2 cm. The SWE indicated Resident 1 was placed on a low air loss mattress and a ROHO cushion. During a review of Resident 1's SWE, dated 9/9/25, the SWE indicated, Resident 1 had a DTI pressure injury to right heel, acquired in-house. The SWE indicated Resident 1's DTI pressure injury to right heel measured area 8.3 centimeters squared (cm2- unit of measure) length 3.7 cm width 3.1 cm. The SWE indicated Resident 1 was placed on a low air loss mattress and heel protectors. During an interview on 12/8/25 at 2:59 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated some of the interventions for residents at risk for PI were to make sure to keep them clean and dry, turn every two hours and as needed, try to encourage the resident to get out of bed and go to activities. CNA 1 stated when a resident refuses, he stated try to encourage the resident or get someone to explain why the intervention is important but when the resident continues to refuse, he reports the resident's refusal to the nurse. CNA 1 stated he documents the interventions completed and refused on the POC (Point of Care - electronic charting system). During an interview on 12/8/25 at 3:24 p.m. with Registered Nurse (RN) 1, RN 1 stated for new admission she does a head toe assessment to check for skin issues. RN 1 stated the CNAs assess the resident's skin daily. RN 1 stated when the CNA report resident's refusal of interventions, she will speak to the resident to see why they are refusing, give risk and benefits of refusing the intervention. RN 1 stated she will give the risk and benefits three times. RN 1 stated the resident has the right to refuse. RN 1 stated she document she spoke to the resident and gave the risk and benefits in progress note. RN 1 stated if the resident continues to refuse, she informs the residents medical doctor and the resident's family and updates care plan. During a concurrent interview and record review, on 12/8/25 at 3:37 p.m. with Director of Nursing (DON), Resident 1's CA' dated 8/26/25. DON stated Resident 1 did not have PI upon admission on [DATE]. Resident 1's SWE, dated 9/9/25 were reviewed. DON stated Resident 1' unstageable sacrococcygeal and DTI to right heel were acquired in the facility. Resident 1's DSR, dated September 2025 was reviewed. DON confirmed Resident 1's multiple refusal to turn and reposition over an eight-day period. Resident 1's care plans were reviewed. DON stated Resident 1 was at risk for PI and was totally dependent on facility staff for turning and repositioning and toileting, requiring one to two staff to assist him with turning and repositioning and toileting. DON confirmed Resident 1 did not have a care plan that addressed his refusal to turn and reposition. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . 9. Care plan interventions are chosen only after data gathering proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on interview and record review, the facility failed to ensure the Interdisciplinary team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) met to discuss if one of three sampled residents (Resident 1) who was high risk for falls (move downward, typically rapidly and freely without control from a higher to a lower level), had a history of falls, and had a diagnosis of Dementia (a progressive state of decline in mental abilities), was safe to have one-on-one monitoring (1:1- a type of care where a healthcare professional provides constant supervision to a resident) discontinued. After discontinuing the 1:1 monitoring the facility failed to conduct a fall risk assessment (medical evaluation used to determine how likely a resident is to fall), update the care plan (CP- a document that outlines a resident's needs, treatment, and expected outcomes) to include updated interventions, and provide adequate supervision. These failures resulted in Resident 1 sustaining a fall with fracture (broken bone), experiencing pain and requiring admission with surgical intervention (a medical procedure that involves physically altering the body to treat or prevent a medical condition) at the acute hospital. Findings: During a review of Resident 1's ADMISSION RECORD (AR), dated 2/11/25, the AR indicated, Resident 1 was admitted to the facility on [DATE]. The AR indicated Resident 1 had diagnosis of history of falling, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia, and spinal stenosis (a narrowing of the spinal column that occurs over time and can put pressure on the spinal cord [a tube-shaped bundle of nerves that runs from the brain to the lower back]) lumbar region (lower back) with neurogenic claudication (a condition that causes pain, weakness, or numbness in the legs while walking or standing), need for assistance with personal care, and difficulty in walking. During a review of Resident 1's admission Minimum Data Set (MDS- an assessment tool) under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns]), dated 1/13/25, the BIMS indicated, Resident 1 had a score of 3 (very low level of cognition [how well a person thinks, remembers, and learns] function). The MDS under the section GG (an assessment of the level a care a resident required), dated 1/13/25, the GG indicated, Resident 1 required supervision or touching assistance to move from a sitting to standing position, move from chair to bed or bed to chair, pick up objects from the floor from a standing position due to medical condition and/or safety concerns. During a review of Resident 1's Fall Risk Evaluation (FRE), dated 1/9/25, the FRE indicated, Resident 1 had a score of 19 (high risk for falls). During a review of Resident 1's CP dated 1/9/25, the CP indicated, to anticipate and meet Resident 1's needs. During a review of Resident 1's Progress Notes (PN), dated 1/28/25, the PN indicated, Resident 1 had an unwitnessed fall at approximately 9:25 p.m. (on 1/28/25) and complained of right knee pain. The PN indicated on 1/29/25, Resident 1 was sent to the acute hospital due to complaint of right knee pain. During a review of the acute hospital ED (Emergency Department) Physician Notes (EDPN), dated 1/29/25, the EDPN indicated, Pt (Patient- Resident 1) BIBA (brought in by ambulance) for