Every finding on record at Royal Oaks Nursing and Rehabilitation Center

Based on observation, staff interviews and policy review, the facility failed to ensure open food items were dated, covered and labeled in the kitchen. The facility reported a census of 73 residents.Findings include:Observation 8/3/26 at 9:45 AM in the main kitchen with the Certified Dietary Manager (CDM) present revealed the following items in the dry storage pantry and the walk in freezer: a. A cardboard box with a plastic liner containing [NAME] powder, the box was not fully closed and the plastic liner was open and not sealed. b. A large cardboard box with a plastic liner containing powdered thickener, the box was not closed and the plastic liner was open and not sealed. c. An open bag of frozen peas not fully sealed and undated. d. An open bag of frozen corn undated and fully open, unsealed. e. Frozen sausage patties in an open cardboard box, the lid was fully open, undated. During an interview 8/3/26 at 9:55 AM, the CDM stated an expectation all food is stored with a date the food item was opened and in a sealed container. During an interview 8/5/26 at 2:15 PM, the Administrator stated an expectation that food is dated and sealed after opened. Review of the facility policy Culinary Services Policies and Procedures, revised 7/2023, documented food is to be covered for storage, label and date foods and perishable foods will be properly covered, labeled and dated.

Based on clinical record review, hospital record review, staff, medical provider and vendor interviews, and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to take steps necessary to avoid the development and worsening of a pressure ulcer for one of four (Resident #8) residents reviewed. This resulted in harm to Resident #8 when her wound continued to worsen and she was sent to the hospital for wound management on [DATE]. Upon admission to the hospital, Resident #8 was diagnosed with a sacral decubitus ulceration extending to the bone. She was additionally diagnosed with an MRSA infection (Methicillin-Resistant Staphylococcus aureus, an antibiotic-resistant infection. It causes dangerous infections when it enters the body and doesn't respond to standard medications) of the wound on [DATE]. The facility reported a census of 81 residents. Findings include: The RAI manual details the following definitions: STAGE 1 PRESSURE INJURYAn observable, pressure- related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues. STAGE 2 PRESSURE ULCERPartial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising.May also present as an intact or open/ ruptured blister. STAGE 3 PRESSURE ULCERFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling STAGE 4 PRESSURE ULCERFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. UNSTAGEABLE PRESSURE ULCER: An ulcer that is known but not stageable due to coverage of wound bed by slough and/or eschar OR is unstageable due to not being able to see the wound due to a non-removable dressing or device. Other staging considerations include: DEEP TISSUE INJURYPurple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. TUNNELINGA passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. UNDERMININGThe destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. SLOUGH TISSUENon-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. ESCHAR TISSUEDead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. The Minimum Data Set (MDS) of Resident #8 dated [DATE] identified a Brief Interview of Mental Status Score of 14, indicating cognition intact. The MDS documented diagnoses which included peripheral vascular disease (a circulation disorder that affects blood vessels most commonly in the legs and feet, when arteries become narrowed by plaque buildup reducing healthy blood flow), quadriplegia, Multiple Sclerosis, and malnutrition. The MDS recorded the presence of one Stage IV pressure ulcer which was not present upon admission or entry to the facility. The MDS documented that the resident was dependent on staff to 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, as well as transfers from surface to surface (example bed to chair). The Care Plan of Res. #8 identified a focus area of actual impaired skin integrity/pressure injury related to impaired mobility, assistance needed with Activities of Daily Living (ADL's) and episodes of incontinence. On [DATE] the Care Plan directed staff to monitor skin with cares, notify nurse and doctor with changes as needed, and assist with incontinent care as needed. On [DATE], the focus area was updated to state Res. #8 prefers to direct her own care and occasionally refuses repositioning/incontinence care and had a note of a Stage 2 pressure to her right buttocks. The Focus area was updated again on [DATE] to read the pressure ulcer was now a Stage 4. The Care Plan directed the resident has been known to turn away care if overly tired. Encourage resident to allow repositioning and incontinence care, dated [DATE]. The Care Plan identified a focus area of ADL self care performance deficit, dated [DATE]. An intervention was added on [DATE] documenting the resident is alert and oriented and prefers to direct her care. Occasionally requests incontinence care at later times or refuses due to preference. The Weekly Pressure Injury Evaluation dated [DATE], locked at 3:43 pm, documented a pressure injury was noted on the resident's right buttock. The evaluation documented the onset was [DATE] and was acquired in the facility, as a Stage II. The measurements were recorded as 3.5 x 4.5 x 0 centimeters. The Medication Admin Audit Report of Res. #8 dated [DATE] documented that Staff M, Licensed Practical Nurse (LPN) applied Z-guard (protective zinc oxide cream) to the resident's peri-rectal area (the skin, muscles, and soft tissues located immediately around the anus and the lower part of the rectum) at 11:10 am and 2:53 pm on [DATE]. A Nursing Note dated [DATE] at 3:49 pm documented during an assessment, a new Stage 2 pressure ulcer to the right buttocks was noted. The note identified the physician was aware and new orders received for treatment. On [DATE] at 3:00 pm, the Director of Nursing (DON) stated the resident had been in bed at the time the pressure ulcer was discovered on [DATE]. She stated it had been found in the approximate time frame of the nursing note late afternoon. (One hour after the documentation of the Z-guard being administered). On [DATE] at 3:20 pm, Staff M, LPN stated she was not the nurse who discovered the pressure ulcer. She stated she recalled coming back in on her next shift and being made aware of the pressure ulcer and a new treatment for it. The Nursing Note dated [DATE] at 12:15 pm documented the resident reporting she felt something pop in her stomach and had some abdominal pain. The resident was transferred to a community hospital for assessment of her catheter. The Nursing Note dated [DATE] at 5:55 pm documented the resident returned from the emergency room with a new catheter and no new orders. Review of facility documentation failed to reveal a skin check being completed until [DATE] when the pressure ulcer was then documented as a Stage III with measurements of 5.0 x 5.0 x 0.2 centimeters. The Documentation Survey Report for Resident #8 for January of 2026 revealed a task assigned to the Certified Nursing Aides to turn and reposition Res. #8 every 2-3 hours. In 31 days of 3 shifts per day (total of 93 shifts) there were 35 shifts of no documentation being completed. Additionally, there were 25 shifts which the CNA on duty documented N for no, the task was not completed and 3 shifts documented Not Applicable. This totaled 63 shifts out of 93 (68%) which revealed no documentation of the resident being repositioned. The Documentation Survey Report for Resident #8 for February of 2026 was next reviewed. A total of 84 shifts were in February. 33 shifts had no documentation of the task being completed. An additional 20 shifts were documented as the task not being completed. This totaled 53 out of 84 shifts (63%) which revealed no documentation of the resident being repositioned. A review of the options for this task revealed the options for the documentation included YesNoResident Not AvailableResident RefusedNot Applicable No shifts were documented as resident refused. Wound assessments were performed weeklyXXX[DATE] measurements of 2.9 x 3.7 x 0.2 centimeters[DATE] measurements of 5.0 x 5.0 x 0.2 centimeters[DATE] measurements of 5.0 x 5.0 x 0.2 centimeters[DATE] measurements of 4.2 x 5.1 x 0.4 centimeters [DATE] measurements of 4.4 x 5.4 x 3.6 centimeters (now documented as a Stage IV)[DATE] measurements of 3.7 x 5.7 x 1.3 centimeters with undermining present from 11-1 o'clock at 1.2 depth[DATE] measurements of 3.6 x 4.3 x 0.9 centimeters with undermining present from 11-2 o'clock at 1.2 depth[DATE] measurements of 3.8 x 4.8 x 0.6 centimeters with undermining present from 11-2 o'clock at 0.8 depth[DATE] measurements of 3.8 x 4.9 x 0.9 centimeters with undermining present from 11-2 o'clock at 0.6 depth[DATE] measurements of 3.4 x 3.9 x 0.5 centimeters with undermining present from 11-2 o'clock at 0.6 depth[DATE] measurements of 4.0 x 4.2 x 0.7 centimeters with undermining present from 11-2 o'clock at 1.1 depth[DATE] measurements of 6.1 x 4.6 x 0.6 centimeters with undermining present from 11-2 o'clock at 0.6 depth[DATE] measurements of 6.8 x 7.9 x 0.4 centimeters with undermining present from 11-2 o'clock at 1.0 depth. The wound APRN, FNP-C (Advanced Practice Registered Nurse, Family Nurse Practitioner-Certified) visited the facility weekly, first seeing Res. #8 on [DATE]. There were times the resident refused to see the APRN on some visits. The original visit notes dated [DATE] documented the wound as a Stage 3 pressure ulcer with the wound being cleansed and debridement type being listed as autolytic (a wound cleaning process that uses the body's own moisture and enzymes to soften and dissolve dead tissue, achieved by applying moisture-retentive dressings to the wound). The visit notes detailed autolytic debridement each visit and wound treatments were monitored and changed periodically. The visit note dated [DATE] noted the wound appeared to have improved on this visit. The following visit on [DATE] was noted as wound not healed, with continued cleansing and autolytic debridement. Each note also documented the resident as having impaired judgement. The final visit dated [DATE] noted the wound status to be deteriorated. A portable 3-view x-ray of the sacrum due to pain, poor wound healing to rule out osteomyelitis (a serious, inflammatory bone infection) was ordered. The Nursing Note dated [DATE] documented the x-rays were reviewed by the APRN, FNP-C and an MRI was ordered. Prior authorization process was started. The next Nursing Note dated [DATE] documented the wound appearing larger and darker. On [DATE] a note documented a rapid decline of the wound and orders to send the resident to the emergency room for evaluation and treatment. A Dietary Note dated [DATE] documented the resident's x-ray showed osteomyelitis. Review of the Treatment Administration Record (TAR) of Resident #8 revealed eleven times the prescribed wound treatment was not documented as completed. One of those dates, [DATE], with the wound care being scheduled for AM, included a nursing note written at 5:57 pm that the resident was up in the wheelchair and refused to lay down, the treatment was passed down to the evening shift. Nine of the remaining ten times the treatment was not documented as being completed had no reasoning for it not being done. The final time was on [DATE] which coincided with the wound nurse seeing the resident and completing wound care that day. None of the other times coincided with the wound care nurse being present. The records from the resident's hospitalization revealed culture results showing MRSA of the wound. The MRI performed on [DATE] confirmed clinical confirmation of the worsening sacral pressure ulcer and specifically identified it as having progressed to involving the bone (osteomyelitis). The Assessment & Plan was noted as acute on chronic sacral osteomyelitis and infection with CR-Pseudomonas aeruginosa (a multi drug resistant bacteria) and MRSA. In the hospital, the surgical team performed bedside debridement on [DATE] and an excision wound debridement on [DATE] along with a bone biopsy. A hospital wound care note dated [DATE] documented the majority of the wound bed remained covered in necrotic tissue (dead, non-viable body tissue that has died prematurely due to injury, infection, or a lack of blood flow) despite two debridements that week. The wound nurse documented she notified the physician regarding a concern for the worsening sacral wound despite the debridements and treatments and requested the resident not discharge from the hospital due to those concerns. The resident remained in the hospital throughout the course of the on site survey. On [DATE] at 1:15 pm, the Occupational Therapy Assistant (OTA) who worked with the resident at the facility stated she worked with Res. #8 for sip and puff chair navigation (the resident was unable to move her electric wheelchair with a joystick due to disease process. She navigated the chair with a mouth piece). She stated she did not work with the resident for any repositioning. She stated as far as she was aware, the resident had a regular cushion in her wheelchair, no specialty cushion. She stated she worked with the resident three times a week. She described the resident as unable to move herself/reposition herself in the chair. She stated the resident only worked with OT and not physical therapy. She stated she was aware of the staff finding the wound on the resident. She said she appeared comfortable during therapy though she was not able to move her arms or reposition at all. She described the resident as fully dependent. She said the resident usually got into her chair around 10:30 in the morning and stayed in the chair all day at least until the evening. On [DATE] at 1:22 pm, the Director of Rehab (DOR) stated the facility works with the wheelchair vendor as needed but stated the resident's wheelchair was less than five years old so therefore she was unable to obtain new equipment (due to Medicare regulations of 5 years for new equipment). She stated when the resident received the wheelchair four years prior, she would have been fit for her needs at that time through an assistive technology assessment. She stated no changes had been made to her chair since that time. On [DATE] at 1:42 pm the resident's wheelchair and cushion were observed. The chair had a gel cushion on the wheelchair seat which was pliable in the rear of the cushion and firmer to the touch towards the front of the chair. On [DATE] at 1:45 pm, Staff L, LPN/Assistant Director of Nursing stated the resident's normal routine was to get up between 9:00 and 10:00 am. Nursing staff would do the wound treatment so she could get up. She stated she usually stayed in the wheelchair until around 9:00 pm. She stated it was difficult to try to reposition her in the chair but they would try to put pillows under her legs, etc. She described it as not being the greatest. She said the resident would state it was her right to stay up in the chair. The ADON was asked if a dressing change would be needed if the resident was incontinent of bowel and she stated that generally would require a PRN (as needed) dressing change. She said the CNAs would tell the nurses when the resident had a bowel movement but that she rarely ever did a PRN dressing change. The TAR for March of 2026 reflected a PRN dressing change was not completed at all during the month. The Survey documentation report recorded 34 bowel movements during the month. The TAR for April of 2026 reflected a PRN dressing change was completed one time during the month. The TAR for May of 2026 reflected a PRN dressing change was completed one time during the month. On [DATE] at 2:50 pm, a representative from the wheelchair vendor stated the resident had a gel pack cushion in her wheelchair. He stated the facility had reached out to the vendor in February of 2026 and in May of 2026 for some configurations and adjustments needed, the arm pads were replaced and some hardware was replaced. He stated the facility had recently reached out reporting Res. #8's chair was not running. He stated he had no record of the facility reporting to them the resident had developed a pressure ulcer. He stated it would have been best practice for them to have been informed and they would have come out and assessed the resident's wheelchair cushion to see if there was a better type to meet the resident's current needs. On [DATE] at 8:27 am, the Director of Nursing (DON) stated the facility had done an internal investigation regarding the pressure ulcer of Res. #8. When she was asked if anyone had looked into an alternative or new wheelchair cushion, she stated if an order was received for a new cushion, they would send that to Occupational Therapy to take care of. She stated it is OT's job to order the equipment. She clarified this was if an order was received. (When the DON was asked if anyone had requested a new cushion or an assessment for a new cushion, she was unable to state if that had been done). The facility form of Unavoidable Pressure Ulcer dated [DATE] included the following information: -diagnosis of quadriplegia. (This was added to her Electronic Medical Record on [DATE], almost two months after the development of the pressure ulcer and over a week after the Unavoidable Pressure Ulcer documentation). -diagnosis of Severe-Protein Calorie Malnutrition -diagnosis of anemia -history of pressure injuries - resident was repositioned every 2 hours in bed - Refuses repositioning, refuses turning schedule Progress notes from January of 2026 through early June of 2026 failed to reveal any documentation of refusal of cares. One note on [DATE] documented the resident refusing a shower. A dietary note on [DATE] stated the resident often refused cares. The facility Advanced Registered Nurse Practitioner wrote a visit note dated [DATE] which mentioned the ER visit on [DATE]. No mention of the pressure ulcer was found in this note, and quadriplegia was not a noted diagnosis. On [DATE] at 10:55 am, the ARNP stated she did not recall when the facility notified her of the pressure ulcer. She said if it was not in her notes, then she was not informed of it. She said the resident's malnutrition was a prior diagnosis and she did not consider that to be a current diagnosis. She stated she has monitored the labs of Res #8 which were within normal range. She stated the routine of Res. #8 is for her to be in bed or in her power chair and that she is often not receptive of cares. She stated she has refused to see the wound nurse on some occasions because she is already up in her chair when the wound nurse arrives. She stated at one time the resident believed the pressure ulcer was an end of life ulcer and she desired to go on hospice care. She stated she discussed this with her and told her it was not an end of life ulcer and she did not qualify for hospice care at that time. During a follow up interview with the Director of Rehab on [DATE] at 11:30 am, it was asked if therapy can change the plan of care for a resident currently receiving therapy. The DOR stated the provider or the nursing team would have needed to initiate that. She stated if a further evaluation of therapy had been initiated for Res #8, therapy could have established an up/down schedule or an off loading schedule. She stated Res. #8 is physically unable to use the tilt feature in her wheelchair. She only has passive range of motion in her fingers (cannot move them on her own). She stated to use the tilt feature for repositioning, staff needs to do this for her. She stated Res. #8 had straps around her feet an ankles to stop her from sliding in the wheelchair which often needed adjusted. She stated when these adjustments were made, she would advise the tilt function be used at the same time to assist in repositioning. She stated Res. #8 is able to verbalize when she wants to sit back up. She also stated the resident received her wheelchair in February of 2022 and could provide that documentation. On [DATE] at 2:00 pm, Staff A, Certified Medication Aide (CMA) stated Res. #8's normal routine is to get up in her chair around 10:00 in the morning. She went to therapy and different things but stayed in her chair. She stated they would tilt her chair back to pull her up in the chair, add a pillow, things like that to reposition. She stated generally Res. #8 would always allow it and would let staff know if she had any pain or wanted repositioned. On [DATE] at 2:25 pm, Staff W, CNA stated she was a newer employee to the facility. She stated she had assisted Res #8 during her orientation time. She stated the resident called whenever she wanted to be repositioned and would let staff know if she was uncomfortable. On [DATE] at 2:30 pm, Staff V, CNA stated for the night shift, normally Res. #8 would use her call light. Staff would check on her every two hours, but the resident liked to stay up in her chair till as late as midnight. She said around midnight they would get her ready for bed and the resident would ring her call light (using her chin) whenever she needed anything. She stated unless the resident rang, then they just let her sleep but would check on her. On [DATE] at 2:50 pm, Staff Y, CNA stated her shift begins at 6:00 am. She stated she would check on the resident until she was ready to get up. She stated usually around 10:00 or 10:30 am is when the resident would want to get in her chair. She said once she is up, she stays up. She said she will call if she needs something but otherwise she just checks in on her. She stated she will always to offer to reposition each round and sometimes the resident says yes and sometimes she says no. She stated she will inform the nurse if the resident had a bowel movement. On [DATE] at 3:01 pm, Staff X, CNA stated the resident spent most of her time in her chair during her 2pm-10pm shifts. She said sometimes she would be ready for bed towards the end of the shift but was often visiting with another resident who she is friends with. She stated Res. #8 tells staff when she wants repositioned. She stated if the resident told her this, then she would get help from another employee and would normally use the sling from the mechanical lift to reposition her. She stated she generally was always upright in the chair and normally did not tilt back in the chair. She said the resident is really good about telling them when she wants to move. An email from the DON dated [DATE] at 3:08 pm clarified some of the information from the Non Avoidable Pressure Ulcer form. The email included the following information: -Res #8 had a prior history of a Stage 3 Pressure Ulcer to the sacrum identified in August of 2022 which resolved. -She stated the documentation of Res #8 refusing care prior to the development of the pressure ulcer included: July of 2021: intermittent refusals of care with preference to remain in bed[DATE]: refusals of showers, incontinence cares and other direct care interventions[DATE]: episodes of care refusal with redirection and re-approach attempts documented[DATE]: refusals of care with preference for select staff members to provide assistance. -She stated the diagnoses of malnutrition and anemia were historical diagnoses in the resident's medical record and remain listed on the problem list. She added that recent weight trends and laboratory data do not indicate current evidence of acute protein calorie malnutrition; however, the resident continues to present with nutritional risk factors due to overall clinical condition and comorbidities that may impact wound healing the skin integrity and her most recent labs revealed a low vitamin D level. Progress Notes were reviewed for the year 2022 and no mention of a pressure ulcer was revealed in these notes. One note from [DATE] noted MASD (moisture associated skin damage) to the sacrum was improved. The first MDS for the time frame of a pressure ulcer being found in August of 2022 was dated [DATE]. It failed to reveal any documentation of a pressure ulcer. The receipt for the resident's wheelchair in February of 2022 did note a history of pressure ulcers of the right and left heel. On [DATE] at 3:54 pm, the Registered Dietitian stated the resident is very particular about what supplements she will take and she will not take them more than once a day. She stated her labs are very good and she does not consider to be malnourished but meets the requirements of risk of malnutrition. She stated she has heard that the resident does not accept repositioning well and is very specific about what she will do. On [DATE] at 4:22 pm, the Administrator stated Res. #8 is alert and oriented and knows she should be repositioned and has been educated and has been non compliant and the team determined the pressure ulcer development was not avoidable. The Wound Care Nurse was out of state and unavailable for an interview. The resident remained in the hospital. In a second interview with the facility ARNP on [DATE] at 9:15 am, she stated she knows Res. #8 very well and she has a good relationship with her. She stated she had talked to her many times and more than once she would find her laying on her right side (the side the wound is on) and she reminded her and the resident stated she knew what she should be doing for the wound. She stated Res. #8 is very much her own person. The facility policy titled Skin and Wound Management System, Revision Date [DATE], documented the following policy statement: It is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. Point 4: Preventative intervention will be implemented for residents identified at risk as appropriate, for example beds, wheelchair cushions, nutrition, incontinence, therapy etc. These interventions are documented in the medical record based on overall score. Point 9: Ongoing monitoring and Quality Assurance and Performance Improvement (QAPI) will be achieved through a Multidisciplinary Team. The Team will meet regularly to review residents who are found to be at risk or with compromised skin integrity. The Team will evaluate resident skin changes, treatment modalities and interventions, and make recommendations, based upon the interdisciplinary evaluation.

Based on review of the Centers for Medicare & Medicaid Services (CMS) 2567's, staff interview and policy review the facility failed to have an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility had repeat deficiencies identified on the facility's recertification revisit and complaints survey. The facility identified a census of 81 residents.Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's recertification survey completed 5/20/25, complaint investigations 5/20/25, 2/11/26, 4/9/26 and the current revisit survey and complaint investigations. The repeat deficiencies cited included: F760 cited 5/20/25 and 4/9/26F880 cited 5/20/25, 2/11/26, 4/9/26 and during the current surveyIn an interview on 6/2/26 at 1:10 PM, the Administrator reported Quality Assurance (QA) meetings held daily with the leadership team, and the QA committee met monthly. The QAPI Committee had identified performance improvement areas they needed to work on including infection control. The facility had provided staff education on appropriate use of PPE (personal protective equipment) as well as staff competency and audits on donning and doffing PPE and handwashing. When the surveyor asked the Administrator how they were addressing repeat deficiencies cited since the past recertification survey and complaints survey, and how they were going to ensure future compliance related to the prior and current surveys, the Administrator responded the facility had planned to ramp up staff education, observe staff for PPE use at the appropriate times, conduct audits, as well as implement peer to peer training, and interview the residents about the staff's use of PPE. They also planned to have a more experienced certified nursing assistant (CNA) take on a leadership role and assist with ensuring things got completed properly when on duty. The facility's Quality Assurance and Performance Improvement Policy revised 9/2022 revealed the facility is committed to developing, implementing, and maintaining an effective QAPI program that focused on outcomes of care and quality of life. The leadership team looked for trends or faulty systems in order to prevent undesirable outcomes. Data is collected, analyzed, and the QAPI process applied for focus areas such as infection control compliance. The Root Cause Analysis are used to identify improvement opportunities and to understand how to improve them. Staff will be taught to focus on system and process correction and improvement, not placing blame or treating symptoms, and to support a culture of QAPI. The goal of QAPI is to achieve improvement and prevent recurrence of the problem.

Based on the record review, observations, staff interviews and policy review the facility failed to ensure staff utilize Enhanced Barrier Precautions (EBP) and infection control practices to prevent the potential spread of infection for 1 of 3 nursing units reviewed (100 Hall). Staff reached into their uniform pocket to obtain hand sanitizer and then placed the hand sanitizer back into their uniform pocket during the course of a treatment and dressing change for 1 of 3 residents observed for treatments (Resident # 8). The facility additionally failed to properly sanitize a full body mechanical lift after resident usage and properly sanitize a mattress which was pooled with urine. The facility reported a census of 81 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had diagnoses of Stage 4 pressure ulcer, quadriplegia and multiple sclerosis. The Care Plan revised 4/6/26 revealed Resident #8 had a Stage 4 pressure injury to her right buttock related to impaired mobility and incontinence. The resident also had a ESBL (bacteria that is resistant to many common antibiotics). The Care Plan directed staff to administer treatments as ordered and utilize enhanced barrier precautions as ordered to prevent transmission to others. The Physician's Orders and Treatment Administration Record (TAR) revealed to use a gown and gloves for high contact resident care including dressing and transfers. The orders also included to administer Bactrim DS (an antibiotic) by mouth two times a day for seven days for osteomyelitis (a bacterial or fungi infection spread to the bone from an open wound or infected tissue) had a start date of 5/28/26. During observation on 5/26/26 10:55 AM Staff H, Licensed Practical Nurse (LPN), gathered supplies and placed the supplies on a paper towel on an overbed table. Staff H and Staff I, Registered Nurse (RN) donned a gown, washed their hands and donned a pair of gloves. Resident #8 was positioned onto her right side. The resident's right upper buttock had a baseball sized open wound with a blackened area around the wound. Staff H cleansed the open wound with wound cleanser and gauze. Staff H removed her gloves, moved the gown and reached into her uniform pocket. Staff H sprayed hand sanitizer on her hands, then donned a pair of gloves and cleansed the wound area again. Staff H placed a gauze with vashe (wound cleanser) solution inside and over the wound for 5 minutes. Staff H then removed the gauze from the wound area, removed her gloves and reached into her uniform pocket, took a hand sanitizer container out of her pocket, applied hand sanitizer to her hands, put the hand sanitizer back into her pocket then donned a pair of gloves. Staff H proceeded to pat the wound area with a dry gauze, removed her gloves, reached into her uniform pocket to obtain hand sanitizer, applied hand sanitizer to her hands and put the hand sanitizer back into her uniform pocket. Staff H donned gloves, placed calcium alginate into the wound bed then removed her gloves and washed her hands. Staff H donned a pair of gloves, applied a gauze dressing and a bordered dressing over the coccyx and right buttock area and removed her gloves. Staff H again reached into her uniform pocket to get hand sanitizer, sanitized hands and put the hand sanitizer back into her uniform pocket. After the resident's soiled brief was removed Staff I, RN, took disposable wipes and cleansed the buttocks area. Staff I removed her gloves, reached into her uniform pocket to get hand sanitizer, sanitized her hands, placed the hand sanitizer back into her uniform pocket and donned a pair of gloves, then placed a clean brief on the resident. In an interview on 6/1/26 at 4:35 PM Staff B, Infection Preventionist (IP), confirmed supplies including hand sanitizer should be prepared and available when staff performed a treatment or dressing change. Staff should not reach into their pocket for hand sanitizer as they performed a treatment. A Long-Term Care Isolation Precautions policy dated 5/15/20 revealed Standard precautions are the minimum infection prevention practices that apply to care in any health care setting. Hand hygiene performed when moving hands from a contaminated body site to a clean body site during resident care. An updated Wound Care Competency revealed wound care shall be provided in accordance with CDC infection-prevention practices including proper preparation such as gathering all supplies needed for the treatment. 2. The MDS assessment dated [DATE] revealed Resident #4 had diagnoses of dementia, Stage 3 pressure ulcer to the left buttock and two other sites, and an open lesion to her foot. The MDS indicated the resident had dependence on staff for bed mobility and transfers. The Care Plan revised 4/21/26 revealed the resident required assistance with ADL's (activities of daily living) and transfers related to her dementia. The resident also had a Stage 3 pressure ulcer to her right outer foot, a pressure area to the left buttock and right gluteal cleft related to immobility. The Care Plan directed staff to follow EBP's. The TAR revealed EBP's: Use a gown and gloves for high contact resident care including dressing, transfers, hygiene care, peri care and wound care. During observation on 5/27/26 at 7:45 AM, Staff Q, certified nursing assistant (CNA), and Staff R, CNA, provided care for Resident #4. An EBP's sign indicating use of a gown and gloves needed for high contact care activities. Staff Q and Staff R did not have a gown on. At 7:50 AM, Staff Q and Staff R used a mechanical lift and transferred Resident #4 from the bed to a large portable recliner chair. Staff Q and Staff R wore gloves but no gown worn. At the time, Resident #4 had a dressing visible on her right foot and dark brown drainage on the dressing around the right heel. Staff Q pushed the mechanical lift into the hall but did not sanitize the lift after use. A continuous observation on 5/27/26 from 7:50 AM to 8:11 AM revealed the mechanical lift used on Resident #4 remained parked in the 100 hallway. At 8:11 AM, Staff S, LPN, took the mechanical lift into another resident's room and used the mechanical lift to transfer that resident. In an interview on 6/1/26 at 3:05 PM, Staff N, certified medication aide (CMA), reported EBP's required for residents that had a bacterial infection or had a catheter. A gown and gloves worn for EBP's. Staff N reported an EBP's sign was on the door to the resident's room if a resident needed EBP's. In an interview on 6/1/26 3:10 PM Staff L, CNA, reported EBP's needed if a resident had a catheter or some kind of infection. A gown and gloves worn when a resident on EBP's. In an interview on 6/1/26 at 4:35 PM Staff B, IP, reported EBP's implemented for residents that had a wound or catheter. Staff should wear a gown and gloves for residents requiring EBP's. An Enhanced Barrier Precautions policy revised 12/2024 revealed EBP's are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents during high contact care activities such as transferring the resident and the provision of care. Gloves and gown are applied prior to performing the high contact resident care activity. 3. On 6/11/26 at 10:37 am, observation of morning cares of Resident #18 performed by Staff T and Staff U, both CNAs, began. Staff assisted Res #18 to remove her night clothes, and perform incontinence care. Resident #18's mattress was drenched in urine. During the provided care, Staff U, CNA absorbed the urine on the mattress with the dirty sheets and placed them in a plastic bag. He then placed new sheets under Resident #18 during care. No sanitization of the mattress was observed. After the resident's incontinence care, clothing and sheet change was completed, staff brought a full body mechanical lift over to the bed in order to obtain the resident's weight. Staff had placed the sling to the lift under the resident. After properly securing Res #18 to the sling and lifting her in the air over her bed, staff obtained her weight. They then lowered her back down and removed the sling from beneath her. After completing all cares for Res #18, Staff T then obtained a standard wet wipe (the type used for incontinence cares, not a sanitizing type of wipe) and cleansed the full body lift with the wet wipe. She told Staff U that the lift had been sanitized. On 6/11/26 at 11:00 am, Staff T, CNA verified Res #18 had not priorly received incontinence care on this shift which started five hours earlier. She also verified the full body mechanical lift was sanitized using regular wet wipes from the same package as what had been used for incontinence care. On 6/11/26 at 1:05 pm, the Infection Preventionist Nurse stated equipment such as the full body mechanical lift are to be cleaned with sani wipes (a germicidal wipe used to clean microorganisms on hard, non porous surfaces).

Based on record review, resident and staff interview and policy review the facility failed to provide medication as ordered by the physician after the resident admitted to the facility for one of four residents reviewed for medications (Resident #2). The facility staff also failed to prepare and administer medications to one resident at a time for two of five residents observed for medication pass (Resident #13 and #14). The facility reported a census of 81 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 admitted to the facility on [DATE] and had diagnoses of atrial fibrillation (irregular heart rhythm), heart failure and anxiety disorder. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Care Plan initiated 3/25/26 revealed the resident had altered cardiovascular status related to CHF (congestive heart failure), pulmonary hypertension (high blood pressure in the arteries of the lungs), and anxiety. The Care Plan also revealed the resident had a behavior problem and high anxiety. The Care Plan directed staff to provide medication as ordered. The After Visit Summary dated 3/24/26 revealed instruction to take the following medications in the evening or bedtime (HS): a. Metoprolol tartrate (Lopressor) (used to treat high blood pressure) 12.5 mg by mouth (PO) two times a day (BID) was last given on 3/24/26 at 8:24 AM. b. Rivaroxaban (Xarelto) (a blood thinner used to prevent blood clots) 15 mg PO daily with dinner was last given on 3/23/26 at 4:59 PM. c. Senna-docusate (a laxative and stool softener) 8.6-50 mg take 2 tablets PO at HS was last given on 3/21/26 at 8:55 PM. d. Simethicone 80 mg (used to relieve symptoms of bloating and gas) 2 chewable tablets four times a day (with meals and nightly) was last given on 3/24/26 at 8:23 AM. e. Spironolactone (a water pill) (used to treat heart failure and high blood pressure) 12.5 mg PO BID was last given on 3/24/26 at 8:25 AM.f. Sulfamethoxazole-trimethoprim (Bactrim DS) (an antibiotic) 800-160 mg one tablet PO BID was last given on 3/24/26 at 8:25 AM. g. Trazodone (used for treating major depression) 25 mg PO at HS was last given on 3/23/26 at 9:15 PM. h. Hydroxyzine HCL (used to treat anxiety) 50 mg tablet PO every six hours if needed for anxiety was last given on 3/22/26 at 3:39 AM. A Physician's Encounter Note dated 3/26/26 revealed the resident had a recent hospitalization for fluid overload secondary to an acute on chronic heart failure. She had two paracentesis (a procedure to remove excess fluid buildup in the abdomen) with five liters of fluid removed each time. She had a history of cardiomyopathy, HTN and CHF. She is on spironolactone, metoprolol and hydralazine. She has significant anxiety. She reports she was on a trazodone to help her sleep. A Progress Notes revealed the resident admitted to the facility on [DATE] at 4:00 PM. A Nursing Progress Note on 3/25/26 at 5:51 AM documented by Staff E, Licensed Practical Nurse (LPN), revealed the resident alert and oriented x 4 (to person, place, time and situation) and able to make her needs known. She was a new admit on the previous shift. Resident had intermittent episodes of anxiety and tearfulness. Resident called this nurse at 1:00 AM and asked for her HS meds. Upon checking, all meds were signed off. When the resident was informed of this she stated I'm sure I did not take my medication, the nurse said she's coming back and I'm still waiting. On further discussion resident said she wants her bumetanide (water pill) and ABX (antibiotic). The ABX was scheduled to start this AM. The E-kit list of medications revealed sulfamethoxazole-trimethoprim (Bactrim DS) 800-160 mg available in the E-kit. The Pharmacy Delivery Report revealed medications for Resident #2 delivered to the facility on 3/24/26 at 8:43 PM. The medications included tramadol, hydroxyzine, metoprolol, spironolactone, xarelto and sulfamethoxazole-TMP DS. The Medication Administration Record (MAR) dated 3/2026 revealed Resident #2 did not receive any medications on the evening or at HS on 3/24/26. In an interview on 5/27/26 at 9:15 AM, Resident #2 reported she did not get her medications the first night she was at the facility. She was told when the pharmacy delivered the medications the nurse would bring the medications to her. Later that evening, she asked about her medications again. The next nurse on duty told her that another nurse checked the medications in and locked the medications in the medication cart. Resident #2 reported she did not get her blood pressure medication, antianxiety medication, or hydroxyzine medication. Resident #2 reported she took antianxiety and hydroxyzine medication because her anxiety got bad at time. In an interview on 5/27/26 at 2:00 PM, Staff E, LPN, reported the nurse or unit manager entered the orders when a resident got admitted to the facility. Staff E reported the pharmacy does not deliver on Sunday but she knew the pharmacy made two runs (delivery) each day. She is not sure what time the pharmacy delivered medication but they have delivered medication after 10 PM. Staff E reported she checked the E-kit or called the pharmacy if she did not have the medication. Staff E reported the first night Resident #2 was at the facility, Resident #2 told Staff E she did not get her medication. Staff E notified the ADON about the concern. She also checked the resident's blood sugar and her blood sugar reading was fine so she did not need insulin. Resident #2 was anxious but not confused. In an interview on 5/27/26 at 3:20 PM, Staff F, LPN, reported she had not done an admission at the facility. She believed the nurse or nurse leader entered the orders. The Pharmacy delivered medication in the afternoon.In an interview on 5/27/26 at 3:25 PM, Staff G, LPN, reported management staff entered the orders and someone else from leadership checked the orders after they had been entered. Staff G reported the pharmacy made a delivery to the facility around 2:00 or 2:30 PM each day and again after 6:00 PM. The facility had an E-kit with controlled substances and an E-kit tackle box for other medications such as an antibiotic or an anticoagulant. A list of medications was posted on the inside of the plastic bin. Staff G reported they obtained medication from the E-kit and gave the medication to the resident if the medication was needed and not delivered from pharmacy yet. In an interview on 6/1/26 at 2:35 PM, the Administrator reported they do not have a policy about processing doctor's orders.In an interview on 6/1/26 at 2:45 PM, the Director of Nursing (DON) reported the Assistant Director of Nursing (ADON) and the DON entered physician orders into the computer. The orders were also faxed to the pharmacy, and then the pharmacy delivered the medications to the facility. The DON reported it depended on the time of day when a resident got admitted . If a resident admitted to the facility in the AM and orders had been entered, the pharmacy delivered medications around 3 PM. If a resident admitted to the facility and orders entered in the afternoon or evening (PM), the pharmacy delivered medication between 9:00 to 10:00 PM. The DON confirmed the staff could obtain medications from the E-kit or call for a STAT delivery when needed. The floor nurse checked and verified the orders when they did their assessment. Orders were checked and entered into the computer when a resident admitted to the facility from the hospital. If a medication was supposed to be given medication BID, for example, and a dose of the medication was given at the hospital that AM, then another dose of the medication should be given at HS or when scheduled. At the time, the surveyor requested the DON to look at the electronic health record for the orders that were entered for a resident that came from the hospital. The DON stated she had entered the orders for Resident #2. She guessed since the resident admitted at 4:00 PM, the orders got put in later in the day and the system had populated the start time for that medication pass. Since it was later in the day, the HS medication time started as early as 6 PM. The DON thought since it was later in the day and after the time the computer likely did not flag for the nurse to give the medication on that shift, but rather for the following day. A Processing New Doctor's Orders procedure updated 4/9/26 revealed the nurse is responsible for entering new orders into the computer. The procedural steps included: select orders, select new, select order type (such as pharmacy, other, etc.), enter the order, fill out the order schedule, and press save. It was important to remember new orders needed processed timely and to make sure the order is designated to flag to the MAR (VERY IMPORTANT). Antibiotics need to be pulled from the E-kit and started immediately. If the medication is not in the E-kit then the pharmacy needed to be notified so the order could be requested as a STAT delivery. 2. On 5/28/26 at 11:51 AM, as the surveyor spoke with Resident #13 and Resident #14 in their room, Staff O, certified medication aide (CMA), brought medication in a medication cup for Resident #13, then walked over and handed a medication cup to Resident #14. Resident #14 asked Staff O what is this? Resident #14 told Staff O he normally got three pills at this time of the day. Staff O told the resident his Tylenol was in the cup. Resident #14 said he gets gabapentin and Lasix but he doesn't usually get Tylenol. Staff O told the resident the medication order showed up on the computer. Resident #14 then proceeded to take the medication. The MDS assessment dated [DATE] revealed Resident #13 had diagnosis of an essential tremor. The MDS recorded the resident had a BIMS of 15, indicating intact cognition The Medication Administration Record (MAR) dated 5/2026 revealed carbidopa-levodopa (given for tremors) documented as administered on 5/28/26 for the Mid AM dose. The MDS assessment dated [DATE] revealed Resident #14 had diagnoses of chronic atrial fibrillation (irregular heart rhythm), peripheral vascular disease and anxiety. The MDS documented the resident had a BIMS score of 14, indicating intact cognition.The MAR dated 5/2026 revealed furosemide, gabapentin and extra strength acetaminophen (Tylenol) documented as administered by Staff O, CMA, on 5/28/26 for the Mid-AM dose. In an interview on 5/28/26 at 12:05 PM, Resident #13 reported a lot of times staff brought medications in at the same time for her and Resident #14. Resident #13 said one time she got Resident #14's medication and she thought Resident #14 got her (Resident #13's) medication. In an interview on 5/28/26 at 12:10 PM, Staff O, CMA, reported she gave Resident #14 Tylenol, gabapentin and Lasix on 5/28/26 for the Mid-AM doses. In an interview on 6/1/26 at 3:05 PM, Staff N, CMA, reported they are only supposed to set up one resident at a time for medication pass. In an interview on 6/2/26 at 9:05 AM, the DON reported she expected staff to set up and administer medications for one resident at a time. An Administering Medications policy revised 12/2012) revealed medications shall be administered in a safe manner and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, staff interview, resident interview, and facility policy review, the facility failed to provide incontinence care within the time frames established in the comprehensive care plan and failed to maintain infection control standards during the provision of incontinence care for one of three (Res #18) residents reviewed. The facility reported a census of 81 residents.Findings include:The Minimum Data Set (MDS) Assessment of Res. #18 dated 4/29/26 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented the resident to be always incontinent of bowel and bladder. The Care Plan of Res. #18 documented a Focus Area of requiring assistance with Activities of Daily Living (ADL). The Care Plan directed staff that Res. #18 does not use a toilet, bed pan or bed side commode. It further directed staff to assist with checking and changing of incontinence brief and providing peri-care (cleansing of the genital area and buttocks) with each incontinent episode and as necessary as the resident allows, date initiated 11/29/23. An additional Focus Area of risk of impairment to skin integrity directed that Res #18 had vocalized she did not want disturbed on the overnight shift (10:00 pm - 6:00 am) or to be awoken during rounds. It further directed that Res #18 would use her call light to ask for assistance with changing her brief overnight, date initiated 11/29/23. Observation of incontinence cares of Res #18 began on 6/11/26 at 10:37 am. Staff T and Staff U, both Certified Nurse Aides (CNA) knocked on the door to assist Res #18. They brought supplies for incontinence care and bed linen change, as well as a full body mechanical lift into the room. Both staff washed their hands and donned gloves.Staff U assisted to remove Res. #18's nightgown and then began removing the soiled incontinence brief from Res #18 as Staff T was looking for wet wipes to use for peri care. Staff T removed her gloves and put new gloves on with no hand hygiene observed. She obtained a package of wet wipes that was sitting on the resident sink vanity. She then told Staff U they would need more supplies. She removed her gloves and left the room with no hand hygiene observed. Staff U then assisted Res. #18 to turn to her right side as he removed her soiled brief and placed it in the trash can near his feet. He used the sheets to clean up the mattress which was wet with urine. With no sanitizing of the mattress and no glove change, he then picked up clean sheets off the bedside table and began to tuck them under the resident. He obtained wipes from the package and cleansed the resident's buttocks front to back. Staff T then returned to the room with another package of wet wipes. She used hand sanitizer and placed new gloves on her hands. Staff T obtained a clean brief as Staff U completed cleansing the resident's buttocks. Staff U then reached for more clean bedding still wearing the same soiled gloves. He then handed Staff T a roll of plastic trash bags. Staff U obtained a clean cloth incontinence bed pad and tucked it underneath the resident. He then turned and obtained a second cloth incontinence bed pad and double padded underneath the resident. He then began to tuck a clean brief under the resident. He assisted the resident to turn towards him, on her left side. He passed Staff T another clean plastic bag and removed his gloves. Staff U went to the sink and washed his hands, leaving the resident lying on the bed with no clothing or bed sheets. After washing his hands, Staff U placed clean gloves on his hands. He returned to the resident and tucked the bed pads further underneath her. Staff T gathered the soiled linens from the foot of the bed and placed them in a plastic bag. She then removed her gloves, performed hand hygiene and obtained clean gloves. Staff U then began to do peri care on the front of the resident, cleansing her vaginal area back to front and then closed her incontinence brief with the tabs. Staff U then obtained the resident's clean clothing and with the same gloves on, assisted the resident to place a clean dress on. Both staff assisted the resident to roll left to right to get her dress in place and to put a sling underneath her for the full body mechanical lift. Staff U then removed his gloves. No hand hygiene was observed. He obtained the full body mechanical lift and put it in place to use for the resident. After placing the sling loops in place and verifying safety, the resident was raised above the bed and her weight obtained. The resident was then lowered back to the bed, and the sling was removed from behind her. Staff U removed his gloves and used hand sanitizer and placed new gloves. Staff T kept her gloves on, picked up the bed remote control and put the bed at the appropriate height while they removed the sling from under the resident and made her comfortable with position and coverings. Staff T then obtained cleaned wet wipes from the package that was used for performing peri care and wiped down the full body mechanical lift. On 6/11/26 at 11:00 am, Staff T was asked if the observed cares was the first time the resident had been checked and changed for incontinence since the day shift started. Staff T verified it was and verified the shift started five hours earlier at 6:00 am. Staff T was also asked what she had used to clean the full body mechanical lift and she verified she used regular wet wipes, the same type used to clean a resident. On 6/11/26 at 11:07 am, Res. #18 stated she had last been checked and changed for incontinence at approximately 6:00 pm the prior evening (16.5 hours earlier). She stated it is her desire to not be awoken overnight and said this was a part of her care plan. She said she normally goes to sleep sometime after dinner and wakes up anytime between 5:00 am and 7:00 am. She said that morning she had awoken at approximately 5:30 am. She said she normally won't ring her call light unless she needs to have a bowel movement and she will just wait for staff to come in. She confirmed that she was aware that on this day, she was very wet. She added that although she knew how wet she was, she knew staff would be coming. She confirmed that it did not bother her when she was left lying exposed with no clothing or coverings on. On 6/11/26 at 1:15 pm, the Director of Nursing stated her expectation for incontinence cares for Res. #8 is every two hours and as needed, outside of the night shift per Res. #8's requested routine. The facility policy titled Activities of Daily Living (ADL), Supporting, revision date April 2025, documented the following:Policy Statement: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Point 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:a. hygiene (bathing, dressing, grooming, and oral care);b. mobility (transfer and ambulation, including walking);c. elimination (toileting); d. dining (eating, including meals and snacks); and e. communication (including speech, language, and other functional communication systems).