fall. Pt (Resident 1) is from (facility) and had an unwitnessed fall at the Nurses station around 2100 (9 p.m.) last night. Pt (Resident 1) is complaining of Right Knee/Hip/Lower back pain (no specific pain information given) from the fall. The patient (Resident 1) is a female with history of dementia . During a review of the acute hospital History and Physical (H+P), dated 1/29/25, the H+P indicated, Resident 1 had, frequent falls . who presents to the hospital after having a ground-level fall at (facility). The patient (Resident 1) was in a wheelchair when she fell forward out of the wheelchair landed on her right side. (Resident 1) was complaining of right-sided pain (no specific information given about pain) . X-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) is positive for a right comminuted (producing multiple bone splinters) intertrochanteric (hip) fracture. The EDPN indicated Resident 1 was given morphine (narcotic [pain medication] medication for severe pain) four mg (milligram- a unit of measurement) in the ED. During a review of the acute hospital Discharge Summary (DC), dated 2/1/25, the DC indicated, Patient (Resident 1) was taken the (sic) OR (Operating Room) for (surgical procedure) intramedullary (hollow center of the bone) nailing (a metal rod placed into the bone to stabilize a break) of the right femur (thigh bone). Medications to Continue . acetaminophen-Hydrocodone (a narcotic drug) . 5 mg -325 mg oral (by mouth) tablet . 2 (tablets) every 6 hours as needed for severe pain. During an interview on 2/11/25 at 2:26 p.m. with Director of Nursing (DON), DON stated Resident 1 had an unwitnessed fall in front of the nurse's station on 1/28/25 at approximately 9:25 p.m. DON stated Resident 1 was at the nurse's station at the time of the fall due to Resident 1 being confused (exhibiting an inability to understand) and needing to be monitored/supervised closely by staff to prevent falls. During an interview on 2/11/25 at 3:33 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was confused and attempting to get out of her wheelchair or bed without assistance. CNA 1 stated staff would place Resident 1 at the nursing station to monitor/supervise due to her high risk for falls. CNA 1 stated staff would place Resident 1 in her bed when she was exhausted to rest and sleep. CNA 1 stated Resident 1 used to be on 1:1 monitoring (not sure of the dates) but it was discontinued (not aware by who) prior to her fall incident on 1/28/25. CNA 1 stated on 1/28/25 she was at the nurse's station, Resident 1 was behind her (approximately five feet- [unit of measurement]), but she was not monitoring/supervising Resident 1. CNA 1 stated she heard a loud noise, turned around, and observed Resident 1 lying on the floor. During an interview on 2/11/25 at 3:45 p.m. with CNA 2, CNA 2 stated Resident 1 had a 1:1 monitoring (not sure of the dates) but no longer on 1:1 monitoring at the time of the fall on 1/28/25. CNA 2 stated she was about three feet away from Resident 1 prior to her fall (1/28/25) but was not directly monitoring/supervising Resident 1. During an interview on 2/11/25 at 4:03 p.m. with Nursing Supervisor (NS), NS stated prior to Resident 1's fall incident on 1/28/25, Resident 1 was on 1:1 monitoring to prevent falls (not sure of when the 1:1 started and when was it discontinued). NS stated on 1/28/25, Resident 1 was found lying on the floor and complained of right leg pain. NS stated the facility process was to place high risk residents on 1:1 monitoring, If they (residents) are a really high fall risk (for falls) and staff . express (they) are not able to keep up (with the resident). During a review of Resident 1's Electronic Medical Record (EMR), on 2/11/25 at 1 p.m., there was no evidence the facility conducted an IDT meeting to discuss if Resident 1 was safe to have the 1:1 monitoring discontinued, there was no fall risk evaluation (FRE), and there was no updated care plan noted after discontinuing the 1:1 monitoring for Resident 1. During a concurrent interview and record review on 2/20/25 at 1:10 p.m. with Administrator, Resident 1's EMR, dated 1/2025 was reviewed. Administrator stated Resident 1 was started on 1:1 monitoring on 1/11/25 due to staff being overwhelmed with Resident 1 trying to get up without assistance. Administrator stated the 1:1 monitoring was discontinued on 1/17/25. Administrator stated the facility did not conduct an IDT meeting to discuss if Resident 1 was safe to have the 1:1 monitoring discontinued, there was no fall risk evaluation (FRE) done until after the fall incident on 1/28/25, and there was no updated care plan for updated interventions. Administrator stated there should have been an IDT done to discuss if Resident 1 was safe enough to come off 1:1 monitoring, fall risk assessment and updated CP. Administrator stated the staff (not identified) last observed Resident 1 on 1/28/25 at 8:54 p.m. and the unwitnessed fall happened at 9:25 p.m. (31 minutes after last observation). During an interview on 2/25/25 at 9:41 a.m. with CNA 3, CNA 3 stated she was assigned to Resident 1 on the day she fell on [DATE]. CNA 3 stated Resident 1 was on 1:1 monitoring in the past (not sure of the dates). CNA 3 stated prior to the fall incident on 1/28/25 Resident 1 attempted to get up without assistance at least four times by the nurse's station and at least twice in her room (from 2:30 p.m. to 9 p.m.). CNA 3 stated she was helping another resident when Resident 1 fell on [DATE]. CNA 3 stated she had not asked any other staff member to monitor/supervise Resident 1 because, We (staff) all knew to put her in the nurse's station and monitor her (Resident 1). During a review of the facility's policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team, dated 3/2022, the P&P indicated, The interdisciplinary team is responsible for the development of resident care plans. During a review of the facility's P&P titled, Fall Risk Assessment, dated 3/2018, the P&P indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include . cognitive impairment (how well a person thinks, remembers, and learns) . Resident-Centered Approaches to Managing Falls and Fall Risk .