Based on observation, clinical record review, hospital record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision for two out of five (Resident #3 and Resident #15) residents reviewed for nursing supervision by failing to provide one person assistance to Resident #3, resulting in the resident eloping from the building. The facility additionally failed to provide staff accompaniment to an off site physician's office visit for a cognitively impaired resident (Resident #15). The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment of Resident #3 dated 5/14/26 documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. The MDS documented the resident exhibited wandering daily during the look-back period, placing the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). The MDS documented an admission date to the facility of 5/8/26. The Care Plan of Res #3 documented a Focus Area of limited physical mobility related to use of cane or walker, date initiated 5/8/26. The Care Plan included an intervention of Mobility: The resident requires 1 staff participation for mobility, dated 5/8/26. The Focus Area and interventions were resolved on 5/11/26. The Care Plan documented a Focus Area of the resident being an elopement risk/wanderer, as evidenced by resident wanders aimlessly, initiated 5/9/26. The Focus Area was updated on 5/10/26 to state the resident has had an actual elopement from the facility. On 6/2/26 at 8:40 am, the Regional Nurse verified Res #3 was Care Planned to be one staff assistance for mobility from 5/8/26 through 5/11/26. She added the resident's Baseline Care Plan was done on pen and paper and they would provide that. On 6/2/26 at 9:05 am, the Director of Nursing (DON) provided the Baseline Care Plan of Res #3, dated 5/8/26. The Baseline Care Plan documented Resident #3 required assistance of one staff member for transfers and mobility, but also noted the resident desired to be independent in the facility and would be evaluated. The DON stated that the therapy team evaluated the resident later that day and the resident was deemed to remain care planned as requiring one staff assist for transfers and mobility. The Physical Therapy Evaluation dated 5/8/26 documented the Clinical Impressions of the resident as: Patient demonstrates decreased balance, decreased strength, decreased activity tolerance limiting patient's ability to perform functional mobility. The Reason for Therapy was documented as: Patient requires physical therapy services to analyze gait pattern, facilitate independence with all functional mobility, improve dynamic balance, increase functional activity tolerance and promote safety awareness in order to enhance patient's quality of life by improving ability to decrease level of assistance from caregivers. The Elopement/Wander Risk Evaluation dated 5/9/26, completed by Staff B, Assistant Director of Nursing (ADON) documented the resident to be forgetful and have a short attention span. It further documented that the resident had a recent change in financial status, loss of self control, expressing the desire to go home and aimless, non goal directed wandering. The Evaluation documented the resident was independent with a cane/walker, although the care plan directed the resident was to have the assistance of one staff member. The Evaluation failed to document the resident having decreased cognition, although his BIMS score was a 9. The Evaluation documented the resident had no history of wandering, and no substance use disorder. The Evaluation scored the resident to have a risk factor of 8, moderate risk. The hospital referral paperwork, uploaded into Resident #3's chart on 5/7/26 prior to facility admission, documented the following:a. Diagnosis of alcohol use disorder, noting the resident was actively intoxicated on arrival to the hospital (this conflicts with the documentation on the Elopement Risk Evaluation) as well as being homeless. b. Hyponatremia (low sodium), noted to likely be chronic and exacerbated by excessive alcohol use.c. A Nursing Note dated 5/3/26 documented that the resident had removed his gown, IV and leads (heart monitor), put his pants on, and stated he wanted to leave. He was found after having fallen in the doorway of his room. The Facility Reported Incident (FRI, also known as a self report) dated 5/11/26 documented that on 5/10/26 at approximately 1:00 pm, Res #3 was seen walking on the sidewalk outside of the facility. Staff immediately went to the resident and redirected him back to the facility. It was noted that Res #3 had removed his wanderguard (an electronic bracelet placed on a resident which sets off alarms when the resident is too close to an exit door). The FRI documented staff had last seen the resident inside the facility approximately ten minutes earlier at approximately 12:50 pm. The Medication Admin Audit Report of Resident #3 for 5/10/26 documented medications had last been administered to Resident #3 at 12:25 pm. This was the last documented time a staff member had visualized the resident. During an interview on 5/27/26 at 12:14 pm, Staff C, a Certified Nurse Aide (CNA), confirmed she was assigned to the hallway where Resident #3 resided on 5/10/26. She stated at the time he was observed being outside, she was in a different resident's room providing cares. She said she had last seen him around lunchtime but was unable to give any details as to whether she had seen him in his room, in the dining room or elsewhere in the facility. She could not recall where he had eaten lunch that day or give a specific time as to when she had seen him last. She said the only thing she could really recall was that he was kind of agitated and was constantly asking for coffee.On 5/27/26 at 1:06 pm, Staff L, Licensed Practical Nurse (LPN), reported working at Station 1 (the area of the facility where the resident's room was) on 5/10/26, though she was not assigned to Resident #3's specific hallway. She detailed that she and Staff M (LPN) were counting medications as Staff M prepared to cover the medication cart for the rest of the shift. She reported a nurse from Station 2 came running down and informed them that Resident #3 was seen outside. Staff L and Staff M immediately exited the front door of the building to search for him. She stated that Resident #12, who was sitting outside, pointed them in the direction that Resident #3 had gone. Staff L stated that as they rounded the south corner of the building, they saw another staff member who had already reached Resident #3 and was walking him back toward the facility. On 5/27/26 at 1:13 pm, the Dietary Manager stated she was not on duty on 5/10/26 but she stated Resident #3 always ate lunch in the dining room and not in his room. She stated lunch is served daily at 11:30 am. On 5/27/26 at 1:15 pm, Staff A, Certified Medication Aide (CMA), reported that she and other staff were alerted that Resident #3 was outside. She said two nurses exited the front door while she took the west door of the Station 1 area, as it had been reported Resident #3 was heading towards the bank (located directly west of the facility). Staff A found him on the sidewalk, aligned with the facility's south-facing door. She turned him around and walked him back inside the facility. Staff A added that she had last seen him approximately half an hour earlier that day. She believed he had a room tray for lunch and ate in his room, noting it was rare for him to eat in the dining room. She described Resident #3 as looking more like a visitor than a resident. She added that although staff kept a close eye on him if he wandered to the front of the building, he generally stayed in his room. Staff A voiced she had no concerns regarding him that shift prior to his leaving the building.On 5/27/26 at 1:38 pm, Staff B, one of the two facility Assistant Directors of Nursing (ADON) said she was in the building on Station 2 on the day shift of 5/10/26. The other nurse at Station 2 had received a phone call from Resident #12 that she had spotted Resident #3 outside independently. After the resident was assisted back inside the building, Staff M, LPN came and reported the incident to her. She then went to his room and performed a head to toe assessment, finding no injuries to the resident but noting he had removed his wanderguard. She stated she sat with him one to one (1:1) until 6:00 pm where he was cooperative although agitated that staff was sitting with him. (another staff member relieved her at 6:00 pm). She stated she oversees the other portion of the building and did not really know Resident #3 as he had only been admitted to the facility recently. On 5/27/26 at 1:50 pm, the Director of Rehabilitation (DOR), Occupational Therapist, stated Res #3 had admitted the Friday afternoon prior to his elopement and she performed her initial evaluation with him. She reported he walked with a walker and was able to ambulate approximately 50 feet.On 5/27/26 at 3:33 pm, Staff C, activities assistant, confirmed she was in the building on 5/10/26 and, at approximately 1:00 pm, she gathered several residents to the locked front door. She described escorting residents one at a time to the courtyard area, which is in visual distance from the front door. She stated Resident #3 was not in the area, nor in the group of residents she took outdoors. She also confirmed Resident #12 was not part of the group that day. She said at no time during that time period had she seen Resident #3 and she felt he must have gotten outdoors prior to her taking other residents out. She added she had only been outside for a short amount of time when staff came outside looking for him and asked her if she had seen him. After telling them she had not seen him, staff went in another direction to look for him. On 5/27/26 at 4:25 pm, Resident #12 (BIMS score of 15, cognitively intact) stated that on 5/10/26, she was sitting near the end of the sidewalk towards the south end of the facility parking lot. She saw Resident #3 outside, recognized he was a new resident, and verbally tried to stop him. When he did not stop, she immediately called the staff using her cell phone to report that he was outside alone. Resident #12 stated she did not see anyone else outside with him or in the area immediately prior to the resident being seen outdoors.In a second interview on 5/28/26 at 1:00 pm, Resident #12 confirmed that she saw Resident #3 outdoors prior to the activities staff bringing other residents outside. She added that 5/10/26 was Mother's Day, which resulted in more visitors than usual. Although she did not witness Resident #3 exit the building, she guessed he had walked out as a visitor was entering, noting the front door was open more frequently that day than normal. She also stated there was no staff at the front desk that day.On 5/28/26 at 2:25 pm, the DON stated there is no code used to open the front door from inside. There is a button behind the reception desk which staff can push (behind a locked door) or the door can be opened with a staff badge/fob. Only staff can exit the building without assistance. She stated the building does not have security cameras. She also added the facility does keep a badge inside of the double entrance doors so visitors can use that badge to enter the building only, but it is not available for exiting the building. She stated it was likely that a visitor entered the building and Resident #3 exited at the same time. On 5/28/26 at 2:35 pm, Staff M, LPN stated the ADON had previously called her and stated she was concerned about Resident #3 being anxious and requested she place a wanderguard on him. She said after placing the wanderguard around his ankle, he was wandering and setting off multiple alarms that day. She also described that on Mother's Day, there were a lot of people in the building and also that the Activities department was taking residents to sit outside in the nice weather. She felt that Resident #3 likely got out either following activities or following a visitor. She said when the Station 2 nurse (who answered the phone when Res #12 called) came down telling her the resident was outside, she and Staff L went running out the front door and did not see him and then headed around the corner (south side of building). When they spotted him, Staff A, CMA had already gotten to him. She stated when he was back inside an assessment was completed and his wanderguard was found in the trash. She described the wanderguard had been ripped. She said it definitely had not been cut, it was ripped and he had pried it off somehow. She said he may have used a fork or some other object. On 5/28/26 at 3:20 pm, the ADON clarified she had asked Staff M to place a wanderguard on Resident #9 on 5/9/26 and the elopement was on 5/10/26. The facility policy titled Elopement, revision date 6/2023 documented the following policy statement: It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff. Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: Point 1: Upon admission, readmission, quarterly, and with a significant change of condition, residents will be assessed for elopement risk.Point 3: Elopement risk will be care planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made. The facility policy titled Care Plans, Comprehensive Person-Centered, revision date 03/2022 documented the following: Policy Statement: 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.Policy Interpretation and Implementation:Point 1: The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Point 3: The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.Point 7e: The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions.Point 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 2. The admission MDS of Resident #15, dated 4/23/26 identified a BIMS score of 5 which indicated severe cognitive impairment. The MDS documented diagnoses which included cancer, Non Alzheimer's Dementia, anxiety, depression and schizophrenia. The MDS documented the resident had experienced a fall since admission on [DATE]. The Significant Change MDS of Resident #15, dated 5/8/26, identified her BIMS had declined to a 4.The Physician Order Note dated 4/21/26, authored by the DON, documented a phone call had been received from the Mental Health clinic of a local hospital in regards to the medications which the hospital had ordered upon the resident's recent hospital discharge. Updated orders were received as well as orders to draw labs on 5/17/26 and to fax the results to the clinic. The note additionally documented the resident's next follow up appointment at the clinic was scheduled for 5/28/26 at 10:00 am. The note detailed the van transportation service had been contacted with a pickup time of 9:15 am. The History and Physical of Resident #3 dated 3/17/26 from her records of pre-admission status documented increasing confusion in addition to frequent falls over several weeks. Review of additional facility progress notes revealed that between 4/19/26 and 5/25/26, the resident experienced eleven (11) falls, one with injuries resulting in bruising and a laceration requiring stitches. The Nursing Note dated 4/27/26 documented due to physical decline, the resident's guardian requested a hospice referral. The resident was hospitalized for a short time and the admission summary dated [DATE] identified the resident had enrolled in hospice.The Interdisciplinary Note dated 4/30/26 identified the resident had a diagnosis of Stage 4 breast cancer with metastasis and was receiving hospice care. The Nursing Note dated 5/26/26, authored by Staff B, ADON documented she had spoken to the provider at the hospital clinic regarding the ordered monthly labs and stated due to the resident no longer taking psychotropic medications, labs were not needed to be drawn. On 5/28/26 at 10:30 am, Res #15 was observed sitting in a wheelchair behind the nursing station and attempted to stand up by the desk. Staff approached the resident and asked her to sit down. The resident then grabbed the phone and was pulling on the cords. Another staff member walked by the desk and requested she give the phone to him.On 6/1/26 at 7:42 am, Res #15 was observed sitting at the nursing station in her wheelchair. A bruise was noted to her left chest and stitches above her eyebrow extending to her forehead were seen. On 6/1/26 at 11:45 am, a representative of the van transportation service stated the service had no policy regarding cognitively impaired residents using the service without a facility staff member accompanying them but added that most facilities sent a staff member along in these situations. He looked up the records for Resident #15 and stated he showed a pick up time of 9:15 for a 10:30 appointment at the Behavioral Health Clinic on the second floor of the clinic. He stated if the resident did not have accompaniment, the van driver would take the resident to the second floor and assist to get her checked in before leaving the clinic. He added the driver would additionally leave a card with a contact phone number with the clinic. On 6/1/26 at 12:34 pm, a driver from the transportation service stated he did not pick Resident #15 up from the facility that day, but he was the driver who picked her back up from the clinic and returned her to the facility. He stated he picked the resident up from the clinic approximately 10:45 or 11:00 am but he did not have the exact time documented. He stated he picked up only the resident, no staff accompanied her. On 6/1/26 at 1:22 pm, Res #15 was observed sitting behind the nursing desk next to a hospice employee. The hospice employee was gathering her items to leave and wheeled Res #15 over to the lounge area where Staff B, ADON was sitting doing paperwork. The hospice employee asked Staff B if she could leave Res #15 with her.On 6/1/26 at 1:24 pm, Staff B, LPN, ADON stated Res #15 was being seen at the clinic for the psychotropic medications she had been taking. She stated during a phone call on 5/26/28, the clinic told her the resident no longer needed to have labs drawn due to no longer taking the medicaions as she had started hospice care and was only on comfort medications. She voiced that during that phone call, the clinic also stated the resident no longer needed to be seen at the clinic. She stated she was told Res# 15's next appt was June 28th, not May 28th which was when the appt was. She said she called the van transportation service to cancel the appointment but was told there was no appointment for June 28 and she added she was not aware of the May 28th appointment. The ADON stated normally if a cognitively impaired resident has an outside appointment, a CNA or another employee would ride with the resident. She stated most cognitively impaired residents do not leave the building as the vendors (medical providers) come into the building instead. She reported she was not in the building on 5/28/26 so she was unsure if anyone accompanied the resident to the appointment.During this interview, Resident #15 was observed to be sitting in her wheelchair a few feet from the ADON. She appeared semi anxious and fidgety but did not make any attempts to stand or transfer. On 6/1/26 at 1:30 pm, the DON stated she was not aware if any staff member accompanied Res #15 to the clinic appointment but stated she would find out.At 1:35 pm, the DON returned and verified no staff member was present with Resident #15 during the 5/28/26 clinical visit. She stated the van transportation service drove the resident and assisted her to the area of the building she needed to be in. She voiced the 5/28/26 appointment was set up prior to her admission to the facility when she was more independent and at a different level of function than she currently was. She stated had she been aware, she would have cancelled the appointment. She said if the facility was the one to set up the appointment, then it would have been arranged to have an employee attend with her. She detailed the facility has an appointment book at each station and normally the night shift nurse on the night prior to the appointment prepares the paperwork for the appointment. She stated the who had been on duty the day of the appointment was a new employee. (Review of the schedule detailed the nurse assigned to Resident #15 that day was an agency nurse, not a facility employee. The nurse the DON referred to as being new was assigned the same station but a different hallway).On 6/1/26 at 2:29 pm, the Administrator stated the facility does not have a policy regarding resident transportation.On 6/1/26 at 4:00 pm the Administrator stated it is a case by case basis if a staff member accompanies resident appointments. She said they would do that if it was needed. She acknowledged she would have advised someone to set up for a staff member to ride along with Resident #15 but that the facility did not have a designated person to set up appointments or transportation, it can be any nursing staff. She said it is just communicated when a resident needs accompaniment but was unable to voice any specific procedure that was followed. The Administrator acknowledged the Resident had a BIMS of 5 upon admission and had since declined to a current BIMS of 4. On 6/1/26 at 4:15 pm, the Administrator provided a list of residents who had been evaluated by therapy and deemed safe to be outdoors independently. Resident #15 was not included on the list. She stated both ADONs would be auditing the appointment books weekly to monitor if a resident had an appointment who would need staff accompaniment. She stated the Interdisciplinary Team (IDT) would review these audits monthly and as needed and education had been provided to the nursing team that day. On 6/2/26 at 1:05 pm, the Behavioral Health Nurse Practitioner (NP) for the clinic where the Resident had her appointment clarified the resident's appointment time on 5/28/26 had been scheduled for 10:00 am. She verified the van driver did accompany the resident to the second floor and leave a card with a phone number to call for pickup. She stated that the resident was not checked in at the front desk until 10:17 am for the 10:00 am appointment. She also stated that her nurse at the clinic had entered a note on 5/26/26 into the resident's chart at the clinic which documented he had spoken to a nurse at the facility instructing that due to the resident being on hospice and on comfort medications only, she no longer needed to have labs drawn or have further clinic appointments.

Based on record review, facility investigation summary report, resident and staff interview and policy review the facility staff failed to provide care for a resident in an environment that maintained or enhanced dignity for one of six residents sampled that required assistance (Residents #1). The facility reported a census of 81 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 admitted to the facility on [DATE] and had diagnoses of a colostomy and an ileostomy. The MDS documented the resident had a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS indicated the resident had dependence on staff for toileting and had a surgical wound.The Care Plan initiated 4/9/26 and revised 4/16/26 revealed the resident had a colostomy and ileostomy related to an ileus (a temporary slowdown or stoppage of intestinal movement). The Care Plan directed staff to change the bag after each bowel episode or when the bag was full, and to alert the nurse to change the bag. Progress Notes dated 4/10/26 at 10:44 AM, revealed Resident #1 reported to the Social Services Director (SSD) that on the evening of 4/9/26, he activated the call light due to a concern that his colostomy bag was leaking. The resident stated the nurse responded and applied tape to further secure the colostomy appliance. The resident called the nurse back shortly thereafter, stating the bag continued to leak. The resident expressed concern that the removal caused or worsened a skin irritation around the stoma site, and he felt the irritation was done intentionally by the nurse. The nurse reported she responded to the resident's call light regarding a leaking colostomy appliance and initially attempted to secure the bag with tape. Upon being notified that the appliance continued to leak, the nurse removed the appliance, stating a concern that it may have been contributing to the skin irritation. The nurse reported she attempted to loosen the appliance using a warm washcloth during removal. The nurse noted that a skin irritation was present around the stoma site. The appliance was subsequently replaced by the facility nursing staff. The resident expressed dissatisfaction with the placement and independently adjusted the colostomy appliance himself. The facility's investigation summary revealed on 4/10/2026 at approximately 9:00 AM, the SSD was made aware of an allegation of abuse from Resident #1. Resident #1reported to the SSD that on 4/9/2026 at approximately 6:45 PM, Staff K, Registered Nurse (RN), removed his colostomy bag causing skin irritation. Resident #1felt that it was intentional. The SSD immediately reported the concern to the Director of Nursing (DON). The DON reported it to the Administrator. The Administrator reported the incident to DIAL (Department of Inspections, Appeals and Licensing). The facility's investigation revealed Staff K denied taking the colostomy bag off in a manner that caused skin irritation. The other staff member present that evening was Staff J, certified nursing assistant (CNA). Staff J stated that he was at the nurse's station when Staff K asked him to assist with cleaning up Resident #1. When Staff J entered Resident #1's room, he noted that there was BM (stool) present from the colostomy bag and noted that Resident #1seemed agitated and yelled to his family on the phone. Resident #1 kept telling Staff J that she [Staff K] should have never done that, and I'm going to report her. Resident #1 then requested pain pills. Staff K brought him Tylenol. Staff J stated that Resident #1cleaned his body and that Staff J cleaned down the chair and leg rest. Staff J was not in the room when the colostomy bag was removed by Staff K. Staff J went in the room after Staff K asked him to assist cleaning Resident #1 up. A head-to-toe assessment was completed on Resident #1 and irritation was noted around the stoma measuring 2.4 centimeters (cm) by 1.6 cm by 0.2 laterally. Irritation was also noted below the stoma measuring 4.8 cm by 0.8 cm by 0.3 cm and anteriorly 1.6 cm by 1.2 cm. Resident #1 reported feeling safe and that his needs were being met since the evening of 4/9/26. The Facility's Investigation Summary revealed Staff K was suspended. In an email dated 4/10/26 at 9:26 AM, Staff B, Assistant Director of Nursing (ADON) sent Staff K's Statement to the DON. Staff B wrote: Upon arrival to her shift, staff alerted Staff K that the resident's bag was leaking. Staff K took a wet washcloth to loosen the adhesive and pulled back slowly and then she put a new one on. Stool got on the resident's clothes so she asked Staff J to assist in changing the resident. Resident #1 said that she (nurse) ripped it off but Staff K stated that she did not. In an email dated 4/10/26 at 9:51 AM, Staff B wrote to the DON regarding Staff J's Statement. Staff B wrote the following: Staff J was at the nurses station and Staff K came in to ask him to clean the resident up. The resident had BM all over but not super bad when Staff J entered the room. Resident #1 was agitated and yelling but not cussing. The resident called his family and kept telling Staff J that she should have never done that. I'm gonna report her. Staff J notified Staff K that the resident was upset with her. The resident asked for management and the resident was told they (management) would be back in the AM. The resident wanted pain pills and asked who could get them for him. Staff J said Staff K was passing pills. The resident said he did not want to ask her (Staff K) for anything. Staff K did bring the resident Tylenol. The resident cleaned his body and Staff J cleaned the chair and the leg rest. Staff J states that he was not in the room when it happened he was just there after Staff K asked him to clean the resident up. In an interview on 5/26/26 at 4:05 PM, Resident #1 reported he had a colostomy and an ileostomy. Someone ordered the wrong bag/supplies initially and he had trouble with the ostomy bag leaking. Some of the staff did not know how to take care of the colostomy and do the bag changes. On the day of the incident, he sat in the brown recliner chair in his room. When he sat down in the chair, his bag was leaking under and around the bag. He pressed the call button. The nurse came in and said she did not know how to do it, left his room and then came back. When the nurse came in, the colostomy bag was leaking. The nurse was trying to find something and she was not paying attention to what he was trying to say and she just ripped the bag off. There was blood and stuff like that all over. The CNA then came in and cleaned it up. When the nurse ripped it off, she put another bag on and it also started leaking 5 minutes later. The resident stated the nurse seemed like she was in a hurry, she did not clean the area or apply anything before she put a new colostomy appliance or the bag on. In an interview on 5/26/26 at 3:35 PM, Staff J, CNA, reported the nurse came out and told him to go to Resident #1's room and clean him up. Staff J went into the room and told the resident he was going to get him cleaned up. Resident #1 was very angry and bent out of shape. Resident #1 said the nurse came in and just ripped his colostomy bag off. Staff J believed something had happened because there was feces everywhere. Feces was on the resident's back, all over the front of him and on his clothes. Staff J apologized to the resident. Resident #1 was cussing and said he did not want that bitch back in his room again. Staff J told the resident that she was the only nurse working and he would have to deal with her for the time being. Resident #1 was on the phone telling a family member what had happened. After Staff J cleaned the resident up, Staff J told the nurse do not be surprised if she got called in by management because the resident was upset and on the phone telling his family about it. The next day, Staff J got a call from the ADON asking about what happened. Staff J thought the colostomy bag was forcibly removed because of how it looked with feces all over the resident. Staff J stated he had worked for several years as a CNA and he had put colostomy bags on before but it never looked like that. Staff J stated he did not notice any skin irritation when he cleaned the resident up that day. Staff J reported the resident had thrown a towel on the floor and said there was blood on the towel. Staff Jj reported when he picked the towel up, the towel had a brownish- red color. Staff J thought it was feces, not blood. Staff J reported he had never worked with Staff K before the night of the incident. Staff J reported he was in training at the time and another CNA was working on the opposite hall of where Staff J was assigned. In an interview on 5/26/26 at 4:00 PM, the SSD reported the Director of Therapy asked the SSD to talk to Resident #1. Resident #1 reported he had a concern that a nurse had ripped off the bag. He told her he had turned on the call light, the nurse came down and said the bag was fine. He turned the call light on again because the bag was leaking. The resident said the nurse got irritated and ripped it off. The SSD notified the DON and Administrator about the concern. The SSD stated she provided supportive visits afterward, and the resident voiced no other concerns after that day. In an interview on 5/27/26 at 9:45 AM, the Administrator reported Resident #1 had a colostomy and was very particular about the bag. The colostomy/bag was leaking and he wanted the nurse to take a look at it. The nurse went in, checked the bag and said it was fine. The resident put his call light on again because it was leaking. The nurse went in again and removed or ripped the bag off. The resident thought it was intentional. Staff B, ADON, talked to Staff K. Staff K denied doing it intentionally. In an interview on 5/27/26 at 9:55 AM, Staff B, ADON, stated Resident #1 reported a concern to the SSD. The DON asked Staff B to assist in getting the story from the resident. Staff B and the SSD talked with Resident #1. Resident#1 said the colostomy kept leaking. He reported it to the nurse. Resident#1 said the nurse came in and appeared frustrated and just ripped the bag off. Resident #1 appeared frustrated when he talked to Staff B about the incident. Staff B then called Staff K per the Administrator's request. Staff K told Staff B that she used a wet washcloth to remove the edges around the bag to make it easier and less painful to get the bag off. Staff K denied pulling or ripping the colostomy bag off. Staff J, CNA, went in to change the resident. Staff J reported to the nurse the resident was upset with her. In an interview on 5/27/26 at 1:04 PM, Staff K, RN, reported she had worked at the facility since 1/2026 and had been a nurse for 18 yrs. She received training /orientation on one evening shift with a nurse that worked PRN and one shift with a seasoned night nurse. She had a total of two shifts for orientation at the facility. Staff K reported Resident #1 had a colostomy. He also had a lot of generalized anxiety. Staff K reported she thinks she got in a little bit of a hurry while working with the resident. His colostomy was leaking and when she changed it, she did not go through all of the steps, such as to ensure the area got cleaned. On the day of the alleged incident, the CNA came to her and let her know the resident's colostomy was leaking. Staff K said oh, bummer. She went in and grabbed a new colostomy bag then said ok we need to get this emptied. That was the plan, but it was such a mess. The colostomy was leaking pretty bad and stool was coming down at the site where the stoma was. She wondered if she just pulled the bag off and just started fresh that it would work better. It did not work out the way she thought it would. She apologized and said oh I am so sorry. Staff K explained that she used a wet washcloth to wipe the area off when she removed the colostomy bag, and then she went around the edges to loosen and wiped things off. Staff K stated again that it did not work out the way she thought it would. She told the resident she would get him some pain medication, then left the room and told the CNA to go in. Staff K went back in the room after the CNA cleaned him up and gave the resident his pain medication. The surveyor asked Staff K if the CNA said anything to her about the resident being upset. The CNA told Staff K he cleaned the resident up, and that it was a mess. The CNA said the resident was frustrated and shook up about the whole thing. The CNA told her Resident#1 was pretty upset and that the resident would possibly be saying something to someone about it. Staff K said she notified the ADON on duty about it. Staff K stated she had not worked extensively with a colostomy or ostomy. She worked at another facility where another resident had a colostomy but that resident took care of the colostomy for the most part. Resident #1's colostomy was different than what Staff K had seen before. In an interview on 5/28/26 at 2:20 PM, the DON reported the SSD let her know that Resident #1 was not happy. The DON and SSD spoke with the resident. Resident #1 said his bag had been leaking. He called the nurse. The nurse attempted to tape the area where it was leaking. He pushed his call light when the colostomy leaked again. The nurse came back and said the bag needed to be changed. Resident #1told the DON that the nurse ripped the bag off. He thought the incident was deliberate. The DON talked with Staff K. Staff K said she used a washcloth to loosen the adhesive. The DON requested the ADON to perform a skin assessment. The ADON performed the skin assessment. There was a skin tear around the underside of the stoma. The DON stated she thought maybe it was where the adhesive was but the colostomy had been leaking as well. A Quality of Life-Dignity policy revised 8/2009 revealed residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall keep the resident informed. Procedures shall be explained before they are performed.

Based on observation, record review, and staff interviews, the facility failed to provide proper wound care for two of two residents reviewed with pressure ulcers and failed to document a total of 9 treatments for 3 different pressure ulcers for Resident #21 and failed to document a total of 7 treatments for 3 different wounds as being completed and failed to utilize proper infection control techniques while providing wound care to Resident #22. The facility reported a census of 83 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] identified Resident #21 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 2 and had the following diagnoses: Coronary Artery Disease, Heart Failure and Alzheimer's Disease. The MDS also identified Resident #21 to be totally dependent on staff for assistance with all activities of daily living except for eating. The MDS also identified Resident #21 with two unstageable pressure ulcers. A review of the Physician Orders revealed the following:1/25/26 heel boots on at all times as tolerated.2/5/26 Left Heel: cleanse with wound cleanser, pat dry, apply betadine moistened gauze secure with gauze roll and tape QD and PRN one time a day for pressure sore and as needed.2/22/26 Weekly Skin Assessment in the evening every Saturday for monitoring.2/25/26 Right Coccyx: cleanse wound with quarter strength Dakins, loosely pack wound bed with Dakins moistened calcium alginate, cover with ABD pad daily and PRN if becomes loose or soiledevery day shift for coccyx wound care and as needed for if becomes loose or soiled On 3/7/26, The Care Plan identified Resident #21 with the problem of a pressure ulcer or potential for pressure ulcer development and directed staff to administer treatments as ordered and observe for effectiveness A review of the March 2026 TARs (Treatment Administration Records) revealed the following:Left heel: cleanse with wound cleanser, pat dry, apply betadine moistened gauze secure with gauze roll and tape QD (once daily) and PRN (as needed) one time a day for pressure soreTreatments were not signed out as completed on March 18, 25, and 29Right Coccyx: cleanse wound with quarter strength Dakins, loosely pack wound bed with Dakins moistened calcium alginate, cover with ABD pad daily and PRN if becomes loose or soiled every day shift for coccyx wound careTreatments not signed out as completed on March 2, 10, 14, 21, 25 and 30LT Buttock: Cleanse with cleanser of choice apply magic butt paste BID and PRN two times a day related to unstageable pressure ulcerTreatments not signed out as completed on March for 8:00 AM dose on March 18 and 25 and for 4:00 PM dose on March 2, 3, 4, 10, 17, 25, 29, and 30.RT Buttock: Cleanse with Cleanser of choice apply magic butt paste BID and PRN two times a day of woundTreatments not signed out as completed on March for 8:00 AM dose March 18, 25 and for 8:00 PM dose 15, and 25. An observation of wound care on 4/1/26 at 10:33 AM revealed staff donned isolation gown and gloves, changed gloves and sanitized hands appropriately between wounds which all appeared without signs of infection. A review of the April 2026 TARs revealed the following:Left Heel: cleanse with wound cleanser, pat dry, apply betadine moistened gauze secure with gauze roll and tape QD and PRN one time a day for pressure soreTreatments not signed out as completed on for 8:00 AM on April 3 and 7Right Coccyx:: cleanse wound with quarter strength Dakins, loosely pack wound bed with Dakins moistened calcium alginate, cover with ABD pad daily and PRN if becomes loose or soiled every day shift for coccyx wound careTreatments not signed out as completed on for day shift on April 3, 5, 7Sacrum: cleanse with Vashe soaked gauze and allow to dwell for 3-5 minutes, pat dry. Apply xeroform gauze, cover with ABD pad and secure with tape QD (daily) in the morning for wound.Treatments were not signed out as completed on for the morning dose on April 1. In an interview on 4/8/26 at 12:29 PM, the DON (Director of Nursing) reported after a nurse completes a treatment for a pressure ulcer, she would you expect the nurse to initial the TAR (Treatment Administration Record) to show it had been completed, right after the treatment had been completed. In an interview on 4/8/26 at 1:00 PM, the DON reported the following regarding Resident #21's treatments not signed out: she could not speak to the specific reason the treatments were not completed throughout March/April. She did confirm is that this has been identified as a concern. The facility is reviewing the documentation and processes with staff, reinforcing expectations for completing and documenting treatments per physician orders, and implementing increased auditing to ensure compliance moving forward. A review of the Facility Policy Titled: Administering Medications with the last revision date of December 2012) had documentation of the following:Medications must be administered in accordance with the orders, including any required time frame.The individual administering the medication must document such in the eMAR (electronic Medication Administration Record) system after giving each medication and before administering the next ones.Topical medications used in treatments must be recorded on the resident's treatment record (TAR). The MDS dated [DATE] identified Resident #22 as cognitively intact with a BIMS score of 13 andhad the following diagnoses: Renal Insufficiency (Kidney Failure), Diabetes Mellitus and Spina Bifida. The MDS also identified Resident #22 to be totally dependent on staff for assistance with most activities of daily living except for oral hygiene and eating. The MDS also identified Resident #22 with an indwelling urinary catheter and had one Stage IV pressure ulcer. An observation of wound care on 4/3/26 revealed the following:10:35 AM both Staff B, LPN and Staff C, LPN used hand sanitizer, donned isolation gowns and gloves11:00 AM Staff B, LPN used scissors to cut through the kerlix dressings from each foot. Staff C, LPN then lifted up Resident #22's left foot, which had open area to left heel with necrotic area in the middle, surrounding skin appears reddened. Staff B, cleansed the left heel wound with VASHE wound cleanser then applied betadine soaked 4x4s and wrapped with kerlix dressing. Staff B did not disinfect scissors before cutting the new kerlix dressing.11:11 AM Staff B then cleansed the wound to the right medial calf with VASHE soaked gauze. She did not change gloves after cleansing the wound and before she picked up the new calcium alginate dressing. She did not disinfect the scissors before she cut the calcium alginate dressings. She then applied the calcium alginate dressings to the wound followed by the soft silicone dressing. Staff B then removed her gloves, used Alcohol Hand Rub and pointed to the dressing to Resident #22's right foot and said to the surveyor I don't know what's going on with that foot Staff B asked Staff C to check to see TAR (Treatment Administration Record). Staff C left the room.11:16 AM Staff B did not disinfect the scissors before she cut the kerlix (which was dated 4/2/26) off the right foot then placed the scissors in a plastic bag beside the resident. She found an open area with a necrotic center approximately quarter sized and removed the dressing from the foot and verified the surveyor's observation.11:18 AM Staff C returned to the room wearing isolation gown and gloves and reported the wound nurse came yesterday and healed that area out and discontinued the dressing. Staff B then placed the soiled dressings into trash and did not cleanse the wound to the right heel or apply a new dressing. Both used correct technique to doff both gown and gloves and washed hands. A review of the physician orders and April 2026 TARs revealed the following:Left heel: cleanse with Vashe, pat dry apply betadine moistened gauze and cover with roll gauze daily. in the morning for wound.Treatments were not signed out as completed on April 5 and 6.Right foot lateral cleanse with wound cleanser of choice, pat to dry, apply calcium alginate to wound bed, cover with abd pad and roll gauze, secure with tape. Change daily and as needed if becomes soiled or falls off. one time a day for wound.Treatments were not signed out as completed on April 2, 5, 7.Right medial lower leg and left posterior thigh) cleanse with Vashe soaked gauze and allow to soak for 3-5 minutes, pat dry apply TRIAD paste to wound bed and cover with Allevyn foam change Monday, Wednesday, Friday in the morning every Mon, Wed, Fri for wound.Treatments were not signed out as completed on April 1.Right medial lower leg and left posterior thigh) cleanse with Vashe soaked gauze and allow to soak for 3-5 minutes, pat dry apply TRIAD paste to wound bed and cover with Allevyn foam change Monday, Wednesday, Friday in the morning every Mon, Wed, Fri for woundTreatments were not signed out as completed on April 1. On 4/2/26, the Care Plan identified Resident #22 with an unstageable pressure ulcer on the left heel and a stage 3 pressure to the Coccyx and directed staff to:Administer medications as ordered. Observe for/document side effects and effectiveness.Administer treatments as ordered and observe for effectiveness.Pressure reduction mattress to prevent skin breakdown as ordered In an interview on 4/8/26 at 10:45 AM, Staff B, LPN reported the following:When asked when she would you need to disinfect her scissors during wound care, sheadmitted she knew she forgot to do that after she cut the dressing off. She should have disinfected them afterward and before she cut the new dressings.When asked when she would need to change gloves during wound care, she reported fromclean to dirty. She would remove the bandages, remove the gloves, sanitize her hands and put on clean glovesWhen asked about the wound Resident #22 had on the bottom of her right foot, she did verifythere was a necrotic area there. She discussed it with the DON as there was no order to treat that wound on the TAR. The order was in a different place and did not get transcribed to her TAR. She returned to Resident #22's room later and completed the treatment after she found the order. The DON found the order under other. In an interview on 4/8/26 at 12:29 PM, the DON reported the following:She would expect the nurses to disinfect their scissors during wound care anytime they go from dirty to clean She would expect nurses to change gloves during wound care between areas and between dirty to clean.When asked about the wound to the right foot and that Staff B, LPN could not find orders to treat the wound on the right foot, the DON explained that wound had not healed out as Staff C had originally stated. The order to treat that area on the bottom of the right foot was in the physician orders, but it did not get transcribed to the TAR. When the nurse enters an order in the system, there is a box on the bottom of the screen where the nurse should choose where it should appear at: the MAR, TAR or standard other. It had shown up on standard other. Staff P, LPN/ADON, made rounds with the Nurse Practitioner, entered the orders into PCC (Point Click Care electronic medical records), however, the orders did not get transcribed on to the TAR. In an interview on 4/8/26 at 12:55 PM, Staff C, LPN/ADON reported the following:She would disinfect her scissors during wound care after cutting one dressing off and before cutting the new one.She would change her gloves during wound care when going from one area to the next area or moving from one piece of the treatment to the nextWhen asked if she could verify that Resident #22 did have a wound to the bottom of her right foot, she verified she did report that wound had been healed out. She also reported the order appeared on the TAR that NP discontinued the order to treat that wound and then she started a new treatment to it, but instead of it being transcribed to the TAR, it went to standard other. They never use that option standard other, when putting the order it, the nurse needs to physically change it from standard other to the standard TAR. She would need to clarify what kind of wound it is, pressure or otherwise. A review of the Facility Policy titled: Skin and Wound Management System dated as last revised September 2022 had documentation of the following:Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. Wound location, characteristics and a physician's order for treatment are documented in the medical record. Wound status will be evaluated and documented in PCC on the Wound Evaluation Flow Sheet form.