Based on observation, interview, and record review, the facility failed to follow their policy and procedure on change of condition for one of three sampled residents (Resident 1). This failure resulted in a delay in care and had the potential for negative medical outcomes. Findings: During a concurrent observation and interview on 12/3/24 at 2:35 p.m. with Resident 1 in the hallway, Resident 1 was observed with a large area of raised reddened scaly appearing skin from the bottom of her left side of neck stretching toward her left shoulder approximately 6 inches in length and width. Resident 1 was observed scratching at this reddened area as well as picking and scratching at her face. Resident 1 was confused to time and place. Resident 1 could not answer questions appropriately. During an interview on 12/3/24 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1. LVN 1 stated Resident 1 is alert but confused. LVN 1 stated she did not know what the cause of the scaly redness was on Resident 1 ' s bottom of left side of neck toward her left shoulder. LVN 1 stated Resident 1 could scratch herself to the point of bleeding and would state it was mosquito bites causing her itchiness. LVN 1 stated Resident 1 had a history of cellulitis (a bacterial infection of the skin and the tissue beneath the skin) of the face in October 2024 and was on antibiotics (medication for bacterial infections). LVN 1 stated the only treatment Resident 1 was currently getting for the redness to her left bottom of neck toward left shoulder was barrier cream (a product applied directly to the skin surface to help maintain the skin's physical barrier, providing protection from irritants and preventing the skin from drying out). During an observation on 12/3/24 at 2:43 p.m. in the hallway, Resident 1 was observed scratching and picking at her face and at the redness located on the bottom left side of her neck going towards the left shoulder. During an interview on 12/3/24 at 2:52 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1. CNA 1 stated when Resident 1 is not sleeping she is constantly scratching at her face and body. CNA 1 stated Resident 1 states she is itchy. CNA 1 stated the nurses will apply barrier cream on her to help. CNA 1 stated she could not recall exactly how long Resident 1 had scaly redness to the bottom of the left side of her neck toward her left shoulder but it had been a few weeks or more. During an interview on 12/3/24 at 3:26 p.m. with Treatment Nurse (TXN), TXN stated Resident 1 picks and scratches at her face and body due to it being a behavior/bad habit. TXN stated the raised scaley reddened area on Resident 1 ' s bottom of left neck going toward her left shoulder was from her behavior of scratching and picking. TXN stated Resident 1 did have a previous history of cellulitis. TXN stated Resident 1 had not been seen by a dermatologist (specialist in skin disorders). TXN stated Resident 1 was being treated with barrier cream. During a concurrent observation and interview on 12/3/24 at 4:22 p.m. with Director of Nursing (DON) in the administrator office, Resident 1 ' s raised redness to the bottom of left neck going toward the left shoulder was observed. DON stated the reddened area appeared as definitely a skin issue and appeared to be psoriasis (a chronic skin disease that causes the immune system to overreact, resulting in rapid skin cell growth, inflamed, scaly patches, and other symptoms) or eczema (a medical condition in which patches of skin become rough and inflamed, with blisters that cause itching and bleeding) requiring medical attention and not scratches. DON stated Resident 1 ' s Medical Doctor needed to be informed of her skin condition for further instructions on how to treat it. During a review of Resident 1 ' s Order Summary (OS), dated 12/4/24, the OS indicated Resident 1 Medical Doctor was informed of her raised scaley redness to the left side of her lower neck toward her left shoulder and was placed on Doxycycline (antibiotic for skin infection) one tablet two times a day for 14 days for diagnosis of cellulitis. During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's attending physician or physician on call when there has been a . significant change in the resident's physical/emotional/mental condition . need to alter the resident's medical treatment significantly . A significant change of condition is a major decline or improvement in the resident's status that . will not normally resolve itself without intervention . Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . Enter comment here Based on observation, interview, and record review, the facility failed to follow their policy and procedure on change of condition for one of three sampled residents (Resident 1). This failure resulted in a delay in care and had the potential for negative medical outcomes. Findings: During a concurrent observation and interview on 12/3/24 at 2:35 p.m. with Resident 1 in the hallway, Resident 1 was observed with a large area of raised reddened scaly appearing skin from the bottom of her left side of neck stretching toward her left shoulder approximately 6 inches in length and width. Resident 1 was observed scratching at this reddened area as well as picking and scratching at her face. Resident 1 was confused to time and place. Resident 1 could not answer questions appropriately. During an interview on 12/3/24 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1. LVN 1 stated Resident 1 is alert but confused. LVN 1 stated she did not know the cause of the scaly redness on Resident 1's bottom of left side of neck toward her left shoulder. LVN 1 stated Resident 1 could scratch herself to the point of bleeding and would state it was mosquito bites causing her itchiness. LVN 1 stated Resident 1 had a history of cellulitis (a bacterial infection of the skin and the tissue beneath the skin) of the face in October 2024 and was on antibiotics (medication for bacterial infections). LVN 1 stated the only treatment Resident 1 was currently getting for the redness to her left bottom of neck toward left shoulder was barrier cream (a product applied directly to the skin surface to help maintain the skin's physical barrier, providing protection from irritants and preventing the skin from drying out). During an observation on 12/3/24 at 2:43 p.m. in the hallway, Resident 1 was observed scratching and picking at her face and at the redness located on the bottom left side of her neck going towards the left shoulder. During an interview on 12/3/24 at 2:52 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1. CNA 1 stated when Resident 1 is not sleeping she is constantly scratching at her face and body. CNA 1 stated Resident 1 states she is itchy. CNA 1 stated the nurses will apply barrier cream on her to help. CNA 1 stated she could not recall exactly how long Resident 1 had scaly redness to the bottom of the left side of her neck toward her left shoulder, but it had been a few weeks or more. During an interview on 12/3/24 at 3:26 p.m. with Treatment Nurse (TXN), TXN stated Resident 1 picks and scratches at her face and body due to it being a behavior/bad habit. TXN stated the raised scaley reddened area on Resident 1's bottom of left neck going toward her left shoulder was from her behavior of scratching and picking. TXN stated Resident 1 did have a previous history of cellulitis. TXN stated Resident 1 had not been seen by a dermatologist (specialist in skin disorders). TXN stated Resident 1 was being treated with barrier cream. During a concurrent observation and interview on 12/3/24 at 4:22 p.m. with Director of Nursing (DON) in the administrator office, Resident 1's raised redness to the bottom of left neck going toward the left shoulder was observed. DON stated the reddened area appeared as definitely a skin issue and appeared to be psoriasis (a chronic skin disease that causes the immune system to overreact, resulting in rapid skin cell growth, inflamed, scaly patches, and other symptoms) or eczema (a medical condition in which patches of skin become rough and inflamed, with blisters that cause itching and bleeding) requiring medical attention and not scratches. DON stated Resident 1's Medical Doctor needed to be informed of her skin condition for further instructions on how to treat it. During a review of Resident 1's Order Summary (OS), dated 12/4/24, the OS indicated Resident 1 Medical Doctor was informed of her raised scaley redness to the left side of her lower neck toward her left shoulder and was placed on Doxycycline (antibiotic for skin infection) one tablet two times a day for 14 days for diagnosis of cellulitis. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's attending physician or physician on call when there has been a . significant change in the resident's physical/emotional/mental condition . need to alter the resident's medical treatment significantly . A significant change of condition is a major decline or improvement in the resident's status that . will not normally resolve itself without intervention . Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Water Management Program for 71 of 71 sampled resident's when the facility cooling tower (device that removes heat from water and used to cool a building) tested positive for Legionella (bacteria causing lung infection). This failure had the potential to spread a highly contagious, infectious bacteria to residents, visitors, and staff. Findings: During an interview on 11/6/24 at 9:30 a.m. with Safety Officer (SO), SO stated the cooler connected to the water tower tested positive for Legionella and the water treatment company treated the water. SO stated he got the report on October 16th and he notified the facility Administrator, Infection Preventionist (IP), and Director of Operations (DO). During an interview on 11/6/24 at 9:35 a.m. with Director of Nursing (DON), DON stated the staff had not been in-serviced on Legionella or legionella pneumonia. During an interview on 11/6/24 at 12:26 p.m. with Field Technician (FT), FT stated the facility was responsible for treating water sources and following facility policy. During a concurrent interview and record review on 11/7/24 at 8:21 a.m. with IP, Legionnaire Testing (LT) dated 10/17/24, was reviewed. The LT indicated The first report is the annual water treatment test, which indicated a small amount of Legionella in the cooling tower; however, testing confirmed that it was not present in the kitchen or the health center. Please note that the tower was sanitized on October 16, 2024. IP stated an internal email indicated the building was not affected. During a concurrent interview and record review on 11/7/24 at 9:03 a.m. with SO, Analysis Report prepared for [NAME] (AR) dated 9/16/24 was reviewed. The AR indicated the following: 9/17/24, Sample 1 Tower Legionella Analysis on water using STL 127, CFU/Milliliters (unit of measure counting viable microbial cells) 5600 9/17/24, Sample 2 Kitchen sink CFU/ Milliliter 4, and 9/17/24, Sample 3 East Wing Sink CFU/ Milliliter less than 1. SO stated the analysis report in the cooling tower showed a slightly above normal and the sink was at an acceptable range. During a review of the facility's policy and procedure (P&P) titled, Water Management dated July 2017, the P&P indicated, Reviewing medical and microbiology records. b. Actively identifying all new and recent residents with healthcare-associated pneumonia and testing them for Legionella using both culture of lower respiratory secretion and the Legionella urinary antigen test. c. Developing a line list of cases. h. Decontaminating environmental source(s). During a review of Centers for Disease Control and Prevention, Developing a Water management Program to Reduce Legionella Growth & Spread in Building, dated 6/24/21, indicated Identifying & Investigating Legionnaires Disease Cases. Healthcare facilities are often uniquely positioned to identify and respond to cases of Legionnaires' disease. A healthcare facility's water management program to limit Legionella growth and spread should include the actions to take when a patient is diagnosed with Legionnaires' disease or environmental triggers occur. If you decide to conduct a full investigation of the source of an infection, key elements should be included, as noted on the next page. A full investigation following a diagnosis of Legionnaires' disease can help determine whether the infection was acquired in the facility or the community. Clinicians should test patients with healthcare-associated pneumonia (pneumonia with onset [greater or equal to] 48 hours after admission) for Legionnaires' disease. This is especially important among patients at increased risk for developing Legionnaires' disease, among patients with severe pneumonia (particularly those requiring intensive care), or if any of the following are identified in your facility: Other patients with healthcare-associated Legionnaires' disease diagnosed in the past 12 months. Positive environmental tests for Legionella in the past 2 months. Current changes in water quality that may lead to Legionella growth (e.g., low residual disinfectant levels, temperatures permissive to Legionella growth, nearby construction, areas of stagnation) Other patients, besides those with healthcare-associated pneumonia, should also be tested for Legionnaires' disease. The preferred diagnostic tests for Legionnaires' disease are culture of lower respiratory secretions on selective media and the Legionella urinary antigen test.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Medication Labeling and Storage for two of 32 sampled residents (Resident 219, Resident 58) and two of two medication carts when: 1. Medications were at the bedside for two of 32 sampled residents (Resident 219, Resident 58). This failure had the potential for medication to be accessed by unauthorized staff and residents. 2. Four of 14 insulin (medication to lower sugar levels in the blood) vials were expired on two of two sampled medication carts. This failure had the potential to result in a loss of medication potency (strength), inaccurate test results, and adversely affect the residents' health. Findings: 1. During a concurrent observation and interview on [DATE] at 10:52 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 219's room, Resident 219 had Calazinc (helps protect and relieve minor skin irritation due to rashes) on the bedside table. LVN 2 stated medication should not be at bedside. During a concurrent observation and interview on [DATE] at 1:15 p.m. with LVN 2 in Resident 58's room, Resident 58 had Vitamin A&D ointment (used for skin irritation such as diaper rash and skin burns from radiation therapy). LVN 2 stated Vitamin A&D should be applied by nurses. During a concurrent interview and record review on [DATE] at 11:32 a.m. with Assisted Director of Nursing (ADON), Resident 219's Medical Record (MR), was reviewed. The MR indicated, Resident 219 had no self-medication assessment done and had no physician order to keep medication at bedside. ADON stated Resident 219 had no physician order and no self-medication assessment done. During a concurrent interview and record review on [DATE] at 2:36 p.m. with ADON, Resident 58's MR, was reviewed. The MR indicated, Resident 58 had no self-medication assessment done and had no physician order to keep medication at bedside. ADON stated Resident 58 needed a physician order to keep medication at bedside. ADON stated Resident 58 had no physician order and no self-medication assessment done. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, The facility stores all medications and biologicals [class of medicine made from living organisms] in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 2. During a concurrent observation and interview on [DATE] at 2:39 p.m. with LVN 3 on South-wing the following medications were stored in the medication cart: Insulin Lispro (used to lower blood sugar) opened on [DATE] and expired on [DATE]. Insulin Humalog (used to lower blood sugar) opened on [DATE] and expired on [DATE]. LVN 3 stated both insulins were expired. During a concurrent observation and interview on [DATE] at 3:11 p.m. with LVN 2 on West-wing at medication cart, the following medications were found: Insulin Lantus (lowers blood sugar) opened on [DATE] expired on [DATE]. Insulin Lispro opened on [DATE] and expired on [DATE]. Insulin Lispro opened on [DATE] and expired on [DATE]. LVN 2 stated all three insulins were expired. During a review of the facility's P&P titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Catheter Care, Urinary, for one of two sampled residents (Resident 49) when timely nursing assessment and interventions were not provided when Resident 49 complained of pain. This failure resulted in Resident 49 experiencing discomfort. Findings: During a concurrent observation and interview on 11/4/24 at 9:43 a.m. with Resident 49, in his room, a catheter (flexible tube that continually drains and empties urine from the bladder into a collection bag outside the body) urine collection bag was seen suspended from the left side of his bed. Resident 49 stated he had the catheter because he had a lot of kidney stones (small, hard deposits that form in the kidneys and are often painful when passed) and a lot of sediment (the material from a liquid that settles to the bottom) drained from his urine. During an interview on 11/5/24 at 9:56 a.m. with Resident 49, he stated he was having pain from his catheter, and he made his nurse aware of the discomfort. Resident 49 stated his nurse told him something was going to be done about the catheter discomfort. During an interview on 11/5/24 at 11:03 a.m. Resident 49 stated no one had done anything about the pain from the catheter site and he was still having pain. During an interview on 11/5/24 11:05 a.m. Licensed Vocational Nurse Supervisor (LVNS), LVNS stated she was covering for LVN 2, who was Resident 49's nurse. LVNS stated LVN 2 was at lunch. LVNS stated she would check with LVN 2 to find out what was happening with Resident 49's catheter issues. During an interview on 11/5/24 at 11:10 a.m. with LVNS, LVNS stated LVN 2 was aware of Resident 49's catheter pain and LVN 2 was going to tell Treatment Nurse (TN) about Resident 49's catheter discomfort. LVNS stated any licensed nurse could assess catheter issues, not just TN. During a record review on 11/5/24 at 11:20 a.m. Resident 49's medical record was reviewed, the medical record indicated, no nurse's notes regarding Resident 49's catheter discomfort. During a record review on 11/5/24, Resident 49's Order Summary (PO-physician orders) dated 8/11/24 was reviewed. The PO indicated, an indwelling catheter was to be placed to relieve urinary retention (inability to urinate) and be changed as needed when catheter stops draining, becomes dislodged, or leakage occurs. During an interview on 11/5/24 at 11:30 a.m. with LVN 2, LVN 2 stated Resident 49 complained of pain from his catheter. LVN 2 stated Resident 49 told her his catheter was leaking from the placement area (tip of the penis). LVN 2 stated she looked in the urine collection bag and saw it was draining. LVN 2 stated she did not assess Resident 49 for a reason the catheter caused Resident 49 discomfort. LVN 2 stated she should have assessed for a reason for the discomfort but did not because his tray [meal tray] was in front of him. LVN 2 stated she was going to tell TN about Resident 49's catheter discomfort, but stated she should have assessed the reason for the pain herself. LVN 2 stated she medicated Resident 49 with Tylenol. During an interview on 11/5/24 11:47 a.m. with TN, TN stated she assessed Resident 49's catheter discomfort. TN stated it was leaking from the tip of the penis. TN stated she replaced the catheter and immediately drained 300 ml of urine (people will feel the need to urinate (pee) when their bladder has between 150 and 250 ml of urine in it) with a little bit of sediment. TN stated Resident 49 stated he felt better once the catheter was replaced. During an interview on 11/5/24 at 12:28 p.m. with Resident 49, Resident 49 stated he felt better after the catheter was replaced. Resident 49 stated he felt a lot of pressure before it was replaced. During an interview on 11/7/24 at 11:40 a.m. with Director of Nursing (DON), DON stated LVN 2 should have completed a focused assessment to determine what caused Resident 49's catheter discomfort. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications . Complications 1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately . d. if the resident complains of burning, tenderness, or pain in the urethral area [in men- tube that carries urine from the bladder to the tip of penis]. e. if signs and symptoms of urinary tract infection or urinary retention occur [condition that makes it difficult to empty the bladder, either partially or completely].

Based on observation, interview, and record review, the facility failed to update the care plan for for one of three sampled residents (Resident 20). This failure resulted in Resident 20 developing Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture). Findings: During an observation on 11/4/24 at 10:42 a.m. two staff members repositioned Resident 20. Resident 20 was non-verbal. During a review of Resident 20's Admission Record (AR), the AR indicated diagnoses including, weakness or the inability to move on the left side of her body, severe loss of strength on the left side of her body, inability to talk, and obesity. During a concurrent interview and record review on 11/6/24 at 11:06 a.m. with Director of Nursing (DON), Resident 20's Care Plan (CP), revision date of 9/27/24, was reviewed. The CP indicated two staff were to reposition Resident 20 at least once a shift and as necessary. DON stated dependent residents are turned every two hours and as needed. DON stated Resident 20's CP should have been updated to turn every two hours after she was diagnosed with MASD on 10/24/24 and that there was no reason for the CP to not be updated. During an interview on 11/6/24 at 3:40 p.m. with DON, DON stated if a resident is not turned, pressure injuries and skin breakdown will occur.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Resident Informed Consent for the use of Psychotherapeutic [medication to treat mental disorders] Drugs, for two of six sampled residents (Resident 48 and Resident 217) when their informed consents were not complete. This failure had the potential for Resident 48 and Resident 217 to receive psychotropic medication without knowing the risks and benefits of the medication. Findings: During an interview on 11/6/24 at 2:06 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the doctor was responsible for getting the informed consent and the nurse was the one who witnessed the resident's signature. During a review of Resident 48's Physician Orders (PO) dated 5/16/23, the PO indicated, Temazepam (used to treat inability to sleep) 15 mg capsule, 1 capsule through the feeding tube (tube inserted into stomach for nutritional and medication needs) one time daily. During a review of Resident 48's Informed Consent (IC) dated 5/19/23, the IC indicated This documentation is to be completed before treatment is initiated which chemical restraints, physical restraints, phsychotherapeutic drug .The IC indicated Resident 48 had a Resident Representative. The IC did not indicate the Resident Representative had signed the consent, and there was no signature by a facility representative. 46958 During a review of Resident 217's Order Review History Report (ORHR), dated 11/4/24, the ORHR indicated Resident 217 was receiving Temazepam 15 mg capsule, 1 capsule by mouth at bedtime and Mirtazapine (used to treat depression) 45 mg 1 tablet by mouth at bedtime. During an interview on 11/7/24 at 3:20 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 217's IC were incomplete. During a review of the facility's policy and procedure (P&P) titled, Resident Informed Consent for the use of Psychotherapeutic Drugs, dated 4/4/24, the P&P indicated, Before receiving treatment with a psychotherapeutic drug the facility must verify that this consent is signed and, [sic] in the individual's, [sic] medical record.