Based on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure residents had physician orders for urinary catheters for 1 of 5 residents reviewed for urinary catheters (Resident #25), and failed to ensure staff provided appropriate catheter care that included infection control precautions for 2 of 5 residents reviewed for urinary catheters (Resident's #25 and #27). The facility reported a census of 83 residents.Findings include:1.The Minimum Data Set (MDS) Assessment tool with 1/07/26 reference date revealed Resident #27 had diagnoses that included obstructive uropathy, urinary tract infection, hemiplegia (paralysis on 1 side of the body), sepsis from unspecified organism, gross hematuria (blood in the urine) and bacteremia (infection in the blood). The assessment revealed a urinary catheter used for urination. The Care Plan for Resident #27 identified a focus with initiated date of 3/18/22 as follows; resident had a urinary catheter with diagnoses of hydronephrosis (the swelling of one or both kidneys causing urine buildup, occurring when urine flow is blocked or flows backward), with renal and ureteral calculous obstruction (kidney stone). The Care Plan documented interventions to be completed by staff to include; follow enchanced barrier precautions, monitor catheter tubing for drainage and kinks with all cares, position catheter tubing and bag below the level of the bladder and away from entrance to the door. A urinalysis with reflex microscopic and culture report (urine sample tested for bacteria identification and antibiotic treatment recommendations) collected on 3/30/26, reported on 4/1/26 revealed the resident's urine infected with more than 100,000 colony forming units per milliliter of urine of Proteus Mirabilis/Penneri, a harmful bacteria that caused a urinary tract infection and required treatment with antibiotic medication. A physician order dated 4/1/26 directed staff to administer Ceftriaxone (a very strong antibiotic medication) 1 Gram injected by intramuscular injection (a shot) 1 time daily for 6 days. The resident was hospitalized from [DATE] to 3/5/26 for treatment of a heart arrythmia, gross hematuria, urinary tract infection with sepsis, and treatment of renal calculi (stones). A computed tomography (CT) scan of the abdomen and pelvis completed on 2/25/26 revealed multiple coarse calcifications surrounding the urinary catheter, that indicated the catheter could not have been changed on 2/24/26 as documented. Observation on 4/6/26 at 2:29 p.m. revealed Staff L, Certified Nursing Assistant (CNA) in Resident #27's room, stated he had to transfer the resident from his wheelchair to his bed. When Staff L left the resident's room at 2:32 p.m. observation revealed the resident in bed and his urinary catheter bag laid directly on the floor near the resident's bed. 2. The MDS dated [DATE] identified Resident #25 as cognitively impaired and did not have a BIMS (Brief Interview for Mental Status) score. The MDS also identified Resident #25 had the following diagnoses: Hemiplegia (paralysis of one side of the body) after cerebral infarct (stroke), Gastrostomy and Slow Transit Constipation. The MDS also identified Resident #25 to be totally dependent on staff for assistance with all activities of daily living and being incontinent of both bladder and bowel. A review of the Hospital Discharge Instructions dated 4/6/26 did not include orders for the indwelling urinary catheter. The Order Summary Report with run date of April 15, 2026 lack order for a indwelling urinary catheter. A review of the Care Plan on 4/8/26 did not have documentation of the indwelling urinary catheter. Observations on 4/7/26 revealed the following at: 12:09 PM lying in bed with the head of the bed elevated, air mattress in place and properly inflated. Tube Feeding bag dated 4/6/26 and running via Covidien pump at 60 ml/hr (milliliters per hour). Foley bag without a dignity flap or bag hanging below bladder level on side of the bed facing the door to his room which was wide open and visible from the doorway. The Foley tubing was observed on the floor. 12:20 PM assessment unchanged. Foley tubing remained on the floor. No staff noted in the hallway. 12:26 PM Staff G, CNA walked past this room pushing a food cart, picking up food trays and did not pick up the Foley tubing off the floor. 12:30 PM Staff II, RN/ADON walked past this room to talk to another resident yelling at the end of the hall. Did not stop to pick up Foley tubing off the floor after tending to the other resident. 12:31 PM Staff G, CNA and Staff II, RN,/ADON walked past this room and did not pick up Foley tubing off the floor. 12:32 PM Staff I, LPN stood in doorway to room next to this room with a medication cart. 12:35 PM Staff I, LPN walked into the resident's room, did not pick up Foley tubing off the floor. 12:44 PM Staff G, CNA walked past this resident's room with 2 full bags of trash and did not stop to pick up Foley tubing off the floor. 12:50 PM Staff I, LPN walked into the resident's room and did not pick up Foley tubing off the floor 1:03 PM Staff I, LPN walked into the resident's room and did not pick up Foley tubing off the floor. 1:18 PM Foley tubing remains on the floor, currently no staff in the hallway at this time. 1:25 PM assessment unchanged. 1:40 PM assessment unchanged. 1:55 PM assessment unchanged. 2:09 PM Staff H, CNA entered resident's room with isolation gown and gloves on, used correct technique to empty Foley bag and picked up tubing off the floor. In an interview on 4/8/26 at 7:36 AM, Staff G, CNA reported if a resident had an indwelling urinary catheter, the tubing should never be on the floor. In an interview on 4/8/26 at 8:15 AM, Staff H, CNA reported when taking care of a resident with an indwelling urinary catheter, he would ensure the Foley tubing would never be on the floor. In an interview on 4/8/26 at 9:38 AM, Staff I, LPN reported when taking care of a resident that had an indwelling catheter, she would make sure the Foley tubing is never on the floor. When a resident comes back from the hospital with an indwelling catheter and does not have orders for it, the nurse should call to get an order within 24 to 48 hours. She reported Resident #25 did not have the catheter before he went to the hospital and she informed the Staff II, RN/ADON that he did not have orders for it. In an interview on 4/8/26 at 12:29 PM, the DON reported she would expect staff to ensure that Foley catheter tubing should never be on the floor. When a resident returns from the hospital with an indwelling catheter and has no physician orders for it, she would expect the nurse to call the physician for orders within 24 hours. She could not explain why this was not completed for Resident #25. In an interview on 4/8/26 at 12:55 PM, Staff C, LPN/ADON reported if she received a resident after being transferred from a hospital with an indwelling catheter and no order for it, she would call the physician for an order within the first 24 hours. A review of the Facility Policy titled: Catheter Care, Urinary dated as last revised August 2022 had documentation to be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, record review and staff interviews, the facility failed follow proper isolation precautions for 4 of 4 residents reviewed and failed to put on (don) an isolation gown while providing catheter care and incontinence cares for Resident #11. The facility also failed to provide personal protective equipment (PPE) for two residents that required contact precautions for Parainfluenza Virus for Resident #17, and for Clostridium difficile for Resident #29. The facility additionally failed to don PPE prior to transferring Resident #27. The facility reported a census of 83 residents.1.The Minimum Data Set (MDS) Assessment tool with 1/07/26 reference date revealed Resident #27 had diagnoses that included obstructive uropathy, urinary tract infection, hemiplegia (paralysis on 1 side of the body), sepsis from unspecified organism, gross hematuria (blood in the urine) and bacteremia (infection in the blood). The assessment revealed a urinary catheter used for urination. A physician order dated 3/16/26 directed staff to change the urinary catheter size 16 French with 10 cubic centimeter (cc) sized balloon and drainage bag monthly and as needed. A physician order dated 3/16/26 directed staff to used Enhanced Barrier Precautions (EBP), with gown and gloves worn for high contact resident care that included transfers. A urinalysis with reflex microscopic and culture report (urine sample tested for bacteria identification and antibiotic treatment recommendations) collected on 3/30/26, reported on 4/1/26 revealed the resident's urine infected with more than 100,000 colony forming units per milliliter of urine of Proteus Mirabilis/Penneri, a harmful bacteria that caused a urinary tract infection and required treatment with antibiotic medication. A physician order dated 4/1/26 directed staff to administer Ceftriaxone (a very strong antibiotic medication) 1 Gram injected by intramuscular injection (a shot) 1 time daily for 6 days. Observation on 4/6/26 at 2:29 p.m. revealed Staff L, Certified Nursing Assistant (CNA) in Resident #27's room, without personal protective equipment (PPE) worn, stated he had to transfer the resident from his wheelchair to his bed, and provided 1 to 1 assistance with direct resident contact as the resident was transferred to bed. When Staff L left the resident's room, he was questioned about the PPE equipment located on the resident's room door, and the Enhanced Barrier Precautions sign affixed to the door with the PPE equipment. Staff L stated this was only his 2nd or 3rd day there, he saw the sign but saw other staff go into the resident's room without any PPE on and didn't think he was required to use PPE. Observation at that time revealed the resident in bed, and his urinary catheter bag laid directly on the floor near the resident's bed. During an interview on 4/6/26 at 3:20 p.m. the Administrator stated the facility did not utilize Skills Competency Checklists, new staff were assigned to work with another employee with the same position to orient to the facility, and continued to work with the assigned employee until the new-hire was comfortable and thought they didn't require additional guidance or instruction. 2. A direct observation on 04/06/2026 at 2:33 PM noted two doors, one marked Transmission Based Precautions and another marked Droplet Precautions to be opened without staff in them. The Room marked Droplet Precautions was identified as Resident #17's room. The room marked Transmission Based Precautions was identified as Resident #29's room. The surveyor approached Staff DD, CNA, at this time and asked him if the doors should be open. He stated he did not know. He was then asked if Resident #17 was on droplet precautions and if Resident #29 was on transmission based precautions, he stated he did not know. It was requested at this time that Staff DD close the doors for safety. Staff DD entered both rooms to inform the residents he was closing the doors, both times without Personal Protective Equipment (PPE). After closing the doors he was asked if he should have worn PPE when entering a resident's room who was noted to be on droplet precautions. He stated he did not know.Review of Resident #17's nursing progress notes revealed the resident had recently returned from the hospital with a diagnosis of Parainfluenza Virus, a contagious respiratory illness, and confirmed he was on droplet precautions as of 04/06/2026Review of Resident #29's nursing progress notes revealed the resident was on isolation precautions due to a diagnosis of Clostridium Difficile (C-Diff), a highly contagious fecal bacteria that causes cramping and diarrhea as of 04/08/2026In an interview on 04/06/2026 at 03:11 PM with the Director of Nursing (DON), she confirmed that Resident #17 was on droplet precautions and Resident #29 was on isolation. She confirmed the doors should have been closed and not let open to the hallway. 3.The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 12 and had the following diagnoses: Cancer, Neurogenic Bladder and Coronary Artery Disease. The MDS also identified Resident #11 as totally dependent on staff for assistance with toileting, showers, dressing, putting on and removing footwear and repositioning. The MDS also identified Resident #11 had an indwelling urinary catheter and was incontinent of bowel. On 9/10/24, the Care Plan identified Resident #11 with the problem: she has a SP (Supra Pubic) urinary catheter due to a diagnosis of MS (Multiple Sclerosis) and Neurogenic Bladder, and is at increase risked for UTIs. On 10/4/24, the Care Plan directed staff to follow enhanced barrier precautions. Observations of catheter care and incontinence cares on 4/1/26 revealed the following: 6:30 AM Staff A, CMA/CNA in Resident #11's room providing incontinence care after she had a bowel movement. Staff A wore gloves, however, did not don an isolation gown. 6:42 AM Staff A, CMA/CNA changed gloves, however, did not don an isolation gown before he emptied the catheter bag. A review of the Physician Orders revealed the following order: 3/16/26 Enhanced Barrier Precautions (EBP): Use gown and gloves for high contact resident care including dressing, bathing, showering, transfers, hygiene care, assisted toileting, peri care, wound care and care of any device (Catheter, wound care) every shift. In an interview on 4/8/26 at 7:36 AM, Staff G, CNA reported before providing catheter care on a resident, he would inform the resident what he would be doing, put on the gown and gloves and complete cares. In an interview on 4/8/26 at 8:15 AM, Staff H, CNA reported before providing catheter care on a resident, he would need to put on a gown, mask and put on gloves. In an interview on 4/8/26 at 9:38 AM, Staff I, LPN reported before providing catheter care on a resident, she would need to don an isolation gown and gloves. In an interview on 4/8/26 at 12:29 PM, the DON (Director of Nursing) reported before providing catheter cares, she would expect the staff to don a gown, wash hands and don gloves. A review of the undated Infection Control Precautions Summary had documentation that Enhanced Barrier Precautions will be utilized for residents that have active or colonized epidemiological important MDROs (Multi Drug Resistant Organisms). The PPE (Personal Protective Equipment) to be utilized include gown and gloves. This would include during dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs/toileting, device care including catheter, open wound care, central line, feeding tube, or trach/ventilator.

Based on direct observation, clinical record review, staff and resident interview, and facility policy review, the facility failed to protect residents from significant medication errors by allowing residents who were not assessed as competent to self administer medication to do so, and by preparing and issuing medications to multiple residents simultaneous. This impacted two residents. (Resident #1, #16). The facility reported a census of 83 residents. Findings include: Review of Resident #1's Minimum Data Set (MDS), revealed his Brief Interview for Mental Status (BIMS) score was 15, indicating intact cognition. Review of other clinical files for the resident revealed he did not have an order to self-administer medication. Review of Resident #16's MDS revealed her BIMS score was 15, indicating intact cognition. It revealed the following relevant diagnoses: Anemia, Hypertension (High blood pressure), heart failure, renal insufficiency (kidney disease), seizure disorder or epilepsy. Review of other clinical files for the resident showed she did not have an order to self-administer medication. A direct observation on 04/06/2026 at 02:40 PM of Resident #1's room revealed a medication cup with two small white pills on a bed-side table next to the resident's bed. The resident was in bed and informed the surveyor the medication was Tylenol. During the observation Resident #1 told the surveyor staff members let him take his medication on his own, setting the pills on his table for him to take it. He stated they usually do not watch him take his medication. Review of the nursing progress notes for Resident #16 documented the following: During the night shift on 04/08/2026 a staff member prepared both Resident #16 and her roommates medication at the same time, entered the room, and gave both residents their medication. It documented the staff member did not observe the residents taking their medication and left the medication with the residents to self-administer. Upon returning back to the room, the staff member was informed by Resident #16's roommates that the name on the medication cup she was handed was not hers. Upon review the staff member realized she had given the residents the wrong medication. Resident #16 had already consumed her roommates medication when she entered the room again. Nursing progress notes also document a change in the resident's mental status, increased thirst, and an increase in desire to sleep. The following medications were noted to have been given in error: Simvastatin Oral Tablet 40 MG Gabapentin Oral Tablet 600 MG oxyBUTYnin Chloride Oral Tablet 5 MG In an interview on 4/7/26 at 10:06 a.m., Staff V, LPN stated since the last Iowa DIAL visit nursing staff had been instructed they were to observe residents take their dispensed medications, and they were not to leave dispensed medications in resident rooms for them to take later. Staff V stated despite the instruction there were at least 2 times that night shift staff had left medications in resident rooms that she found when she worked on her assigned 6 a.m. to 6 p.m. shift. She reported the issue to the manager and the staff responsible were not happy about it. She went on to say when she spoke to the nurse responsible for it they expected her to dispense the medications for them (since they were already signed out), which she would not do and part of the reason she reported it to the manager. In an interview on 04/08/2026 at 03:07 PM with Staff Q, Licensed Practical Nurse (LPN), she identified herself as the staff member responsible for the medication error. She stated it is never appropriate to pass medication to two residents at the same time and noted that it is because medication errors like this are more likely to occur when you are passing medication to multiple people at the same time. She confirmed she is required to watch residents take the medication unless they have an order to self administer and confirmed the resident did not have an order to self administer medication. She also confirmed that preparing multiple residents medication had been a source of ongoing education within the facility. In an interview on 04/08/2026 at 03:26 PM with Staff JJ, Certified Medication Aide (CMA), she stated she is only allowed to pass medication to one resident at a time. Only when she is finished and the resident has either taken or refused the medication can she move on to the next resident. She stated it is to avoid confusion and prevent medication errors. Additionally, she stated it wasn't appropriate to leave a medication at a residents bedside unless they have an order to take it themselves. In an interview on 04/08/2026 at 03:29 PM with Staff KK, CMA, She stated they are instructed to pass medication to only one resident at a time. She also stated she wasn't allowed to leave medications at a residents bedside. In an interview on 04/08/2026 at 01:03 PM with the Assistance Director of Nursing (ADON), she confirmed it was inappropriate to prepare multiple medications for multiple residents at the same time, and stated it was prohibited to leave medication at a residents bedside unless they had an order to self-administer medications. She stated it had to be assessed by the team and the resident had to be cleaned before that could happen. She confirmed the residents involved did not have orders to self-administer medications. In an interview on 04/08/2026 at 12:37 PM with the Director of Nursing (DON), she stated she was aware of the medication error that had occurred in the early morning hours of the day. She stated it is her expectation that staff members prepare one residents medication at a time, watch them take the medication or document a refusal, and then move on to the next resident. She confirmed the residents did not have an order to self administer their medications and agreed staff members cannot leave medications at a residents bedside without the order. Review of a facility provided document titled Administering Medications, with a last revised date of December 2012, documented the following: Staff members must confirm the identify of the resident they are administering medication to. Residents may self administer medication only if the medical team has assessed the resident as competent to do so and the physician has written and order for them to do so. Staff members must follow the seven rights of medication administration, which includes ensuring the medications are passed to the right person.

Based on observation, clinical record review, staff, resident, and family member interviews, the facility failed to provide necessary assistance with eating and failed to implement ordered nutritional interventions to address significant weight loss for 2 of 3 sampled residents (Resident #24 and Resident #28). Specifically, staff failed to assist residents during meals, leaving them with untouched food for extended periods, and failed to provide ordered supplements even as the residents experienced significant weight declines. The facility reported a census of 83 residents. Findings include:1. The Minimum Data Set (MDS) Assessment with reference date 1/7/26 revealed Resident #24 had diagnoses that included non-Alzheimer's dementia, anxiety and abnormal weight loss, weight 135 pounds with mechanically altered diet provided. The resident required substantial staff assistance for all activities of daily living including eating, reposition in bed, transfer to and from bed or chair, dressing and hygiene, unable to stand or ambulate, cognition not assessed and symptoms of delirium present. Physician orders included; Provide House Supplement (a liquid protein supplement) 6 milliliters (ml) (2 ounces) 3 times daily, with start date of 4/30/26. Resident #24's recorded weights included:4/3/2026 127.6 pounds4/1/2026 129.2 pounds3/17/2026 128.7 pounds2/18/2026 130.2 pounds12/3/2025 134.6 pounds11/11/2025 136.8 pounds10/15/2025 137.6 pounds9/29/2025 146.0 pounds The resident's recorded weights indicated a weight loss of 5.75 percent in 1 month, and an 11.5 percent weight loss in 6 months, both defined as significant weight losses. Notes recorded by the facility's Registered and Licensed Dietician (RDLD) Staff EE, revealed, in part:1/6/26: Quarterly Assessment: Diet is mechanical soft, intakes are fair. Resident is assisted with meals as needed/accepted. Will indicate when she does not want more. Weight 135 pounds, a loss of 8 pounds in past 6 months. House supplement given 3 times a day, shakes provided twice a day. Intakes are adequate to maintain weight, no changes. 2/19/26: Weight 130 pounds, a loss of 12 pounds in past 6 months, loss of 5 pounds in past 2 months. Weight is stabilizing. Resident tolerates mechanical soft diet well, Hospice care continues. Resident dines on assisted side of Dining Room. Shakes given twice daily, house supplement provided 3 times a day. No changes.3/19/26: March weight of 129 pounds is a significant loss of 17 pounds in past 6 months, Intake of mechanical soft diet are fair, supplement intake varies also. Res assisted as accepted. Continue current interventions. The April, 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal documentation that shakes were ordered or provided, and there were no additional physician orders that addressed the resident's significant weight loss as identified by the RDLD on 3/19/26. The resident's Nursing Care Plan included a problem labeled (Resident's name redacted) requires assistance with activities of daily living (ADL's) and is at risk for late loss ADLs due to: Venous insufficiency and the aging process, initiated 3/9/20, revised 11/2/23.The 4/12/26 goal listed in the care plan was (resident's name redacted) wishes to maintain current level of physical function through the next review, initiated 3/9/20, revised 3/28/25.The Nursing Care Plan directed staff to provide 1 staff assistance for resident eating, initiated 3/10/2020, revised 2/17/25. Another care problem listed on the Nursing Care Plan was labeled, in part (resident name redacted) is at risk for weight loss related to decreased cognition, need for a mechanical soft diet and assist with meals, initiated 2/12/24, revised 4/8/26.The 4/12/26 goal listed in the care plan was (resident's name redacted) will have 3 meals offered daily, intake as she desires through next review, initiated 4/11/25, revised 5/12/25.The Nursing Care Plan directed staff:Monitor at meals for signs of aspiration, choking, runny nose/eyes and report to physician as indicated, initiated 2/12/24.Monitor weight, notify Doctor of any significant change, initiated 2/12/2024, revised on 6/16/24.Monitor/document/report as necessary to physician any signs or symptoms of dysphagia: Pocketing food in cheeks, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, initiated 2/12/24.Resident dines with supervised/assisted. Please assist as she needs/allows, initiated 2/12/24, revised 6/16/24.Resident has a chocolate shake with lunch/supper. Res will drink if they are called B-Bop shakes, initiated 4/5/24, revised 10/2/25.Serve supplement per orders, initiated 11/13/24. The nursing schedule for the 6 a.m. to 2 p.m. day shift on 4/8/26 revealed the following staff scheduled and present:Three (3) nurses including Staff V, Licensed Practical Nurse (LPN), Staff Q, LPN, and Staff I, LPN.Seven (7) Certified Nursing Assistants (CNA's) including Staff G, CNA, Staff H, CNA, Staff T, CNA, Staff U, CNA, Staff Y, CNA, Staff Z, CNA and Staff FF, CNA.Three (3) Certified Medication Aides, that are also CNA's, including Staff K, CMA, Staff GG, CMA, Staff HH, CMA, and 1 new hire CMA assigned to train with Staff HH. In all, 11 CNA's were present in the facility during the 4/8/26 day shift. Observations in the Dining Room revealed: On 4/8/26: 11:36 a.m. Resident #24 seated at a table right next to a window that was open, sheer curtain over the window that blew towards the table. The temperature outside was 45 degrees Fahrenheit at the time. A glass of orange juice with a straw was on the table, about 12 inches from the edge of the table. A blanket covered the resident from mid-chest to over her feet, her arms under the blanket. 11:44 a.m. Resident #24 remained seated in the same position, Staff K, CNA seated next to the resident approximately 3 feet from the open window. The glass of orange juice was positioned approximately 3 inches from the edge of the table, there was no visible amount of orange juice out of the glass, the resident's arms remained covered under the blanket. 11:55 a.m. Resident #24 received a grilled cheese sandwich and a yellow cake dessert, Staff K removed the crust/edges from the sandwich, did not cut the sandwich or attempt to break the sandwich into smaller pieces and placed a spoon in the bowl of dessert. 12:02 p.m. Resident #24 at the table alone, sandwich untouched on the plate, the resident's arms uncovered and rested on her lap area. Staff K now seated at the next table and assisted a different resident, turned 180 degrees around from her position at Resident #24's table, approximately 4 feet from the open window. 12:04 p.m. Resident #24 remained seated alone at the table without feeding assistance, her food untouched, Staff K remained positioned in the same seat and assisted the same resident. 12:07 p.m. Resident #24 remained seated alone, without feeding assistance, food untouched, Staff K continued to assist a resident at the next table, remained approximately 4 feet from the open window. 12:09 p.m. Staff FF, CNA brought Resident #28 into the Dining Room and positioned her across from Resident #24 at the same table, then left the Dining Room. Resident #24 remained seated with her arms in her lap, food untouched and without feeding assistance. 12:11 p.m. Staff Y, CNA was seated at the Nurses Station next to the Dining Room, and not engaged in any activity as 2 medication aides, Staff HH and a trainee were positioned at a medication cart next to the Nurses Station, and not in process of medication administration. 12:12 p.m. Resident's #24 and #28 remained seated at the table, Resident #24's food untouched and Resident #28 held a cup of milk or supplement to her own mouth, no staff assistance at the table. Staff K remained seated at the same table next to the 2 resident's table, assisted a resident at that table, the window remained opened. 12:14 p.m. Resident #28 received a divided plate of pureed food, Resident #24 remained at the table without assistance and food untouched, and Staff K moved to a different table along the opposite wall of that section of the Dining Room and provided assistance to a resident. There were 3 CNA's in the Dining Room at that time, with at least 9 residents seated that required feeding assistance. 12:15 p.m. No change at the 2 resident's table, 3 CNA's remained in the Dining Room and assisted other residents. 12:17 p.m. Staff U, CNA moved from a different feeding assistance table to Resident #24's table, closed the window, sat next to Resident #24 and attempted to feed the resident cake. Staff K left the Dining Room with a different resident after a Hospice aide arrived in the Dining Room and started to assist a different resident. 12:22 p.m. Staff U continued to assist Resident #24 with the same food, approximately 2 bites of dessert and 1 to 2 ounces of orange juice consumed by the resident, Resident #28 remained without feeding assistance at the same table. 12:23 p.m. Staff K returned to the Dining Room, sat next to Resident #28 and provided feeding assistance to the resident (9 minutes after her food was served and remained at the table uncovered). 12:31 p.m. Staff's K and U remained seated at the 2 resident's table, Resident #24 without further intake, no other food offered to the resident, Resident #28 had ate approximately 1/2 of the food served. Staff Y observed seated at the Nurses Station, not engaged in any activity. 12:33 p.m. Staff K removed Resident # 24 from the Dining Room, Staff U switched to the chair next to Resident #28 and provided feeding assistance to the resident. 12:36 p.m. Resident #24 positioned in the Broda chair near the doorway in her room, Staff U remained next to Resident #28 and attempted feeding assistance, no observed change in the amount of food eaten by the resident. On 4/9/26 revealed: 11:36 a.m. Resident #24 seated at the table covered with a blanket from her waist area to over her feet. Glass or orange juice on the table, no food and no staff assistance. 11:58 a.m. Resident #24 fed by a Hospice CNA seated next to her. A grilled cheese sandwich that was cut into small bite-sized pieces was fed to the resident with a fork, at times the resident nodded her head back and forth to indicate no, and at the same time opened her mouth, accepted the food and chewed the food, willingly accepting additional bites as served by the aide. The resident was offered a drink with a straw in between the bites. Resident #28 was now seated at the table, did not have food or drink. 12:13 p.m. Resident #24 continued to be fed by the Hospice CNA, Resident #28 had pureed food on a divided plate in front of her, no feeding assistance provided to the resident. There were 2 other facility CNA's seated in the Dining Room at the time and provided feeding assistance to other dependent residents. 12:18 p.m. Resident #24 continued to be fed by the Hospice CNA, has ate over 1/2 the sandwich and at least 6 ounces of orange juice. Another CNA sat down next to Resident #28 at this time and began to provide feeding assistance, the resident had not attempted to feed herself. On 4/3/26 revealed: 8:34 a.m. Resident #24 seated in Broda chair in the Dining Room covered with blanket from waist to feet waiting to be served breakfast. Staff DD, CNA stood beside her. 8:40 a.m. Staff DD pushed resident out of Dining Room to the TV room, when asked if she ate breakfast, he reported she did not want to eat anything this morning. Resident family interview revealed: 4/7/26 at 7:22 p.m. a family member stated they had a relative that visited Resident #24 nearly daily during a meal time, and they went at least twice a week on days that their relative couldn't visit Resident #24. The family member reported they always found the resident seated at a table with cold food, without any staff assistance and the resident unable to feed herself. If there were staff in the Dining Room they were on their cell phones, didn't assist residents that needed help, there were several residents that needed help, and nobody there would do anything about it. Their family brought milk shakes to the resident daily that they fed the resident, they also brought tuna salad sandwiches as they were soft and the resident ate them. The family member believed the only reason the resident hasn't lost very much weight was from their family's support, because the resident did not get assistance from the staff. They reported their concerns to management staff at least 3 times and nothing changed. They would move the resident to another facility where the staff actually assisted the residents but feared the resident would further decline due to the sudden change and her dementia diagnosis. 2. The Minimum Data Set (MDS) Assessment tool with 2/23/26 reference date revealed Resident #28 had diagnoses that included anemia, thyroid disorder and non-Alzheimer's dementia, scored 6 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated severe cognitive impairment, without symptoms of delirium present, and weight of 133 pounds identified as a significant weight loss of 5 percent or greater in 1 month or 10 percent or greater in 6 months that preceded the assessment. The MDS document revealed the resident required substantial/maximal staff assistance to reposition in bed, transfer to and from bed or chair, dressing, toileting and bathing, and required staff supervision or touch assistance for eating. Physician orders included; Provide House Supplement (a liquid nutritional supplement) 60 milliliters (ml) (2 ounce serving) 3 times daily, ordered 6/19/25. Weights recorded in the clinical record included: 12/5/25 151.2 pounds2/2/26 150.0 pounds3/3/26 147.2 pounds3/17/26 143.2 pounds4/6/26 128.4 pounds The resident's recorded weights indicated a weight loss of 13.9 percent in 6 months, identified as a significant weight loss by the Centers for Medicaid/Medicare Services (CMS) Notes recorded by the facility's Registered and Licensed Dietician (RDLD) Staff EE, revealed, in part: 1/15/26 - Resident dines in Dining Room for assist as needed. Intakes ~75 percent. Weight 151pounds, stable. Resident accepts 60 milliliters (ml) house supplement TID (3 times daily) intakes vary. Est Needs (68 Kg) 1836-2176 Kcals, 68-88 grams protein 2040 ml fluids(30ml/Kg). Intake of meals & supplements adequate to meet estimated needs. Recommended 500mg L-Arginine TID to support wound healing, continue weekly weights. 1/29/26 - Weekly meeting completed with IDT (interdisciplinary team) area to foot classified as stage III pressure sore. 1+ pitting edema of bilateral lower extremities per notes. Recommend Prostat daily, to add 100 Kcals and 15grams protein to diet,January weight of 153.6 pounds is stable past 6 mos. Interventions in place/accepted for healing. 2/13/26 - Weekly weight 133.2 pounds, a significant loss of 17 pounds in past week. Diet is puree, intakes ~50%. Interventions in place as above. Stage III pressure sore to Rt foot continues. Wound has declined. Per nursing resident has admitted into Hospice care. Will transition to monthly weights for comfort. Nutrients are provided in-excess ofestimated needs, but are not adequately consumed. 3/5/26 - Met with IDT to review monthly weights. Weight 144 pounds is a loss of 6 pounds in past month, 4pounds in past 6 mos. Resident continues on Hospice care and staff assist with meals as accepted. Continue current interventions as weight is stable. The resident's Nursing Care Plan included a problem labeled (Resident's name redacted) requires assistance with ADL's (activities of daily living) and transfers related to her dementia and impaired gait, initiated10/7/2021, revision on 4/22/2025, with 6/3/26 goal(resident's name redacted) wishes to remain well-groomed and free of odors daily through the next review. The Nursing Care Plan directed staff:(Resident's name redacted) prefers to feed self independently with set up assistance, initiated11/26/2021, revised on 9/10/24. Another Nursing Care Plan problem labeled (resident's name redacted) is at risk for impaired nutrition related to: moderate protein calorie malnutrition, dementia, adult FTT (failure to thrive), altered diet, significant weight loss past month, initiated 10/7/2021, revised 4/99/2026, with 6/3/26 goals:(Resident's name redacted) will have 3 meals served daily, intake as desired through next review date, initiated 4/15/2025, revised 4/9/2026.(Resident's name redacted) will weigh 145-155# through next review date, initiated 4/15/2025, revised 3/15/2026.The Nursing Care Plan directed staff:(Resident's name redacted) set up/assist as needed, initiated 7/13/2023, revised 4/9/26.Offer ice cream PRN (as needed), initiated 1/19/2023, revised 9/10/2024.Provide alternates at meals as needed, initiated 10/12/2021, revised 9/10/2024.RD (registered dietician) to evaluate as needed, initiated10/12/2021, revised 9/10/2024.Serve diet as ordered, initiated 4/20/2023, revised 7/2/2025.Serve supplements per orders, extra foods per tray ticket, initiated 4/9/2026.Weights as directed, notify Dr of any significant change. Weights may fluctuate due to diagnoses CHF (congestive heart failure), CKD (chronic kidney disease), initiated 10/12/2021, revised 9/10/24. Staff interviews revealed: 4/8/26 at 2:06 p.m. the Director of Nursing (DON) stated she expected staff to be present and assist residents that required feeding when meals were served in the Dining Room. Staff should tell them what is on their plates and offer/accommodate the resident's preferences. There were residents that received room trays and required feeding assistance, she expected staff that passed the trays to provide the assistance needed to the resident. Resident #24 liked egg salad, grilled cheese sandwiches, ice cream, the dietary department makes their own protein shakes that she will drink. If the resident did not eat the food offered, she expected staff to offer other foods that the resident preferred to encourage her food intake. The DON stated there were 7 residents that required feeding assistance and 10 residents that required staff supervision and coining assistance for meals. 4/9/25 at 8:38 a.m. Staff EE, Registered and Licensed Dietician (RDLD) stated staff should provide the supplements that are ordered for Resident #24, dietary serve her shakes twice a day and fortified ice cream. She should be brought to the Dining Room and staff should encourage and assist her to eat. Staff EE is included in a weekly interdisciplinary meeting where they review monthly and weekly weights, and how she is notified of recent changes. Staff EE made recommendations for the residents identified with weight loss/gain and communicated the recommendations to staff for implementation. 4/9/26 at 11:34 a.m. Staff Z, CNA, stated on the day shift 3 CNA's were to be in the Dining Room to provide feeding assistance to residents, the other CNA's on duty were to pass room trays provide feeding assistance to those residents if needed.

Based on observations, clinical record review, consultant pharmacy interview and staff interviews, the facility failed to complete routine urinary catheter care, monitor urinary output and administer an antibiotic to treat an urinary tract infection (UTI) per physician order for 2 of 3 residents (Resident #1 and Resident #11) reviewed for urinary catheter. Resident #1 did not receive a full nine-day course of antibiotics to treat an UTI which resulted in a hospitalization. The facility reported a census of 88 residents Findings include: 1.The Quarterly Minimum Data Set (MDS) Assessment completed on 11/19/25 revealed Resident #11 with a Brief Interview for Mental Status (BIMS) score of 10, indicating a moderate cognitive impairment. Diagnoses include multiple sclerosis and neurogenic bladder (bladder dysfunction contributing to incontinence). The MDS confirmed the use of a urinary catheter. The Care Plan, last revised 6/3/25, documented the following; the resident was at risk for urinary tract infections, also noted the presence of a catheter. The Care Plan directed staff to empty the catheter bag every shift and as needed. The Physician's Order, initiated on 4/6/25, directed staff to record catheter output every shift for monitoring. The Treatment Administration Record (TAR) for December 2025 showed catheter output was recorded 47/62 entries. The TAR for January 2026 showed catheter output was recorded 52/62 entries. The TAR for February 2026, thus far, showed catheter output was recorded 12/16 entries. 2. The admission MDS assessment dated [DATE] revealed Resident #1 had diagnosis of obstructive uropathy (a condition when urine cannot drain through the urinary tract). The MDS indicated the resident had an indwelling catheter and had dependence on staff for toileting hygiene. The MDS assessment dated [DATE] revealed the resident readmitted to the facility from the hospital on [DATE], and had a diagnosis of a urinary tract infection (UTI) in the past 30 days. The MDS indicated the resident had indwelling catheter and took an antibiotic. The Care Plan initiated on 8/9/25 and revised on 1/6/26 revealed the resident had an indwelling catheter. The staff directives included to encourage fluids and check the catheter tubing for kinks each shift. The Care Plan lacked directives for the provision and/or frequency for catheter care. The Order Summary Report revealed the following orders: a. Provide catheter care every shift and as needed (PRN) for soilage (start date 7/28/25). b. Change the catheter PRN for leakage, dislodgement or occlusion (start date 7/28/25). c. Administer Amoxicillin (an antibiotic) 500 mg (milligrams) two times a day (BID) by mouth (PO) for a UTI started on 10/22/25, and continued 10/23/25 until 11/1/25 (for a total of 9 additional days). d. UA (urinalysis) with C & S (culture and sensitivity) ordered on 10/16/25 related to UTI was discontinued on 10/21/25. A UA was ordered again on 10/27/25 for agitation, elevated temperature and an upset stomach. e. Record output BID (start date 1/8/26) f. Use enhanced barrier precautions (EBP) (start date 1/19/26) g. Cephalexin 500mgs by mouth four times a day for infection start 12/31/25 and date 1/4/26 h. Tamsulosin HCL 0.4mg (2 capsules) by mouth two times a day (medication commonly used for enlarged prostate, and kidney stones) The Census Report revealed Resident #1 hospitalized from [DATE] - 10/22/25 and 12/28/25 - 12/31/25. The Interact Transfer Form revealed Resident #1 transferred to the hospital on [DATE] due to urinary retention and also transferred to the hospital on [DATE] due to uncontrolled pain. The transfer form documented the catheter was last inserted on 9/1/25. The Nurse Practitioner (NP) Encounter Note dated 10/23/25 revealed the resident was hospitalized for sepsis secondary to a UTI and urinary retention. Resident currently on Amoxicillin and had a Foley (catheter) due to urinary obstruction. The NP ordered to administer medications as ordered and encourage fluids. The NP Encounter Note dated 1/5/26 revealed the resident recently hospitalized for increased pain and was found to have a UTI. He returned to the facility on Cephalexin (an antibiotic). The Hospital Discharge Orders revealed the following diagnoses: 7/22/25 - Obstructive uropathy nephrolithiasis (obstruction of urine flow caused by kidney stone) 10/17/25 - Sepsis (a life threatening response to an infection) secondary to UTI 10/18/25 - Enterococcal bacteremia (a serious bloodstream infection) 12/28/25 - Complicated UTI The Progress Notes revealed the following: a. On 7/28/25 at 7:50 PM, resident admitted to the facility from the hospital. b. On 7/30/25, catheter patent and draining yellow urine. c. On 9/1/25 at 2:55 PM, resident demonstrated intermittent confusion and forgetfulness. Moisture-associated skin disorder (MASD) noted to the groin area. Area cleansed with soap and water and treated with Nystatin (an antifungal) powder. Indwelling catheter present, patent, and draining well. d. On 10/17/25 at 6:38 AM, off-going nurse reported a UA needed for this resident. New drainage bag changed. A 5:30 AM the nurse went to collect a urine sample only to find zero (amount) in the catheter. No kinks noted. Resident complained of pain. Abdomen distended. PRN pain medication given. e. On 10/17/25 at 6:57 AM, the oncoming nurse evaluated resident. Abdomen distended and tender when area palpated. Catheter was patent. A scant amount of yellow urine observed in the bag. The NP was contacted and provided an order to send the resident to the Emergency Department (ED). f. On 10/18/25 at 7:18 PM, resident admitted to the hospital with sepsis and urinary retention. g. On 10/22/25 at 1:09 PM, resident returned to the facility. h. On 10/24/25 at 2:53 PM, resident continues on ATB. i. On 10/29/25 at 1:53 PM, resident seen by NP. New order received for a UA with C & S. j. On 12/28/25 at 3:35 PM, at 3:30 PM this nurse was alerted by assigned CNA that resident was in pain and having discomfort, and in the process of contacting 911. Once the nurse arrived in the resident's room, resident was informed that a pain medication was available for him. Resident stated that he does not feel as though his Hydrocodone (narcotic pain med) was effective and continued to communicate on the phone with dispatch. The EMTs (Emergency Medical Technicians) arrived at 3:35 PM. k. On 12/31/25 at 3:08 PM, resident returned from the hospital. The Medication Administration Record (MAR) dated 10/2025 revealed an order to administer Amoxicillin 500 mg PO BID for 10 days for a UTI started on 10/22/25. The MAR lacked documentation that the medication was administered on 10/27/25 for one dose, 10/28/25 for 2 doses and 10/29/25 for one dose. Medication Administration Note 10/27/25 at 7:17 PM documented Amoxicillin oral tablet 500 mg by mouth two times a day for UTI for 9 days, medication on order waiting for pharmacy delivery, author of note Staff L, Certified Medication Aide (CMA). Review of the TAR dated 9/2025 to 11/2025 revealed an order for catheter care every shift started on 7/28/25. The TAR indicated catheter care on hold 10/18/25 to 10/22/25 (when the resident was in the hospital). The TAR lacked documentation for catheter care on the following dates: 9/1, 9/3, 9/11, 9/17 x 2, 9/18, 9/19, 9/21. 10/5, 10/10, 10/26, 10/27 11/2, 11/13, 11/15, 11/27 x 2, 11/29 The TAR also revealed on order to Record Output (started on 11/5/25). Review of the TAR dated 11/2025 to 1/2026 revealed Urine Output not recorded on the following dates: 11/13, 11/15, 11/17, 11/27, 11/29 x 2 12/9, 12/14, 12/15, 12/18, 12/25 1/20, 1/21, 1/22, 1/26, 1/27, 1/28, 1/29, 1/31 The TAR also revealed an order to change the catheter PRN for leakage, dislodgement or occlusion. Review of the TAR dated 10/1/25 to 1/31/26 revealed no catheter change documented. In an interview on 2/9/26 at 10:45 AM, Staff I, Certified Medication Aide (CMA), reported the CMA's could reorder medications in the computer except for the narcotics. She also faxed the order to make sure the order went through when the prior pharmacy was the vendor for the facility. She requested the nurse to obtain medication through the E-kit (emergency kit) if the medication was available. In an interview on 2/9/26 at 11:35 AM, Staff D, Licensed Practical Nurse (LPN), reported the facility switched to a different pharmacy vendor in 11/2025. Medications are ordered through the computer, except for narcotics and IV meds. An order was faxed to the pharmacy for narcotics and IV meds. Staff D explained the process for ordering medications in the computer: click on the medication needed, go to the summary, and click on reorder to order the medication that was needed. The last reorder date and the date when the medication was received could be viewed on the computer. If it showed ordered that meant the medication had been ordered from the pharmacy. If the medication had not been received in a couple of days from the ordered date, she called the pharmacy to let them know. The pharmacy did not deliver on Sundays though. Staff D reported she obtained an antibiotic (ATB) medication from the E-kit to start the medication right away when she got an order for an ATB medication. In an interview on 2/9/26 at 11:40 AM, Staff G, LPN, reported she recalled sending Resident #1 to the ED for an evaluation because she tried to flush the catheter but it wouldn't flush and he complained of difficulty voiding. At that time, he did not have any other symptoms such as a fever. Staff G reported whenever she found a medication card in the medication cart without any medication left, she called the pharmacy and called the doctor. Staff G explained she reordered medication when she noted there were less than 5 days of medications left on the card. Staff G stated staff do not always do this though. Medications are ordered on the computer. She obtained medication such as an antibiotic from the E-kit and gave the medication to the resident while waiting for the pharmacy to deliver the medication. Staff G was unsure how long it took for the pharmacy to deliver the medications from the date/time it was ordered. On 2/9/26 at 11:45 AM, the pharmacist reported no Amoxicillin dispensed from their pharmacy for Resident #1. The original order for Amoxicillin was for 9 days and the facility should have received the entire ATB course from the previous pharmacy vendor. The pharmacist stated the facility began to use their pharmacy on 11/1/25. The pharmacist was unsure who the prior pharmacy vendor was for the facility. In an email on 2/9/26 at 12:37 PM, the Administrator wrote the facility switched to new pharmacy vendor on 11/1/25. The former pharmacy vendor's contact information was provided to the surveyor. In an interview on 2/9/26 at 12:40 PM, a pharmacy technician from the pharmacy vendor used prior to 11/1/25 reported their pharmacy dispensed Amoxicillin on 10/22/25 for Resident #1. The pharmacy technician stated 10 amoxicillin tablets dispensed for a 5-day supply. She stated the amoxicillin was supposed to be for one tablet BID for 9 days for a UTI. She is not seeing anything else that showed additional Amoxicillin was dispensed other than the 10 pills for a 5-day supply. In an interview on 2/9/26 at 1:00 PM, Staff F, CMA, reported she had no training when she started to work at the facility. She was just thrown to work on the floor. She had worked as a CMA for a number of years before and knew the proper way to set up and give medications. When she started working at the facility, there were a lot of medications left in the drawer that were not supposed to be there, like blood pressure medications that had been discontinued. She also had to pull cards and reorder a lot of medications when she worked because the medications had not been reordered from the pharmacy. Staff F reported she was told they could not document that a medication was not available or a medication was ordered from the pharmacy. Staff F reported there was a resident that was sick. A family member came in and was upset so she contacted the DON. Staff F asked Staff H, LPN, to come and evaluate Resident #1 until the DON came in. Staff H did not do it. It was a hot mess. There was a situation when Resident #1's ATB did not come in. She told Staff H and Staff V, LPN, about it but they said it's fine and not to worry about it. The ATB kept popping up on the MAR though. It was supposed to be given for 6-10 days but they did not have the medication even for 6 days. He only had 4 tabs of the ATB and it was supposed to be given BID. He was started on the ATB to help with an infection. Whenever a medication was not in the drawer, she checked the MAR, pulled the sticker off the card, and faxed it to pharmacy. The nurse could go to kiosk to get a medication out of the E-kit, but she was a CMA and did not have any access to the kiosk / E-kit. The ADON's Staff V and Staff A were the ones who told her not to document that a medication was not available or waiting for delivery from pharmacy. In an interview on 2/9/26 at 2:05 PM, the DON reported that no longer had paper charts, the residents' records were in the computer. The diagnostic tests such as labs and x-rays could be viewed under the results tab in the computer. In an interview on 2/9/26 at 2:10 PM, Staff D, LPN reported all of the labs that had been done on a resident would be in the computer under the results tab. If no UA results listed then no UA was done. In an email 2/9/26 at 4:09 PM, the former pharmacy vendor wrote the last date of service at the facility was on 10/31/25. A report was attached that reflected the medications that were available in the E-kit for the facility prior to 10/31/25. The Inventory Snapshot revealed medications stocked in the E-kit. Amoxicillin 250 mg capsules for a quantity of 6 doses was listed as in stock. In an email, 2/9/26 at 4:34 PM, the pharmacy manager confirmed if a resident had an order for Amoxicillin 500 mg, the facility staff could take 2 tabs of the Amoxicillin 250 mg from the E-kit and give the medication until the pharmacy delivered the supply of medication (per the Dr's order) for a resident. In an interview 2/9/25 at 4:40 PM, Staff H, LPN, reported she removed the sticker on the medication card usually within 7-10 days from when a medication would run out and reordered the medication in the computer system. Previously (before using the new pharmacy vendor), the sticker from the medication card was sent to the pharmacy to reorder the medication. Staff H reported the process for when a new medication order such as an antibiotic was received. She checked the E-kit to see if the medication was available and pulled the medication from the E-kit. Otherwise, she requested a Stat order for the pharmacy to deliver the medication. Staff H stated there was no pharmacy delivery on Sundays though. Staff H confirmed she was working on the day Resident #1 was sent to the hospital. He was complaining of pain. Staff I, CMA, told her he had requested something for pain and she was waiting for the timeframe to give him the pain medication. Staff H checked to see what was on hand and what Resident #1 could have for pain, then she told Staff I to give the medication. Staff H stated when she went to assess Resident #1, he had already called 911. Staff H reported the resident was not complaining of pain earlier in the day when she evaluated him. Staff H reported she would have entered her assessment in a progress note. Staff H reported Resident #1 was compliant but not if he was really, really anxious. His mind got set on something and it was hard to get him back. Resident #1 had his mind made up that the medication was not going to help and he wanted to go to the hospital. In an interview on 2/10/26 at 8:00 AM, Staff L, CMA, reported she clicked on the medication that needed ordered and checked to see if the medication had been reordered and the date it was ordered. If the medication had not been ordered, she clicked on the reorder button, and entered a nursing note such as waiting for pharmacy to deliver, or that the medication was on order. The pharmacy delivered every day except on Sundays. Staff L reported she had not been told not to document waiting for pharmacy to deliver or that the medication was on order. In an interview on 2/10/26 at 9:00 AM, Staff A, LPN, reported the ADON's and nurses processed and entered orders in the computer and faxed the orders to the pharmacy. The pharmacy delivered the medications. The process could be lengthy putting the orders in so she faxed the orders so the pharmacy would deliver the medications by that evening or the next day. When they switched to a new pharmacy (in 11/2025), a STAT order would be at the pharmacy's discretion. She would call the pharmacy to see if the medication could be sent over STAT. The pharmacy would say they would deliver the medication within 2 hours but a lot of the time it was not delivered in 2 hours. If the medication was in the E-kit, she got the medication from the E-kit but they had to call the pharmacy first. The pharmacy needed the doctor's order first. It was a fiasco with the new pharmacy. Staff A stated she filled out a paper and put it in the E-kit box whenever she took a medication from the E-kit. Staff A reported whenever they were out of a medication, she entered a note awaiting pharmacy in a pop-up box on the computer or wrote waiting for pharmacy to delivery in the progress note. She never told staff they could not document not available or waiting for delivery from pharmacy. However, the DON told her not to document not available because it was an unacceptable reason. The nurse told the CNA if a UA needed to be collected on a resident whenever a UA was ordered. She contacted the lab after the UA was collected. UA results would be listed under the results tab in the computer. The facility also received a fax for the Dr to review the results. The DON told staff a resident's catheter only needed to be changed if there was a problem such as the catheter was leaking or not draining. Prior to the new DON, they changed the resident's catheter monthly but the new DON said they only needed to change catheter as needed. In an interview on 2/10/26 at 9:55 AM, the DON reported she expected staff to document on the MAR/TAR or the plan of care. The CNA's documented in POC, and the nurses documented in the EHR or on the nursing notes. The DON stated a urinary catheter was changed per the Dr's order. It was best practice only to change the catheter PRN such as if the catheter was plugged or leaked. The staff should let the charge nurse know if a medication was not available so the charge nurse could follow up with the pharmacy. The nurse could get a medication from the E-kit if the medication was in the E-kit. She also expected staff to call the Dr to let the Dr know the medication was not available or why the medication was not given. Staff could enter a comment or the reason why a medication not available, or document the medication was on order or unavailable. The DON reported the pharmacy usually delivered medications once a day. The pharmacy delivered medication the following day if the medication was ordered after a certain time. In an interview on 2/11/26 at 9:18 AM, the NP reported she wrote orders out and let the staff know about the orders. The facility managers then entered the order in the computer. If the order is for lab to be drawn in a couple of days, she entered the order in her notes, then the Manager entered the order in the computer. She expected orders to be processed and followed. She let facility management know if an order was not followed. This happened a lot. Sometimes when the order is not carried out it was not a huge deal but she expected orders to be done. Sometimes there had been times when a medication such as an ATB had not been given, but sometimes it was because pharmacy had not delivered the medication. The facility used to have a Hot Chart but they no longer had a hot chart. She told the manager they needed to bring the hot chart back. Staff can pull medication from the E-kit but they had problems with not having the medication in the E-kit because someone had used it. She spoke with the manager to make sure they have the medications available for weekend staff. There was a lot of education and follow up that needed to be done. In an email 2/11/26 at 9:35 AM, the surveyor requested a policy for physician's orders. At 10:35 AM, the Administrator wrote they just have a medication order policy. A Resident Assessment policy revised 10/2023 revealed the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments are conducted. Information in the assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. The Administering Medications Policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed, including any required time frame. The attending physician or Medical Director shall be contacted to discuss the concern. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. A Pharmacy Services Policy revised 11/28/16 revealed the facility will provide routine and emergency drugs and biologicals to its residents. A drug, whether prescribed on a routine, emergency, or a PRN basis, will be provided in a timely manner. The nursing home shall have pharmaceutical services that meet the needs of the residents and are in accordance with the Board of Pharmacy statutes and rules. The medical staff is responsible for developing policies and procedures that minimize drug errors. A facility shall have at least one emergency medication kit or automated dispensing system with emergency medications (kit). The kit used in the facility shall be governed by the following: The kits shall be kept readily available to staff. If a prescribed medication is not given, the reason shall be recorded on the resident's medical record.

Based on clinical record review, observation, staff interview and policy review, the facility failed to follow infection control measures in order to prevent the spread of infection for 2 of 3 residents who received insulin(an injectable medication used to lower blood sugar) (Resident #6 and #14). The facility failed to ensure staff did not utilize multiple dose insulin pens for more than one resident. The facility staff failed to perform hand hygiene and change gloves before, during, and after resident cares for 2 of 5 residents observed for cares (Resident #7 and #11). The facility also failed to ensure staff followed infection control practices to protect against cross contamination and potential spread of infection for 2 of 3 residents on Enhanced Barrier Precautions (EBP's) (Resident #7 and #11). The facility staff also failed to use a barrier when a catheter was emptied and failed to properly disinfect a graduate container after use for 1 of 3 residents observed for catheter care (Resident #7). The facility reported a census of 88 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 10/22/25, listed diagnoses for Resident #6 which included diabetes mellitus (a condition which caused abnormal blood sugars), anxiety disorder, and heart failure. The MDS stated the resident received insulin and listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Administering Medications, revised December 2012, stated insulin pens containing multiple doses were for single-resident use only. The policy stated changing the needle did not make it safe to use insulin pens for more than one resident. Resident #6's December 2025 Medication Administration Record (MAR) documented Staff A, Licensed Practical Nurse(LPN)/former Assistant Director of Nursing (ADON) administered the resident's insulin Lispro(a type of fast-acting insulin) on dates which included 12/23/25 and 12/24/25 and administered her insulin Aspart (a type of fast-acting insulin) on dates which included 12/15/25, 12/17/25, 12/18/25, 12/19/25, and 12/22/25. 2. The MDS assessment tool, dated 10/25/25, listed diagnoses for Resident #14 which included diabetes mellitus, muscle weakness, and cognitive communication deficit. The MDS stated the resident received insulin injections and listed her BIMS score as 15 out of 15, indicating intact cognition. The resident's Care Plan did not address the resident's insulin. Resident #14's December 2025 MAR documented Staff A administered the resident's insulin Glargine(a type of long-acting insulin) on dates which included 12/22/25 and administered the resident's insulin Lispro on dates which included 12/23/25 and 12/24/25. A 12/26/25 Corrective Action form stated that Staff A did not dispose of insulin pens from discharged residents and reused the pens and other current resident pens for multiple residents who used the same type of insulin. This was an infection control violation and placed residents at risk for infection. The form stated the facility would discharge Staff A. On 2/4/26 at 3:50 p.m., via phone, Staff B Licensed Practical Nurse(LPN) stated she observed an insulin pen in the top of a cart and it had a used needle attached which had blood on it. She stated there was a bag of insulin pens with multiple resident names on them. She stated Staff A told her to utilize those pens until they ran out. Staff B stated the pens were from discharged residents. Staff B stated she discharged residents on the rehabilitation wing and then the resident's pens appeared in the bag. Staff B stated she removed the bag but Staff A put them back in the cart and directed her to use them as they were saving the company money. Staff B stated she did not use any of the pens and reported this to the Director of Nursing(DON). On 2/5/26 at 8:41 a.m., via phone, Staff A , LPN stated she did not have insulin to administer to residents so she borrowed from other residents. She stated she did not know which residents the pens belonged to but she borrowed from residents who used the same type of insulin. She stated she did this with Resident #14 and her roommate(Resident #6). She stated she was on work overload and panicked. She stated she did this for approximately one to one and a half weeks during which she worked 50-70 hours over 8-10 shifts. She stated she did not report that she had no insulin to use to the DON or anyone else in management. On 2/5/26 at 9:21 a.m., Staff A stated she utilized other resident's insulin during the time frame of late December 2025. On 2/5/26 at 10:32 a.m., the DON stated that Staff B came to her with a bin of insulin pens. Staff B told her Staff A instructed her to use the pens for those who didn't have their own. The DON asked Staff A why she did that and stated Staff A told her because that was how they had done it since she started there. The DON stated the facility terminated Staff A that night. On 2/5/26 at 12:55 p.m. the DON stated staff should not share insulin needles and should administer per physician's order. She stated if staff didn't have insulin, they could obtain it from the emergency pharmaceutical kit. 3. The admission MDS assessment dated [DATE] revealed Resident #7 had diagnoses of benign prostatic hyperplasia (BPH) (an enlarged prostate), diabetes, and cerebrovascular accident (stroke) (CVA). The MDS revealed the resident had an indwelling catheter and had dependence on for toileting. The Care Plan revised 1/19/26 revealed Resident #7 had an indwelling urinary catheter. The Care Plan directed staff to use Enhanced Barrier Precautions (EBP) and monitor urine output The Order Summary Report dated 2/2025 revealed catheter care every shift. During observations on 2/9/26 at 11:20 AM, Staff C, certified nursing assistant (CNA), wheeled Resident #7 in a wheelchair to his room. An EBP sign hung on the door along with a pocketed device containing personal protective equipment supplies with gowns and gloves. Staff C donned a yellow gown and a pair of gloves. Staff C did not use hand sanitizer or wash her hands. Staff C obtained a graduate container from the bathroom and placed the graduate directly on the tile floor by the resident's wheelchair. No barrier was used when the graduate was placed on the floor. Staff C took the catheter bag from under the wheelchair, unclamped the catheter port, and drained the urine contents into the graduate. Staff C clamped the port on the catheter, touched and pulled her yellow gown toward the side of her uniform, reached her other hand wearing a contaminated and dirty glove into her uniform pocket, and pulled out an alcohol swab. Staff C took the alcohol swab and cleansed the catheter port, and then attached the catheter bag under the wheelchair. Staff C picked up the graduate with urine from the floor, opened the bathroom door with her hand wearing the same gloves, and emptied the graduate contents into the toilet. Staff C then tipped the graduate over and placed the graduate on a paper towel by the toilet. Staff C removed her gown and gloves, pulled the divider / privacy curtain back, then pushed the resident in the wheelchair to the dining room. Staff C then walked down the 100 hallway into another resident's room and answered the call light. At 11:28 AM, Staff C stood near the nurse's station and placed a handful of gloves into her uniform pockets. In an interview 2/10/26 at 9:55 AM, the Director of Nursing (DON) reported she expected staff changed gloves whenever they went from a dirty to a clean task or area and washed their hands before, during and after cares. The DON stated she also expected staff rinse the graduate with water after contents were emptied and place the graduate on the back of the toilet. The DON also stated she expected a gown and glove worn whenever staff provided cares, wound care or catheter care for EBP's. Staff reaching into their pocket after they emptied a catheter is not ok. She would expect staff to make sure supplies are available prior to provided cares or performed catheter care. Staff needed to remove the dirty gloves and then apply clean gloves. An Infection Prevention and Control Program policy dated 12/23 revealed an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility was responsible for ensuring that staff adhere to proper techniques and procedures for prevention of infection. An undated Catheter Care policy revealed the following steps: a. Gather supplies needed. b. Perform hand hygiene. c. [NAME] gloves. d. Perform perineal/catheter care e. Perform hand hygiene. A Hand Hygiene document dated 5/15/20 revealed hand hygiene is the single most important procedure in preventing infection. Hands washed with soap and water when hands are visibly soiled or contaminated with body fluids. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact, before putting on gloves, after contact with a resident or touched an inanimate object in the resident's environment, and after removing gloves. A Personal Protective Equipment: Gloves policy revised 7/2009 revealed hands washed after gloves removed. 4. The Quarterly MDS Assessment completed on 1/14/26 revealed Resident #13 with a BIMS of 3, indicating severe cognitive impairment. Diagnoses include dementia and bowel/bladder incontinence. Resident #13 noted as dependent on staff for all personal cares. The Care Plan, last revised 10/22/25, documented that Resident #13 required the assistance of one to two staff members for personal hygiene and toileting. During an observation on 2/5/26 at 11:25 AM, Staff R, CNA, and Staff S, CNA, donned on gloves, and transferred Resident #13 from a wheelchair to their bed via a mechanical lift. Once situated in bed (laying flat with staff rolling the resident on their side) Staff S initiated personal cares. A soiled incontinence brief was removed. Staff S voiced the resident had a small bowel movement and used several wipes to clean the gential areas. Once finished and still with gloved hands, Staff S assisted Staff R to roll the resident on their back, used the bed control to elevate the head of the bed, resituated blankets to ensure privacy, and proceed to change Resident #13's clothing. Staff S & Staff R both lifted the soiled shirt off with Staff S repositioning the resident's head/face area with their gloved hands. Staff S handed Staff R a clean shirt for the resident. Staff S took the soiled shirt as well as a soiled mechanical lift sling, opened the door and left the room, all with gloved hands. Staff R remained in the room and finished dressing Resident #13. At no point during the completion of personal cares and prior to leaving the room did Staff S perform hand hygiene or change gloves. Staff S returned to the room, donned a new pair of gloves and assisted Staff R with transferring Resident #13 back into the wheelchair via a mechanical lift. Once the resident was situated and ready to be assisted into the lunch room, both staff members removed their gloves and completed hand hygiene. During an interview on 2/5/26 at 1:00 PM, the DON, explained hand hygiene and glove change should be performed at the start of cares, anytime ending a dirty or contaminated care/task to a clean care/task, if need to step away during the middle of a cares, and at the end. The policy Administering Medications, version 2.0 (H5MAPL0028), stated insulin pens containing multiple doses of insulin are for single-resident use only. Changing the insulin needs does not make it safe to use insulin pens for more than one resident. Insulin pens will be clearly labeled with the resident's name. Prior to administering insulin with an insulin pen the nurse will verify the correct pen is used for that resident. The policy Personal Protective Equipment-Gloves, version 1.0 (H5MAPL0622) and revised July 2009, stated staff must wear gloves when touching blood, bodily fluids, secretions, mucous membranes and/or non-intact skin. Gloves shall be worn only once and discarded. The facility document Hand Hygiene, revised 5/15/20, noted hand hygiene should be completed before touching the patient, before clean/aseptic procedures, after body fluid exposure, after touching the patient and after touching patient surroundings.

Based on observations, staff interviews, and policy review, the facility failed to maintain a home-like environment for residents due to persistent pungent odors throughout 2 of the 3 nursing units (Station 1 and Station 2). The facility reported a census of 88. Findings include: During an observation on 2/4/26 at 10:45 AM, an unpleasant strong odor was noted on the Station 2 nursing unit, especially near the shower room and the environmental service door. During an observation on 2/4/26 at 11:00 AM, a strong pungent odor was detected down the Station 1 nursing unit East hallway. It became stronger as one walked further down the hall. Approximately four hours later, at 2:00 PM, the same pungent odor was still present but not as strong.During an observation on 2/5/26 at 7:50 AM, a pungent odor was noted on the Station 1 nursing unit down the East hallway. There was evidence the facility attempted to combat the odor with the use of an air freshener. At 11:00 AM on this day, Staff O, Housekeeping Director, was seen using a deodorizing machine down the Station 1 East hallway. The pungent odor was mildly detected afterwards. At approximately 3:15 PM, the pungent odor returned and was present down the hallway. During an observation on 2/9/26 at 7:40 AM, a lingering pungent odor was noted on the Station 1 nursing unit East hallway. At 7:50 AM, on the Station 2 nursing unit, an unpleasant odor was noted. An uncovered trash and linen cart, noted with trash, soiled briefs, and soiled linens, was observed in the hallway. On 2/5/26 at 11:00 AM, Staff O reported using a deodorizing machine throughout the facility approximately 2 times per week and as needed. There is no set schedule when the deodorizing machine is used on a specific unit. When asked, Staff O used the machine on Station 1 this day as they could detect a strong pungent odor. Staff O acknowledged the odor is present daily. Staff O suspects the odor may be related to personal habits of several residents. Staff instructed to change bedding daily and ensure trash is emptied timely. On 2/10/26 at 10:30 AM, Staff P, Maintenance Assistant, acknowledged the pungent odors, especially on Station 1 and down the East hallway. Staff P suspects the carpets may be the source of the odors and reported they are shampooed one time per month. On 2/11/26 at 12:15 PM, the Administrator acknowledged the pungent odors throughout the building. The policy Quality of Life-Homelike Environment, version 1.2 (H5MAPL1202), stated facility staff and management shall maximize, to the extent possible, a personalized, home-like setting which include pleasant, neutral scents. The policy also stated to minimize, to the extent possible, a depersonalized, institutional setting which include institutional odors.

Based on electronic health record review (EHR), staff interviews, and policy review, the facility failed to complete and document neurological exams (neuro-checks) and skin assessments for 1 of 4 residents reviewed for assessment and intervention (Resident #2). The facility reported a census of 88. Findings include: The Significant Change Minimum Data Set (MDS) Assessment completed 10/9/25 reviewed Resident #2 with a Brief Interview for Mental Status score of 13, indicating intact cognition. Diagnoses included anxiety, aphasia (communication disorder), diabetes, heart failure, hemiplegia, and stroke. Resident #2 noted to be dependent on staff for all cares and transfers. The MDS documented two or more falls since prior assessment. Resident #2 at risk of developing pressure injuries and was reported with a diabetic foot wound and an open foot lesion. The Care Plan, last revised 10/17/25, reported Resident #2 with falls. Interventions include neuro-checks per facility policy. Due to self-care performance deficits, skin inspections are care planned. Staff directed to observe for redness, open areas, scratches, cuts, bruises, and to report changes to the nurse. Review of Facility Incident Reports showed Resident #2 with a total of 21 unwitnessed falls between 9/1/25 and 12/14/25. Of the 21 unwitnessed falls, neuro-checks were initiated and documented for 13 of these falls. For the 13 documented neuro-checks, 8 of neuro-check forms were incomplete and missing one or more of the scheduled assessments. The EHR form Weekly Skin Reviews-v 3, which documents nursing full body skin assessments, were completed on a regular basis from 7/21/25-11/11/25. No further full-body skin assessments, either electronically or paper, identified from 11/11/25 to 12/31/25. The only documented skin assessment identified after 11/11/25 was the Weekly Non-Pressure Diabetic/Neuropathic Injury Evaluation. The assessment focused on the right foot or left toes and did not address full-body. The Progress Note dated 11/20/25 at 7:11 PM documented a small bruise to Resident #2's left upper eye area. No further documentation regarding this injury identified in the Progress Notes or skin assessments. The Incident Report #3190, dated 12/14/25, documented Resident #2's injuries related to a fall that occurred. Injuries included a bruise and skin tear to the right elbow. No further documentation identified in the Progress Notes or skin assessments identified tracking the injuries. Nursing Note dated 12/17/25 at 11:03 AM documented as follows; resident was restless this morning. Gave resident his meds and noticed gauze in residents hand, removed it and cleaned area and noticed finger nail cutting into his hand, so this nurse cleansed area with wound cleanser. Then cut residents fingernails, applied a Derma Foam, and wrapped with Kerlix at this time.The Progress Note dated 12/17/25 at 11:15 AM documented cuts on Resident #2's hand related to their fingernails cutting into the skin. Orders to apply Silvadene cream, a foam bandage and to wrap with gauze initiated. No further documentation identified in the Progress Notes or skin assessment identified tracking the injury. During an interview on 2/10/26 at 9:00 AM, Staff A, Licensed Practical Nurse (LPN), explained neuro-checks completed with all unwitnessed falls for up to 72 hours. Neuro-checks are documented on paper. The nurse who initiates the neuro-check form should fill out the dates and times when the checks are needed so upcoming staff know when to assess. During an interview on 2/10/26 at 9:30 AM, Staff D, LPN, explained skin assessments are completed during bath days. The Certified Nurses Aide (CNA) would notify the floor nurse when bathing is complete so a full-body skin assessment can be performed. The nurse would then document the assessment in the EHR. During an interview on 2/10/26 at 1:25 PM, Staff U, Assistant Director of Nursing, acknowledged Resident #2's frequent falls and overall skin condition. Weekly rounds were made with the Wound Care Provider with the focus mainly to the resident's foot. Full-body checks would not have been completed during this time. Staff U believes there may have been some bruises on the resident's arm towards the end of December. Staff U would expect the CNAs to notify nursing staff of any skin abnormalities during scheduled bathes. Staff U would also expect skin abnormalities, including bruises, to be documented during weekly skin assessments. The facility document Falls Management System, revised 2016, noted any fall that involves an actual head injury and all unwitnessed falls will include follow-up neurological checks. Neurological checks will be documented. The Neurological Assessment form noted checks should be performed every 15 minutes x4, every 30 minutes x4, every 4 hours x4, and every shift x3.

Based on clinical record review, facility bath records, resident interviews, staff interviews and policy review, the facility failed to offer and provide resident bathing on a consistent basis for 3 of 5 resident reviewed for bathing (Resident #1, #3, and #5). The facility reported a census of 88. Findings include: Resident Council meeting minutes from 11/24/25 noted 6 residents voiced not receiving showers consistently. 1.The Annual Minimum Data Set (MDS) Assessment completed on 1/21/26 revealed Resident #5 with a Brief Interview for Mental Status (BMIS) score of 15, indicating intact cognition. Diagnoses include arthritis, chronic pain syndrome, and heart failure. The Care Plan, last updated on 1/29/26, noted Resident #5 requires staff assistance with bathing and showers. During an interview on 2/4/26 at 11:10 AM, Resident #5 reported going over two weeks in-between showers. On many occasions, a bath or shower was not offered. At one point, the resident had to ask about receiving a shower. Resident #5 explained this mainly occurred in January. The Dec'25 Documentation Survey Report v2 revealed Resident #5 should be offered bathing two times per week on Tuesdays and Fridays. Between this report and the Resident Bath/Skin Assessment paper documentation, bathing was documented as complete four times out of nine scheduled days. No further documentation identified as to the status of the other five scheduled bath days (completed, not offered, offered but resident refused). The Jan'26 Documentation Survey Report v2 revealed Resident #5 should be offered bathing two times per week on Tuesdays and Fridays. Between this report and the Resident Bath/Skin Assessment paper documentation, bathing was documented as complete two times out of nine scheduled days. No other documentation identified as to the status of the other seven scheduled bath days (completed, not offered, offered but resident refused). 2. The MDS for Resident #3, dated 12/23/35, revealed the resident was admitted to the facility on [DATE] with diagnoses of Osteoporosis (bones become fragile and brittle) and Major Depressive Disorder, and dependent on staff for bathing. A BIMS score of 15, indicated no cognitive impairment for decision-making. During an interview on 2/4/26 at 10:30 AM, Resident #3's family member stated the resident was admitted to the facility on [DATE] and did not receive her first shower until 19 days after being admitted . The family member stated during a meeting with the facility care team, after the first shower, he was promised the resident would receive a shower two times per week. The family member stated the resident went 8 days before receiving her next shower. The family member stated the resident received 2 showers total in 30 days. Resident #3's Document Survey Report v2 for Showers for 12/25 and 1/26 revealed from 12/17/25 – 1/17/25, the resident received a shower on 12/31/25 and 1/8/26. 3. The admission MDS dated [DATE] for Resident #1 revealed preferences for customary routine and activities such as the resident's preference for receiving a bath or shower was left blank. The quarterly MDS assessment dated [DATE] revealed Resident #1 had diagnoses of urinary tract infection and hip pain. The MDS recorded the resident had a BIMS score of 15 indicating intact cognition. The MDS documented the resident had no behaviors and had no days when he rejected care. The MDS revealed the resident had dependence on staff for transfers and bathing. The Care Plan revised 8/11/25 revealed Resident #1 had an ADL (activities of daily living) self-care performance deficit related to pain and impaired balance and mobility. The Care Plan directives staff to provide assistance of one for bathing activities. Review of the Generations Hall Bath Schedule in a binder at the nurse's station revealed baths for Resident #1's room were scheduled on Tuesday and Friday mornings. Review of facility's paper bath sheets for Resident #1 reviewed 11/1/2025 to 1/31/2026 revealed baths documented on 11/1/25, 11/7/25, and 12/19/25. The documentation revealed the resident did not receive a shower on 12/30/25 because he was hospitalized . The bath sheet dated 1/16/26 revealed the resident refused a shower/ bath. Review of the Documentation Survey Report revealed an X indicated on non-bath days but an area to document a bath or shower on Tuesdays and Fridays. The Documentation Survey Reports dated 11/1/25 to 1/31/26 revealed bathing was documented as complete two out of nine times in 11/2025 (on 11/7/25 and 11/14/25), one out of nine times in 12/2025 (on 12/19/26), and two of nine times in 1/2026 (on 1/13/26 and 1/30/26). Refused was documented on 1/16/26. In an interview 2/4/26 at 11:10 AM, Staff J, Certified Medication Aide (CMA) reported the Certified Nursing Assistant's (CNA's) were responsible for giving the residents a showers. They had a book with the resident rooms listed and the days each room was assigned to get a bath. The CNA's filled out a shower sheet every time a resident's shower was completed. The bath schedule did not change usually as it was assigned by room numbers but a change could be made based on a resident's preferences. Whenever they had a new resident admission, the resident was assigned to get a shower based on the schedule. This process just started a couple of weeks ago. The previous process was by assigning the residents based on how many residents they had each day. In an interview on 2/4/26 at 11:25 AM, Staff K, CNA, reported the facility did not have a bath aide. The CNA's that were working were responsible for getting the residents' baths done. Staff K reported she looked at the list with resident rooms and who was supposed to get a bath that day. Staff K reported she documented the resident's bath in the computer whenever she gave a resident a bath or a shower. In an interview 2/4/26 at 11:25 AM, Staff Q, CNA, reported the residents were scheduled to receive a shower twice a week. The shower list went by room numbers, so that is how he knew which resident got a shower on that day. Staff Q reported a paper shower form filled out and he gave it to the charge nurse, but he also documented in the computer whenever he gave a shower or a bath. On 2/4/26 at 2:50 PM, the Director of Nursing (DON) stated she wanted to talk to the surveyors about baths. She had only been at the facility since 9/2025. She reported she had started a PIP (performance improvement plan) for bath and skin assessments. There had been grievances and complaints from residents and family members that baths/showers were an issue. Once she identified a concern about baths, she implemented some things so staff knew who bathes when. She felt there had been progress and she had tried to undertake an improvement in getting the residents' baths done. They had implemented bathing sheets and managers were auditing if a resident had a bath. If no bath had been given then the resident was scheduled for the next day or the following day. The DON stated there was not a process in place before. They had a bath schedule in place but it was overwhelming for staff to get things done, so they split up the baths so it was fair to everyone and staff don't get overwhelmed. The Assistant Director of Nursing (ADON) was monitoring if baths got done but there had been a turnover in the ADON's. Three ADON's had been termed in a timeframe of a couple of months. The facility only had one ADON currently. In an interview on 2/10/26 at 9:00 AM, Staff A, Licensed Practical Nurse (LPN), reported the CNA's gave the baths at the facility. When she worked at the facility, the facility had a problem with the water heater and they did not give baths because there was no hot water. She had put together a schedule for residents to get baths twice a week. The CNA's documented the baths in the computer and filled out a (paper) bath sheet. Nine times out of ten, the paper bath sheet did not get done. The facility's Supporting Activities of Daily Living (ADL's) policy revised 3/2018 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good grooming and personal hygiene such as bathing.

Based on clinical record review, staff interviews and policy review the facility failed to follow the physician's orders for 1 of 4 residents reviewed (Resident #3). The facility staff failed to return a [NAME] Monitor in a timely manner to the vendor after resident use which delayed downloading and analysis of the heart monitor data, follow up with the physician, and the potential treatment required. The facility reported a census of 88 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 admitted to the facility on [DATE] from an inpatient psychiatric facility and had diagnoses of atrial fibrillation, hypertension, catatonic disorder, and major depressive disorder. The MDS revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating cognition intact. The Inpatient Adult Psychiatry Discharge summary dated [DATE] revealed Resident #3 admitted to the medical-psych unit for management of the severe catatonic, depressive symptoms. During this hospitalization, noted to have EKG changes, suspected to be due to her baseline tremors. EKG changes concerning for atrial flutter on admission. Cardiology reviewed EKG data and thought that the tremor may be cause for what appeared to be flutter. They recommended a 2-week [NAME] monitor at discharge with EP to follow-up. The Care Plan revised 12/29/25 lacked information about a [NAME] monitor. The Order Summary Report revealed an order start date 1/3/26 to monitor the heart monitor for placement every shift. Mail the monitor back on Friday and discontinue the order when done. The Clinical Physician Orders revealed an order entered on 1/3/26 at 6:00 PM by Staff T, Licensed Practical Nurse (LPN) to monitor the heart monitor for placement every shift for heart health. Mail the monitor back on Friday and discontinue the order when done. The order end date was 1/6/26. The Medication Administration Record and Treatment Administration Record dated 1/2026 lacked documentation for monitoring the placement of the heart monitor. The Progress Notes revealed the following: a. On 12/17/25 at 2:11 PM, resident arrived to facility.b. On 12/24/25 at 9:02 AM, a family member requested to inform nursing staff that resident needs her [NAME] monitor placed on today.The Progress Notes lacked any other information about application of a [NAME] monitor, monitoring that the monitor was on over a 2 week period of time, when the monitor was removed, or who removed the [NAME] monitor. The facility records lacked a process for tracking or the disposition of a [NAME] monitor being sent back to the appropriate vendor or the provider facility. In an interview on 2/4/26 at 10:30 AM, a family member voiced concern the resident was discharged from the hospital and was to wear a [NAME] monitor for 2 weeks. The monitor was not placed on the resident until about one week later. The monitor was on the floor for quite a while before the staff put it back on. Last week, the hospital called and asked about the monitor because it was 3 weeks past due. He had no idea where the monitor was or where it went. The resident was transferred to another facility on 1/23/26. In an interview on 2/4/26 at 11:10 AM, Staff J, certified medication assistant (CMA) reported she was unaware of a [NAME] monitor for Resident #3. In an interview on 2/4/26 at 2:12 PM, Staff N, CMA, reported Resident #3 was dependent on staff for all cares and used a mechanical lift for transfers. Staff N reported she did not recall Resident #3 wearing a [NAME] monitor. In an interview 2/9/26 at 11:35 AM, Staff D, LPN, reported Resident #3 had a [NAME] monitor on at one time. She recalled because of who Resident #3's roommate was at that time. Staff D reported she had to put the [NAME] monitor back on Resident #3 because it came off, she thought when the resident got a shower. Staff D stated she was told about the monitor during report and went to put the monitor on the resident. The monitor was believed to be off from the evening/overnight shift and put back on in the AM. In a follow up interview on 2/9/26 at 2:10 PM, Staff D reported she was not sure what happened to Resident #3's [NAME] monitor. Staff A was the Assistant Director of Nursing (ADON) at that time and was the one who handled the [NAME] monitor. Staff A no longer worked at the facility though. In an interview on 2/10/26 at 8:22 AM, Staff B, LPN, reported she started to work at the facility on 12/24/25 and only worked at the facility for 3 1/2 weeks. Staff B stated she took a phone call from someone who was checking on a heart monitor for Resident #3. She took his name and number and said she would look into it. She talked to people at the facility to see if anyone knew about the monitor. Everyone was looking for the monitor. Then one day, she went into the unit's Medication Room and it was sitting on top of the refrigerator. The monitor was in a box and the box had a label on it. Staff B recalled she gave the box to the ADON on the unit where the resident resided. She did not know the name of the ADON, but the ADON no longer worked at the facility. In an interview on 2/10/26 at 9:00 AM, Staff A, LPN, reported she worked at the facility from 8/2025 to 12/27/25. She applied the [NAME] monitor on Resident #3 but she did not know who took the [NAME] monitor off or when it was removed. Staff A reported orders are entered into the computer by the nurses and ADON's. Whenever there was a new admission, she obtained the orders and entered the orders. Staff A recalled she entered orders for Resident #3's [NAME] monitor because the nurse did not know how to do it, so she showed the nurse what to do. In an interview on 2/10/26 at 9:55 AM, the Director of Nursing (DON) stated she did not believe Resident #3 had a [NAME] monitor. She did not know if they ever received a [NAME] monitor for Resident #3. The DON stated Resident #14 had a [NAME] monitor but could not say for sure that Resident #3 had one. In an interview on 2/10/26 at 12:00 PM, Staff M, Registered Nurse (RN), reported she was only familiar with Resident #3 for MDS assessment purposes only. There was no [NAME] monitor on Resident #3 upon admission or when Staff M completed her MDS assessment. Staff M reported Staff A, Staff D, Staff J, and Staff Q worked in the area where the resident resided and she thought those staff would by more familiar with the resident. In an interview on 2/10/26 at 12:10 PM, Staff J, CMA, reported Resident #3 was not at the facility very long. Staff J stated she was not able to recall if Resident #3 had a [NAME] monitor when she first came in. The first time she became aware that the resident had a monitor is when the resident's husband asked for it to be put on. In an interview on 2/10/26 at 12:35 PM, Staff Q, CNA, reported he recalled Resident #3 was only at the facility for about a month. She did not have a monitor when she first came in but she did have a heart monitor put on while she was at the facility. One day the monitor was off and he gave it to Staff B, LPN. Staff B no longer worked at the facility though. In an interview on 2/10/26 at 2:35 PM, the DON reported she vaguely remembered Staff T coming to her and telling her about a resident's monitor. Staff T boxed it up and brought it to her office. The box had a return label but she did not know where it was being shipped to. The DON stated she could not recall who would have taken the box from her office. There is not a specific person or department that picked up the packages or mail. There was not a process for who took the mail packages out of the facility nor for tracking when things were shipped. In an interview on 2/10/26 at 2:40 PM, the Regional Director of Operations (RDO) reported she had looked in the ADON's office and the medication rooms and carts. She did not find any kind of monitor. Staff A told the RDO she put the monitor on the resident. At 2:44 PM, the RDO said she found the monitor. She had just talked to the DON who said the box was in her office and she took the box to the post office and mailed it. On 2/10/26 at 2:45 PM, the DON reported she took the box and dropped it off at the Post Office downtown as that Post Office was on her way home. The DON claimed she did not know what was in the box, she just mailed it. When the surveyor inquired why she did not tell the surveyor this during a recent interview. The DON stated she had to process it. In an interview on 2/10/26 at 3:25 PM, Staff T, LPN, reported she took the [NAME] monitor off of Resident #3 at least 3-4 weeks ago. There were instructions to put the monitor on and a certain number of days the monitor needed to be on. She had talked to the resident and family during the resident's stay because she did not see an order in the computer about the monitor. Staff T stated she called the 800 number to find out what they needed to do about the monitor. The ADON at the time took over and was supposed to take care of the monitor but when Staff T came back to work a few days later, the resident still had the monitor on. The ADON that took over for her and knew about the monitor had quit or got fired. Staff T said she then went to talk to the DON and told her the monitor needed to be removed. Staff T removed the monitor from Resident #3, packed up the monitor, and took the box with the monitor to the DON's office. That was 3-4 weeks ago. Staff T stated she put an order in the computer about the monitor and that it had been discontinued. In an interview on 2/11/26 at 9:18 AM, the Nurse Practitioner (NP) reported she wrote orders out and let the staff know. The facility managers then entered the order in the computer. She expected orders to be processed and followed. She let facility management know if an order was not followed. This happened a lot. Sometimes when the order is not carried out it was not a huge deal but she expected orders to be done. In an interview on 2/11/26 at 10:35 AM, the University Hospital Clinic nurse confirmed no [NAME] monitor or data received yet for Resident #3. The computer showed they were still waiting for the data. The surveyor advised the clinic staff that the facility staff (where the resident resided) had reported they took the monitor in a box and dropped it off at the main Post Office. The clinic staff reported the box needed to be shipped by UPS, and that was most likely why they had not received the monitor back yet. The clinic nurse confirmed since the monitor had not been received, they are not able to download the information to determine if there is any kind of arrhythmia. This had led to a delay in the physician getting the report and being able to make a treatment plan. Also, if the monitor was not found, the physician would have the resident repeat the study. The clinic nurse reported they often had trouble getting the monitor returned when a resident resided at a facility. They also had trouble with the staff at care facilities not knowing what to do with the monitor and doing what needed to be done to get the monitor back timely. In an interview on 2/11/26 at 11:00 AM, the DON reported she does not know the date she took the box to the Post Office to drop it off, but whatever day Staff T brought the box to her office is the day the DON took the box with the monitor to the Post Office. She just dropped it off in the mailbox. Staff A was the ADON at the time and should have put the orders in for the [NAME] monitor. The surveyor advised the DON the vendor had not received the monitor yet, and understood that the box was supposed to be mailed by UPS. The DON stated she did not know that. She planned to let Staff M (the new DON) know to follow up with the Post Office. On 2/11/26 at 11:10 AM, the RDO and Administrator stated they would check with the Post Office to see if they could locate the missing monitor. In an interview on 2/11/26 at 11:40 AM, the University Hospital Clinic staff confirmed Resident #3 should have received the [NAME] monitor on 12/17/25. The monitor ran for 15 days. If the monitor was applied on 12/17/25, then it should have been done and removed on 1/1/26. The monitor would have been done recording by that date. If it was mailed via UPS right away after the monitoring was completed, then the results would have been obtained within 2 weeks. In an email, 2/11/26 at 9:02 AM the Administrator wrote they do not have a policy for the mail. In an email 2/11/26 at 9:35 AM, the surveyor requested a policy for physician's orders. At 10:35 AM, the Administrator wrote they just have a medication order policy. A Resident Assessment policy revised 10/2023 revealed the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments are conducted. Information in the assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan.

Based on electronic health record review (EHR), observations, staff interview, and policy review, the facility failed to supervise resident administration of medications for 1 or 4 residents reviewed for medications (Resident #4). The facility reported a census of 88.Findings include:The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 with a Brief Interview for Mental Status score of 15, indicating intact cognition. Diagnoses atrial fibrillation (irregular heart rhythm), anxiety, arthritis, depression, diabetes, edema, and high blood pressure.The Care Plan, last revised on 10/20/25, documented that Resident #4 was resistive to cares and had a history of refusing medications if they did not feel the medications were necessary. Interventions for staff include education for the resident of possible outcomes of not complying. The Care Plan lacked documentation that the resident could self-administer medications.The Medication Administration Record (MAR) directed staff to offer 2 different medications mid-morning for a total of 3 pills to Resident #4. The MAR as well as current Physician Orders did not indicate Resident #4 may self-administer medications. During an observation on 2/4/26 at 11:22 AM, Staff J, Certified Medication Aide (CMA), entered Resident #4's room with a small cup of medications (3 pills total) and placed it on the bedside table in front of the resident. Staff J visited with Resident #4 for a few minutes and then left the room without acknowledging or administering the medications which were still sitting on the bedside table. On 2/4/26 at 1:00 PM, the Director of Nursing (DON) explained that staff need to stay with residents when administering medications. Staff should not leave residents alone with medications. On 2/4/26 at 2:15 PM, Staff J stated they were not aware of any residents who may independently keep mediations in their room. Staff J noted they typically stay with residents to ensure medications are taken and do not leave medications in resident rooms. On 2/4/26 at 3:15 PM, Resident #4 acknowledged the medications left in the their room by Staff J. Resident #4 reported this happens periodically.On 2/5/26 at 10:20 AM, Staff R, CMA reported that no residents are independent to keep medications in their room, and reported she would not leave medications with a resident in their room.The policy Administrating Medications, version 2.0 (H5MAPL0028), stated medications shall be administered in a safe and timely manner and as prescribed. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined the resident has the decision-making capacity to do so safely.