Based on interview and record review, the facility failed to ensure physician ordered medication was available for one of six sampled residents (Resident 217). This failure resulted in Resident 217's pain not being controlled as evidenced by Resident 217's statement of pain of 6 to 7 out of 10 (on a 10 point pain scale 0 is no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 unbearable pain). Findings: During an review of Resident 217's Physician Order (PO), dated 11/1/24, Glucosamine-Chondritin Tablet (used to treat joint pain) 500mg-400 mg give 2 tablet by mouth two times a day. During a concurrent interview and record review on 11/7/24 at 8:23 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 217's Medication Administration Record (MAR), dated November 2024 was reviewed. The MAR indicated the following: 11/2/24 a.m. shift medication was not administered. 11/2/24 p.m. shift medication was not administered. 11/3/24 a.m. shift medication was not administered. 11/3/24 p.m. shift medication was not administered. 11/4/24 a.m. shift medication was not administered. 11/5/24 a.m. shift medication was not administered. 11/5/24 p.m. shift medication was not administered. 11/6/24 a.m. shift medication was not administered. 11/6/24 p.m. shift medication was not administered. LVN 1 stated medication was not available to administer and when when medication was not available the pharmacy should be notified. During an interview on 11/7/24 at 8:34 a.m. with Resident 217, Resident 217 stated when I move, I have pain of 6 to 7 in my left knee. During an interview on 11/7/24 at 4:02 p.m. with Director of Nursing (DON), DON stated expectation is for new admission medication should be available within 4-6 hours and if it is over the counter medication than facility can buy from a local pharmacy. During an review of Resident 217's Progress Note (PN), dated 11/7/24, the PN indicated the Pharmacy would not deliver medication due to the medication being over the counter(OTC). A policy for notifying the physician when medication was not available to administer was requested, none was provided.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Psychotropic Medication Use, for one of seven sampled residents (Resident 217), when the facility did not monitor changes in behavior and side effects for physician ordered medications, Mirtazapine (to treat depression) and Temazepam (to treat inability to sleep). This failure had the potential to affect the health and safety of Resident 217. Findings: During a concurrent interview and record review on 11/6/24 at 11:52 a.m. with Assistant Director of Nursing (ADON), Resident 217's Order Review History Report (ORHR), dated 11/4/24 was reviewed. The ORHR indicated, Resident 217 was on Mirtazapine 45 mg 1 tablet by mouth at bedtime. ADON stated the facility was not monitoring for behavior changes and no monitoring for side effects of Mirtazapine. Licensed nurses administered four doses of Mirtazapine to Resident 217 between 11/2/24-11/5/24 in p.m. During a concurrent interview and record on 11/6/24 at 11:54 a.m. with ADON, Resident 217's ORHR, dated 11/4/24 was reviewed. The ORHR indicated, Resident 217 was on Temazepam 15 mg capsule, 1 capsule by mouth at bedtime. ADON stated the facility was not monitoring for behavior changes and no monitoring for side effects of Temazepam. Licensed nurses administer four doses of Temazepam to Resident 217 between 11/2/24-11/5/24 in p.m. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2001, the P&P indicated, Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. 3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: . d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying and responding to adverse consequences.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Repositioning for one of three sampled residents (Resident 20). This failure resulted in Resident 20 developing Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture). Findings: During an observation on 11/4/24 at 10:42 a.m. two staff members repositioned Resident 20. Resident 20 was non-verbal. During a review of Resident 20's Admission Record (AR), the AR indicated diagnoses including, weakness or the inability to move on the left side of her body, severe loss of strength on the left side of her body, inability to talk, and obesity. During a concurrent interview and record review on 11/6/24 at 11:06 a.m. with Director of Nursing (DON) stated dependent residents are turned every two hours and as needed. Care Plan (CP) with a revision date of 9/27/24 was reviewed. The CP indicated two staff were to reposition Resident 20 at least once a shift and as necessary. DON stated Resident 20's CP should have been updated to turn every two hours after she was diagnosed with MASD on 10/24/24 and that there was no reason for the CP to not be updated. During a concurrent interview and record review on 11/6/24 at 12:01 p.m. with DON and Assistant Minimum Data Set Coordinator (AMDSC), Resident 20's Documentation Survey Report (DSR) dated November 2024 was reviewed. The DSR indicated the following: 11/1/24 Turned/Repositioned at 8:15 a.m. and 4:11p.m. 11/2/24 Turned/Repositioned at 11:09 a.m. and 6:51 p.m. 11/3/24 Turned/Repositioned at 10:31 a.m. and 6:33 p.m. 11/4/24 Turned/Repositioned at 11:15 a.m. and 5:17 p.m. 11/5/24 Turned/Repositioned at 2:11 p.m. and 6:03 p.m. AMDSC and DON unable to find documentation of Resident 20 being turned on the night shift (10 p.m. to 6:30 a.m.). DON stated there was no other documentation of Resident 20 being turned more than once per shift. During an interview on 11/6/24 at 3:40 p.m. with DON, DON stated if a resident is not turned, pressure injuries and skin breakdown will occur. During a review of the facility's P&P titled Repositioning dated 2001, the P&P indicated, The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents . General Guidelines 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . Interventions .3. Residents who are in bed should be on at least an every two (q 2 hour) repositioning schedule . Documentation The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed. This may be on a flow sheet.