Based on clinical record review, staff and resident interviews, official city records, facility policy review, and guidance from the Centers for Medicare & Medicaid Services (CMS), the facility failed to provide necessary nursing coverage for approximately four hours on two nursing units housing a total of 53 residents, after one of two on duty nurses left the facility unscheduled. During this period of time, the facility failed to provide requested medications to three residents (Res #3, #6, #9). As a result, one resident's pain (Res #3) became so severe that she contacted 911 (emergency services) to obtain assistance with receiving her pain medication. Additionally, the facility failed to assess another resident (Res #6), who had a documented history of multiple anaphylactic reactions requiring intubation, when she reported symptoms of an allergic reaction.On 10/14/25 at 10:10 am, the State Survey Agency informed the facility the failure to assess the residents, provide needed medications, and take action to ensure resident care and safety needs were met created an Immediate Jeopardy situation. The facility removed the immediacy prior to the survey on 10/09/25 when the facility staff implemented the following Corrective Actions: Facility attendance policy, nurse job description, and scheduling process were reviewedFacility review of current and future staffing patterns to ensure an adequate number of competent licensed nurses and nurse aides being scheduled to meet the needs of the residentsFacility assigning one person from the leadership team to monitor staffing levels daily to ensure adequate nursing staff are availableFacility developed an orientation tool for agency nurses to include procedure for notifying facility leadership for staffing adjustmentsFacility's Regional Director of Operations began providing oversight of staffing and providing weekly facility visits for three monthsOn-Call and emergency staffing process education to all staffEducation to all nursing staff (nurses, medication aides, nurse aides) of the expectation to communicate directly with nursing leadership or administration of emergent staffing changes or when circumstances require a reassignment of staff to cover absences. Additional education to licensed nurses regarding procedure to follow prior to exiting the facilityEducation to all nurse aides of the expectation to report resident needs immediately to licensed nurses onsite, nursing leadership, or administration. Posting of the Director of Nursing's phone number visibly at each nursing station for all staff to contact in emergenciesPain assessments conducted on all facility residentsPlan for audits to be conducted with staff and residents of staffing processAn unplanned Quality Assurance and Performance Improvement meeting conducted to review staffing and medication administrationThe scope and severity was lowered from a K to an E at the time of the survey after ensuring the facility implemented the education, assessments, audits, policy reviews/updates, orientation tools and staffing oversight procedures. Findings include:1.The Minimum Data Set (MDS) Assessment of Resident #3, dated 8/28/25 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognition intact. The MDS documented diagnoses that included: incomplete paraplegia, renal insufficiency, and chronic pain. The MDS recorded the resident received both scheduled and as needed pain medication during the look-back period, as well as non medication pain intervention. The MDS recorded the resident reported they experienced pain on a frequent basis and rated the worst pain at a 5 on a 0 to 10 pain scale, with 10 being the worst pain imaginable. The Care Plan of Resident #3 documented a Focus Area of refusal of care due to her pain tolerance, dated 4/22/25. The Care Plan documented an additional Focus Area of chronic pain, dated 6/10/24. The Care Plan directed staff to administer scheduled and as needed pain medications as ordered. The Care Plan additionally directed staff to assist in being timely with medication delivery per the resident specific interval requests. 2. The MDS of Resident #6 dated 10/12/25 documented a BIMS score of 15, which indicated cognition intact. The MDS documented diagnoses which included unspecified immunodeficiency. An encounter note by the facility's Advanced Registered Nurse Practitioner (ARNP), dated 10/13/25 documented Resident #6's medical history to include a diagnosis of systemic mastocytosis (a rare condition where the body makes too many abnormal mast cells, a type of immune cell, which build up in the body's organs. The buildup causes various symptoms, as excess cells release too many chemicals, similar to a severe allergic reaction. Treatment is symptom management as there is no cure), and noted she had been intubated (mechanical ventilation for a patient who is unable to breathe on their own) several times as a result of anaphylaxis (severe, potentially life-threatening allergic reaction).Hospital referral information for Resident #6 dated 9/29/25 listed greater than 30 medications Resident #6 is allergic to. The reaction listed for these allergies noted anaphylaxis for greater than 10 of these allergies.3. The MDS of Resident #9 dated 10/1/25 documented a BIMS score of 15, which indicated cognition intact. The MDS documented the resident was independent for walking at least 150 feet in a corridor or similar space. The MDS documented diagnoses that included: cerebral palsy, generalized osteoarthritis, bilateral primary osteoarthritis of the knee, and osteoporosis. The Care Plan of Resident #9 documented a Focus Area of Chronic Pain related to Cerebral Palsy and Osteoarthritis, dated 7/15/25. It directed staff to administer medications as ordered by the physician. The Medication Administration Record (MAR) of Resident #3 for October of 2025 documented medications for pain management to include the following:Acetaminophen, scheduled three times a day (common name: Tylenol)Tizanidine, scheduled three times a day (a muscle relaxer)Baclofen, scheduled four times a day (a muscle relaxer)Gabapentin, scheduled four times a day (an anticonvulsant, often prescribed to treat nerve pain)Tramadol, scheduled four times a day (a synthetic opioid)Diazepam, ordered as needed (for muscle spasms for pain unrelieved by the scheduled medications)The MAR reflected that on the night shift of October 8, 2025 the resident recorded her pain at a 5 out of 10. Per the Medication Admin Audit Report, this pain level was recorded at 7:34 pm. At this time, the resident's scheduled gabapentin, tizanidine, baclofen and tramadol were administered. Additionally, at 8:21 pm, the resident's as needed diazepam was administered.The MAR documented the next scheduled medications to be Tizandine scheduled for early (per the Director of Nursing, this is between 4:00 - 6:00 am), Baclofen, scheduled for early, Gabapentin scheduled for early, and Tramadol scheduled for 4:00 am.The Medication Audit Report documented the Tramadol, Baclofen, and Gabapentin were next administered at 6:38 and 6:39 am and the Tizanidine was administered at 7:23 am, all by members of the scheduled day shift which started at 6:00 am, though all four of the medications were scheduled to be given by the night shift.Per the Patient Care Report provided by the city Fire Department, dated 10/9/25 at 5:49 am, emergency units arrived to the facility after a 911 call was placed by Resident #3 due to staff not providing her medications. The report also detailed that the dispatcher who took the call reported other people could be heard laughing in the background so a police officer was also requested to respond. Upon arrival, the report stated Resident #3 informed crews that she had not been given her pain medication that was supposed to be given around 3:00 am. It detailed the resident was visibly upset and was crying. The resident informed the crew of chronic pain in her legs and that she had not received medications hours past the scheduled time. She also reported when she asked staff for her medications due to being in pain, they laughed at her from the hallway and told her the nurse was gone and had left around 2:00 in the morning so there was nobody there that could give her the medications.The report documented after locating staff, it was found that the nurse for 2 hallways, including the one which Resident #3 resides on, had left around 2:00 am and there had been no follow-up with the patient's medications since then. The incident report provided by the city Police Department dated 10/9/25 at 5:49 am detailed the police officer arrived at the facility at approximately 6:00 am and met with the fire fighters/paramedics at the room of the Resident #3. The resident reported she had called 911 because she was in chronic pain and the nursing staff on duty were not giving her medication as required. The report documented the officer asked a group of employees who was in charge and was told Staff D, Registered Nurse (RN) was covering the other side of the building and stated the nurse who was covering Resident #3's side of the building had left at approximately 2:00 am. The officer asked the staff who had been in charge for the last four hours and was told nobody had been in charge. The staff advised that the nurse who had left had not given the keys to anyone and there was no access to the medication cart. The nurse who had been in charge, Staff F, RN, had been scheduled to work until 6:00 am and was the only one who had access to the medication cart.Per the report, Resident #3 reported to the police officer there was an issue with the nurses and she missed her medication and was late getting her valium (diazepam) which threw off her medication routine the rest of the day causing her to be in pain. The Resident stated to the police officer her medications were due between 3:00-3:30 in the morning but she was unable to get her medication due to no one covering her unit/side of the building. The report detailed the resident appeared to be in pain and was continuing to have spasms as he spoke to her.The body camera footage of the police officer, provided by the city, was reviewed. On the body camera footage, time stamped 10/9/25 at 06:03:10 am, Staff D, RN, Staff B, Certified Nurse Aide (CNA) and Staff G, CNA were present speaking to the police officer. When the officer asked who was in charge, Staff D, RN responded that the nurse had left around 2:00 am. Staff B, CNA then stated the nurse that left didn't give the keys to her (Staff D) and Staff D, RN then stated nobody (was in charge). The officer asked the name of the nurse who left, and Staff D, RN went to the nursing desk to obtain the schedule. Staff B, CNA again told the officer the nurse who left had not left the keys with staff or counted the medication cart. At time stamp 06:04:03 am, Staff D, RN told the officer she had been on the other unit of the building and provided Staff F, RN's name (who was employed by a nursing agency, not the facility). The officer then asked what was needed to get Resident #3 her medications. Staff D stated she could not touch it. Someone in the background could be heard asking who the on call person was. Staff D, RN stated the on-call person was Staff E, LPN and stated she thought the other nurse had called Staff E prior to leaving the facility. Staff D, RN then said Staff F had told her she had called Staff E but did not give any report or anything, she just walked out. The other staff member in the background said to call the on call person. Staff D, RN then walked behind the desk to the phone to call on the on call manager. At this time (time stamped 06:05:30 am) the officer walked back down the hall towards the fire fighters/paramedics. As the police officer and the EMS (emergency medical services) staff were speaking to one another, Res #3 could be heard loudly crying out in pain on the body camera footage (06:05:32 am). The officer told the EMS crew the staff would not open the drug cart until the other nurse who had reportedly been called arrived. Loud distress sounds consistent with pain continued to be heard on the body camera (06:06:06 am). As the emergency responders continued to discuss the situation, the ongoing loud, persistent crying and screaming of Resident #3 was heard (06:07:46).The officer returned to the nursing station desk (06:08:14), and told Staff H, RN, who had arrived for day shift, that there was a resident who didn't get her pain meds and she needed them. Staff D, RN at this time was on the phone telling the on call manager that the prior nurse reported she had called the on call staff before she left. Staff D, RN was heard stating she was not touching the medication cart until it was counted (06:09:32). Staff H, RN then stated she would count the medication cart.At 06:21:27, Staff H, RN entered the resident's room, told the resident her name, stated she had just gotten there, and gave her a medication cup, telling her it contained tramadol and diazepam. The resident stated she also needed her baclofen and gabapentin. Staff H was not heard asking the resident what level her pain was prior to administering the medication. Staff H stated she would go get the other medications. Staff H, RN returned at 06:24:13 to administer the other medications, with again no pain assessment being heard on the video. The officer left the building at 7:01 am after confirming the medication carts had been counted with no concerns. The CMS document titled Psychosocial Severity Guide, dated October 2022, documented the following:Purpose - The purpose of the Psychosocial Outcome Severity Guide is to help surveyors determine the severity of psychosocial outcomes resulting from identified noncompliance at a specific deficiency (Ftag), including how to determine the severity of the outcome when the impact on the resident may not be apparent or documented. The Guide is used to determine the severity of a deficiency in any regulatory grouping (e.g. Quality of Life, Quality of Care) that resulted in, or may result in, a negative psychosocial outcome.The Guide defines Severity Level 4 Considerations: Immediate Jeopardy to Resident Health or Safety to be a situation in which the facility's non compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The guide listed examples of negative psychosocial outcomes as a result of a facility's noncompliance at severity level 4 to include, but not limited to:Crying, moaning, screaming, or combative behavior that is above the resident's baseline.Expressions (verbal and/or non-verbal) of avoidable pain that is severe, and more than transient. Pain is considered avoidable when there is a failure to assess, reassess, and/or take steps to manage the resident's pain.Staff A, Certified Medication Aide (CMA) was working at Station 2 (The area where Resident #3 resides) for the night shift of October 8, 2025 into October 9, 2025.On 10/13/25 at 12:13 pm, Staff A, CMA stated when she worked the overnight shift of 10/8/25, she was completing her rounds and did not witness the nurse assigned to that area leave. She stated another CNA told her she had put the keys down and walked out without counting the medication carts or giving any report on the residents. She stated when Res #3 was asking for medications, as well as other residents, she went to the other nursing station but that nurse was busy in a patient room. She said Staff B, CNA told her that the nurse had said she would not touch medications on the other hall because she didn't count them. She stated that nobody got their medications for her unit.Staff B, CNA was working at Station 1 (the opposite portion of the facility) for the night shift of October 8, 2025.On 10/13/25 at 12:28 pm, Staff B stated on the morning of 10/9/25, approximately 2:00 am, she was sitting at the desk of Station 1, with Staff D, RN when the nurse from Station 2 came to them and stated something about her son was being rushed to the emergency room, that his throat was closing up. Staff F said she had spoken to Staff E, LPN (the on-call manager) and Staff E was supposed to come in. Staff B stated after the other nurse left, Staff D, RN was very confused. She described Staff D as talking to herself, saying the other nurses hadn't given her any medication cart keys or counted the cart. Staff B recalled Staff D stating that since Staff E was coming in, they would figure it out. Staff B stated Staff C, CNA came to Station 1 a short time later asking if they knew where her nurse was and she and Staff D told her she had left. Staff B recalled Staff C telling them that she had told the other nurse 40 minutes earlier that a resident was needing an epi pen (epinephrine, used for emergency treatment of severe allergic reactions) and nobody had come. Staff B stated that Staff D, RN asked who needed help and asked if Staff C knew where the keys were. Then she stated they would wait for Staff E. She stated Staff D did not get up to go check on the resident and told Staff C she did not have any medication cart keys so she didn't know how she was supposed to help her. Staff B stated after that, she went to complete her rounding on residents and did not know if Staff D ever went to look for the keys or if any other staff members reported needing assistance. Staff C, CNA was working the overnight shift on October 8 at Station 3. A single nurse was assigned to both Station 2 and Station 3 as Station 3 has few residents.On 10/13/25 at 12:41 pm, Staff C, CNA stated when she arrived for the shift, she introduced herself to Staff F, RN as she had not worked with her before. She said it was a busy night and the residents of Station 3 were ringing the call lights a lot. She stated somewhere around 2:00 am, she told Staff F that there were some residents who were requesting medications. She said it was 30 or 40 minutes later, and she went and asked another CNA where the nurse was, and he said he was looking for her too. She said she returned to her station and waited another 10 minutes or so then went down to Station 1 and asked the staff there. She said they told her Staff F, RN had walked out. She stated she asked who was taking over and told them that Resident #6 was requesting an epi pen. Staff C said she then returned to her unit and checked again on Resident #6. She stated Res #6 was still up and was really anxious for a while but she eventually calmed down and said she would use her own epi pen. She said Res #6 was agitated but she administered the pen herself, then watched TV for an hour or so and said she was fine. Staff C, CNA clarified she had asked Staff D, RN if there was another nurse coming and she said that Staff F had left but Staff E was coming in. She stated Staff E had been in the building till sometime between 11:00 pm and midnight earlier in the shift. She said after she returned to her unit, things were fine until she saw the police arrive. She said Resident #6 had been really mad at first and had said she was having a reaction to the medications she was taking. At first Staff F, RN was still there and she reported this to Staff F. It was when she rang again later on when she could not find Staff F. She stated two other residents were asking for medications around the same time. One wanted some benadryl and one wanted something for pain and neither of them rang again the rest of the night so she assumed Staff F had given them the requested medications. She said the only resident who was having concerns after Staff F left on Station 3 was Resident #6.Staff I, LPN came on duty for the day shift of October 9, 2025 at Station 1. On 10/13/25 at 2:07 pm, Staff I, LPN stated she had arrived at around 5:45 am on 10/9/25. She stated Staff B, CNA had told her that Staff F, RN had left several hours earlier. She said she then went to speak to Staff D, RN, who told her she was the only nurse in the building. She said Staff D told her Staff F had left, and left the keys. She said Staff D also told her Resident #9 had walked down from Station 2 asking for her pain medication and she told her she couldn't give them to her. Staff I stated she responded to Staff D that it was resident neglect. She reported Staff D told her no, she could not give the medications and Staff I then asked her if anyone had been called to come in. She said Staff D told her that Staff F had called the on-call manager but nobody ever came, she had not counted the medication carts and she didn't know anything about the residents at Station 2 or Station 3. Staff I reported shortly after that someone came and told them that the police were in the building. Someone came down and asked who the nurse was and to come with him. She reported Staff D went with him and sometime later then she (Staff I) went down to Station 2 as well. She said the officer told her there was a resident in extreme pain and hadn't gotten her pain medication. She remembered Staff H was counting the cart so she could get the medication for Resident #3. She stated she didn't remember who else was there, and added she just could not believe that Staff D had done that, that it just baffled her. She said Staff D showed no sympathy for the residents needing medications or for anything else that happened on that end. She said they called Staff E, the Assistant Director of Nursing and Staff E had spoken to the Director of Nursing. She said later Staff E told her she had only received a text message during the night after two in the morning from Staff F telling her she was leaving for a family emergency, but she was sleeping and didn't see the text until later. She clarified that to her knowledge, Staff D, RN had not attempted to contact anyone between when Staff F left and when the EMS services and day shift arrived.Resident #9 did not wish to speak to the State Surveyor. Review of her MAR for October of 2025 (performed on 10/15/25 at 10:00 am) revealed an order for Percocet (A combination medication of Oxycodone/Acetaminophen, a narcotic given for pain). The MAR failed to reveal the scheduled 4:00 am dose for 10/9/25 had been administered. On 10/13/25 at 2:21 pm, Resident #3 stated she has a lot of chronic pain which can get really bad. She reported she takes baclofen, tramadol and gabapentin daily. She stated most times on the night shift, staff would bring her medications to her around 3:00 or 3:30 am. She stated it was about 3:45 am on 10/9/25 when she rang her call light and requested her medications. She stated she was in a lot of pain that morning. She felt the CNA who answered her call light was mad because she was screaming in pain. She stated she also asked her to refill her water and to empty her catheter and the staff member laughed at her. She stated the staff member slammed the door and left. She said it got to be later and later, nearing 6:00 am and she was in a lot of pain, and knew it was getting to be close to shift exchange. She said someone said the nurse had left at 2:00 in the morning. And the other nurse could not take over the cart. She stated that if Staff D had been scheduled on her hall, she never would have left her like that so she didn't understand it. She reported that is when she called 911 and requested an ambulance. She said the EMS crew arrived quickly, but she was so far behind in her pain control that nothing was helping. She remembered taking a diazepam before bed and had woken back up around 10:30 pm and started having pain then. She reported she had a salve she used for pain and it gave her some relief until around 3:00 am when she was again in a lot of pain. She stated she had told the night shift nurse that she wanted her medications around 3:00 or 3:30 am when she had spoken to her earlier in the shift. She said the EMS crew seemed shocked by how much pain she was in.On 10/13/25 at 2:51 pm, Resident #6 described the events of the early morning hours of October 9th. She stated she was getting very itchy and felt her face start to swell up. She reported this to the CNA and the nurse at that time came in and administered Benadryl. (Her October MAR documented she received 100 mg of Benadryl on 10/9/25 at 2:09 am, administered by Staff F, RN). She reported she tried to go to sleep after receiving the Benadryl and felt her right eye was swelling shut. She took a selfie on her phone at 2:09 am and when she wasn't able to get to sleep, repeated the photo at 2:40 am, with her face appearing slightly further swollen than in the first photo. She said she was going crazy with how badly she was itching and rang her call light again and reported to the CNA she needed an epi pen injection. She stated a nurse never came down to assess her or administer medication. She said that luckily she had her own epi pen in her purse in her room so she eventually administered it herself and began to feel better within 10 minutes of the injection. She reported her symptoms as a lot of itching and a swollen face and eye. She denied shortness of breath but reported she felt a lump in her throat. Resident #6 said Staff C was very nice to her and she asked if she had told the nurse she needed her. She said Staff C asked if the nurse had come to see her and sat with her in the lounge area for a while. She said she never did see a nurse the rest of the night shift.On 10/13/25 at 3:01 pm, Staff E, LPN, Assistant Director of Nursing (ADON) stated she was the manager on-call for October 8th and October 9th. She said she had worked in the building until 11:30 pm or later on the 8th. She went home and went to sleep. She stated Staff F sent her a text around 2:00 in the morning but it did not wake her. She said she woke up when Staff D called her around 6:00 in the morning and told her the police were in the building. She reported Staff D told her that she hadn't given any medications for Stations 2 or 3 because she had not counted the medication carts. She added Staff D was no longer an employee of the facility. She recalled Staff D told her she saw the other nurse leaving sometime around 2:00 am, carrying a bag on her shoulder. Staff E stated no employee called her until the call around 6:00 am. During those early morning phone calls, staff confirmed to her the day shift nurses had arrived and all the carts had been counted with correct medications. She stated when she arrived, the Medical Director was in the building and he told her that Resident #6 had an issue on the night shift and he told her the resident had self administered an epi pen. She stated she then went to speak to Resident #6. She described the look on Resident #6's face as that the resident appeared terrified. She stated when the Director of Nursing (DON) arrived, the facility started their internal investigation and the Medical Director wrote orders for a cocktail of medications for Resident #6 to take during an allergic reaction.Staff D, RN was assigned as the nurse for Station 1 for the night shift of October 8, 2025.On 10/13/25 at 3:15 pm, Staff D, RN stated her shift began at 2:00 pm on October 8th, scheduled to work 16 hours until 6:00 am on October 9th. She stated Staff F, RN was also scheduled to work 16 hours on Station 2. She stated she had two CNAs working with her, Staff B and Staff G during the overnight shift. She stated that sometime around 2:00 am, she happened to be at the desk, and she saw Staff F, RN walking out the door with her purse. She said Staff F told her that her son was sick and she needed to leave and that she had called the on-call and she was on her way in. She said Staff F was in a rush, she didn't give her any kind of report. She stated she should have called and told her what was going on but she just rushed out. Staff D said her expectation was that the on-call was on her way in like Staff F had told her she was. She stated the entire shift was busy and she didn't get a break during the entire 16 hours. She felt Staff E was coming in as a replacement and she had a lot of work to do. She stated she did go look for the medication cart keys but did not locate them. She did not call Staff E until several hours later when the police arrived. She said Staff E told her that nobody had called her earlier. The police asked her what happened and she told them the other nurse left at 2:00 am and left her alone in the building. She again stated how Staff F did not count the carts or give a report, she just ran away. She denied that any other staff ever asked her for medications at the other end of the building. When asked whether Staff C had spoken to her about Resident #6, she said that Staff C had told her she had reported to the prior nurse that she needed to see Resident #6, but Staff F did not ask her to follow up. When asked about Resident #9 coming to her and requesting medications, she stated Resident #9 tends to ask for her medications early and she was too busy to help her when she came to the desk. She stated she had planned to help Resident #9 at the time the police officers arrived. (Resident #9's medication was scheduled at 4:00 am, the police arrived at 6:00 am). On 10/13/25 at 3:31 pm, the Director of Nursing (DON) stated sometime after 6:00 or so, the ADON, Staff E, called her and told her the police were in the building. She said she was told that one of the residents had called the police for not getting her medications and there was only one nurse in the building. She stated other nurses arrived for shift exchange around that same time. She said during their internal investigation, they found Staff F, RN had apparently left sometime around 2:00 am and had told the other nurse, Staff D, RN that she was leaving. She described that Staff D had claimed that Staff F then just left the building and left the medication cart keys in the narcotic count books on top of each medication cart. She said that Staff D told her Staff F she had called the on-call. She said they reviewed the call log for the on-call manager's phone and there was no phone call in the log in the time frame of Staff F leaving the facility. She said that Staff D, instead of calling someone herself, she just didn't even check on the residents at Stations 2 and 3 and just left that end without a nurse. She stated at that time, Staff D was suspended due to patient neglect. She stated Resident #3 did receive all of her medications. She said Resident #3 has a history of requesting medications earlier than they are scheduled. She added Staff F was placed on the Do Not Return list through the staffing agency she is employed through and Staff D did end up being terminated. She acknowledged that Resident #6 did have an allergic reaction, which began prior to Staff F leaving. She stated that Resident #6 had an autoimmune disorder which causes a lot of allergies. She stated when Resident #6 symptoms came on, a nurse didn't get there in time and she self administered her epi pen. She added the medical director wrote new orders that morning, and the facility did a self administration safety assessment. She stated Resident #6 had given herself an epi pen many times (prior to facility admission) and knows how to do it. She added Res #6 keeps an epi pen at her bedside and there is also one in the medication cart. She said they added a special bell in her room that she rings only in the event of an allergic reaction and also that Res #6 has the DON phone number and can call her at any time. The DON clarified that they had asked Staff D if she had gone down to check on residents on the other side and she stated she had not. She said they asked her why and she stated she was too busy on her side and had too much going on. She said they also asked her if anybody had come and reported anything to her and she stated no, and again said she was too busy. She reported they then asked Staff D if she had called anyone to come help and she replied no because Staff F had told her that the ADON had been called and nobody came. The DON described that they reiterated to Staff D, did she call anyone and she replied no. The Corrective Action Form of Staff D stated, Staff D was notified by the other nurse in the facility around 2:00 am that she was leaving. This left Staff D as the only nurse in the building until the next shift came in at 6:00 am. Staff D did not call the on-call nurse to have another nurse come to the building. Staff D refused to provide care for any residents that were outside of h[TRUNCATED]

Based on family and staff interviews, resident record review, and policy review, the facility failed to verify resident identity to ensure accurate resident antipsychotic medications were ordered upon admission for 1 of 3 residents reviewed (#56). The facility failed to identify the discrepancy which prevented Resident #56 from receiving antipsychotic medications for two (2) weeks. This resulted in psychosocial harm to Resident #56 due to exacerbation of psychosis, agitation, antipsychotic medication withdrawal symptoms, and subsequent hospitalization with a worsening sacral pressure ulcer. The facility reported a census of 84 residents. Finding include: On 5/13/25, Resident #56 indicated she believed she had been hospitalized but wasn't sure. On 5/13/25 at 12:00 PM, Resident #56's family member verified Resident #56 transferred from another Long-Term Care (LTC) facility on 4/17/25. She stated a facility staff member contacted her on 5/01/25 and reported Resident #56 looked out of it. She also stated when she arrived to the facility, Resident #56 looked like she had a stroke with left-side affect and was sent to the hospital because she appeared to have had a stroke. She added Resident #56 did not meet admission criteria to the first hospital due to her declined physical abilities. She further stated when she questioned the Director of Nursing (DON) if Resident #56 received her psychotropic medications, the DON confirmed the orders the facility received and entered into the Electronic Health Record (EHR) were not for Resident #56. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of hypertension, Gastroesophageal Reflux Disease (GERD - acid reflux), hypothyroidism, schizoaffective disorder, and Fibromyalgia (chronic condition that causes musculoskeletal pain, fatigue, and memory, mood, and sleep disturbances). It revealed the resident was independent with repositioning in bed; required setup assistance with eating; supervision with oral hygiene, personal hygiene, sit-to-lying, and lying-to-sitting; moderate assistance with toileting, dressing, and all transfers and mobility; and maximal assistance with bathing, and footwear. It also indicated the resident did not exhibit physical or behavioral symptoms directed at others or herself nor had she rejected care. It also indicated she was occasionally incontinent of bowels and frequently incontinent of urine. It further indicated she was at risk of developing pressure ulcers but did not have any. It revealed she received antidepressants but not antianxiety or antipsychotic medications within the 7-day look-back period. The resident's initial Order Summary Report (list of current orders) was scanned into Resident #56's EHR on 4/15/25 by the Director of Admissions and Marketing. It contained the resident's name, date of birth, allergies, and transferring facility. The Order Summary Report included the following medication orders: a) Benztropine Mesylate Oral Tablet 0.5 MG Give 0.5 mg by mouth every morning and at bedtime for involuntary movements related to other long term (current) drug therapy b) Levothyroxine Sodium Oral Tablet 175 MCG Give 1 tablet by mouth one time a day for hypothyroidism c) Olanzapine Oral Tablet 10 MG (Olanzapine) Give 10 mg by mouth at bedtime for mood related to Schozoaffective disorder, unspecified with 20 mg tab at bedtime d) Olanzapine Oral Tablet 20 MG (Olanzapine) Give 20 mg by mouth at bedtime for mood related to Schozoaffective disorder, unspecified give with 10 mg Olanzapine e) Seroquel Oral Tablet (Quetiapine Fumarate) Give 50 mg by mouth in the morning related to Schozoaffective disorder, unspecified f) Seroquel Oral Tablet (Quetiapine Fumarate) Give 75 mg by mouth at bedtime related to Schozoaffective disorder, unspecified The Medication Administration Record (MAR) dated April 2025 revealed Resident #56 did not receive any of the aforementioned medications between 4/18/25 and 4/30/25. The Physician Orders revealed the aforementioned medications were ordered on 5/01/25. A Progress Note dated 4/24/25 revealed Resident #56 expressed a strong desire to return home and appeared somewhat emotional. Subsequent progress notes dated 4/30/25 by Staff GG, Licensed Practical Nurse (LPN) revealed Resident #56 refused all her morning medications because the meds are poisoned and she would not take them. A secondary progress note indicated Resident #56 had been refusing all meds and did not enjoy any of the food. It also revealed the resident complained of generalized all over discomfort/pain, did not want staff to get her out of bed, and stated she wanted to see Jesus, she was dying and wanted to drop dead. A Progress Note dated 5/01/25 revealed Staff M, LPN documented the resident's orders the facility received upon admission were incorrect and Resident #56 had not been receiving her psych meds since admission on 4/17/25. It further revealed she was slurring her words that afternoon, was calling staff names, and her eyes were observed to be glossed over and jumping when neurological system was checked. A Progress Note dated 5/05/25 revealed Staff H, LPN documented the resident refused all meds over the weekend and refused all meds and cares that morning. This nurse and two other nurses attempted to give her meds but the resident cursed and yelled at every attempt. New orders were obtained to send the resident to the hospital for a psych evaluation. A Progress Note on 5/08/25 indicated the resident returned from the hospital with a stage 3 sacral pressure ulcer. The Care Plan dated 4/18/25 included information accurately applicable to Resident #56. It also included her date of birth. The resident's hospital notes for 5/06/25 date of service revealed the resident received the following medications: a) 5/05/25 at 9:54 PM - Quetiapine Fumarate 300 mg b) 5/06/25 at 2:29 AM - Haloperidol Lactate 2.5 mg c) 5/06/25 at 3:30 AM - Haloperidol Lactate 5 mg On 5/13/25 at 4:02 PM, the DON stated she received Resident #56's admission paperwork and gave it to Staff AA, former Assistant Director of Nursing (fADON) to complete the admission process which included entering admission orders into Resident #56's EHR. The DON also stated the original admission paperwork could not be located. She provided the Cover Letter and Order Summary Report the Director of Admissions and Marketing electronically sent her on 4/17/25 at 10:08 AM. She stated Staff AA, fADON would've entered the admission data and orders in the EHR because the resident was admitted to her unit. She clarified that another ADON could have entered the orders. The Cover Letter and Order Summary Report revealed the information was for a resident at a different Long-Term Care (LTC) facility with the same name and psychiatric provider but different date of birth. It also contained a statement OK. For transfer to <facility name> continue same medications and treatments Follow-up with Primary Care Physician (PCP) there - <receiving ARNP name> goes there from <provider's group> if desired. It was signed by the transferring Advanced Registered Nurse Practitioner (ARNP). The EHR for Resident #56 revealed five documents with an accurate resident date of birth identifier were scanned and available prior to her admission on 4/17/25. On 5/13/25 at 4:33 PM, Staff P, Director of Admissions and Marketing stated he receives a face sheet (demographic sheet), History & Physical (H&P), medication list, and PreAdmission Screening and Resident Review (PASRR - screening tool used for appropriate Long-Term Care (LTC) facility placement for people with mental health illness or disabilities) prior to a resident's admission. He provided a document of resident information that is required (name, date of birth, SSN, demographics sheet, rehabilitation notes, History & Physical, medication list, PASRR, sex offender check) prior to the resident admission and stated he loads the documents into the EHR. He indicated Staff D, LPN ADON was responsible for reconciliating the resident's information. On 5/14/25 at 8:02 AM, a staff member at the different LTC facility confirmed the resident with the same name still resided there and still received care by the same psychiatric provider. On 5/14/25 at 9:00 AM, Staff D, LPN ADON stated previously, ADON's usually did their own admission but would enter other admission's orders if needed. She also stated she usually enters orders for others, if needed, but completes all of her own admissions. She further stated after she enters the orders, she usually gives the ADON of the admitting unit the orders back so they can check the orders. She indicated the admissions department gets orders, scans them into the EHR, and brings the paper copies to the ADONs. The ADONs enter the orders in the EHR, faxes them to pharmacy, and returns the paper to the admitting unit ADON. She stated the 6 rights of medication administration (patient, medication, dose, route, time, documentation) should be verified while entering the orders but admitted she did not confirm the 6 rights when she entered them into the EHR. She stated she took the paperwork to Staff AA, fADON who should have verified the reconciled orders. On 5/14/25 at 4:50 PM, the fDON stated the medication order error was identified by the resident's sister on 5/01/25 and corrected. The resident was sent to the hospital, returned, and resent on 5/05/25. On 5/15/25 at 8:29 AM, the medical provider's office director stated the transferring ARNP wrote the order but would not have been the one to have sent it. 5/15/25 at 8:48 AM, the transferring ARNP stated she was not directly involved in the transfer process. Her understanding was she believed the facility sending the resident is who sends the paperwork to the accepting facility. On 5/15/25 at 10:03 AM, the medical provider's office director stated his office received an email from the transferring facility which indicated Resident #56 was being admitted to another facility. The provider's office staff pulled a similarly named resident's file and sent it to the transferring facility which was signed by the practitioner. He also stated his staff nor the practitioner verified the date of birth to ensure the correct resident orders were sent to the facility. On 5/15/25 at 10:29 AM, the Director of Admissions and Marketing provided an email that he received the admission orders from the transferring facility staff on 4/17/25 at 9:54 AM. On 5/19/25 at 2:59 PM the contracted Pharmacist stated the potential risks of abruptly stopping Resident #56's Seroquel could lead to rebound psychosis (return of psychotic symptoms and potential physical symptoms such as agitation, difficulty sleeping, and not feeling well. He also stated abruptly stopping her Olanzapine could result in Parkinson-type symptoms such as tremors, rigidity, or return of extrapyramidal symptoms that may or may not resolve over time. On 5/19/25 at 3:25 PM, the facility provided a provider encounter note that revealed Resident #56 had a re-admit and post-hospitalization for psychotic episodes and a urinary tract infection (UTI). It also revealed some of her medications were not started at admission and she was showing signs of psychiatric distress and altered mental status on 5/1/2025. It further revealed she was sent to the ED where she was given a dose of Olanzipine. She returned to the facility with no new orders. Discussed restarting Olanzipine and Seroquel. Tapering them up to previous doses. The note continued that the resident was re-sent to the ED and admitted to hospital on 5/5/25, returning to the facility on [DATE]. She got a pressure area to her coccyx during hospitalization , following by wound Nurse Practitioner. The Psychiatric Consultation from the hospital dated 5/5/25 documented the following entries; Patient is seen at bedside in the Emergency Department (ED) today, she is resting with her eyes closed. When approached she states You gave me Prolixin, I can't have that. I'm a Medical Doctor (MD), what are they? I know they are all below me. Advised patient we did not give her any Prolixin and attempted to ask about her medications, she states she is taking Only Latuda, my heart medication, and Levothyroxine for my high thyroid. Patient is adamant she has hyperthyroidism instead of hypothyroidism. She states her mood is shit because I'm in Hell. She is unable to elaborate on this statement. She does deny SI, HI but tells this resident she is done speaking and declines further interview. Psychosis: Endorses being an MD and that everyone else is beneath her and states she is talking to God. She also states we gave her Prolixin in the ED which was not done. Psychiatric treatment: - START Quetiapine XR 300 mg oral at bedtime for mania, psychosis, mood stabilization - Start Quetiapine 25 mg oral every 6 hours as needed for agitation OR Haloperidol 2.5 mg IM every 6 hours as needed for severe agitation ED MD Note dated 5/5/2025 documented as follows: Resident#66 presented to the ED via EMS for altered mental status, behavioral issues and medication noncompliance. History obtained from patient and nursing staff at the Royal Oaks nursing and rehabilitation center; external records reviewed. Vitals on arrival were largely within normal limits and nonconcerning. Pertinent workup was obtained to assess the patients' current medical condition. All data - including labs, imaging and EKG's - were independently interpreted and integrated into the clinical decision-making process. Royal Oaks nursing staff was contacted upon patient's arrival. Patient was without her psychiatric medications for the past 2 weeks. Due to this and her altered mental status, an expanded diagnostic workup was obtained. CT head was negative for any acute intracranial process. Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) were largely unremarkable. Liver enzymes were mildly elevated, but this was similar to prior. Polly ingestion labs were negative but the patient's TSH was elevated at 27.700 with a free T4 low at 0.5. Per chart review, this was worse than [AGE] years ago. Troponin was mildly elevated but EKG was reassuring against cardiac ischemia and her urinalysis was questionable for an underlying infection. On reevaluation, patient continued to become more altered. She was saying that she was a medical doctor and that everybody around her was below her. Due to her underlying psychiatric history with recent medication noncompliance, IP psychiatry was consulted. They recommended admission to the hospital under geriatric psychiatry with internal medicine as a consult due to her hypothyroidism and concern for polypharmacy. The case was further discussed with Dr. <name redacted> (IM) who agreed to consult on the patient and she was ultimately admitted under Dr. <name redacted> (Psychiatry). While in the ED, patient was restarted on her Quetiapine and as needed Haldol was ordered. Her presentation is most consistent with an acute psychiatric illness. Her labs are concerning for hypothyroidism, but her presentation is not consistent with myxedema coma as she is without hemodynamic instability, bradycardia or hypothermia. Patient was made aware of admission. Admitting team(s) to reassess and adjust care as needed. On 5/19/25 at 11:06 AM, the DON stated staff are expected to enter the correct orders. On 5/20/25 at 3:00 PM, Staff AA, ADON stated she was not working the week Resident #56 was admitted and did not receive the admission packet that accompanied the resident. A policy titled Reconciliation of Medications on admitted d 2001 indicated when a resident is transferred to another facility, or within the organization, the reconciled medication list will be sent to the receiving care provider and the communication will be documented. It also directed staff to; 1. Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form; b. Discharge summary from referring facility; c. Admission order sheet; d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent Medication Administration Record (MAR), if this is a readmission. 2. Find a quiet place that is free from distractions.

Based on clinical record review, hospital record review, resident and staff interviews, facility education review and facility policy review, the facility failed to ensure safety during transfers for 1 of 3 residents reviewed (Resident #61). This failure caused harm when Resident #61 was improperly transferred in the shower room, resulting in a fall with two fractures. These fractures caused the resident to have an increase in pain, a need for increased pain management and a decrease in her ability to transfer. During observations of other residents, the facility additionally failed to properly use a full body mechanical lift in a safe manner and per manufacturer's instructions for Residents #4, #17 and #39. The facility reported a census of 84 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) of Resident #61 dated 3/13/25 identified a Brief Interview for Mental Status Score of 15 which indicated cognition intact. The MDS coded the resident required partial/moderate assistance to move from sitting to standing and for shower transfers. The MDS documented diagnoses which included seizure disorder or epilepsy. The MDS recorded the resident experienced pain during the 5-day look back period and rated her pain as moderate and over the last 5 days had rarely or not at all limited her day to day activities because of pain. The Care Plan of Resident #61 identified a Focus Area of ADL (Activities of Daily Living) Performance Deficit, initiated on 12/13/24, revised on 4/22/24. The interventions included a transfer status of one staff participation with transfers, dated 12/13/24. The Care Plan reflected this status was changed to assistance of two staff members with a full body mechanical lift, revised on 5/1/25. The Care Plan additionally identified a focus area of a left fibula fracture after a fall dated 4/25/25 and an additional care area of leg numbness and weakness due to fibula fracture as well as prior laminectomy surgery (a surgical procedure of the spine to relieve pressure on the spinal cord or nerves), initiated on 5/8/25. The Care Plan identified an additional focus area of acute pain due to fracture of the left fibula initialed 5/8/25. Facility Incident Report #2833, dated 4/20/25 at 10:00 am identified a fall incident with the following information: Nursing Description: Staff stated that she was transferring resident to a shower chair and the resident fell . Resident Description: Resident stated she fell and jammed her knee against the wall. Then she fell on left hip. Fall Intervention: Resident to have proper footwear on feet and utilize staff assistance when transferring. Predisposing Situation Factors: Bare feet or inappropriate footwear. The impression findings of radiology reports from a local hospital dated 4/20/25 documented an acute-appearing minimally impacted proximal left fibular diaphyseal fracture, localizing proximal to a chronic-appearing fibular deformity (a fracture near the top part of the left fibula, the smaller bone in the lower leg. Appears recent but is near an area of an older deformity or previously healed injury) On 5/12/25 at 9:42 am, Resident #61 stated a staff member (Staff A, Certified Nurse Aide [CNA]) had taken her from her room to the shower room in her wheelchair. She stated once in the shower room, she was standing up, trying to reach for the grab bars. She said she lost her grip and fell to the floor. She stated Staff A was aware she was attempting to stand but did not offer assistance but that she was behind her. She stated Staff A apologized to her, telling her she was so sorry after the fall. Resident #61 stated when she fell she started screaming in pain. On 5/13/25 at 1:14 pm, Staff B, Registered Nurse (RN) stated she was working at the time Resident #61 suffered her fall, although she was not assigned to the resident. She said Staff A, CNA came out of the shower room for assistance explaining the fall. When Staff B entered the shower room, she noted Resident #61 was barefoot, and there was no gait belt (a safety device used to assist patients with limited mobility during transfers and walking. It provides a secure grip around the patient's waist, allowing caregivers to help with balance, prevent falls and guide them safely between surfaces) observed on the resident or anywhere in the room. She stated the shower floor was wet. She noted the position of the resident's chair and the position the resident was lying in and asked Staff A what had happened. Staff B stated Staff A had turned away from the resident with no gait belt on and wearing no footwear. She stated Resident #61 during the post fall assessment asked Staff B to pray with her and that she was in a lot of pain. Staff B described the shower room as when a person enters the room, and goes towards the back left, there is a corner where the shower chair is kept then a half wall separating the storage stall from the shower stall. She stated Staff A had pushed Resident #61 into the shower stall, near the grab bars in her wheelchair. She believed Staff A had left Resident #61 to grab the shower chair. She said that Staff A had told her that she had stood the resident up at the grab bars and then stepped away to get the shower chair which was out of reach, and that is when the resident fell . On 5/13/25 at 2:44 pm, Staff A, CNA stated she assisted Resident #61 from her room to the shower room via wheelchair. She stated she was getting ready to switch her into the shower chair. She said the resident had partially stood up and she (Staff A) reached for the shower chair to place it under her. She stated the resident had a reaction or something. She felt the resident's mind had just blanked for a moment, her hand fell off of the grab bar and she fell . Staff A stated she thought the resident was barefoot but may have been wearing socks. She said the resident was clothed from the waist down. She said she had turned her head away from the resident for only about two seconds and the resident slipped. She verified she had not used a gait belt during the transfer. She then went for help and found Staff B first and asked her to come help. On 5/13/25 at 4:04 pm, the Administrator stated the resident was barefoot at the time of the fall She stated any resident who is a one staff member assist would require the use of a gait belt. She confirmed a gait belt was not used during the transfer. The Administrator stated the resident now required a two person assist using a full body mechanical lift due to her fracture and her weight bearing status. She stated the resident's pain had increased, especially when she returned from the hospital and began working with physical therapy. She stated due to the facility not being able to get the resident's pain under control, they sent her back to the hospital for a second evaluation. The Administrator stated that during the second hospital visit, a Computed Tomography (CT scan) was performed and a second fracture was found on the CT scan. The Administrator stated she felt that having not known about the second fracture (a tibial fracture, the larger and stronger of the two bones of the lower leg), her leg was not stabilized and working with therapy increased her pain in the leg. She stated following the fall, transfer audits and education to staff were started immediately. The CT scan dated 5/7/25 identified a subacute (delayed related) fracture of the proximal tibial metaphysis with a slightly greater displacement compared to prior study (a fracture near the top of the shinbone, which has shifted slightly more since the prior imaging. The fracture was at the wider part of the bone shaft, near the knee joint.) The hospital notes dated 5/7/25 documented the resident presented to the emergency department for evaluation of left lower extremity pain. It stated the resident had sustained a left fibular fracture on 4/20/25 after a fall and was discharged back to the facility for rehabilitation. The note documented that despite taking Oxycodone (a narcotic pain medication) the resident had continued to experience left lower extremity pain radiating from her knee to her ankle, worse with movement as well as swelling of the lower extremity and chronic numbness. The Assessment/Plan notes stated she would be kept NPO (no food or drink) for potential surgical intervention and be admitted inpatient to the hospital. The orthopedic physician who saw her during this hospitalization documented that another physician would plan for a surgical revision of knee arthroplasty (knee replacement) within the following week. The Medication Administration Report (MAR) of Resident #61 for April of 2025 documented the resident had an order for Tramadol (a less potent opioid pain medication) scheduled twice a day which was discontinued on 4/25/25. A new order for Oxycodone, 5 mg every four hours as needed began on 4/25/25 and was discontinued on 4/28/25. At that time, the order was changed to be scheduled four times a day. The Pain Scale portion of the resident's Electronic Health Record documented that in the month prior to the fall, the resident rated her pain as zero on most days, with other days rating her pain as high as a 6 out of 10. On the day of the fall, 4/20/25, she rated her pain a 10/10. The following dates leading up to her second hospitalization , she rated her pain anywhere from 0 up to a 10 with greater than 10 instances of rating her pain at an 8 or above. The Consult report from a local hospital dated 5/13/25 documented the resident was hospitalized following left total knee arthroplasty revision performed on that date. Per this note, the resident's pain was poorly controlled, rated 8/10 and was requiring 2 liters of oxygen. The Medication Discharge Report dated 5/19/25 documented the resident's order for pain management to be Oxycodone, 5 mg, every 8 hours as needed for pain (severe 7-10) and acetaminophen, 1000 mg every six hours. The Progress Note dated 5/20/25 at 12:05 am documented the resident had returned from the hospital on 5/19/25 at 6:00 pm following her knee surgery six days prior. The Progress Note dated 5/20/25 at 2:06 am documented the resident requested pain medication at 1:10 am. The staff provided 500 mg of acetaminophen first, followed by Oxycodone half an hour later. The resident voiced these interventions were ineffective and stated she wanted to go to the hospital and would call 911. The staff contacted the physician on call and received orders for Morphine (an opioid pain medication) which was administered. The Progress Note dated 5/20/25 at 10:34 am documented the Advanced Registered Nurse Practitioner (ARNP) was notified of the resident's pain being uncontrolled during the overnight shift. The ARNP wrote orders to resume prior pain medication orders of 7.5 mg of Oxycodone scheduled every 8 hours and an additional 5 mg as needed every 8 hours. The facility provided undated records of Educational Inservice with topics of Proper Footwear and Gait Belt Education. The subject lines noted the following: A. Proper Footwear: All residents must have proper foot wear on when being transferred. Examples are gripper socks or tennis shoes. Do not transfer barefoot. B. Gait Belt Education: Gait belts are to be worn with all transfers. Must be around the resident's waist with about a finger wiggle room between belt and waist so belt does not slide up when transferring. On 5/14/25 at 1:49 pm, Staff M, Licensed Practical Nurse, Assistant Director of Nursing (LPN, ADON) stated education for staff began the day of the fall, on 4/20/25. She stated the education continued over several days until all staff had been educated. 52637 2. Review of Resident #39's Significant Change MDS dated [DATE] revealed diagnoses of Stage 3 pressure ulcer of left heel, non-traumatic brain dysfunction, non-Alzheimer 's dementia, senile degeneration of the brain not elsewhere classified and chronic peripheral venous insufficiency. The MDS further revealed total dependence or assistance of 2 or more helpers for toilet hygiene, personal hygiene, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer and tub/shower transfer. In addition, the MDS indicated the resident is unable to ambulate. Review of Resident #39's Care Plan revealed interventions for transfers initiated 3/10/20 and revised 4/11/25 as assist of 2 with a full body mechanical lift. Observation of Staff F, Licensed Practical Nurse (LPN) and Staff I, CNA, began on 5/13/25 at 9:25 am. The two staff transferred Resident #39 from her wheelchair to the bed using a full body mechanical lift. When raising Resident #39 from the wheelchair in the mechanical lift sling, the legs of the lift were observed to be extended. Staff retracted the legs of the lift when moving Resident #39 to the bed. On 5/13/25 at 9:25 am, Staff I CNA stated the legs of the lift were opened only to get around the wheelchair and then they are to be retracted. Staff F did not make a comment. On 5/14/25 at 8:45 am, Staff F stated that the legs are extended to get around the wheelchair as well and then retracted. Staff F then demonstrated the use of the full body mechanical lift the way Staff F had described. 49990 3. The Significant Change MDS for Resident #17, performed on 12/16/2024, documented the following relevant diagnoses: Heart Failure, Hypertension, Peripheral Vascular Disease, Arthritis, and Hemiplegia or Hemiparesis (partial paralysis). It documented the resident was fully dependent on staff for all transfers and most cares. The Care plan for Resident #17, last revised on 4/23/2025, documented the resident required a mechanical lift transfer and assistance of two staff members with initiated date of 12/15/2015. A direct observation on 5/12/2025 at 4:07 pm revealed Staff Q, CNA, and Staff O, CNA, performing a two-person full body transfer with a mechanical lift for Resident #17. During the transfer the adjustable base of the mechanical lift was in the closed position while transferring across the room. During the transfer the resident was observed to tilt and the mechanical lift wobbled. 4. The Significant Change MDS for Resident #4, dated 2/7/2025, documented the following relevant diagnoses: Cerebrovascular event (stroke), Paraplegia, and seizure disorder. It further documented the resident was fully dependent on staff for all transfers. The Care Plan of Resident #4, last revised on 5/12/2025, documented the resident required two-person assistance for transfers in a full body mechanical transfer. During an observation on 5/12/2025 at 4:17 pm, Staff Q, CNA, and Staff O, CNA, performed a full body mechanical transfer using a mechanical lift for Resident #4. During the observation, the adjustable base of the mechanical lift was in the closed position, and Resident #4 was observed to tilt and wobble, at one time appearing to lift slightly off the floor as she was transferred across the room. The adjustable base of the mechanical lift was not opened until it needed to be opened to fit around the resident's wheel chair and closed during the transfer across the room. In an interview on 5/15/2025 at 10:41 am, Staff O, CNA, was unable to describe safe transfer technique with a full body mechanical lift. She was unaware what position the adjustable base should be in during transfers. She stated the legs of a mechanical lift must be in the closed position at all times. This finding is discrepant from appropriate transfer techniques for the machine that was used. In an interview on 5/15/2025 at 12:05 pm, Staff K, CNA, stated the mechanical lifts only move if the legs of the adjustable base are in the closed position due to age of the machines. She stated she has noticed side to side movement and residents swinging back and forth on the lift when transferring them with the legs closed. In an interview on 5/15/2025 at 10:43 am, the Director of Nursing (DON), she stated staff are instructed to follow the manufacturer's recommendations for the positioning of adjustable bases, and acknowledged that failure to follow those recommendations could result in injury. Review of the user manual for the mechanical lift used during the observations, with a copyright of 2022, documented the following on page 12: It warns users that failure to follow these instructions creates a potentially hazardous situation which could result in injury or death. The Manual instructs as the user that the adjustable base of the lift must be in the maximum/open position before lifting and while transferring residents short distances. It again warns the user that failure to follow these instructions could cause the model to tip, potentially causing injury. The facility provided document titled Transfer with a mechanical lift, long-term care, revision date November 15th, 2019, documented the following: Set the mechanical lift's adjustable base to its widest position to help ensure optimal stability. The facility policy Gait Belt Use, revision date 5/27/2021 documented the following: Policy statement: Nursing staff may utilize gait belts on residents who need one- person assistance or more for transferring and ambulation unless the use is contraindicated. Gait belts can be used to promote ambulation by providing increased security for resident and staff and to provide a firm, grasping surface for staff to help protect the resident from accidental trauma to the skin. Gait belt use should be included in the resident's medical record when indicated. Guideline: Using a gait belt while transferring or walking with a resident can provide you and the resident with increased safety and security. You can help control a resident's balance and keep the resident from falling by using a gait belt. Point 9: Instruct the resident to be ready to stand at a predetermined signal. Simple instructions are to tell the resident to be prepared to stand on the count of three. Point 13: If the resident loses their balance, use the belt to help them regain it. Point 14: If the resident begins to fall, and you cannot prevent it, slowly lower them to the floor, using the gait belt to help control the descent. It is also helpful to let the resident slide down your leg if possible for a safe, controlled assist to the floor.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to follow professional standards of practice as they allowed the Unit Managers/Supervisors to draw up liquid Morphine (pain medication) and Lorazepam (anti-anxiety medication) in one (1) milliliter (ml) syringes and placed them labeled and unlabeled in the medication carts 3 residents (Res #8, #11 and #13). The staff that drew up the medications failed to dispense the medications and were not licensed pharmacists. The facility also failed to provide sufficient detail to enable an accurate reconciliation and drug records in order to account for all controlled drugs. (Res #2 and #13) The facility identified a census of 83 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 11, 2024 at 3:21 p.m. The Facility Staff removed the Immediate Jeopardy on November 22, 2024 through the following actions: a. Assessment of all medication carts and treatment carts for assurance all medications and treatment ointments/creams and etc. were appropriately labeled. b. Staff education on appropriate labeling and administration of narcotic and anti-anxiety medications. c. Medication administration education updates dated November 20, 2024. d. Destruction of all liquid narcotic and anti-anxiety medications on November 15 2024. e. Pain assessments on all residents completed November 20, 2024. f. QAPI meeting conducted on November 20, 2024. g. Assurance of ongoing monitoring and review. The scope lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures Findings include: 1. During an observation and interview 11.20.24 at 10:10 a.m. revealed a plastic container in the Terrace A and B medication cart contained nine (9) unlabeled Morphine syringes as identified by Staff I, Licensed Practical Nurse (LPN) who confirmed the Nurse Managers/Supervisors drew up liquid Morphine and Lorazepam in unlabeled syringes for 2 months. During an interview 11.20.24 at 10:40 a.m., Staff A, LPN/Nurse Manager/Supervisor confirmed she pre-drew up the liquid Morphine as an estimate to how many a resident may have used in a 24 hour period of time based on the Physician orders. At 10:45 a.m. the staff member confirmed she pre-drew up Resident #13's Morphine syringes, not labeled. During an interview 11.20.24 at 10:40 p.m., the Interim Director of Nursing (DON) confirmed the above described liquid Morphine for Resident #13 had been pre-drawn on 11.17.24 at which time Staff A changed her verbiage and indicated she drew up resident's Morphine and Lorazepam every 24 hours as needed (PRN). During an interview 11.20.24 at 11:31 a.m., Staff J, LPN verbalized frustration because she had pulled Staff A aside that morning and told her the above documented practice had not been acceptable. An email dated 12.20.24 at 1:15 p.m. addressed Staff A pre-drew up liquid Morphine and/or Lorazepam for Resident #8, #11 and #13. 2. Review of the Controlled Drug Record form for Resident #2 with the first date of 11.1.24 revealed several open spaces where staff failed to reconcile Pregabalin (Gabapentin) 100 milligram (mg) tablets delivered on 10.25.24 at a count of 90 pills. According to an email dated 12.13.24 at 12:44 p.m. the Director of Nursing (DON) confirmed the facility staff failed to count the medication with two (2) staff members according to policy and procedure on 11.1.24 ,11.3,11.4, 11.7 thru 11.19, 11.25, 11.29, 11.30 and 12.1 thru 12.4.24. 3. Review of the Controlled Drug Record form for Resident #13 with the first date of 12.3.24 revealed several open spaces where staff failed to reconcile Morphine Sulfate Solution 20 mg/ml. delivered 12.3.24 with the amount of 30 cc/ml in the bottle. According to an email dated 12.13.24 at 3:17 p.m. the DON confirmed the facility staff failed to count the medication with 2 staff members on 12.3 thru 12.12.2024. Review of the Controlled Drug Record form for Resident #13 with the first date of 12.10.24 revealed several open spaces where staff failed to reconcile Fentanyl patches. According to an email dated 12.13.24 at 3:33 p.m. the DON confirmed the facility staff failed to count the medication with 2 staff members 11.23, 11.24, 11.26, 11.27, 11.29, 11.30, 12.1, 12.3, and 12.4. A Storage of Medications policy revised 4.2007 indicated the Policy Statement included the following: The facility should have stored all drugs and biological's in a safe secure and orderly manner. The Policy Interpretation and Implementation included the following: a. Drugs and biological's should have been stored in the packaging, containers or other dispensed systems in which received. Only the issuing pharmacy had been authorized to transfer medications between containers. b. Drug containers that had missing, incomplete, improper or incorrect labels should have been returned to the pharmacy for proper labels before storage. The facilities Controlled Substances policy revised 12.2021 indicated the Policy Statement included the following: The facility complied with all laws, regulations and other requirement related to handling, storage, disposal and documentation of Schedule II and other controlled substances. The Policy Interpretation and Implementation included the following: a. The Charge Nurse on duty maintained the keys to the controlled substance containers. The Director of Nursing (DON) would maintain the set of back-up keys for all medication storage areas which included the controlled substance containers. b. Nursing staff must have counted controlled medications at the end of each shifts. The nurse that came on duty and the nurse that went off duty counted together. They must have documented and reported any discrepancies to the DON. c. The DON maintained and disseminated to appropriate individuals a lit of personnel who had access to medication storage areas and controlled substance containers.

Based on clinical record review, staff interview, and facility policy review, the facility staff failed to ensure a resident who needed respiratory care was provided oxygen for a doctor's appointment for 1 of 3 residents reviewed for oxygen use (Resident #4). The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had diagnoses of heart failure, breast cancer, and seizures. The MDS documented the resident had severely impaired cognition. The MDS indicated the resident had shortness of breath when lying flat and used oxygen. The Care Plan revised on 8/7/23 revealed Resident #4 on oxygen therapy related to a respiratory illness. The staff directives included to apply oxygen as ordered. The Order Summary Report revealed an order started on 8/4/23 for continuous oxygen at 2-4 liters (L) per nasal cannula (NC) to keep oxygen greater than 88 % (percent), and monitor oxygen every shift. The Treatment Administration Record revealed documentation of oxygen set at 3 L and oxygen saturation 93% on 11/6/23. A physician's Progress Note dated 11/6/23 revealed Resident #4 arrived at doctor's office again without any oxygen (which she required chronically) and the clinic had to supply with hospital supplies. This had happened multiple times on 7/24/23 and 11/6/23 and is poor patient care. This resulted in mismanaged time away from the appointment time and caused the patient distress. During an interview on 11/27/23 at 1:55 PM, clinic staff reported the facility sent Resident #4 to her appointment on 11/6/23 without oxygen. The resident needed oxygen 24/7. This was the second time this had happened. The first time the resident came to her appointment without oxygen was on 7/24/23. The resident appeared to struggle without oxygen. A pulse ox was taken, and it was 91 %. The pulse ox reading was 98 % after oxygen applied. The clinic staff reported the resident would've went approximately two hours without oxygen if they had not been able to get her supplemental oxygen there. The timeframe included travel time to and from appointment and time at the appointment. During an interview on 11/30/23 at 4:35 PM, the Director of Nursing (DON) reported whenever a resident is on oxygen and went to a doctor's appointment, she expected the resident continued on oxygen and an oxygen tank went with the resident. The DON stated there had been times when a resident went to an appointment without oxygen. Resident #4 supposed to be on oxygen at all times. The facility switched oxygen vendors in 9/2023. The former respiratory vendor came and took Resident #4's concentrator and didn't replace with an oxygen tank. The new vendor hadn't delivered oxygen yet to replace the one she had. It turned out to be a big incident. She contacted the former respiratory vendor and made them aware of what happened. During an interview on 12/4/23 at 12:45 PM, Staff L, certified nursing assistant (CNA) stated she had only worked at the facility a month. When asked how she knew what cares needed done for residents and to know if a resident used oxygen she reported she just watched residents to see if they need help, and asked another staff person what to do for the resident. Staff L stated she didn't look at the computer to check the residents' care plan. During an interview on 12/4/23 at 12:50 PM, the Administrator reported there was an incident when Resident #4 went to a doctor's appointment and didn't have her oxygen. The facility got a call from doctor's office and sent a staff person from the facility to the clinic to deliver oxygen for the resident. During an interview on 12/5/23 at 2:10 PM, Staff M, CNA, reported there are no care plans or pocket care plan for CNA's to view in order to know what to do for the residents. Staff M stated she goes off the information other people told her on what to do for the residents. Staff M reported she had worked other places and always had a care plan to know what the residents needed done. The facility had a lot of agency, and they don't know what to do either. Staff M agreed if a resident used oxygen, she should know about it and it should be on the care plan about how many liters of oxygen needed, so she could can check the setting. However the facility had no care plan or anything that showed information such as a resident's oxygen use. Staff M stated she just watched and learned how to do things. During an interview on 12/5/23 at 4:25 PM, clinic staff reported Resident #4 presented to the clinic without oxygen several times. The physician wrote a progress note to the facility that Resident #4 needed oxygen and concerns about the resident coming to appointments without oxygen on more than one occasion. The clinic staff verified no oxygen tank brought in by facility staff to the doctor's office on 11/6/23 after Resident #4 arrived to her appointment without oxygen on. During an interview on 12/6/23 at 10:45 AM, the MDS Coordinator, reported she completed the MDS and care plans for the residents, and the ADON's helped review the care plan. The MDS Coordinator reported she expected oxygen listed on the care plan if a resident had oxygen. She typically entered oxygen under the pertinent diagnoses to show the reason why a resident used oxygen. A policy and procedure for oxygen storage, handling and delivery revised 10/5/15 revealed oxygen administered per physician's orders. Oxygen orders included the liter flow, mode of administration, and frequency of use.

Based on clinical record review, observation, resident and staff interviews, provider interview, and facility policy review the facility failed to ensure 1 of 3 residents (Resident #9) reviewed for pressure ulcers received care and services to prevent pressure ulcers from forming while resided at the facility. The facility reported a census of 81 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had diagnosis of sepsis, diabetes, septicemia (bacterial infection in the blood), and cellulitis (bacterial skin infection) on the right lower limb. The MDS documented the resident admitted to the facility on [DATE]. The MDS documented the resident had a risk for pressure ulcers but had no skin wounds or concerns. The MDS assessment dated [DATE], documented the resident had a risk for pressure ulcers but had no current pressure ulcers or skin concerns. The MDS indicated the resident required assistance of one for bed mobility and transfers. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognition intact. The electronic health record diagnoses list revealed the following: right lower limb cellulitis (added 7/27/23), Stage 2 pressure ulcer left heel (added 10/16/23), Stage 3 pressure ulcer to the right heel (added 11/14/23), and an open wound on the right toe (added 11/27/23). The Admission Narrative Bundle assessment dated [DATE] revealed the Braden score of 17, indicating the resident at risk for development of pressure ulcers. The Care Plan revised 8/30/23 revealed Resident #9 had an activities of daily living (ADL) self-care deficit. The staff directives included to provide assistance of one for bed mobility. The Care Plan revealed the diagnoses of diabetes mellitus and directed staff to inspect the feet daily for open areas, sores, and pressure areas. The Care Plan lacked information regarding altered skin integrity or pressure ulcers, as well as the interventions to prevent development of pressure areas. The Order Summary Report included the following orders: -Weekly skin assessment every Thursday on the evening shift started on 9/7/23. -Extra strength (ES) acetaminophen (Tylenol) 500 milligrams (mg) give 2 tablets by mouth (PO) every 8 hours as needed (PRN) for increased pain started on 10/7/23. -Float bilateral heels on pillows while in bed for skin integrity started on 10/8/23. -Tramadol (opioid pain medication) 50 mg PO every 6 hours PRN for pain started on 10/8/23. -Encourage resident to keep shoes off when not weight bearing to promote wound healing started on 10/12/23. -Place Prevalon boots (used to keep heels floated and relieve pressure to help reduce risk of bedsores) on bilateral feet at bedtime (HS) to promote wound healing for blister on left heel and wound on the right heel started on 10/12/23. -Apply skin prep to the left outer heel topically two times a day for a fluid filled intact blister. Stop skin prep and notify the doctor if the blister opened. The order started on 10/8/23 at 7:00 PM, and discontinued on 10/23/23. -Cleanse left and right heel wound with cleanser of choice, apply silver alginate (dressing to absorb wound fluid) to wound bed, cover with heel foam dressing, wrap with gauze wrap, secure with tape daily and PRN ordered on 11/14/2023. -Cleanse left foot 4th digit with cleanser of choice and apply skin prep daily started on 11/27/23. -Prafo (device to offload and manage pressure to heel/ankles) boots to bilateral feet on during the day, off at HS to promote wound healing started 11/29/23. The Treatment Administration Record (TAR) dated 10/1 -10/31/23 revealed a portable x-ray of the right heel and foot for his foot wound documented as completed on 10/31/23. The TAR 10/1 - 11/30/23 lacked documentation of wound treatment to the left heel wound on 10/26/23, 11/14/23, and 11/21/23. The TAR also lacked documentation of the right heel wound treatment on 11/14/23 and 11/21/23, and weekly skin assessment on 10/26/23. The TAR dated 11/1 - 11/30/23 had an entry for an air mattress to promote wound healing due to bilateral heel wounds added on 11/28/23 at 2:00 PM, and documented as completed on 11/28/23. The Medication Administration Record (MAR) dated 10/1/23-10/31/23 revealed the following orders: -ES Tylenol 500 mg two tablets every 8 hours PRN for increased pain started on 10/7/23. PRN ES Tylenol administered on 10/11, 10/12, 10/16/23 for pain rated up to 5 on a 1-10 scale. This was in addition to scheduled doses of ES Tylenol administered. -Tramadol 50 mg PO every 6 hours PRN for pain started on 10/8/23. A total of 17 doses were administered to the resident between 10/16 - 10/30/23 for pain rated up to 7 on a 1-10 pain scale. -Levaquin (antibiotic) 500 mg PO for wound administered 10/12/23 to 10/21/23. -Prevalon Boots to bilateral feet at HS to promote wound healing to blister on the left heel and wound on the right heel started on 10/12/23 at 6:00 PM and discontinued on 11/28/23. The MAR dated 11/1/23 - 11/30/23 revealed: -Tramadol 50 mg PO every 6 hours PRN for pain administered 9 times 11/1 to 11/14/23 for pain rated at up to 9 on a 1-10 pain scale. -Juven (protein supplement) in the evening related to stage 2 pressure ulcer to left heel and stage 3 pressure ulcer to right heel started on 11/14/23. -Flagyl (antibiotic) 500 mg PO three times a day for wound care started on 11/15/23 to 11/22/23. -Levaquin 750 mg PO daily for wound started on 11/16/23 until 11/22/23. -ES Tylenol 500 mg two tablets every 8 hours PRN for increased pain started on 10/7/23. ES Tylenol administered on 11/2/23 for pain rated at 5, 11/14/23 for pain rated at 6, 11/21/23 for pain rated at 4, and 11/22/23 for pain rated at 5. -A wound culture of right lateral heel wound completed 11/28/23 at 2:02 PM. The Progress Notes for the resident revealed the following: -On 8/2/23 at 9:48 AM, no open areas or skin issues, and no surgical wounds. -On 8/29/23 at 4:28 PM, resident had an unwitnessed fall and sent to the hospital. -On 9/1/23 at 5:16 PM, resident readmitted to the facility. -On 9/4/23 at 2:07 PM, resident sent to the hospital for weakness and altered mental status. -On 9/7/23 at 11:40 AM, readmitted to facility from the hospital. Skin assessment abnormalities included abrasions to bilateral knees and the left lower extremity, and a pressure ulcer to the left buttock. -On 9/22/23 at 2:14 PM, no open areas/skin issues and no surgical wounds -On 10/7/23 at 6:00 AM, resident had increased pain during the shift from a right outer ankle pressure sore. Tylenol administered. -On 10/8/23 at 8:23 AM, pressure ulcer on the right outer heel below the ankle measured 2 centimeter (cm) x 4.2 cm. Wound bed dark in color with 50% wound bed slough. The bed sheet and resident's sock had a moderate amount of serosanguinous drainage. Surrounding skin moist, boggy, and pale in color. Area cleansed with normal saline and an optifoam border dressing applied. Resident complains of pain in right foot and heel off and on. Pain is most severe while lying in bed. Resident educated to keep bilateral lower extremities (BLE) elevated on a pillow while in bed. The outer aspect of left heel below the ankle had an intact fluid filled blister 3 cm x 3.2 cm. Orders received to cleanse skin over blister with normal saline and apply skin prep twice a day while blister remained intact. Placed on wound nurse practitioner's list to evaluate and treat resident on 10/9/23. Order also received for Tramadol 50mg 1 tab PO every 6 hours PRN and to float bilateral heels on pillows while in bed. -On 10/9/23 at 9:37 PM, wound provider saw resident to assess area of concern to buttock and bilateral heels. Staff report the resident had been in and out of the hospital secondary to falls and sepsis in early to mid-September. No recent hospitalization in the past month. He has Type 2 diabetes. He requires staff assistance for transfers. He is able to ambulate short distances with staff assistance and a wheeled walker. He has tennis shoes that are not new and in good repair. Foam cushion in the wheelchair. He reports his right heel is tender. There is a foam dressing on the right heel and odor noted upon removal of the dressing. The resident had a right lateral heel unstageable pressure ulcer measuring 2.8 cm x 1.5 cm x 0.1cm and had a moderate amount of thin, serous drainage. The surrounding skin appeared macerated, and reddened. Pain rated at a 2-3 on a 1 to 10 scale. The treatment order included to cleanse wound with cleanser of choice, apply silver alginate to the wound bed, wrap with gauze wrap, and secure with tape daily and PRN. A left lateral heel Stage 2 pressure ulcer measured 3.0 cm x 3.0 cm x 0.1cm and had an intact serous blister. Treatment order included to cleanse area with cleanser of choice and apply skin prep daily and PRN. Additional orders included to administer Bactrim DS 1 tab PO for 10 days for right heel infection, apply Prevalon boots at HS, and encourage the resident to keep shoes off when not weight bearing to promote wound healing. -On 10/11/23 at 3:32 PM, order to start Levaquin 500mg PO daily for 10 days for wound care. -On 10/15/23 at 10:09 PM, resident complained of pain to bilateral heels. Open blisters noted upon assessment. Legs offloaded with pillow and gauze bandage applied to heels. Scheduled Tramadol administered. -On 10/16/23 at 4:43 PM, resident continues on Levaquin for wound infection. Bilateral heels in bunny boots. Will continue to monitor. -On 10/17/23 at 2:22 AM, at approximately 11:40 PM, while repositioning resident in bed, observed the treatment dressings on both heels had fallen off in the bed. Bilateral heel wounds cleansed with normal saline and treatment performed as ordered. Wound beds dark purple in color and dry. Pain at 8/10 on pain scale with touch and when treatment performed. Resident repositioned in bed, protective boots applied to BLE's, and PRN Tramadol administered. -On 11/1/23 at 3:55 PM, wound round notes from 10/30/23 entered. The notes included: Resident seen to assess area of concern to bilateral heels. Resident wears his tennis shoes when working in therapy. Resident encouraged to take shoes off when not working in therapy. Resident stated he would rather give up his feet then give up his shoes. Education provided about shoes not recommended until the wounds healed. Resident had tenderness to right heel. The right lateral heel wound (Stage 3 pressure area) measured 3.2 cm x 1.8 cm x 0.2 cm and had 100 % unstable eschar and a moderate amount of this serous drainage. Resident rated pain 3-4 out of 10. The left lateral heel (Stage 3 pressure ulcer) measured 3.2 cm x 5.0 cm x 0.1cm (2 areas) and had a moderate amount of serous drainage. The resident rated pain 0-2 out of 10. Treatment to both wounds included to cleanse with cleanser of choice, apply calcium alginate with silver to wound bed, cover with heel foam dressing, wrap with gauze wrap, and secure with tape three times a week and PRN. -On 11/27/23 at 2:22 PM, resident wears tennis shoes when working in therapy. Encouraged to take shoes off when not working in therapy. Recommendation not followed well by the resident. Resident reports he does not wear his Prevalon boots at HS. He is sitting in recliner upon entry into room with feet in a dependent position. Resident had tenderness to bilateral heel wounds. The left heel had no heel foam dressing on. Staff reported their supply is nearly exhausted. The right lateral heel wound (Stage 3 pressure area) measured 2.1 cm x 1.0 cm x 0.4 cm and had a moderate amount of this serous drainage. Resident rated pain 1-3 out of 10. The left lateral heel (Stage 3 pressure ulcer) measured 4.0 cm x 5.0 cm x 0.2 cm (2 areas) and had a moderate amount of serous drainage. The wound bed was boggy and not able to assess. The resident rated pain 0-1 out of 10. Orders to continue treatment to bilateral heel wounds: cleanse with cleanser of choice, apply calcium alginate with silver to wound bed, cover with heel foam dressing, wrap with gauze wrap, and secure with tape three times a week and PRN. A diabetic foot ulcer to the left 4th digit measured 0.5 cm x 0.6 cm x 0.1 cm with eschar. Order to cleanse with cleanser of choice and apply skin prep daily and PRN. In addition, a PCR DNA wound culture obtained of the right lateral heel. Orders included: -Discontinue Prevalon boots per resident request -Place air mattress to promote wound healing -Prafo boots to bilateral feet on during the day and off at HS to promote wound healing On 11/28/23 at 2:45 PM, observed Staff K, Registered Nurse (RN), perform a treatment and dressing changes to Resident #9's bilateral heels and left 4th toe as he sat in his recliner. The resident's right lateral heel had an open area with a moderate amount of purulent drainage. The left lateral and back of the heel had a necrotic area. Resident #9 asked Staff K if he was going to need his feet cut off. Staff K told the resident no, but she had not seen his wounds before. Prevalon boots sat on top of a large cabinet in the resident's room. The resident refused to wear the boots. Staff K encouraged the resident to keep his legs elevated and heels floated. During an interview on 12/4/23 at 10:15 AM, Resident #9 reported he had wounds on both heels for about 4 months. The staff treated it with silver and placed dressings on the area. One wound started out as a blister about the size of a half dollar, then it opened up, and it was painful. He stated the wounds don't hurt as bad when he received pain medication, but sometimes he had trouble getting pain medication. During an interview on 12/4/23 at 11:25 AM, the wound Nurse Practitioner (NP) reported Resident #9 had wounds on both heels, and wounds classified as pressure ulcers. The NP stated she didn't know if the resident had pressure sores on feet when he came to the facility, she only saw the resident when staff had notified her to see the resident because he had wounds. The resident had been in and out of the hospital. The NP reported the heel wounds treated with calcium alginate, heel foam dressing, and wrapped with kerlix. The wound treatment order changed last week by an on-call provider who wasn't familiar with the treatment being done for the resident. The NP changed orders back to calcium alginate and heel foam dressing on 12/4/23. The NP reported the resident not always compliant with recommendations. The resident had Prevalon boots but said he wasn't going to wear them. She ordered Prafo boots to offload the area and allow the resident to walk in them but they were waiting for delivery of the boots. During an interview on 12/4/23 at 12:45 PM, Staff L, certified nursing assistant (CNA) reported she just watched residents and saw if they needed help, and helped residents with ADL's. Staff L reported she didn't look at the computer or know anything about a pocket care plan to reference on what resident needed for cares or interventions, she just asked someone what to do for the resident. During an interview on 12/4/23 at 1:00 PM, Staff N, Licensed Practical Nurse (LPN) reported the nurse performed a head to toe skin assessment whenever a resident admitted to the facility, and documented the assessment on the computer. A Braden scale filled out upon admission, and a head to toe skin assessment completed weekly on each resident. Staff also filled out a shower sheet and marked if any skin concerns observed and the nurse on duty checked the resident's skin and signed off on shower sheet. A progress note entered if staff noted any skin concerns. If a resident at risk for pressure sores, staff repositioned and toileted the resident every 2-3 hours. A roho cushion or air mattress used if needed, depending upon the resident's skin risk. During an interview on 12/4/23 at 1:40 PM, Staff F, Assistant Director of Nursing (ADON) reported a skin assessment completed upon admission or at least within the first 24 hours of a resident's admission. A Braden scale completed with the admission bundle assessment. The ADON reported interventions if a resident at risk for developing a pressure ulcer, such as an air mattress placed on the bed, education provided to resident about moving off their bottom, and encourage resident to wear different pants to prevent clothes from rubbing the area. Bunny boots used if the skin looked or felt boggy and heels floated as much as possible. Resident encouraged to consume protein and supplements, and a referral made to the dietician. A resident also added to the wound provider's list to see the resident when a wound developed. During an interview on 12/4/23 at 1:50 PM, Staff E, ADON, reported the resident skin assessments completed upon admission and weekly by the nurses. The admission skin assessment documented on the admission assessment bundle, that included the Braden scale assessment. Weekly skin assessments typically done to coincide with the resident's shower day, and recorded on the TAR. Interventions put into place if a resident had a risk for pressure ulcer. Interventions such as limited linens on the bed, use one chux, and skin checks by CNA's during cares. An air mattress placed on the bed if a resident had skin issues. Treatments documented on the TAR. Staff E reported she expected interventions in place to prevent pressure ulcers if the resident is at risk for pressure ulcers. Staff E reported Resident #9 noncompliant and liked to sit with his feet down or on foot pedals. The resident developed pressure areas on heels after admission to the facility. He refused to wear bunny boots. Resident told staff he would rather donate his feet then wear bunny boots, and he would rather go to jail then give up his shoes. Staff E reported Prafo boots are on order. During an interview on 12/5/23 at 2:10 PM, Staff M, CNA, reported no care plans or pocket care plan for her to know what to do for the residents. She went off what people told her about the residents and what cares and things needed done. Staff M reported she didn't have access to look at the residents' care plan on the computer. During an interview on 12/6/23 at 10:15 AM, Staff O, CNA, reported she had worked at the facility awhile and normally assigned to work on the same hall, so she was familiar with the residents and what they needed. Staff O reported sometimes they had a set sheet to look at but if no set sheet available, then took a form with resident names and room number and wrote down things needed for the residents. Staff O reported she had the capability to look things up on the computer. Staff O reported Staff F and the DON updated the set sheet. The set sheet included how a resident transferred, if resident needed assistance with eating, if used glasses or dentures, and how the resident liked things done. Pressure ulcer not included on the set sheet. If a resident had a pressure sore and she didn't have certain devices such as bunny boots in place, someone stopped and told her the resident needed them on. During an interview on 12/6/23 at 10:45 AM, the MDS Coordinator, reported she completed the MDS and care plans for the residents. The MDS Coordinator reported the facility had a transition period when the ADON was responsible for completion of care plans on skilled residents, and she mainly worked on MDS and care plans for the other units. For awhile, no ADON on the skilled unit so she worked on MDS completions and worked on resident care plans one day a month for the entire building when she had time to work on them. The transition period without an ADON lasted 2-3 months but there had been three transitions in the past year. The MDS Coordinator reported a baseline care plan completed and care plan built from there. The MDS Coordinator reported she obtained information for care plans from MDS assessment, hospital notes, progress notes, MAR, TAR, and meetings about transition of resident care and needs. The ADON's updated the set sheet for staff reference about resident cares. The MDS Coordinator reported a pressure sore or wound listed on the care plan under focus area of skin, along with the devices needed such as a cushion, mattress, floating heels, etc. if a resident had a pressure area. The MDS Coordinator reported she knew Resident #9 had pressure ulcers and seen by a wound provider. She expected interventions for pressure ulcers placed on the care plan but she hadn't gotten to Resident #9's care plan yet. A Skin Integrity and Pressure Injuries Protocol effective 9/2023 revealed the resident received care consistent with professional standards of practice to prevent pressure injuries and will not develop pressure injuries unless the individual's clinical condition demonstrated pressure injury unavoidable. The resident with pressure injuries received the necessary treatment and services to promote healing, prevent infection, and prevent development of new ulcers. Prevention guidelines included: identification of residents at risk for developing a pressure injury upon admission, quarterly, and a change in condition utilizing the Braden risk scale. Evaluation of risk factors and changes in condition that may impact development and healing of pressure injury, and implementation of interventions to reduce or remove underlying risk factors. Based on assessment and the resident's clinical condition, basic or routine care include but not limited to interventions such as provide appropriate pressure redistributing, support surfaces, non-irritation surfaces, maintain or improve nutrition and hydration status, and provide treatment to prevent the development of additional pressure injuries.

Based on record review, policy review and staff interviews the facility failed to accurately assess and provide intervention to 1 of 1 residents who required hospitalization for reasons which included poor perineal hygiene (Resident #1), and for 1 of 3 residents reviewed for substantial weight change (Resident #1). As a result of the failure of the facility to provide accurate assessment and intervention, Resident #1 was hospitalized from 8/19/22-8/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital staff found that Resident #1 was wearing 3 saturated adult briefs, along with associated skin breakdown and swelling of Resident #1's genital area, which resulted in the hospital staff's inability to obtain a urine sample from Resident #1. The situation posed immediate jeopardy to Resident #1's health and safety. The facility's administrative staff reported a census of 78 residents. Findings include: 1. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The MDS also documented the need for significant assistance for transfers, dressing and toileting, supervision at meals with set up assistance, and supervision for bed mobility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review of Resident #1's weights revealed that Resident #1 had a baseline weight of approximately 250 pounds, for a 9 month period from July 2021 through July 2022. Resident #1 then began experiencing significant fluctuations in his weight, with the staff documenting Resident #1's weight as follows: 7/19/21 255.2 Lbs (pounds, a gain of approximately 5.2 lbs from Resident #1's baseline) 8/2/21 251.4 Lbs (a loss of 3.8 lbs from Resident #1's prior weight) 8/9/21 252.2 Lbs (a gain of 0.8 lbs from Resident #1's prior weight) 9/7/21 252.4 Lbs (a gain of 0.2 lbs from Resident #1's prior weight) 10/11/21 242.4 Lbs (a loss of 10 lbs from Resident #1's prior weight) 11/2/21 248.2 Lbs (a gain of 5.8 lbs from Resident #1's prior weight) 12/8/21 248.8 Lbs (a gain of 0.4 lbs from Resident #1's prior weight) 1/28/22 233.2 Lbs (a loss of 15.6 lbs from Resident #1's prior weight) 2/9/22 234.6 Lbs (a gain of 1.4 lbs from Resident #1's prior weight) 3/10/22 247.2 Lbs (a gain of 12.6 lbs from Resident #1's prior weight) 4/6/22 248.2 Lbs (a gain of 1 lb from Resident #1's prior weight) 5/18/22 252.2 Lbs (a gain of 4 lbs from Resident #1's prior weight) 6/9/22 252.8 Lbs (a gain of 0.6 lbs from Resident #1's prior weight) 7/28/22 283.6 Lbs (a gain of 30.8 lbs from Resident #1's prior weight) 8/10/22 286.4 Lbs (a gain of 2.8 lbs from Resident #1's prior weight) 8/24/22 248.0 Lbs (a loss of 38.4 lbs from Resident #1's prior weight) 8/25/22 248.4 Lbs (a gain of 0.4 lbs from Resident #1's prior weight) 8/26/22 249.0 Lbs (a gain of 0.6 lbs from Resident #1's prior weight) 9/8/22 225.4 Lbs (a loss of 23.6 lbs from Resident #1's prior weight) 9/10/22 216.2 Lbs (a loss of 9.2 lbs from Resident #1's prior weight) 3. Review of document titled Weight Assessment and Intervention F692, last revised on 9/2021, directed that each resident is to be weighed upon admission and readmission and weekly x 4 weeks, and unless indicated otherwise, monthly thereafter. Resident #1 went 7 weeks, from 6/9/22 until 7/28/22 without being weighed. The policy statement further directed that any weight change of 5 pounds or more since the last weight assessment will be retaken the next day for confirmation. The weight on 7/28/22 reflected a weight gain of 30.8 pounds and the nursing staff failed to weight Resident #1 until 8/10/22. 4. A nursing progress note, dated 7/20/22 at 1:56 pm, documented follow up to [MEDICATION(S)] (medication used to reduce extra fluid in the body caused by conditions such as heart failure) 20 mg daily. This note documented that Resident #1 continued to experience [CONDITION(S)] (swelling due to excess fluid accumulation in the body tissues) to both lower legs, lung sounds diminished, no signs or symptoms of shortness of breath. 5. A weight change note from Staff O, Registered Dietitian (RD), dated 7/28/22 at 3:20 pm, documented the following: Monthly weight: 283.6 lbs and up 30.8 lbs x (times) 1 month related to increased [CONDITION(S)]; weight up 20.9% x 5 months. A new order for [MEDICATION(S)] (a medication which causes residents to urinate large quantities of urine, which helps reduce the amount of fluid in the resident's body) for [CONDITION(S)] in both lower legs. This order was noted (transcribed) on 7/19/22. Continues to eat well at meals. No dietary changes needed. 6. A nursing progress note dated 8/12/22 2:07 am, documented to increase [MEDICATION(S)] to twice daily. Further review of this resident's progress notes revealed a failure to document any findings regarding significant weight change. Resident #1's electronic health record lacked any progress notes indicating that the nursing staff notified either Resident #1 ' s physician or Resident #1's family about Resident #1's weight changes or that the nursing staff had received an order to change Resident #1's [MEDICATION(S)] orders. 7. Per the Medical Administration Record (MAR), [MEDICATION(S)] changes were made multiple times in June, July and August. Review of progress notes in Point Click Care (PCC - electronic health record) revealed a lack of documentation regarding [CONDITION(S)], weight gain, or any symptoms related to exacerbation of heart failure. Review of Resident #1's paper chart revealed a lack of documentation of physician visits or orders. Weights were completed on 6/9/22 and 7/28/22, a difference of 7 weeks, which revealed Resident #1 gained 30.8 pounds during the 7 weeks. The next recorded weight on 8/10/22 showed a gain of an additional approximate 3 pounds. No further weight was taken in the next 9 days (Resident #1 was hospitalized on [DATE]). 9. The facility policy required the nursing staff to assess every resident for symptoms of COVID-19 every 12 hours. The assessment form includes a list of potential COVID-19 symptoms, which requires the nursing staff to assess the resident's respiratory system. For each assessment that was completed in the week prior to Resident #1's hospitalization , the option of no respiratory symptoms noted was checked for the resident, with the exception of assessment on 8/12/22 at 7:26 pm. This assessment documented cough and chest congestion. Order had been received earlier that day for an increase in [MEDICATION(S)] (causing Resident #1 to create large amounts of urine). Irregularity was noted in the timing of the assessments. Only 1 assessment was completed on 8/12/22, 8/13/22 and 8/14/22. Assessments dated 8/15/22 8:00 am, 8/15/22 7:00 pm, 8/16/22 8:00 am and 8/16/22 7:00 pm were all signed and locked by Staff P, LPN on 8/17/22 at 8:00 am. Assessments for 8/17/22 were noted to be timed at 6:00 pm and 8:00 pm, both signed and locked on 8/18/22 at 6:00 pm by Staff G, ADON. Assessments do not include a place for pulse oximetry level (oxygen saturation in the blood), respiration rate, noted [CONDITION(S)] or lung sounds. 10. Nursing progress note dated 8/19/22 at 12:48 pm by Staff G, noted the events leading to Resident #1 being sent to the hospital. Per the progress note, Resident #1 was found in the TV room of the facility, sitting in front of his lunch, which had not been touched. Staff attempted to wake up Resident #1 and performed a sternal rub (painfully rubbing a knuckle into the resident ' s breastbone). Resident moaned, was unable to grip Staff G ' s fingers or reply to Staff G's questions, Resident #1's eyes noted to be glazed and rolled back, no verbal communication from Resident #1. Vomit was noted on his shirt and coming from his mouth. Staff G sent Resident #1 to the Emergency Department (ED) due to Resident #1 not responding to Staff G ' s sternal rub. Staff G did not notify Resident #1's physician or send Resident #1 to the ED for cardiac concerns. 11. Review of Resident #1's hospital medical record revealed a progress note dated 8/19/22 (the day Resident #1 went to the hospital). The progress note indicated that the hospital staff diagnosed Resident #1 with acute hypoxic respiratory failure (an acute lack of oxygen, resulting in the resident being unable to breathe), which required the hospital staff to place Resident #1 on 2 liters per minute (lpm) of oxygen, to maintain an oxygen saturation of 93 percent (normal is 95-100 percent). A cardiology progress note, dated 8/21/22, revealed that the cardiologist diagnosed Resident #1 with volume overload (a condition where the body had excess fluid, causing swelling, especially in the lower legs). Further record review of Resident #1's hospital medical record revealed that when Resident #1 presented to the hospital ED, the ED staff found that Resident #1 was wearing 3 adult briefs, each saturated with urine. Resident #1 had skin breakdown in his genital and groin areas from extended exposure to moisture. The tip of Resident #1's urethra (the duct from the bladder which releases urine) had pus coming from it (a potential sign of infection). Resident #1's scrotum and penis were tender to the touch, due to skin breakdown, and had a mild odor. 12. During an interview on 9/14/22 at 1:14 PM, Staff G, the Assistant Director of Nursing (ADON), revealed that she expected the nursing staff to perform incontinence rounding every 2 hours, where the nursing staff should check residents at risk for incontinence to determine if the resident had experienced incontinence. If the resident was incontinent, the nursing staff should change the resident ' s soiled brief, not layer another brief on top of the soiled brief. Staff G acknowledged that the hospital staff had informed Staff G that Resident #1 was wearing multiple saturated briefs when Resident #1 went to the hospital. Staff G further explained that the floor nurse was expected to perform a skin assessment every week. Staff G acknowledged that she documented she performed a skin assessment on Resident #1 in PCC on 8/19/22 (the day Resident #1 went to the hospital). The skin assessment was signed/locked on 8/19/22 at 8:26 AM, but indicated Staff G performed the skin assessment on 8/18/22 at 8:59 PM. According to the documented skin assessment, Resident #1 did not have any alterations in skin integrity (ie: the no skin breakdown, excoriation, infection, or other skin issues). Staff G indicated that when she documented the skin assessment, she had not personally assessed Resident #1, but instead relied upon reviewing the skin sheets (documentation of any identified skin problems) completed by the Certified Nursing Assistant (CNA) on 8/12/22. The CNA had not indicated that Resident #1 had any skin problems, so Staff G did not identify that Resident #1 had excoriation, swelling, and skin breakdown in his groin and genitals. Staff G was not aware that Resident #1 was experiencing skin problems while he was at the facility. 13. During an interview on 9/14/22 at 1:28 pm, Staff B, CNA, revealed that Staff B had witnessed residents at the facility wearing more than 1 adult incontinence brief at a time. Staff B stated she worked the day shift and had found residents wearing a tab style brief with a pull up style brief over the top of it on first rounds following the overnight shift. 14. During an interview on 9/14/22 at 12:45 pm, Staff H, LPN, had not noticed Resident #1 having any pain on the day he was sent to the hospital. Resident #1 rarely ever talks and Staff H did not notice that Resident #1 appears to be in pain when Staff H saw Resident #1. Staff H revealed he had not assisted the CNAs in any personal cares for Resident #1. Staff H denied any knowledge of skin issues with Resident #1 or any knowledge that anything was out of the ordinary regarding Resident #1 ' s hygiene or personal appearance. 15. During an interview with the Director of Nursing (DON) on 9/15/22 at 9:15 am, the DON stated the facility staff was aware of Resident #1 arrived at the hospital with 3 briefs on. The facility staff follow the resident while in the hospital and are able to read the hospital progress notes via access to the hospital electronic medical record software. The DON started an internal investigation following the hospital staff identifying Resident #1 had 3 briefs on when he went to the hospital, and identified a single staff member was responsible for placing multiple briefs on the residents. However, the DON also confirmed that Resident #1 ' s [CONDITION(S)] of the scrotum could not have developed on the same day that the facility staff sent Resident #1 to the ED. 16. During an interview on 9/15/22 at 11:28 AM, Staff Q, CNA revealed that Staff Q provided care to Resident #1 for several days prior to Resident #1 ' s hospitalization . During the days prior to Resident #1 ' s hospitalization , Resident #1 had experienced redness (an early sign of skin breakdown) in Resident #1 ' s groin for several days and Staff Q regularly applied cream to protect Resident #1 ' s skin from injury each time Staff Q changed Resident #1 ' s brief after Resident #1 was incontinent. Staff Q indicated that Staff Q did not notify the nurses about the redness in Resident #1 ' s groin, as the nurses were aware of the redness since the nurses provided the CNAs with a barrier cream to utilize when the CNAs changed Resident #1 ' s brief after an incontinence episode. 17. Review of a bath sheet for Resident #1, dated 8/18/22, revealed that Staff R, CNA, did not document any skin integrity issues (such as redness or skin breakdown). 18. During a phone interview on 9/19/22 at 3:18 PM, Resident #1's Spouse indicated that they thought Resident #1 was hospitalized for cardiac issues, since Resident #1 had experienced significantly worse swelling in his legs, especially with Resident #1's left leg experiencing greater swelling than Resident #1's right leg (a common sign of fluid retention due to cardiac issues). Resident #1's Spouse was aware that the hospital staff found 3 urine saturated briefs on Resident #1, and Resident #1's Spouse did not know why the facility staff would place 3 stacked briefs on Resident #1 to address Resident #1's incontinence. Resident #1's Spouse revealed that the facility staff failed to notify Resident #1's spouse about Resident #1's weight gain or weight loss prior to Resident #1's hospitalization . The facility staff only notified Resident #1's spouse after the dietary staff started Resident #1 on Ensure as a supplement (which occurred on 9/14/22). 19. During an interview on 9/20/22 at 9:15 AM, the DON and Staff W provided a timeline listing interventions for Resident #1 from 6/9/22 to present. The DON and Staff W verified that the nursing staff only documented the [CONDITION(S)] in Resident #1's lower legs on 7/20/22 (almost a month prior to Resident #1's hospitalization ). The DON and Staff W both verified that Resident #1's medical record lacked evidence the nursing staff assessed Resident #1's [CONDITION(S)] or that the nursing staff implemented any interventions to address Resident #1's [CONDITION(S)]. The DON could not explain why the nursing staff failed to weigh Resident #1 for 49 days (between 6/9/22 and 7/20/22). Typically, the nursing staff weigh all residents during the first week of the month, and weigh them the second week of the month if the staff can't get a weight during the first week. While the nursing staff currently weigh Resident #1 weekly, the DON and Staff W verified that the nursing staff were not weighing Resident #1 weekly prior to Resident #1's hospitalization . 20. On 9/20/22 at 11:56 a.m, Staff U, ARNP (Advanced Registered Nurse Practitioner), revealed they did not know the facility's nursing staff failed to document their assessment of Resident #1's condition or their interventions to address Resident #1's condition. Staff U verified they did not know the nursing staff had only documented about Resident #1's [CONDITION(S)] on 7/20/22 (between 6/9/22 and 8/19/22). Staff U was upset that the nursing staff did not document their assessment findings regarding the [CONDITION(S)] and verified that the nursing staff failed to notify Staff U about the [CONDITION(S)]. Staff U emphasized the importance of the nursing staff performing ongoing assessments and interventions to address Resident #1's [CONDITION(S)]. 21. During an interview on 9/20/22 at 2:03 PM, Staff W, LPN, ADON, acknowledged they reviewed the staff documentation as part of the ADON responsibilities. Staff W acknowledged that the nursing staff routinely failed to document assessment findings and interventions they implemented. Staff W acknowledged that if the nursing staff failed to document their assessments or interventions, the facility lacked evidence the nursing staff actually performed the tasks. 22. Review of the policy Health Monitoring and Invention Monitoring/Observation by Staff, last revised 04/2022, employees to monitor residents for changes in their status on an ongoing basis. If the nursing staff identified a change, the nursing staff needed to report any changes to the Wellness Director and/or Executive Director. The policy further directed the nursing staff to document any changes in the resident ' s condition in the resident ' s service notes, along with a summary of the resident ' s condition and actions taken. The facility staff were presented the IJ template on 9/16/22 at 4:30 PM. The Immediacy was removed on 9/16/22 when the facility staff took the following actions: - Educated the nursing staff on assessments of the residents' skin, respiratory status, and weight monitoring. - The nursing staff conducted a facility wide assessment of all residents for previously unidentified skin problems. - Reviewed all resident weights to identify significant changes in the resident ' s weight. - The Administration began monitoring to ensure staff weighed the residents and performed the scheduled skin checks. - The Administration began conducting random audits to ensure the nursing staff did not apply multiple briefs to residents. - The facility ' s QAPI committee reviewed the audit findings, staff education, root cause analysis, and plan for improvement on 9/15/22. The scope and severity of a J level was lowered to a D level deficiency as the facility staff will need to ensure staff compliance with the necessary assessments and interventions.