Based on interview and record review, the facility failed to administer insulin (medication to treat high blood sugar, BS) according to physician's orders for one of four sampled residents (Resident 1) when Resident 1 received a higher dose of insulin than was prescribed. This failure resulted in [DIAGNOSES REDACTED] (condition caused by a very low level of blood sugar, your body's main energy source, also adverse reaction associated with insulin. Severe [DIAGNOSES REDACTED] can cause [MEDICAL CONDITION], may be life-threatening, or cause death) for Resident 1. Findings: During a review of Resident 1's Face Sheet (FS), dated 11/26/19, the FS indicated, Resident 1 was admitted to the facility on [DATE]. FS indicated [DIAGNOSES REDACTED]. During a review of Resident 1's Physician's Orders (PO), dated September 2019, the PO indicated [MEDICATION NAME] (long acting medication to treat high BS) 50 units subcutaneous (is a shot given into the fat layer between the skin and muscle) daily at 9 p.m. During a review of Resident 1's Medication Administration Record [REDACTED] 9/3/19, at 9 p.m., [MEDICATION NAME] 6 units 9/9/19, at 9 p.m., [MEDICATION NAME] 2 units 9/18/19, at 9 p.m., [MEDICATION NAME] 4 units 9/24/19, at 9 p.m., [MEDICATION NAME] 8 units During a review of Resident 1's PO, dated October 2019, the PO indicated [MEDICATION NAME](medication use to quickly reduce the amount of sugar in the blood) subcutaneous four times daily 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. per sliding scale: BS of 151-200 give 2 units BS of 201-250 give 4 units BS of 251-300 give 6 units BS of 301-350 give 8 units BS of 351-400 give 10 units BS of 401-450 give 12 units Administer before meals and at bed time. If BS is less than 60 or more than 400 notify medical doctor (MD). During a review of Resident 1's MAR, dated October 2019, the MAR indicated [REDACTED] 10/19/19, at 9 p.m., [MEDICATION NAME] 50 units were administered, and BS recorded was 269, 10/29/19, at 9 p.m., [MEDICATION NAME] 50 units were administered, and BS recorded was 270. During a review of Resident 1's Nursing Progress Note (NPN), dated 10/30/19, the NPN indicated Resident 1 was found unresponsive at 7:55 a.m., Resident 1's BS was checked and recorded as 24. Orders for [MEDICATION NAME] (medication to treat [DIAGNOSES REDACTED])1 milligram and D50 (50% [MEDICATION NAME] - medication used to treat severe [DIAGNOSES REDACTED]) intravenously (directly into the vein) medication were given. Resident 1 was then transferred to the hospital. The Change of Condition (COC), dated 10/30/19, indicated Resident 1 was admitted to the hospital with [REDACTED]. During a review of Resident 1's ED (Emergency Department) Note, dated 10/30/19, the ED note indicated that prior to transfer Resident 1 had a BS of 24. Patient (Resident 1) was given 250 cc (cubic centimeters- unit of measure) of D10 (10% [MEDICATION NAME]- medication give to treat severe [DIAGNOSES REDACTED]) by paramedics which helped to increase the blood sugar to 96 and minimally helped the patient's (Resident 1) mental status. During a concurrent interview and record review on 11/27/19, at 11:38 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's MAR, dated October 2019, was reviewed. LVN 1 confirmed the MAR indicated [REDACTED]. LVN 1 reviewed the PO, dated October 2019, the PO indicated a sliding scale for [MEDICATION NAME] insulin, LVN 1 stated for a BS of 270 Resident 1 should have given 6 units of [MEDICATION NAME]because it is fast acting. LVN 1 stated she did not have another nurse confirm the physician order to ensure it was the right medication and the right dose prior to administration, she stated it is not their facility's policy to do so. During a concurrent interview and record review on 11/27/19, at 12:11 p.m., with Director of Nursing (DON), Resident 1's MAR, dated October 2019, was reviewed. DON confirmed the MAR indicated [REDACTED]. DON confirmed the MAR indicated [REDACTED]. DON stated, It (the MAR) is a legal permanent document we cannot prove otherwise. It was charted it was given, it was given. During a concurrent interview and record review on 12/5/19, at 1:21 p.m., with LVN 2, she reviewed the MAR, dated October 2019. LVN 2 confirmed the documentation, Resident 1's BS was 269 and [MEDICATION NAME]50 units and [MEDICATION NAME] 50 units were document as administered by her (LVN 2). She stated Resident 1 should have received 6 units of [MEDICATION NAME] for a BS of 269. LVN 2 stated she did not have another nurse witness her insulin dose to ensure the right medication or right dose was prepared for Resident 1. LVN 2 stated, she is not required to do so. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration revised 9/14, the P&P indicated, Purpose- To provide guidelines for the safe administration of insulin to residents with diabetes. 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. Steps in the procedure . 7. Check and re-check that the type of insulin on the vial matches the type of insulin ordered. 8. Check the order for the amount of insulin. 12. Double check the order for the amount of insulin. 15. Re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered. Documentation . 2. The dose and concentration of the insulin injection.