Based on observations, document review, and staff interviews, the facility's administrative staff failed to ensure 1 of 3 residents reviewed for nutrition and hydration status (Resident #1) received adequate eating assistance and the facility staff identified and intervened when Resident #1 began experiencing weight changes. Resident #1's weight fluctuated approximately 70 pounds during a 1 month period. The facility's administrative staff identified a census of 78 residents. Findings include: 1. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The MDS also indicated that Resident #1 required the staff to provide supervision while Resident #1 ate, with the staff setting up Resident #1's meals so Resident #1 could easily eat the meal. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Observations during the breakfast meal on 9/13/22 revealed: a. At 9:25 AM, Resident #1 was in the television area of the facility, sitting at a table. Another resident in a wheelchair sat to Resident #1 ' s right. Staff N, Certified Nursing Assistant (CNA) was sitting to the right of the resident in the wheelchair, assisting the other resident to eat. Resident #1 was attempting to feed himself. Resident #1 was attempting to eat Cheerios in milk with a plastic fork. Resident #1 had a plastic spoon on his tray within easy reach. Resident #1 made multiple attempts to stab the Cheerios with the fork and was able to consume a small amount of food by placing a few Cheerios on the tines of the fork each time Resident #1 took a bite. Resident #1 had crusts from partially eaten toast on his plate. Resident #1 had scrambled eggs and a sausage patty remaining on his tray, which appeared untouched. Resident #1 was able to drink the fluids on his tray independently. b. At 9:45 AM (20 minutes later), Staff L, Certified Medication Aide (CMA) came into the television room and asked Resident #1 if he was finished with his breakfast. Resident #1 replied No! Staff L checked Resident #1's oxygen saturation level and temperature, and then left the room. Staff N continued to sit at the table with Resident #1 and the other resident. c. At 9:48 AM (23 minutes into the observation), Staff N verbally encouraged Resident #1 to eat, but Resident #1 continued to attempt to eat the cereal using only the plastic fork. d. At 9:50 AM (25 minutes into the observation), Staff L returned and examined Resident #1's legs. Staff L reminded Resident #1 that he had eggs and sausage on his plate. Resident #1 picked up the sausage patty whole, uncut, by stabbing it with his fork. Resident #1 took 1 bite of the sausage patty and the remainder dropped into Resident #1's cereal bowl. e. At 9:55 AM (30 minutes into the observation), Resident #1 pushed himself away from the table. Resident #1's eggs remained untouched, he had consumed 1 bite of sausage patty, and less than half of the cereal. Resident #1 had consumed some toast prior to the observation. At no time during the 30 minute observation did any staff member offer to cut Resident #1's food, provide Resident #1 with a spoon to eat his cereal (versus using a fork), or offer Resident #1 any assistance in eating his breakfast. At no time did Staff N reach across the table to assist Resident #1 with his fork, nor did Staff N walk around the table to assist Resident #1 with cutting up his food or choose the correct silverware. 3. During an interview on 9/14/22 at 1:15 PM, Staff G, an Assistant Director of Nursing (ADON) indicated that if a staff member saw a resident struggling to feed themselves at a meal, the CNA should report the situation to a charge nurse, and for the charge nurse to report the observation to Staff G. Additionally, the charge nurse should immediately assign a staff member to assist the resident with eating their meal. 4. During an interview with Staff N on 9/19/22 at 1:30 pm, Staff N confirmed she was in the room during the breakfast meal observed on 9/13/22. She revealed she did notice Resident #1 was taking longer to eat than normal. She denied noticing Resident #1 struggling with silverware or to eat the meal. When she was told the observation revealed the resident was eating his cereal with a fork she then stated she had swapped his fork for a spoon. She stated she had seen no written communication regarding Resident #1's need for meal assistance, but her nurse had told her to monitor him for assistance. 5. In an email response from the Licensed Nursing Home Administrator (LNHA) on 9/2022 at 2:19 p.m., to a request for documentation of communication between therapy and the nursing staff regarding recommendations of meal assistance needed for Resident #1, the LNHA responded that Resident #1 was not on the therapy staff's case load. The LNHA additionally documented that no changes had been noticed in Resident #1 and he remained independent with eating as he always has been. 6. Review of Resident# 1's medical record revealed that Resident #1 was receiving skilled nursing care since Resident #1 returned from the hospital on 8/24/22. Resident #1 was receiving Physical and Occupational Therapy 5 days per week. Record review of weights for Resident #1 revealed a baseline weight of approximately 250 pounds for 11 months, dating July of 2021 through June of 2022. 7/19/21 255.2 Lbs (pounds, a gain of approximately 5.2 lbs from Resident #1's baseline) 8/2/21 251.4 Lbs (a loss of 3.8 lbs from Resident #1's prior weight) 8/9/21 252.2 Lbs (a gain of 0.8 lbs from Resident #1's prior weight) 9/7/21 252.4 Lbs (a gain of 0.2 lbs from Resident #1's prior weight) 10/11/21 242.4 Lbs (a loss of 10 lbs from Resident #1's prior weight) 11/2/21 248.2 Lbs (a gain of 5.8 lbs from Resident #1's prior weight) 12/8/21 248.8 Lbs (a gain of 0.4 lbs from Resident #1's prior weight) 1/28/22 233.2 Lbs (a loss of 15.6 lbs from Resident #1's prior weight) 2/9/22 234.6 Lbs (a gain of 1.4 lbs from Resident #1's prior weight) 3/10/22 247.2 Lbs (a gain of 12.6 lbs from Resident #1's prior weight) 4/6/22 248.2 Lbs (a gain of 1 lb from Resident #1's prior weight) 5/18/22 252.2 Lbs (a gain of 4 lbs from Resident #1's prior weight) 6/9/22 252.8 Lbs (a gain of 0.6 lbs from Resident #1's prior weight) 7/28/22 283.6 Lbs (a gain of 30.8 lbs from Resident #1's prior weight) 8/10/22 286.4 Lbs (a gain of 2.8 lbs from Resident #1's prior weight) 8/24/22 248.0 Lbs (a loss of 38.4 lbs from Resident #1's prior weight) 8/25/22 248.4 Lbs (a gain of 0.4 lbs from Resident #1's prior weight) 8/26/22 249.0 Lbs (a gain of 0.6 lbs from Resident #1's prior weight) 9/8/22 225.4 Lbs (a loss of 23.6 lbs from Resident #1's prior weight) 9/10/22 216.2 Lbs (a loss of 9.2 lbs from Resident #1's prior weight) Resident #1's weight on 7/28/22 revealed a significant weight gain of 30.8 pounds from the last documented weight on 6/9/22, from 252.8 pounds to 283.6 pounds. A supporting weight change note change from the former Registered Dietitian (RD) revealed Resident #1 had swelling in both of Resident #1's lower legs, and that Resident #1's physician had ordered [MEDICATION(S)] (a medication which reduces fluid in the body by causing significant urine production). This resident was hospitalized [DATE]-[DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His readmission weight to the facility dated 8/24/22 revealed he was back to his baseline weight, recorded at 248.0 pounds. The record review of weights for Resident #1 lacked any further documentation of weight until 2 weeks following re-entry to the facility on [DATE]. This weight revealed a significant weight loss, recording his weight at 225.4 pounds. This weight was entered into Point Click Care (PCC - electronic medical record software) by the current facility RD, Staff E. It was shown that this entered weight caused a flag to occur by PCC revealing this to be 21.3% weight loss from weight a month earlier on 8/10/22. Resident #1 was re-weighed 2 days later on 9/10/22, this recorded weight was revealed to be even lower at 216.2 pounds. PCC again flagged this as a significant weight loss. Record review of progress notes lacked any documentation by any nursing staff or dietary staff of any notation of the weight loss through 9/12/22 (the beginning of the survey). 7. During an initial interview with Staff E, current facility RD, on 9/14/22 at 8:10 am, Staff E revealed she was new to the facility and on her first week she had an approximate backlog of 20 residents to review in addition to setting up weekly and monthly reports. The RD further revealed that the normal protocol for reviewing a resident is to coincide with the date of the Minimum Data Set, with any significant weight change, with any significant skin change, and/or for any resident who received tube feedings. She revealed her most recent visit to the facility was on 9/8/22. 8. Review of documentation titled Consultant RD Report and Recommendations, revealed that Staff E was in the facility on 9/2/22 and 9/8/22. This report revealed Resident #1 was named as a resident who was assessed and had their care plan reviewed. No recommendations were included on this report for Resident #1. 9. During an interview on 9/14/22 at 12:45 pm, Staff H, LPN, revealed the normal eating habits of Resident #1 are to eat all of his meal and then seek out more food. Staff H stated on the day that Resident #1 was sent to the hospital, this was the first indication they had seen of something being wrong, as Resident #1 had left his lunch tray untouched. 10. During an interview on 9/14/22 at 3:00 pm, Staff I, Certified Occupational Therapy Assist (COTA) revealed that she was assisting Resident #1 during some meals as part of his Occupational Therapy since his return from the hospital on 8/24/22. She stated he was a maximum to moderate assist at meals upon return from hospital but had improved and on the date of this interview was considered a moderate to minimum assist for meals. 11. Review of records revealed no documentation from therapy to nursing staff of Resident #1's needs for assistance at meals. 12. Review of Resident #1's care plan on 9/12/22, revealed a problem area of Activities of Daily Living (ADL) self-performance deficit related to prior [CONDITION(S)] (stroke), revised on 1/14/2022. It revealed an intervention for eating is documented to provide encouragement and assistance as needed, revised on 4/5/22. 13. In an additional interview on 9/15/22 at 2:27 pm, Staff E, RD was shown the document titled Report and Recommendations'' and verified this was the report written by her and emailed to the facility. Staff E indicated that the report erroneously included Resident #1's name, as Resident #1's care plan had not been reviewed since Resident #1 returned from the hospital on 8/24/22, nor on either of Staff E's visits to the facility on [DATE] or 9/8/22. Staff E further confirmed that she personally had entered Resident #1's weight into PCC on 9/8/22 and did see the flag generated regarding the significant weight loss. Staff E stated she did request weekly weights at that time and further stated that a full assessment should have been completed on that date, and a recommendation for a supplement should have been given, but that she failed to do so. The most recent weight of 220.0 pounds was documented on 9/14/22 as well as an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 14. Review of the policy titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised 4/2021, directed that the Interdisciplinary Team (IDT) through various assessments, will define the individual's current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for impaired nutrition. 15. Resident #1 re-entered the facility on 8/24/22, following a 5 day hospitalization . Resident #1 experienced a significant and rapid weight loss of 31 pounds over a time period of 2 and a half weeks. This weight loss was not noted or acted upon by any staff member at the facility until the survey was started and interviews conducted regarding the weight loss.

Based on record review, staff and family interviews the facility failed to provide care and services to meet resident's physical needs. A sample of 4 residents were reviewed with a concern found for Resident #7. The resident admitted to the facility with skin issues and the facility failed to complete and document accurate wound assessments and ensure wounds have current treatments. The resident was diagnosed with Pyoderma Gangrenosum (an inflammatory skin disorder characterized by small, red bumps or blisters that eventually erode to form swollen open sores or ulcerations) and did not receive follow up from a Dermatologist for care and treatment. The facility reported a census of 90 residents. Findings include: The 4/29/22 Minimum Data Set (MDS) Assessment tool revealed Resident #7 admitted to the facility 4/26/22 with diagnoses that included diabetes, chronic venous hypertension with ulceration of bilateral lower extremities and renal insufficiency, required assistance of 1 staff to reposition in bed, transfer to and from bed and chair, ambulation, dressing, toileting and bathing, at risk for pressure sores and without pressure sores identified, had 2 arterial or venous ulcer wounds and skin tear wound conditions, dependent on renal dialysis treatments and occasionally incontinent of urine. The assessment revealed the resident received pain medication on a scheduled basis for pain rated a a 7 on a 0 to 10 pain scale, with 10 assigned to the worst pain, and the pain interfered with the resident's function in day to day activities. A Hospital Discharge Summary dated 4/26/22 directed the resident's admission to the facility, described the resident hospitalized since 4/10/22, treated for painful wounds on the lower extremities, Dermatology, Nephrology, General Surgeon and Rheumatology physicians required to treat the resident's conditions, a skin biopsy done 4/14/22 with results suspicious for Pyoderma Gangrenosum (an inflammatory skin disorder characterized by small, red bumps or blisters that eventually erode to form swollen open sores or ulcerations), Prednisone 40 milligrams (mg), a high dose of steroid, prescribed oral daily until 4/29/22 required to treat that condition, and the resident was to follow-up with a Dermatologist on 4/29/22 for continued treatment of Pyoderma or related conditions. The nursing admission assessment, completed by Staff F, LPN (Licensed Practical Nurse), documented on the Admission/Readmission Narrative Bundle document on 4/26/22, described skin conditions that included: a. Right inner thigh unstageable pressure sore that measured 3.0 centimeters (cm) by 2.5 cm by 0.1 cm depth. b. Right heel scabs that measured 0.25 cm by 0.2 cm. c. Left foot 4th digit bruise that measured 1.0 cm by 0.5 cm. d. Left leg with scattered bruises, without further description or assessment. e. Left leg with scattered scabs, without further description or assessment. f. Right leg with scattered scab, without further description or assessment. g. Right leg with scattered bruises, without further description or assessment. h. Left hand with scattered bruises, without further description or assessment. i. Left ribs bruise that measured 5.5 cm by 1.6 cm. j. Abdomen with scattered bruises. k. Buttocks with scattered redness, without further description or assessment. l. Left arm with scattered bruises, without further description or assessment. m. Groin with redness scattered, without further description or assessment. n. Abdominal folds with scattered redness, without further description or assessment. o. Right calf with red, dark open area that measured 3.0 cm by 3.5 cm, no depth described. p. Left shin with open area that measured 0.75 cm by 0.5 cm, no depth described. q. Left great toe callus that measured 0.75 cm by 0.75 cm. r. Right elbow scab that measured 1.2 cm by 1.0 cm. s. Face with scattered scabs, without further description or assessment. t. Left arm weeping, without further measurements or description. Physician's orders related to the resident's wound/skin conditions included: a. 4/26/22 Prednisone 40 mg administered oral daily until 4/29/22. Contact Dermatology for further dosing instructions. b. 4/26/22 apply Calmoseptine Ointment 0.44-20.625 percent (Menthol-Zinc Oxide ointment, used as a barrier cream) to buttocks topically every shift for redness and open areas. The order discontinued 5/29/22. c. 4/26/22 apply Nystatin powder (an anti-fungal medication) topically every shift for wound treatment until healed, discontinued 5/30/22. There were no further specific instructions of where the medication was to be applied. d. 5/5/22 apply non-stick gauze to left hand and wrap with rolled gauze daily, discontinued 5/20/22. There were no assessments or descriptions of any skin concerns of the left hand documented in the resident's record. e. 5/5/22 apply Mepilex border foam gauze dressing to area on upper right thigh, change every 3 days and as needed, discontinued 5/30/22. f. Measure and document wounds on bilateral lower extremities weekly and document in the resident's electronic record on weekly Non-Pressure Ulcer Assessment Form, the order transcribed by Staff I, former Director of Nursing (DON). g. 5/21/22 wash right arm skin tear area with Normal Saline (NS), pat dry, apply Vaseline Petrolatum Gauze Pad, cover with rolled gauze, secure with tape daily. May apply additional gauze ABD pads (non-woven 5 inch by 9 inch by 1/2 inch gauze dressing) for excess weeping, discontinued 5/30/22. h. 5/21/22 wash left arm skin tear area with NS, pat dry, apply Vaseline Petrolatum Gauze Pad, cover with rolled gauze, secure with tape daily. May apply additional gauze ABD pads for excess weeping, discontinued 5/30/22. A Skin Integrity Impairment problem initiated 5/6/22 on the Nursing Care Plan, with 5/23/22 goal to have no complications related to skin, Chronic Venous Hypertension, and Idiopathic Ulcers of the Lower Extremity, directed staff to: a. Encourage resident to increase fluids and protein for wound healing and reposition frequently for weight redistribution, initiated 6/6/2022. b. Follow facility protocols for treatment of injury, initiated 5/6/2022. c. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs or symptoms of infection, maceration etc. to physician, initiated 5/6/2022. d. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, initiated 5/6/2022. Nursing Progress Notes contained the following entries: 4/29/2022 at 5:07 p.m. transcribed by Staff L, LPN, stated phone call placed to Dermatologist physician as requested, voice mail left to return call with further Prednisone orders. Call returned by the Dermatologist's nurse who stated the physician would not prescribe any new orders for Prednisone at this time as he did not prescribe it. Current order for Prednisone to stop today 4/29/22. (There was no follow up to ensure resident had a dermatologist follow up on rare skin disorder.) 5/10/22 at 11:21 a.m. transcribed by Staff G, LPN, stated alterations in skin integrity are noted. Multiple bruising and ulcers in several locations. 5/11/2022 at 10:45 p.m. transcribed by Staff H, LPN, stated alterations in skin integrity are noted. Multiple bruising and ulcers in several locations. 5/12/2022 at 10:29 p.m. transcribed by Staff H, LPN, stated alterations in skin integrity are noted. Multiple bruising and ulcers in several locations. 5/14/2022 at 7:32 p.m. transcribed by Staff K, RN (Registered Nurse) and Assistant Director of Nursing (ADON), stated alterations in skin integrity are noted. Scattered bruising throughout BUE (bilateral upper extremities) and BLE (bilateral lower extremities). Resident with open wounds to bilateral calves. Open area to right inner thigh as well. 5/15/2022 at 9:50 a.m. transcribed by Staff F, LPN, stated alterations in skin integrity are noted. Scattered bruising throughout BUE and BLE. Res with open wounds to bilateral calves. Open area to right inner thigh as well. 5/19/2022 at 6:07 p.m. transcribed by Staff L, LPN, stated alterations in skin integrity are noted. Scattered bruising throughout BUE and BLE. 5/22/2022 at 9:11 p.m. transcribed by Staff F, LPN, stated alterations in skin integrity are noted Scattered bruising and open areas throughout BUE and BLE. 5/23/2022 at 7:40 a.m. (late entry, actually transcribed on 5/29/22 at 7:42 a.m. by Staff F, LPN), stated alterations in skin integrity are noted. Scattered bruising and open areas throughout BUE and BLE. BUE continues with open areas, no signs or symptoms of infection. Areas continue to be moist due to ongoing weeping. 5/29/2022 at 7:41 a.m (late entry, actually transcribed on 5/31/22 at 7:44 a.m. by Staff F, LPN), stated alterations in skin integrity are noted. Scattered bruising and open areas throughout BUE and BLE. Open area on hip and buttocks. There are no signs of infection at this time. BUE and BLE continue with open areas, noted foul drainage. Resident continues on antibiotics for cellulitis, no signs of adverse medication side effects noted. Areas continue to be moist due to ongoing weeping. No complaints of increased pain reported. 5/30/2022 at 8:59 p.m. transcribed by Staff F, LPN, stated resident admitted to hospital with diagnosis of sepsis due to leg wounds. A Weekly Pressure Wound Assessment completed by Staff H, LPN on 5/13/22 revealed: Wound on front of left lower extremity measured 3.0 cm by 2.0 cm, small amount of serosanguinous drainage with slight odor, surrounding skin normal. Wound on rear of left lower extremity measured 3.5 cm by 1.5 cm, wound edges well approximated, pain related to wound, Vicodin administered. A Physician Progress Note transcribed 5/23/22 by Staff J, ARNP, (Advanced Registered Nurse Practitioner) revealed scattered bruising, scabs and pressure area to right thigh, wounds to bilateral arms, open areas with purulent drainage (fluid composed of blood and pus) to bilateral calves. Keflex (a strong antibiotic) 500 mg prescribed, administered oral twice daily for 10 days, and the Wound ARNP to see the resident 5/27/22 for treatment. A Non Pressure Wound Assessment completed 5/29/22 by Staff F, LPN, revealed: More than 5 open areas, right hip, back of right calf, left inner buttocks, left thigh blister, right side of left calf, left great toe black discoloration and right heel black area. The assessment included: a. Wound #1 (no location specified) no measurements stated, scant exudate with slight odor, wound bed with slough tissue (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps), open wound edges, surrounding skin reddened, tunneling or undermining of 2.9 cm by 0.5 cm by 2.0 cm and without direction or orientation of condition, wound status deteriorated, treated with wet to dry dressing, and pain associated with wound. b. Wound #2 (no location specified) no measurements stated, no drainage, slight odor, slough tissue at wound bed, wound edges open, surrounding skin edematous, tunneling or undermining measurements 3.0 cm by 0.75 cm by 1.0 cm and without direction or orientation of condition, wound status deteriorated, treated with wet to dry dressing, and pain associated with wound. c. Wound #3 (no location specified) no measurements stated, no drainage or odor, pale pink wound bed, normal surrounding skin, blister intact, wound status deteriorated, covered with foam dressing and no pain associated with wound. d. Wound #4 (no location specified) no measurements stated, no drainage or odor, wound bed necrotic eschar tissue (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges), surrounding skin reddened, tunneling or undermining of 0.5 cm by 0.5 cm and without direction or orientation if condition, wound status deteriorated, treated with Skin Prep. e. Wound #5 (no location specified) no measurements stated, no drainage or odor, wound bed necrotic eschar tissue, wound status deteriorated, treated with Skin Prep and no pain associated with wound. New Wound Care Treatment orders, transcribed 5/30/22, included: a. Apply Triad to left inner buttocks, cover with foam dressing daily. b. Apply foam dressing to left thigh blister daily and as needed. c. Apply Skin Prep to left great toe daily for black area. d. Apply Skin Prep to right heel daily for black area. e. Apply wet to dry dressing to back of left calf and cover with rolled gauze daily and as needed for open area. f. Apply wet to dry dressing to back of right calf and cover with rolled gauze daily and as needed for open area. g. Apply wet to dry dressing to right hip and cover with foam dressing daily and as needed for open area. h. Apply wet to dry dressing to right side of left calf and cover with rolled gauze daily and as needed for open area. A 6/2/22 Hospital Discharge Summary revealed the resident transferred to the emergency room via ambulance on 5/30/22 from her Dialysis Treatment Center due to profound hypotension (low blood pressure) unresponsive to dialysis treatment protocols. admitted with diagnoses that septic shock secondary to healthcare-acquired pneumonia following hospitalization for COVID-19. Diffuse erythematous wounds likely secondary to fragile/brittle skin and end state renal disease. Staff interviews revealed: 7/26/22 at 2:20 p.m. Staff J, ARNP stated she assessed the resident at the facility on 5/23/22, worsened skin wounds with pressure areas on right thigh noted, open areas on bilateral calves that had purulent drainage, she was unaware of the condition prior to the assessment and staff should have notified her of that. She prescribed Keflex 500 mg administered oral twice daily for 10 days to treat the resident's wound infection, and she referred the resident to a Wound Nurse ARNP that was to assess the resident on 5/27/22. 7/27/22 at 1:40 p.m., the facility's Corporate Nurse had been asked to review the resident's record and provide any documentation of wound assessments, beyond the 4/26/22 admission assessment, and 5/13/22 and 5/29/22 assessments. At that time, the Corporate Nurse stated she could not find any other documentation of the resident's wounds, beyond the NP's 5/23/22 assessment, the resident was supposed to be seen by the Wound Nurse but was hospitalized before that occurred. The Corporate Nurse stated nurses should always assess, measure and document all wounds at regular intervals, at least weekly, notify the physician and obtain treatment orders for any skin or wound condition that required intervention. She was unable to locate any other documentation of communication with the physician related to the resident's wound/skin conditions. 7/27/22 at 6:44 p.m., Staff I, RN (Registered Nurse) and former Director of Nursing (DON) stated she wrote an order for the nursing staff to assess the resident's wounds weekly and document on appropriate forms in the resident's record because she expected staff to follow the orders, and staff should assess, measure and document skin and wound conditions at least weekly, or more often if there was a significant change, staff should notify the physician of any skin or wound condition and seek orders for treatment as appropriate. It was not acceptable for a resident to have an open and draining wound without treatment orders. 8/2/22 at 10:50 a.m. Staff F, LPN, stated she admitted and assessed the resident's skin/wound conditions on 4/26/22, physicians assessed the residents after they were admitted and how they found out about the resident's skin conditions. When asked about the resident's follow-up with a Dermatologist physician, Staff F stated the resident went to dialysis, had COVID right after she was admitted , and was unable to see a Dermatologist due to that. 8/2/22 at 11:48 a.m. the Administrator and new DON (started 8/1/22) stated the resident was not seen by a Dermatologist as ordered because she tested positive for COVID 19 infection on 5/3/22, isolated until 5/14/22, the resident had dialysis 3 times a week, the Wound Nurse was supposed to see the resident but wouldn't see her because of her skin condition and said she had to be seen by a Dermatologist. Interview with the resident's Power of Attorney (POA) and decision maker 7/25/22 at 3:21 p.m. revealed their concerns for lack of care by facility staff, the facility had not notified them of new wounds or worsened wounds, a family member called them on the phone when they visited the resident on 5/2/22 and notified them the resident had painful wounds and thought she should be evaluated by a doctor. The POA then contacted nursing staff at the facility, inquired about the resident's wound status and informed by the nursing staff they knew all about her wounds and everything was being taken care of. When the resident went to the hospital on 5/30/22, her legs were so painful from the wounds that she cried out in pain when anyone touched them, and had to be medicated with Morphine (a very strong opiate narcotic analgesic) to control the pain. The POA stated the facility had not notified them of her condition changes and alarmed when they observed her condition at the hospital on 5/30/22. During an interview 8/8/22 at 3:18 p.m., the family member that visited the resident on 5/2/22 stated while at the facility 5/2/22, the resident said she had a lot of pain located in her bottom area due to wounds located there, and said she had more wounds on her legs, fluid seeped from her arms and they thought a doctor should check on her wounds for a treatment plan, then contacted the POA by phone while still at the facility to go over the issues with the POA.

Based on observation, record review, and staff member interviews, the facility failed to provide adequate nursing supervision and assistive devices to prevent accidents (Resident #1). The facility reported a census of 90 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 7/1/22 revealed Resident #1 had diagnoses that included multiple sclerosis, paraplegia, and high blood pressure, scored 14 out of 15 points possible on the Brief Interview of Mental Status (BIMS) cognitive assessment, without symptoms of delirium, and required extensive assistance of at least 2 staff members for transfers to and from bed or chair, bathing, dressing, personal hygiene and toileting, and the resident was unable to walk or stand. The Care Plan dated 6/28/22 revealed Resident #1 was dependent for transfer utilizing two assistants with the use of a mechanical lift called a Hoyer. An Incident/Accident Report form dated 7/2/22 revealed Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistants (CNA's) attempted to transfer Resident #1 with the Hoyer lift and the resident slipped out of the Hoyer sling striking her head on the Hoyer leg. The resident stated she had pain in her head and neck. The resident was transferred by an ambulance to the hospital for evaluation. A review of progress notes dated 7/2/22 at 6:55 PM revealed Resident #1 returned to the facility with a closed head injury and neck sprain. Review of the Emergency Department After Visit Summary documented the exam found Resident #1 had sustained a closed head injury and neck sprain. A written employee statement completed after the incident which Staff B, CNA acknowledged as her own and dated 6/2/22 documented Staff A, LPN and Staff B, CNA placed a disposable bed pad between Resident #1 and the Hoyer sling. When they moved Resident #1 from the bed with the Hoyer, the resident slipped out of the sling, fell to the floor, and struck her head on the leg of the Hoyer. Staff #B wrote the resident had reported her head hurt and rated her pain at 6 on a 0 to 10 pain scale (0 = no pain, 10 = worst pain ever experienced). During an interview on 7/21/22 at 1:20 PM, Staff B, CNA and Staff D, CNA stated they could not identify the sling used during the transfer, and both were unaware that the color of the border of the sling was a visual indicator of the sling size. During an interview on 7/21/22 at 11:57 AM, Staff B, CNA stated that Staff A, LPN assisted with the transfer for Resident #1 from the bed to her motorized chair. The resident asked staff to put a disposable pad between her and the Hoyer sling. Staff B could not describe the color of sling, but thought it was a small 6 point sling. The sling attached at the head, sides and crisscrossed between the legs, putting the resident in a sitting position when the Hoyer is lifting the resident. The LPN controlled the Hoyer and the CNA assisted the resident. When they moved the resident away from the bed, the resident slipped, bottom first, out of the bottom opening of the sling, striking her head on the Hoyer leg and ended up on the floor with the disposable pad still under her bottom. The LPN gave instruction not to move the resident until the paramedic's arrived. Staff B stated, I feel it was too slick between bed pad and sling. She hit her head pretty hard, she said my head and my neck hurts. During an interview on 7/21/22 at 12:30 PM, Staff A, LPN stated Resident #1 asked to get up to her motorized wheelchair, and this was the first time she assisted this resident in a Hoyer. Staff A stated Staff B, CNA assisted the transfer. Staff A stated the resident wanted a disposable pad placed in the sling and they used a solid blue sling, a small one that crisscrossed between the legs, a teal green/green boarder. Staff A stated they didn't get very far from the bed, that the resident came out of the sling so fast, I heard the thump of her head. Staff A stated she gave instruction not to move the resident while she called 911 for an ambulance, left the room, called EMS, the ADON and the resident's husband. Staff A stated, She laid on the floor about 6 minutes, EMS was here fast. Staff A stated the hospital only did a CT scan and returned the resident. During an interview on 7/21/22 at 12:22 PM, Staff C, Certified Medicine Aide (CMA) stated she was called to assist in Resident #1 room. Staff C stated that the resident was laying on her side, on the floor next to her bed with a disposable pad under the resident's buttocks. Staff C stated when she asked why there was a disposable pad under her, Staff B stated the resident wanted it. Staff C stated the resident cried, said her head hurt and that she wanted her phone, which she then used to call her husband. During an interview on 7/21/22 at 12:57 PM, Staff D, CNA stated she was called in to Resident #1's room and the resident was on the floor and the sling was still attached to the Hoyer. Staff D stated the resident's head lay on the Hoyer leg and she cried and asked for the phone. After staff provider her phone, the resident called her husband. Staff D verified the disposable pad was under the resident. The facility provided a policy titled Lifting Machine, Using a Mechanical dated July 2017 which documented the purpose of the policy was to ensure safe lifting, but was not a substitute for manufacturer's training or instructions. The policy also documented staff must be trained and demonstrate competency, and must also measure the resident for proper sling size according to manufacturer's instructions. The Owner's Operation and Maintenance Manual from the manufacturer (Invacare) instructed the user regarding sling use. On page 10, the manual directed staff: do not use any kind of plastic back incontinence pad or seating cushion between patient and sling material that may cause the patient to slide out of the sling during transfer. Invacare Patient Sling Owner's Manual instructed on page 3, Safety Summary, Warning: Do Not use any kind of material (such as a plastic back incontinence pad or seating cushion) between the patient and sling material that may cause the patient to slide out of the sling during transferring. During an interview on 7/26/22 at 3:15 PM, Staff B, CNA stated she was hired a month ago and did not receive an orientation to the equipment to include the mechanical lift (Hoyer), or complete a competency checklist when hired. During an interview on 7/21/22 at 3:15 PM, the Director of Nursing, (DON) stated there was no training for the Agency Nurses nor CNA's. The DON stated she did a 5 minute verbal training for nurses and CNA's to not use chux's (a disposable pad with plastic back) with Hoyer transfers. She reported she did not have a copy of the training or the sign-in sheets to show which staff attended. During an interview on 7/21/22 at 3:15 PM, the Director of Nursing (DON) stated there was no training for the Agency Nurses nor CNA's, but verified she did a 5 minute verbal training for Nurses and CNA's to not use Chux (disposable pads with plastic backing) with Hoyer transfers. On 7/22/22 the facility provided a document signed by Staff E, Assistant DON that indicated the facility provided a verbal training to staff on duty on 7/2/22 related to the proper use of the Hoyer lift. The facility had instructed staff to refrain from using any materials or padding in a Hoyer lift at any time due to the potential danger to residents as it could cause slipping or lead to other potential hazards. During an interview on 7/26/22 at 3:30 PM, Staff E, Corporate Nurse stated she was the DON at the facility from March through September of 2021. She explained that during the COVID-19 pandemic, the facility hired a few people for whom they inadvertently failed to provide orientation.