Based on interview and record review, the facility failed to supervise and assist one of one sampled resident (1) during personal hygiene, which resulted in Resident 1 falling and sustaining a fractured hip. Findings: The clinical record for Resident 1 was reviewed. The care plan dated 2/23/16, indicated, Requires assistance with activities of daily living related to; weakness due to recent illness history of fall, left hip fracture, and history of ORIF (Open Reduction Internal Fixation-Bone surgery). The Functional Status document for Resident 1, dated 3/20/16, indicated, Personal Hygiene: Extensive assistance, one person physical assist. The Fall Risk Assessment for Resident 1, dated 4/7/16, indicated, Fall Risk Score: 20 (score of 10 or above indicates high risk for fall). During an interview with the Director of Nursing (DON), on 4/13/16, at 2 PM, she stated, The CNA (Certified Nursing Assistant 1) stated she did leave resident (Resident 1) while brushing his teeth. (CNA 1) asked the Student Nurses' Aid (SNA-Uncertified Nurses' Aid) not to leave the resident (Resident 1). SNA left (Resident 1). When the CNA (CNA 1) came back, the resident (Resident 1) was on the floor. During an interview with the SNA, on 4/14/16, at 8:34 AM, she stated, (CNA 1) told me to wait outside of the bathroom. (Resident 1) was brushing his teeth. The SNA stated another SNA called for assistance so she left Resident 1. The SNA stated she did not tell CNA 1 she was leaving Resident 1 alone in the bathroom because CNA 1 was not there. The SNA stated no one was watching Resident 1 when she left him alone in the bathroom. During an interview with the SNA Instructor, on 4/14/16, at 9:05 AM, he stated, SNA's are not to replace Staff. They (SNA's) are only to shadow and are under supervision of a CNA or the SNA Instructor. SNA Instructor stated he was not there when SNA was watching Resident 1. During an interview with CNA 1, on 4/14/16, at 11:26 PM, she stated she put (Resident 1) in the bathroom to brush his teeth and told the SNA to watch if (Resident 1) pushes the light. CNA 1 stated she left Resident 1 to help with another resident. CNA 1 stated, We're not supposed to ask them to do our job. They (SNA's) are supposed to just shadow us, they are not allowed to do patient care, they don't have the license. During a review of the clinical record for Resident 1, the Progress Notes, dated 4/7/16, at 2:13 PM, indicated, CNA (Certified Nursing Assistant 1) alerted nurse that resident (Resident 1) had fallen in the bathroom. Charge Nurse went to the room where resident (Resident 1) was found with right leg but in a up position (sic) and left leg bent in a sitting position. CNA (CNA 1) stated, 'I left the resident (Resident 1) in the restroom to brush his teeth, but before I left I told the student (SNA) not to leave him alone. I left the room to help someone else. I noticed the bathroom light on and found resident sitting on the floor'. The Progress Notes, dated 4/7/16, at 6:13 PM, indicated Resident 1 sustained a hip fracture (a broken bone in the hip area) and was transported to the Emergency Department for further evaluation and treatment. The hospital emergency room Report, dated 4/8/16, indicated, Final Diagnosis: [REDACTED]. The facility policy and procedure titled, Assessing Falls and Their Causes, dated 10/2010, indicated, Review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to prevent Certified Nursing Assistant (CNA) 1 from neglecting one of one sampled resident (1), which resulted in Resident 1 feeling neglected and anxious. Findings: The facility's Narrative Investigative Report, dated 3/11/16, indicated CNA 1 was assigned to take care of Resident 1 around 1:30 AM on 3/10/16. Resident 1 requested CNA 1 to help him to the toilet and CNA 1 told him to just go ahead and pee in your pants and I will clean you up after. Resident 1 then called for help after wetting himself and CNA 1 told him, I am the only CNA on the floor. Resident 1 called again for help and asked for a urinal, CNA 1 put the urinal on Resident 1's chest and left. When Resident 1 got wet after using the urinal and asked for help at about 4 AM, CNA 1 answered the call light and promised to come but never came back. Resident 1 on was not changed until the AM shift (AM shift hours are usually 6:30 AM to 2:30 PM). During a concurrent observation and interview with Resident 1, on 3/17/16, at 9:34 AM, Resident 1 was sitting in his wheelchair with braces on both knees, alert and oriented. When asked what happened in the night shift on 3/10/16, he stated, I rang the bell, I waited quite a while about half an hour. I said I want to use the toilet, (CNA 1) said 'just pee in your pants'. I called again and (CNA 1) handed me a urinal and said, 'Do what you can'. Resident 1 stated, I cannot remove the tape of my brief and can't hold on to the urinal so I wet the bed. Resident 1 stated, CNA (1) said she's the only one on duty, she said, 'I'll be back to change the bed.' But she did not come back. The next shift changed me. Resident 1 stated he felt neglected and he stated, I was really upset, I had an anxiety attack. During a review of the clinical record for Resident 1, the Cognitive Patterns (the act of thinking, perceiving, and understanding), dated 3/1/16, indicated a Summary score of 15 (score of 15 means cognitively intact). The Functional Status, dated 3/1/16, indicated, Toilet use: Extensive assistance, one person physical assist. The Kardex Report, dated 2/24/16, indicated, Incontinent: Check the resident frequently throughout each shift and as required for incontinence. Wash, rinse and dry perineum (the area in front of the anus extending to the scrotum in the male). Change clothing PRN (when needed) after incontinence episodes. Observe pattern of incontinence and initiate toileting schedule if indicated. Offer urinal to (Resident 1) every 2 hours due to frequency of urination secondary to Neoplasm of Prostate ([MEDICAL CONDITION]) with recent UTI (Urinary Tract Infection-bladder infection). During an interview with the Occupational Therapist (OT), on 3/17/16, at 10:40 AM, she stated, (Resident 1) talked to me that morning and reported the CNA (CNA 1) at night neglected to help him in multiple occasions with his urinal. The OT stated she filled out the grievance form and placed the paper on the Social Service desk. During an interview with CNA 2, on 3/17/16, at 1:36 PM, she stated, (Resident 1's) wife told me about (Resident 1's) complaint about the night shift but I told her I'm not the right person to talk to so I sent her to the office. During an interview with the CNA 1, on 3/18/16, at 4:02 PM, she stated, I was super busy, I do the whole hall and it was a heavy night. CNA 1 stated she last checked on Resident 1 at 4:30 AM and did not check on him again after that time. The facility policy and procedure titled, Abuse and Neglect-Clinical Protocol, undated, indicated, Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The physician and staff will help identify risk factors for abuse within the facility, example problems related to staff knowledge, skill, or performance that might affect how residents are being cared for. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect, for example recurrent failure to provide incontinence care. The management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.