Based on record review, hospital report reviews, staff interviews, and facility policy review, the facility failed to complete adequate bowel assessments for 1 of 3 residents (Resident #1) reviewed. Resident #1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to the fracture, she experienced a change in her activity level and received PRN (as needed) oxycodone (used to treat severe pain) regularly for the pain. The facility failed did not adequately assess for constipation during the resident's stay. On [DATE], the resident complained of abdominal pain and displayed altered mental status so the nurse sent her to the emergency room (ER). An abdominal Computed Tomography (CT) scan diagnosed a bowel perforation (a hole in the small or large intestine) with the presence of moderate free fluid in the abdominal cavity. The physician told the resident her treatment option would be surgery resulting in a [CONDITION(S)], and although she was at a very high risk for surgical complications, she would not live without the procedure. The resident declined the surgery and admitted to hospice because she chose not to have a [CONDITION(S)]. On [DATE] at 8:34 PM, Resident #1 died of a bowel perforation and [CONDITION(S)]. The facility reported a census of 84 residents. Findings include: According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of [DATE], Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 14 of 15 possible points on the Brief Interview for Mental Status (BIMS) test which meant the resident displayed intact cognitive abilities and required extensive assist of 2 staff for bed mobility, transfers, and toilet use. The MDS also documented the resident as continent of bowel with frequent episodes of urine incontinence. Resident #1's care plan, initiated [DATE] documented the resident had sustained a left pelvic rami fracture and preferred to complete bed mobility, transfers, eating, and toilet use with assist of 1 staff. Further review of the care plan revealed it did not include the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Electronic Health Record (EHR) revealed the following reports: The Final Report from a local hospital with an encounter date of [DATE] and result date of [DATE] revealed the resident had lived at home alone, fell outside her home on [DATE] and sustained a left non-displaced acute fracture of the superior pubic rami with a small hematoma. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician documented her abdomen as soft, non-tender, and non-distended, with normal bowel sounds. A hospital Discharge Face Sheet with a service date of [DATE] listed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] ½ tab every 4 hours PRN. A hospital Patient Discharge and Transfer Form from a local hospital to the facility signed and dated by the discharging physician on [DATE] documented the resident last had a bowel movement (BM) on [DATE]. The Admit History and Physical (H&P) dated [DATE] and completed by the resident's primary care provider (PCP) documented Resident #1 admitted after a fall with a pubic rami fracture and received skilled therapy. The resident reported pain medications help with her pelvic pain. Her past medical history included [CONDITION(S)], hypertension, and constipation and the physician documented the resident's abdomen soft and non-tender. Assessment/plan: pubic rami fracture-continue therapy and pain medications, and constipation - on bowel medications. A hospital After Visit Summary dated [DATE] documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . At the facility, Resident #1 began experiencing abdominal pain but was uncertain of the exact time frame. When asked about onset, she said, Forever and could not tell if it was better or worse than usual and also could not answer any additional questions. Physical examination findings: abdomen appears distended with diminished bowel sounds and diffuse abdominal tenderness to palpation. A CT of the resident's abdomen and pelvis with contrast was completed on [DATE] due to infection suspicion and abdominal pain. Findings included: moderately distended stomach, moderate volume of free fluid and pneumoperitoneum (presence of air or gas in the abdominal cavity) present - concerning for perforation but etiology uncertain. Extensive discussions held with the resident and her family regarding goals of care including surgical options that exist resulting in a [CONDITION(S)] formation although she is a very high risk surgical candidate with her medical co-morbidities and her current septic state from the perforation. Upon further discussion, she reported she does not want to proceed with surgery. She does not want a [CONDITION(S)] and was able to voice understanding that she will ultimately pass away from this if the surgery is not completed. The family present at her bedside demonstrated understanding as well and is in agreement with her decision. They will plan for admission to comfort care. The family has decided to continue with limited cares until everyone arrives and the resident discharged to hospice. Resident #1's Medication Administration Records (MAR) from [DATE] and [DATE] revealed the following orders: a) Oxycodone 5mg (Milligram) 0.5 tablet every 4 hours as needed (PRN) for pain starting [DATE] b) Senna S tablet 8.,d+[DATE]mg, give 1 tablet 2 times daily for constipation starting [DATE] c) [MEDICATION(S)] Suppository 10mg, 1 rectally every 24 hours PRN constipation starting [DATE] d) MOM 30mL (milliliters) every 24 hours as needed for constipation starting [DATE] Review of the [DATE] MAR and the [DATE] MAR revealed Resident #1 received oxycodone 5 mg ½ tab every 4 hours PRN 67 times of 104 total opportunities in December, and 6 times of 7 total opportunities in January. Review of Resident #1's bowel movement (BM) documentation revealed the following: [DATE] [DATE]: admitted to the facility with last BM on [DATE] at the hospital [DATE]: Medium BM at 4:36 PM [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: Medium BM at 12:58 PM [DATE]: Medium BM at 12:58 PM [DATE]: Medium BM at 5:59 PM [DATE]: Large BM at 12:43 PM [DATE]: Medium BM at 5:05 PM [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE] Medium BM at 5:05 PM [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: Medium BM at 2:28 AM and again at 2:51 PM [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: Medium BM at 2:21 PM [DATE]: Medium BM at 4:19 PM [DATE]: Small BM at 3:17 AM [DATE]: Medium BM at 3:06 PM [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: Staff administered PRN milk of magnesia (MOM) with a medium BM as a result. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: Staff administered a PRN [MEDICATION(S)] suppository at 12:17 PM with large results at 4:45 PM. Staff administered MOM at 5:33 PM with no other results. [DATE] [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM and no PRN bowel interventions documented in the resident record or on the MAR. [DATE]: No BM as of 5:10 AM. Staff sent the resident to the hospital emergency room at 6:17 AM. Review of Resident #1's EHR revealed under the assessments tab, facility staff had completed ongoing Skilled Charting Assessments because she received skilled services during her stay at the facility. The assessment provided body systems used to complete the skilled nursing assessment, including a gastrointestinal assessment. Review of the skilled assessments facility staff had completed revealed the end of the assessment contained a space labeled Supplemental Notes where nurses could document education provided, communication with physician and family, compliance with care, complications, and extra comments related to the assessment. The skilled assessment routinely addressed only the resident's continence status with regard to the gastrointestinal system. Review of Resident #1's EHR revealed under the assessment tab staff had completed ongoing respiratory symptoms assessments which were utilized to monitor for COVID 19 symptoms since the resident admitted to the facility during the pandemic. The assessment advised staff to check all signs of respiratory/gastrointestinal/muscular symptoms to include the following gastrointestinal issues: nausea, vomiting, and/or diarrhea. Resident #1's EHR revealed the following progress notes: a) [DATE] at 5:23 PM Admission/Skilled Nursing Note, Admission Assessment: Resident #1 admitted from hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's abdomen is soft without distention, bowel sounds present in all 4 quadrants and remains continent of bowel. b) [DATE] at 10:11 AM Daily Skilled Charting, Note Text: Continent of bladder and bowel. c) [DATE] at 9:47 AM Respiratory Symptoms Assessment, Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment. d) [DATE] at 11:26 AM Daily Skilled Charting, Note Text: Continent of bladder and bowel. e) [DATE] at 11:36 Respiratory Symptoms Assessment, Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment. f) [DATE] at 12:05 PM Respiratory Symptoms Assessment, Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment. g) [DATE] at 11:29 PM Daily Skilled Charting, Note Text: Continent of bladder and bowel. h) [DATE] at 11:35 AM Respiratory Symptoms Assessment, Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment. i) [DATE] at 10:22 AM Daily Skilled Charting, Note Text: Continent of bladder and bowel. j) [DATE] at 10:29 PM, Respiratory Symptoms Assessment Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment k) [DATE] at 4:02 PM Daily Skilled Charting, Note Text: Incontinent of bladder and bowel. Bowel sounds in all four quadrants. l) [DATE] at 8:46 PM Respiratory Symptoms Assessment, Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment. m) [DATE] at 8:24 PM Nurses Note Text: Resident #1 complained of constipation - administered suppository with no results. Also administered MOM per resident request after noon and awaiting results. Assessment revealed abdomen soft, non-tender, non-distended with bowel sounds active in all 4 quadrants, and no complaints of pain or discomfort noted. Report given to evening shift. n) [DATE] at 10:51 AM Respiratory Symptoms Assessment, Note Text: The resident currently does not have a fever. No respiratory/GI/muscular symptoms noted on assessment o) [DATE] at 2:20 PM Nurses Note Text: Increased confusion past couple days. Increased anxiousness. Urine collected and sent to the lab this evening, fluids encouraged. p) [DATE] at 2:28 PM Daily Skilled Charting Note Text: There are no complaints of pain/signs of non-verbal pain. Continent of bladder and bowel. q) [DATE] at 6:40 AM Nurses Note Text: At 5:45 AM Resident #1 reported her pain medication was not helping. Noted respirations had increased and she felt clammy. Vitals obtained, slightly hypotensive, tachycardia, and on oxygen via 2 liters via nasal cannula. Call placed to her son, voice message left. Order obtained to send to the hospital for evaluation and treatment. Resident left the facility at 6:17 AM via non-emergent ambulance. Review of the resident's Death Certificate with a date and time of death of [DATE]at 8:34 PM. The immediate cause of death listed is bowel perforation, with [CONDITION(S)] identified as another significant condition. On [DATE] on 4:00 PM Staff A provided the facility's General Bowel Care Management Guidelines for Constipation. The guideline encouraged staff to always keep in mind potential bowel obstructions. The guideline instructed staff to know the resident's history such as their usual bowel pattern, regimen, assess dietary intake of fiber, assess activity level, assess if on antibiotics, note date and time of last bowel movement, associated discomfort, stool characteristics, and avoid suppositories or enemas for residents at risk for bleeding. The guideline provided physical examination tasks such as observe abdomen for distention, listen for bowel sounds, palpate abdomen for tenderness, digital rectal examination (if appropriate), assess for presence of nausea, vomiting, pain, urinary incontinence or diarrhea. Within the constipation management section contained the following interventions: A) Determine usual bowel habits and use of laxatives B) Encourage fluids, fruit and bran; maintain bowel movement diary. Prescribe stool softener and contact [MEDICATION(S)]: [MEDICATION(S)] sodium, sennosides. If no bowel movement by 48 hours add one of: MOM or [MEDICATION(S)]. If no bowel movement by 72 hours do rectal exam to rule out impaction. If not impacted try relieving with one of these: [MEDICATION(S)] suppository, magnesium [MEDICATION(S)] solution, sennosides, [MEDICATION(S)] enema, or oral fleet [MEDICATION(S)] soda. The guideline provided the severity of constipation may increase with dose of opioid. In an interview on [DATE] at 7:54 AM Staff A Licensed Practical Nurse (LPN) stated that when staff sign in to their electronic charting system they receive a notification of which residents are on day 3 with no bowel movement. The system will notify staff of the need for a PRN to be given. Staff A stated she would give the PRN before day 3 if the resident showed signs and symptoms of constipation; she would start with MOM and if no results she would administer a suppository. If a resident complained of constipation she would review the PRN orders, as even though all residents have standing suppository and MOM orders, some prefer a Senna tablet. When asked if the resident took oxycodone, would that change the way one would handle the prevention of constipation, she stated it would change how staff would monitor them. Staff A stated when a resident has increased pain they have to battle on when to cut back on pain medications to help with constipation as staff will need to be aware of the need for more PRN bowel interventions. She stated there is no policy on that but it is standard nursing practice/knowledge. Staff A reported she remembered Resident #1 had told staff she was having issues going to the bathroom so she administered a suppository. She added Resident #1 was pretty vocal about her constipation. Staff A stated if a resident complains of constipation it would not trigger anything different for their nursing assessments that were being completed. During an interview on [DATE] 8:24 AM, Staff B LPN stated she made sure to ask her residents about their BM status and if they have gone 3 days without a BM, she gives MOM and after 4 days gives a suppository, complete a GI assessment by listening to the resident's abdomen, and notify the doctor the resident had not had a bowel movement for 4 days. Staff B stated their electronic charting system notifies them when residents go 2, 3, or 4 days without a BM and then staff are to click on the PRN tab to see what to give or obtain an order if nothing ordered for the resident. Staff B was asked if a resident took oxycodone and at risk for constipation would that change when a PRN would be given because the pain medication would be a possibility as to why a resident could be constipated. She stated she would monitor the resident more closely, but continue to conduct her nursing assessments in the same way. During a staff meeting on [DATE] at 9:58 AM the Director of Nursing (DON) stated according to the facility constipation protocol, all residents had standing orders for MOM and a suppository and will get either one if they go 3 days no bowel movement. She continued they have an alert in their charting system to tell staff the resident has not had a BM in 3 days, although it does not prompt them to do anything else. The DON stated every resident had standing orders and if a cognitively intact resident asked for a PRN due to constipation they could receive one. The DON stated staff can offer the PRN without the resident asking. When asked about a resident that had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if it changed how staff complete assessments if that same resident routinely received PRN oxycodone, she reported nothing would change because they took it on a case by case basis. When asked during a staff interview on [DATE] at 12:20 PM what a daily skilled nursing assessment entailed, Staff C LPN stated it included the basics: vital signs, lung sounds, and answering a bunch of questions in their charting system in the assessment form. Staff C stated a respiratory symptoms assessment included an assessment of the resident's lung sounds, oxygen level, and checking for shortness of breath or cough. She stated they completed the assessments completed daily. Staff C was also asked what a note that says no respiratory/GI/muscular symptoms noted on assessment meant. She reported staff do a COVID respiratory assessment, once daily and they have a computer generated assessment tool in the system they follow and you can add a note to the bottom of the skilled tool. Staff C was asked if a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C reported she typically gave Resident #1 a pain pill in the morning and had taken it to her the morning she sent the resident to the ER. When she went in her room, Resident #1 was complaining of groin and back hurt and she checked on her again ,d+[DATE] minutes later to see if the pain medication was effective and it was not. She stated Resident #1 was clammy, had an increased pulse and was just not herself. Staff C said they had sent out a urine sample the evening before and did not have the results back, but suspected the resident was septic so called the ambulance then the doctor to have her sent to the ER. Staff C said the resident started to complain of not feeling well that morning when she gave her the pain pills. Staff C stated she received report from the day nurse that said the resident had some increased pain and nausea. Staff C was asked if Resident #1 was constipated and she stated she did not complain to her about it. Staff C said the resident was pretty sharp and could ask for a prn if needed, but added nurses could also step in to offer them if she was constipated and the nurse thought it was needed. During a staff interview on [DATE] at 9:55 AM Staff D Registered Nurse (RN) was asked when completing daily skilled nursing assessments what is included in the assessments, she stated the resident's diagnosis, why the resident was admitted to the facility, if receiving therapy, on antibiotics, reason for antibiotics, are they participating in therapy. Staff D stated it is a full head to toe assessment. Staff D was asked if this assessment included a gastrointestinal assessment, she stated it does and the skilled nursing assessments are done every day. Staff D stated the respiratory symptoms assessments include lung sounds, if the resident has a cough or is experiencing shortness of breath. She stated these assessments are also completed every shift. Staff D was asked about the facility's constipation protocol and she stated all residents had standing orders on admission that directed on day 3 with no bowel movement, administer MOM and then a suppository to the resident. Staff D indicated some residents do not want to take the MOM or suppository when they are constipated so will ask for Senna, [MEDICATION(S)] sodium, or [MEDICATION(S)]. She indicated she would ask the resident what they took at home for constipation and may also offer them prune juice. Staff D stated if the resident does not have a bowel movement after the PRN is given the doctor will need to be called. Staff D was given the following information about Resident #1: has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff D stated definitely because the medication can make someone constipated. Staff D stated she would ask about the resident's last bowel movement, make sure to include a stool softener routinely, especially if the pain medication is received frequently. She stated staff should be asking every day during their assessments if the resident had a bowel movement. During a staff interview on [DATE] at 10:08 AM Staff E CNA was asked when does she complete her charting after a resident has a bowel movement, she stated she tries to chart after it happens but that does not always happen because they do get busy. Staff E stated if a resident complained of being constipated during cares she would tell the nurse on duty. During a staff interview on [DATE] at 2:26 PM Staff F CNA stated she would chart a resident had a bowel movement after cares and would let the nurse know right away if a resident complained constipation. During a staff interview on [DATE] at 10:52 AM Staff G CNA stated she charted residents' BMs after they happened and would tell the nurse if a resident complained of constipation. During a staff interview on [DATE] at 10:20 AM Staff H was asked when she charts a resident has a bowel movement and she stated right after it happens and if the resident did not have a bowel movement on her shift, she will chart at the end of her shift that it did not occur. Staff H stated if a resident complained of constipation to her she would tell the nurse. During a staff interview on [DATE] at 8:57 AM with Resident #1's Primary Care Provider (PCP), he confirmed she was on his caseload and was reminded of the pelvic fracture, constipation diagnosis, frequent oxycodone PRN use due to left pubic fracture, and with orders for PRN MOM and [MEDICATION(S)] suppository. He was asked if he would have expected staff to give a PRN upon request, he stated oh yes they should be offering the PRN medication. He added if the resident is not requesting the PRN, staff should be monitoring her bowel habits and if she reached the point of 3 days without a bowel movement, they should have been offering it. He added this is what he thinks the facility's constipation policy entails, without actually looking at it. During a staff interview on [DATE] at 3:17 PM the DON reported she rewrote the bowel program after our initial conversation. When asked why that was done she stated so she knew they had better management of their resident's bowel movements. She stated they still use the basic standard for PRN usage: day 3 with no bowel movement would receive MOM, day 4 would get a suppository and day 5 would receive an enema. She stated these would require an assessment and a call to their physician. She stated the overnight nurses would pull a list of residents with their bowel records and provide that list to the day shift staff. She said she wanted to update the policy, re-evaluate it to simply the policy for the whole building. The DON was asked with Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? She stated she believed the GI assessment is part of skilled assessments daily. Her thought is skilled assessment is a head to toe assessment. After looking at the skilled assessment she stated it was not part of the daily skilled assessment tool. The DON stated Resident #1 did have a [MEDICATION(S)] ordered twice daily, was participating in therapy, and up moving with staff. She stated she would not expect GI assessments to be completed with Resident #1 because she was admitted for skilled nursing related to her pelvic fracture. She added constipation was not her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked if the nurses should have assessed Resident #1's abdomen daily, she stated she does not feel her abdomen should have been assessed daily because Resident #1 was alert and oriented and able to make her needs known. She added if her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, clinical record review, resident, staff and physician and wound care nurse interviews and facility policy review, the facility failed to provide timely resident assessments and interventions to maintain the resident's highest physical well being for 1 of 4 residents reviewed (Resident #3). The facility identified a census of 81 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 3/28/17 indicated Resident #3 had [DIAGNOSES REDACTED]. The assessment revealed he/she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS assessment revealed the resident as dependent on staff with bed mobility, with impairments on both sides of his/her upper and lower extremities, at risk for pressure ulcers and with 2 stage 3 pressure ulcers and 1 stage four and as not on a turning and repositioning program. A Care Plan initiated 12/11/16 indicated the resident had focus areas that included an activities of daily living (ADL) self care performance deficit and with impaired skin related to having been a quadriplegic, preferred to stay up in wheel chair all day, with a chronic stage 4 sacral/coccyx ulcer, a chronic stage 3 left ischial ulcer and left scapula ulcer and an unstageable right thumb wound with surgical repair. The approaches included the following: a. Assistance of 2 staff with bed mobility. b. Administer treatments as ordered and monitor for effectiveness. c. Blue/green positioning pillow under the right arm when in bed. The Occupational Therapy (OT) would have liked the pillow placed at all times but the resident refused to use the pillow when up in the wheelchair. d. Encourage the resident to lay down between meals. Position side to side. No laying on his/her back when in bed as resident tolerated and allowed. Resident often had been non complaint and stayed up in the wheelchair for long periods of time and refused repositioning (revised 3/17/17). e. Padded mitt with velcro for positioning of the right arm when in the wheel chair. f. The resident required a pressure reducing mattress and wheel chair cushion. A Injury/Incident Report form dated 2/22/17 at 10 a.m. indicated the resident rubbed his/her right thumb on the call light multiple times and obtained an open area. Review of the facilities Progress Notes form dated 2/17/17 at 7:48 p.m. through 2/22/17 at 2:48 p.m. revealed no assessment of the resident's right thumb. Review of the facilities Progress Notes form dated 2/22/17 at 3:40 p.m., revealed the resident obtained an open area on his/her right thumb by rubbing the thumb on his/her call light and the Physician had been notified at that time. The documentation revealed no measurements or a thorough assessment of the wound. According to a N*Weekly Nursing Skin Assessments form dated 2/20/17 at 6 a.m., the facility staff observed a 3 centimeter (cm) x (by) 2 cm open area on the resident's right thumb. A physician's orders [REDACTED]. According to N-Non Pressure Wound Sheet forms the Resident had a right thumb ulcer that measured as follows: a. 2/28/17 - 2.0 cm x 2.8 cm, no depth, tunneling or undermining, a moderate amount of serosanginous drainage, beefy red granulation and normal surrounding skin. b. 3/7 - 1.7 x 2.2 - no depth, tunneling or undermining, a moderate amount of serosanginous drainage, beefy red granulation, [MEDICATION NAME] cells filling in at the edges, and with the entire thumb as [MEDICAL CONDITION]. c. 3/14 - 1.8 x 2.2 - no depth, tunneling or undermining, a moderate amount of serosanginous drainage, beefy red granulation and with the entire thumb as [MEDICAL CONDITION]. d. 3/20 - 2.0 x 2.9 - no depth, tunneling or undermining, a large amount of serous drainage, beefy red granulation and with the entire thumb as [MEDICAL CONDITION]. A History and Physical form dated 3/15/17 at 10 a.m. documented the resident's symptoms to his/her right thumb began on 2/20/17 with what had been then at an open wound the IP joint (end joint of the thumb) exposed and necrotic bone. The Physician discussed treatment options and the resident agreed to a partial amputation of the right thumb. An Operative Report form dated 3/21/17 indicated the Physician performed a right thumb amputation. A Pathology Report form dated 3/23/17 at 5:42 p.m. indicated the resident received a right thumb amputation with [DIAGNOSES REDACTED]. a. A necrotic ulcer with underlying acute osteo[DIAGNOSES REDACTED]. b. Excision margins grossly free of the ulcer. During an interview 6/6/17 at 2:45 p.m., the resident indicated he/she received a skin tear while he/she used a call light and did not know it because he/she felt no pain and the next thing he/she knew the wound had been to the bone and the physician took of the thumb. During an interview 6/7/17 at 12:00 p.m., the resident stated in a way he/she had been upset about the amputation of the right thumb and in a way he/she had to accept it. During an interview 6/7/17 at 11:16 a.m., the Director of Nursing (DON) confirmed Staff A, Licensed Practical Nurse (LPN) observed the abrasion on the resident's right thumb on Friday 2/17/17, placed a Band-Aid to the site but failed to perform a nursing assessment of the area and/or report the area to any other staff member. On 2/22/17 the resident's granddaughter asked Staff B, LPN to change the dressing on the resident's thumb. The DON confirmed the first assessment had been performed on 2/22/17 with proper follow-up. During an interview 6/7/17 at 12:24 p.m., Staff A confirmed she could not remember the day but it had been a Friday when an aide told her the resident had blood on his/her shirt. The staff member assessed the resident and found a small, (as she pointed to the end of a pen which measured 0.4 and 1/2 cm) superficial skin tear with no drainage on the resident's anterior right thumb which she covered with a Band-Aid. The staff member stated she failed to assess the area and follow through per facility policy because she had been unaware of the policy. The staff member also confirmed she failed to report the incident to the next shift. During an interview 6/7/17 at 9:54 a.m., Staff B confirmed the resident's granddaughter found the bandage and requested she look at the area. The staff member felt there had been a white [MEDICATION NAME] pad that covered the area but really could not recall however she remembered there had been sanguineous drainage present, no treatment ordered for the area and she had been unaware who placed the bandage. During an interview 6/7/17 at 8:08 a.m., a Physician confirmed the following: a. The resident had predisposing factors that may have contributed to the amputation such as contractures and his/her medical condition however, the facility staff should have assessed the area immediately and notified the office as a means to properly treat the area immediately b. He/she had not been aware if the amputation could have been avoided however the resident would have had a better chance to save his/her thumb if assessed and treated when the area had been first observed. During an interview 6/8/17 at 12:44 p.m., a wound care nurse practitioner confirmed the following: a. He/she would have expected staff to report the resident's skin tear to a Physician and/or himself/herself as the area may have started as a skin tear however over any bony prominence could change to pressure related. So, in light of the location and the resident's medical condition the area should have been reported. He/she had been unaware if it would have changed the outcome but at least there would have been eyes on the area. b. The first time he/she observed the area had been on 2/23/17. c. Any medical change with the resident warranted medical attention right away. d. He/she had been concerned because the resident's finger nails had been long, rough and jagged and with the resident's compromised medical condition and contractures that put him/her at risk for pressure related injuries. According the facilities Policy and Procedure Manual form dated 1/09, the purpose had been to assure each resident with a pressure ulcer/wound received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers/wound from developing. The protocol included the following: a. An initial assessment would have been performed by a designated wound nurse at admission or if the ulcer/wound had not been present at admission, at the time of the discovery of the ulcer/wound. The assessment included the following: 1. Type 2. Location 3. Peri-wound condition 4. Size i. Length ii. Width iii. Depth 5. Undermining 6. Sinus tracts 7. Tunneling 8. Exudates 9. Odor 10. Necrotic tissue 11. Pain 12. Presence or absence of granulation tissue and [MEDICATION NAME].

Based on observation, clinical record review, resident, staff and physician interview, facility policy review, the facility failed to promote the healing of current pressure sores for 1 of 4 residents reviewed and failed to provide measures to reduce the potential for the development of additional or worsening pressure ulcers for 1 of 4 residents reviewed with pressure sores (Resident #3). The facility identified a census of 81 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 3/28/17 indicated Resident #3 had [DIAGNOSES REDACTED]. The assessment revealed he/she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The MDS assessment revealed the resident as dependent on staff with bed mobility, with impairments on both sides of his/her upper and lower extremities, at risk for pressure ulcers and with 2 stage 3 pressure ulcers and 1 stage four and as not on a turning and repositioning program. A Care Plan initiated 12/11/16 indicated the resident had focus areas that included an activities of daily living (ADL) self care performance deficit and with impaired skin related to having been a quadriplegic, preferred to stay up in wheelchair all day, with a chronic stage 4 sacral/coccyx ulcer, a chronic stage 3 left ischial ulcer and left scapula ulcer and an unstageable right thumb wound with surgical repair. The approaches included the following: a. Assistance of 2 staff with bed mobility. b. Administer treatments as ordered and monitor for effectiveness. c. Blue/green positioning pillow under the right arm when in bed. Occupational Therapy (OT) would have liked the pillow placed at all times but the resident refused to use the pillow when up in the wheel chair. d. Encourage the resident to lay down between meals. Position side to side. No laying on his/her back when in bed as resident tolerated and allowed. Resident often had been non complaint and stayed up in the wheel chair for long periods of time and refused repositioning (revised 3/17/17). e. Padded mitt with velcro for positioning of the right arm when in the wheel chair. The resident required a pressure reducing mattress and wheel chair cushion. A Weekly Wound Assessment MGM form from a previous facility dated 11/29/17 indicated the resident's wounds measured as follows: a. Left gluteal fold - 2 centimeters (cm) x (by) 0.5 cm and 1.3 cm deep, [DIAGNOSES REDACTED], maceration, no tunneling or undermining and a small amount of serosanginous drainage. b. Coccyx - 5 cm x 3 cm and 2 cm deep, 1.0 cm undermining at 2 o'clock and 0.5 cm at 5 o'clock, no tunneling or exudate. A N-Nursing Admission Assessment - V 1 form dated 12/7/16 indicated the resident had a coccyx and left buttock wound area that required an assessment by the Nurse Practitioner or the wound care nurse. Review of the facilities Progress Notes dated 12/7/17 at 8:40 p.m. failed to reveal an assessment of the resident's coccyx and/or left buttock ulcered areas. Review of the facilities N-Pressure Ulcer Wound Sheet - V2 forms revealed the following: a. 12/12/16 at 6:30 a.m. - A left ischial ulcered area that measured 2.5 cm x 1.0 cm and 1.8 cm deep, tunneling at 1.8 cm in the crevice of the wound, a moderate amount of serosanginous drainage, no tissue description and normal surrounding skin. b. 12/12/16 at 6:30 a.m. - A coccyx ulcered area that measured 6.0 cm x 2.5 cm and 2.2 cm deep, undermining 1.0 cm along all edges of the wound, a moderate amount of serosanginous drainage, no tissue description and normal surrounding skin. During an interview 6/6/17 at 3:30 p.m., the Director of Nursing (DON) confirmed there had been no admission nursing assessment of the resident's ulcered areas and she would have expected the staff to assess the areas if not that day the next day. A physician's orders [REDACTED]. During an interview 6/6/17 at 2:45 p.m., the resident stated some of the night shift staff only repositioned him/her every 3 to 4 hours and he/she wanted repositioned more often at times. The resident indicated he/she called out for staff assistance as he/she had been unable to use the call light however, there had been times no staff responded and he/she had not been on a routine repositioning program. During an interview 6/7/17 at 12:00 p.m., the resident stated the repositioning at night remained a problem up until last night because he/she received a new call light. The resident confirmed there had been times he/she refused to be repositioned in bed because he/she had been comfortable however, there had also been times there had been only 1 staff member who worked at night on his/her hallway and one person could not reposition him/her up in bed and get a pillow properly behind the back so repositioning had not occurred on those nights. During an interview 6/7/17 at 3:18 p.m., the resident stated he/she allowed the facility staff to reposition him/her in the wheelchair in fact he/she had been the one that asked the staff to pull him/her back in the wheelchair. During an interview 6/8/17 at 8:08 a.m., a Physician confirmed he/she expected staff to reposition the resident as needed (PRN) when in bed and certainly upon the resident's request. The Physician also confirmed staff should have properly assessed the resident's ulcered areas upon admission to the facility especially with his/her compromised medical condition. During an interview 6/8/17 at 12:44 p.m., a wound care nurse practitioner confirmed the following: a. He/she expected staff to reposition the resident every 2 hours even if the resident had been positioned on the alternating air flow mattress. b. He/she confirmed there had been times the resident refused to go to bed during the day however, the staff should have still repositioned him/her in the wheelchair and/or shift positions. c. Any medical change warranted medical attention right away for the resident. d. He/she had been concerned related to the resident's compromised medical condition and contractures long finger nails put him/her at risk for pressure related injuries. According the facilities Policy and Procedure Manual form dated 1/09, the purpose had been to assure each resident with a pressure ulcer/wound received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers/wound from developing. The protocol included the following: a. An initial assessment would have been performed by a designated wound nurse at admission or if the ulcer/wound had not been present at admission, at the time of the discovery of the ulcer/wound. The assessment included the following: 1. Type 2. Location 3. Peri-wound condition 4. Size i. Length ii. Width iii. Depth 5. Undermining 6. Sinus tracts 7. Tunneling 8. Exudates 9. Odor 10. Necrotic tissue 11. Pain 12. Presence or absence of granulation tissue and [MEDICATION NAME].

Based on observation, record review, and interviews, the facility failed to ensure each resident received adequate assistance devices to prevent accidents for 1 of 5 residents reviewed (Resident #2). During a transfer from a bed to wheelchair, a staff member failed to use proper safety measures and it caused the resident to fall. As a result, the resident sustained [REDACTED]. Findings include: According to the Minimum Data Set (MDS) Assessment tool dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident required limited assist of one staff for bed mobility and personal hygiene, and limited assist of two staff for transfers. The MDS also documented the resident required extensive assist of two staff for toilet use. The Resident's Care Plan dated [DATE] identified the resident displayed impaired cognitive function and had a [DIAGNOSES REDACTED]. The Resident's Care Plan initiated [DATE] identified the resident had a potential for falls related to unawareness of safety needs, confusion, psychoactive drug use, and gait/balance problems. The Care Plan directed staff to ensure the resident wore their left (AFO) leg brace, and had transfer loops to the bed. The Care Plan revised [DATE] identified Resident #2 experienced a self-care deficit related to history of a stroke. The Care Plan directed staff to use one staff to assist the resident with transfers. The Fall Report dated [DATE] at 10:15 p.m. revealed the resident rolled out of bed and documented the root cause of the fall as confusion. The Fall Report documented the fall as unwitnessed and revealed the resident sustained [REDACTED]. The reported revealed staff sent the resident to the emergency room for evaluation, and returned with orders to follow up with their primary care doctor in two days. The facility put a scooped mattress in place after the fall. The Fall Report dated [DATE] at 8:20 a.m. documented the Certified Nursing Assistant (CNA) assisted the resident into the wheelchair. The resident reported left leg pain and refused to wear their AFO. The resident was using a transfer bar to transfer to the wheelchair, the resident's hand slipped, and he/she fell . The report documented the root cause of the fall as failure to follow the Care Plan. As an immediate intervention, the facility educated the CNA to follow the set sheets (mini care plans the CNAs carry with them). The Resident Summary Investigation dated [DATE] documented the resident as alert and oriented to person but exhibited confusion regarding place and time. The resident required assist of one staff for transfers, and the summary documented the resident as nonambulatory (did not or unable to walk). According to the CT Final Report dated [DATE], the resident sustained [REDACTED]. The Progress Note dated [DATE] revealed the X-ray report documented a mottled appearance of the proximal femur that suggested the possibility of marrow infiltrative disorder such as [DIAGNOSES REDACTED] or less likely metastatic disease. However, the findings may simply be related to bony demineralization related to the patient's age. During an interview on [DATE] at 10:53 a.m., Staff A, Licensed Practical Nurse (LPN), described Resident #2 as confused and related he/she often searched for his/her deceased spouse while the resident propelled a wheelchair throughout the facility. Staff A reported prior to the fall the resident required staff assist of one with the use of a left lower extremity AFO, shoes, and a gait belt. It's the facility policy to use a gait belt unless the care plan directed staff otherwise. Staff A reported she did not witness the fall, although Staff J, CNA came to alert her Resident #2 fell in his/her room during a transfer from the bed to the wheelchair. Staff A reported the resident fell on [DATE] at about 8:20 a.m. and related she saw the resident lying on his/her left side with feet under the bed when she entered the room and added the resident was still in the hospital. Staff A, stated Staff J, told her she did not use the AFO, shoes, or gait belt during the transfer and added CNAs carry set sheets that contained documentation that directed residents' care needs. Staff A reported the facility had an inservice regarding all types of transfers after Resident #2 fell . During an interview on [DATE] at 12:59 p.m., Staff B, CNA described Resident #2 as confused and revealed the resident's care plan directed staff to transfer Resident #2 with assist of one and an AFO, a gait belt, and shoes. Staff B, reported the resident experienced left-sided weakness due to a past stroke and tried to talk staff out of the use of the gait belt, leg brace, and shoe. Staff B added if the resident tried to avoid gait belt use, she educated the resident about safety, or asked the nurse to do so. Staff B stated there is no excuse not to use a gait belt because there are plenty available. During interviews on [DATE] at 1:07 p.m. and [DATE] at 1:04 p.m., Staff C, CNA described Resident #2 as confused and reported the resident needed staff to transfer him/her with assist of one person, a gait belt, a lower extremity AFO, and shoes. Staff C also reported facility policy directed staff to use gait belts and added the belts were located in the break and shower rooms and on med carts in each hallway. During interviews on [DATE] at 2:10 p.m. and [DATE] at 12:55 p.m., Staff D, CNA described Resident #2 as confused and reported the resident needed transfer assist of one staff with a gait belt, leg brace, and shoes. Staff D also reported the resident told staff he/she could transfer independently and tried to talk them out of safety equipment use. Staff D stated they educated the resident staff needed to use the devices for safety or told him/her to talk with the nurse or therapy about changing the transfer technique. Staff D reported the gait belt is part of their uniform and should be used with all transfers and added set sheets were in a binder at the nurse's station to find changes and to see how to take care of the residents. Staff D related she had not seen other staff transfer a resident without a gait belt and reported it was easy to get Resident #2 to use the gait belt. During an interview on [DATE] at 2:35 p.m., Staff E, LPN reported she worked both day and evening shifts and she did not have staff who very often told her Resident #2 refused the gait belt, shoes, or AFO. Staff E, reported she just needed to chat with the resident for bit so the resident would cooperate. During an interview on [DATE] at 12:40 p.m., the Director of Nursing (DON) reported Staff J told her she ran late for work and left her gait belt in her car. The DON reported she completed interviews and conducted a reenactment of the incident. The DON related Staff J told her Resident #2 grasped the transfer bar and then started to fall, so Staff J tried to put the wheel chair under the resident. Staff H stated facility policy directed and she expected staff to use a gait belt with assist of one for transfers, and added gait belts were at the nurse's station, on the med carts. During an interview on [DATE] at 1:14 p.m. Staff I, LPN reported that she had not seen a resident being transferred without a gait belt, and wouldn't let that happen, it would not be a safe transfer. Staff I added it was facility policy to use a gait belt with all transfers (unless otherwise directed on the care plan). During an interview on [DATE] at 2:04 p.m. Staff K, C.N.A reported she had no problems persuading Resident #2 to use the gait belt. During an interview on [DATE] at 1:23 p.m. Staff J, C.N.A, stated she began employment at the facility on [DATE] and reported she was with the resident when the resident fell . Staff J, reported she went to the resident's room to get the resident up for a shower, and the resident didn't want to put on the AFO because his/her foot hurt. Staff J reported she put slipper socks on the resident, and the resident stood up and used the rail on the bed (small buddy rail). Staff J stated the resident lost his/her grip on the transfer bar on the bed and fell . Staff J said the resident was holding the wheelchair and couldn't get it under the resident before the resident fell . Staff J, reported she did not use the gait belt because the resident always complained of using the gait belt. Staff J added the resident always did fine before, and the resident didn't weigh that much anyway, so she thought he/she would be fine. Staff J, reported upon hire everyone is given a gait belt, but she thought she thought she left hers in the break room or at the nurses station. She stated assignment sheets at the nurse's station directed staff how to transfer the resident and listed other care needs. Staff J reported if the resident refuses the AFO and shoes next time she would get the nurse and tell her. The resident only refused to use the AFO and shoes the day he/she fell . Staff J, didn't try and put a gait belt on the resident, because she didn't have it with her. The Gait Belt Policy dated [DATE] policy documented the use of a transfer belt is for safety measures for both residents and staff when transferring or ambulating. A transfer belt will be placed on each resident prior to transfer or prior to ambulation with assistance. The only exception is when a resident is transferred by using a mechanical lift. In order to accomplish this efficiently, all nursing personnel will have immediate access to a transfer belt while on duty. The expectation is the gait belt be a part of the uniform dress code (must be worn at all times). Noncompliance may result in disciplinary action. This policy had been signed by Staff J with the date of [DATE], and had been in her personnel file. Observation on [DATE] at 3:00 p.m. revealed C.N.A staff all wore gait belts. Nurses at the nurse's stations able to show surveyor gait belts at the nurse's station, and on the medication carts. Observation on [DATE] at 2:00 p.m. revealed all C.N.A staff members wore gait belts. All shower rooms and medication carts at the nurse's station contained gait belts. Observation on [DATE] at 2:20 p.m. revealed a gait belt on a recliner in Resident #4's room. The investigation revealed the facility corrected the noncompliance prior to the Department representative's entrance to the facility to initiate review of the incident and therefore was in substantial compliance on [DATE].

Based on clinical record review, resident, staff and family interview and facility policy review, the facility failed to properly administer medications for 2 of 6 residents reviewed. (Resident #1 and #7). The facility identified a census of 104 residents. Findings include: 1. Resident #1 ' s Minimum Data Set (MDS) assessment form dated 9/6/16, indicated the resident had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 with 15 indicating no cognitive impairments. Resident #1 required extensive staff assistance with most activities of daily living (ADL'S), had no pain and weighed 155 pounds. A Care Plan with a focus area revised 9/20/16, indicated the resident had an ADL self-care performance deficit and at risk for pain related to a bilateral lower extremity amputation and gastrointestinal [MEDICAL CONDITION] regurgitation disease (GERD). The approaches included the following: a. Administer medications per physician's orders [REDACTED]. A Medication Error Report form dated 11/29/16 at 11 a.m., indicated at 8 a.m. Staff D, Licensed Practical Nurse (LPN) took medications for Resident #11 into Resident #1 ' s room and left them on the table when she answered the resident's call light. When the staff member left Resident #1 ' s room she left the medications on the table and Resident #1 got up and took the medications meant for Resident #11. During an interview 12/8/16 at 1:18 p.m., Staff D, Registered Nurse (RN) indicated around 7:25 a.m., she was preparing medications for Resident #11, she noticed Resident #1 ' s call light on. Staff D took Resident #1 ' s [MEDICATION NAME] (insulin shot) and the glucometer machine (blood sugar machine), and went to Resident #1 ' s room and also carried the medications prepared for Resident #11 into Resident #1 ' s room. The nurse placed the medications for Resident #11 on the bedside stand by the bathroom door. Resident #1 was in bed he/she did not need anything so the staff member checked blood sugar and gave the [MEDICATION NAME] subcutaneous injection and then left the room. After the Resident #1 completed breakfast around 9 a.m. he/she appeared lethargic, which was not abnormal because of a current urinary tract infection [MEDICAL CONDITION]. She assessed the resident but failed to document the assessment and took the resident to room, administered Resident #1 ' s medications and assisted the resident to bed and applied oxygen. Later a Certified Nursing Assistant (CNA) asked her if she administered the medications for Resident #11 and then it sunk in what she had done. The nurse went to Resident #1 ' s room, looking for the medications for Resident #11. A family member was in room. The family member stated the resident took the medications. The nurse then informed the family, Director of Nursing (DON) and the Nurse Practitioner of what had occurred. Around 11 a.m. the resident went out of the facility for a cat scan with family and returned sometime before 2 p.m. The nurse and a CNA assisted Resident #1 into the building at which time the resident was lethargic and weak but responded to physical stimuli. Upon return the Nurse Practitioner saw the resident and ordered hourly vital signs. During an interview 12/8/16 at 3:35 p.m., a family member indicated at 8 to 8:10 a.m. Resident #1 was up in wheel chair at the sink in room performing morning cares. Once the teeth had been placed the resident leaned back and took the medication cup from the wooden table beside him/her and took the medications. The family member then took the resident to breakfast and left. At 10:15 a.m. the family member returned to take the resident to a cat scan appointment. The resident was hard to arouse. The family member took the resident to the cat scan and returned to the facility around 1:15 p.m. and the resident never woke up during that time span. Review of the facilities Progress Notes revealed the following entries as dated: a. 11/29/16 at 4:16 p.m. - The resident inadvertently received the wrong medications. Lethargy and weakness noted. The Nurse Practitioner notified and stated to monitor the blood pressure (B/P), pulse (P) and oxygen saturation rate (SpO2). B/P 131/64, P 64, SpO2 95% with oxygen running at 1 liter (L). The resident went out to radiology for a cat scan of his/her right shoulder with family and awaiting results. All further medications had been held throughout the evening except the [MEDICATION NAME] and [MEDICATION NAME]. The resident had been difficult to arouse. b. 11/29/16 at 8:58 p.m. - The resident had been sleeping throughout the shift with vital signs within normal limits. (WNL) and no signs and symptoms (s/s) of respiratory depression. Respirations had been 12-15 breaths per minute throughout the day. c. 11/30/16 at 5:21 a.m. - The resident noted to have a [MEDICAL CONDITION] /jetting movement of hands at 3:50 a.m. The on call Physician had been notified and received an order to send the resident to the hospital. The resident had been sent to the hospital at 5:00 a.m. with vital signs stable up until the time the resident had been sent to the hospital. According to a Medication Administration Record [REDACTED] a. [MEDICATION NAME] 2 milligrams (mg's) - given for [MEDICAL CONDITION]. b. [MEDICATION NAME] 20 mg's - spasms. c. Senna S 2 pills - constipation d. [MEDICATION NAME] 90 mg's - anti-depressant and/or nerve pain. e. [MEDICATION NAME] Sodium 88 micrograms (mcg) - [MEDICAL CONDITION]. f. [MEDICATION NAME] 7.5 mg's - anti-[MEDICAL CONDITION]. g. Movantik 25 mg's - constipation. h. [MEDICATION NAME] 40 mg's - gastro-intestinal upset. i. Polyethylene [MEDICATION NAME] 17 grams (gms) - constipation. j. [MEDICATION NAME] 10 mg's - anti-anxiety. k. [MEDICATION NAME]/[MEDICATION NAME] 10 mg's/325 mg's - pain. l. [MEDICATION NAME] 100 mg's - fribromyalgia. m. [MEDICATION NAME] (HCL) 4 mg's - muscle spasms. According a MAR indicated [REDACTED] a. [MEDICATION NAME] HCL 200 mg's - AF. b. Aspirin 81 mg's - AF. c. [MEDICATION NAME]-[MEDICATION NAME] 18 mg's - nutritional deficiency. d. [MEDICATION NAME] 75 mg's - chronic ischemic [MEDICAL CONDITION]. e. Cranberry 405 mg's - nutritional deficiency. f. [MEDICATION NAME] 2.5 mg's - [MEDICAL CONDITION]. g. NAME] 40 mg's - gastro-[MEDICAL CONDITION] reflux. h. Polyethelene [MEDICATION NAME] 17 gm's - constipation. i. Tamsulosin HCL 0.4 mg's - enlarged prostate. j. Vitamin D3 2000 units - vitamin D deficiency. k. [MEDICATION NAME] 40 mg's - venous [MEDICAL CONDITION]/embolism. l. [MEDICATION NAME] 300 mg's - pain. m. Senna-[MEDICATION NAME] Sodium 17.2 mg's - constipation. n. Bactrim DS - urinary tract infection. o. [MEDICATION NAME] 3 units - diabetes mellitus. An Emergency Department History and Physical form dated 11/30/16 at 6:08 p.m., indicated the resident accidentally received one dose of Vitamin D, [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] about 22 hours prior to arrival and became somnolent and minimally responsive 20 hours ago at the nursing facility. The clinical impression had been acute [MEDICAL CONDITION], polypharmacy (disorder of brain caused by medication) and acute kidney injury. [MEDICATION NAME] (medication to reverse the effects of opioids) had been administered at 6:15 a.m. with no change in the patient's condition. During an interview 12/1/16 at 3:27 p.m., a physician confirmed Resident #1 receiving the wrong medications could have, without a doubt, contributed to his/her death. A Significant Event form from the Adult Critical Care unit identified on 12/1/16, Resident #1 as unresponsive and the resident was pronounced dead at 9:16 a.m. An autopsy was offered and declined. During an interview 12/2/16 at 2:45 p.m., the Interim Administrator confirmed, per the hospital, the wrong medications taken by the resident contributed to his/her drowsiness. During an interview 12/7/16 at 2:45 p.m., the Interim Administrator and Staff E, Registered Nurse (RN) confirmed thru the facilities internal investigation three (3) Licensed Practical Nurses, Staff F, Staff G and Staff H were identified as having left resident medications with residents without having observed the administration of the prescribed medications. 2. A MDS assessment form dated 10/9/16, indicated Resident #7 had [DIAGNOSES REDACTED]. During an interview 12/7/16 at 2 p.m., the resident indicated he/she received ear drops in her eye recently and it burned so bad he/she screamed. A Medication Error report form dated 11/2/16 at 8:10 a.m., indicated on 10/31/16 at p.m., Staff I, Certified Medication Aide (CMA) administered [MEDICATION NAME] (ear wax removal solution) ear solution in the residents left eye instead of an eye drop. A Progress Notes entry dated 11/1/16 at 3:02 p.m. included the following documentation: The resident went to an eye clinic to have the left eye evaluated. Orders had been received for [MEDICATION NAME] ointment 3 times a day for 10 days to the left eye. The progress report came back and stated the resident had a small corneal abrasion. The resident accidentally received an incorrect drop to his/her eye yesterday. The eye had been very red and irritated. The peri-orbital area puffy and reddish pink as well. The resident had been noted rubbing the area on and off. Per the residents report he/she had also been applying warm water compresses to the site as well. During an interview 12/9/16 (time unknown), the Regional Director of Clinical Operations stated the [MEDICATION NAME] ear solution had been a stock supply item. 3. During a group interview 12/7/16 at 2 p.m., the identified residents indicated the following: a. Resident #7 - Staff H, Licensed Practical Nurse (LPN) left medications in his/her room especially when she worked a double. Additionally, the nurse gave the resident his/her hour of sleep (HS) medications at 7 p.m. so he/she waited until closer to bedtime to take the medications because he/she would have gone to sleep. b. Resident #9 - Staff F, LPN left medications in his/her room cause she knew the resident would take them. The resident went onto say the nurse no longer left the medications as of yesterday. (12/6/16) During an interview 12/8/16 at 3:53 p.m., Staff H confirmed she had a few residents she left medications with without properly having observed the administration. During an interview 12/8/16 at 1:07 p.m., Staff G confirmed he left medications with residents unattended until he had been recently educated by the facility. During an interview 12/8/16 at 1:22 p.m., Staff F indicated she administered most resident medications in the dining area and denied having left medications with residents unattended even though Resident #9 said she did. 4. Review of the facilities General Medication Guidance form revised 3/2015, indicated the policy as the facility ensured medications were administered safely and accurately to resident to whom they had been prescribed. The procedure included the following: a. Medications had been administered in accordance with written orders of the attending physician. b. Medication supplied for one resident would not have been administered to any individual other than that for whom the medication had been prescribed. c. During the medication pass the nurse should have adhered to the 6 R's. Which included the following: 1. Right Resident. 2. Right Drug. 3. Right Dose. 4. Right Dosage Form. 5. Right Time. 6. Right Route. 5. Review of the facilities Medication Pass Observation form (checklist) revised 5/19/10, included the following questions: a. Residents observed to assure medications were consumed? b. Eye drops administered according to manufacturer's instruction and center policy? A In-service/Meeting Attendance Record form dated 12/1/16, indicated medications are never to have been left at a bedside and nurses are not to have carried medications for more than one resident at a time. Note: At the time of the complaint investigation, the complaint was coded at a K immediate jeopardy. By 12/7/2016, the facility implemented measures that adequately addressed the jeopardy and the grid placement was lowered to a G level. The facility educated all nursing staff administering medication on not leaving medication in residents room, ensuring the medication was taken by the resident and not bringing other resident's medications into other resident rooms. Each nurse was observed administering medication by administrative staff. As of the 12/14/16 exit conference the facility failed to monitor nursing staff to assure compliance with policy of medication administration.

Based on observation, record review and staff interviews, the facility failed to ensure 1 of 6 residents reviewed for falls received adequate supervision to prevent accidents and failed to direct the nursing services so the resident ' s needs were met (Resident #1). Resident #3 required alarms to alert staff when attempting to stand and ambulate by self. Based on facility staff interviews, the facility staff was aware the roommate disabled the alarms and additional supervision or plan was not implemented to prevent falls. The facility reported a census of 92 residents. Findings include: 1. According to the facility Face Sheet dated 1/16/09, Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set Assessment (MDS) tool with a reference date of 3/18/11 documented [DIAGNOSES REDACTED]. The MDS further documented the resident required extensive assistance of 1 staff member for walking, locomotion, dressing, eating, personal hygiene; extensive assistance of 2 staff members for transfer and toilet use and totally dependent on 1 staff member for bed mobility and 2 staff members for bathing. The MDS documented the resident's Basic Interview for Mental Status (BIMS) scored 3 points which assessed the resident as severely cognitive impaired The Fall Report, dated 3/11/11 noted at 3:30 PM the resident was found lying on the bathroom floor on the right side. The resident stated was trying to go to the restroom. The alarm did not sound. The roommate of the resident had turned off the alarm. The report identified an injury to the right shoulder and pain rated at 10 on a scale of 1 to 10. The resident ' s vital signs registered at blood pressure 105/51, pulse 59, respirations 20 and temperature at 99.0. The Nursing notes dated 3/11/11 at 3:45 PM documented the resident's roommate alerted staff that the resident needed help. Staff found the resident lying on the bathroom floor on right side at approximately 3:30 PM. The resident voiced complaints of pain to the right shoulder. The physician was notified and ordered an x-ray of the resident's right shoulder. The facility received the x-ray results at 5:30 P.M. and the physician ordered the resident be transported to the hospital. The Portable X-ray report dated 3/11/11 identified a comminuted impacted fracture of the humeral neck (shoulder). The care plan, updated through 4/11/11 and in place at the time of the fall incident, noted pressure alarms to bed and to chair, tab alarms to chair and wheelchair at dining room table and skid strips in front of recliner. The care plan also directed staff to keep alarm boxes out of the reach of the resident. Updated facility Face Sheet noted the resident was readmitted to the facility from the hospital on [DATE]. The Social Service Notes dated 3/25/11 for 5/day admit noted the residents was readmitted to the facility after recent hospitalization for a fractured shoulder following a fall in the facility. Resident #1 had a history of [REDACTED]. Resident #1 and spouse had a history of [REDACTED]. The facility had frequent checks by staff to anticipate the resident ' s needs and monitor alarm compliance. The resident and roommate had received frequent education about using a call light. The roommate had been going into the hallway to find help for the resident lately. The resident scored 3 on BIMS, which could indicate severe cognitive impairment. The resident scored 3 on mood interview, which could indicate minimal depression. During an interview with the social worker on 3/30/11 at 2:10 PM, the social worker stated she/he had not recently given education to the resident and roommate regarding alarms. The social worker stated knew they had recently been educated by nursing staff and she/he had offered education in the past but did not recall dates. The social worker stated she/he had been in the resident ' s room in the past when the resident was in the bathroom and the roommate assisted the resident with no alarm sounding. This happened once or twice but stated could not recall dates. The social worker stated one time in their room and heard a faint alarm sounding and could not hear the alarm in the hallway. Upon searching, she/he found the alarm box in a drawer with clothing covering the box. It didn't happen recently. The roommate had come into her/his office, on the past, to get help for roommate. The only reason she/he remembered this is he/she wanted help getting into bed. Neither of these incidents happened recently. The social worker stated she/he had previous conversations with a family member where she/he asked about the resident being made independent in his/her room. The resident worked with therapy and could not demonstrate retaining the safety skills needed to have the alarms removed. The resident has had a cognitive decline after hospitalization s. She is very familiar with the resident and can see the decline in the ability to interact in a conversation and the resident did not initiate conversations with staff or tablemates like the resident did formerly. A BIMS interview with the resident scores severely impairment range. In January he/she scored 5, March scored 3 and today scored 1, yet he/she can answer the mood questions and questions about his/her daily routine appropriately. On 3/30/11 at 9:30 AM, the Administrator was interviewed and stated she/he interviewed the staff and they told her the resident's roommate had previously removed the clip alarm from Resident #1 ' s clothing so he/she could get up and go to the bathroom per self without setting off the alarm. The Administrator stated this was the first time she/he had any knowledge about the roommate of Resident #1 removing the clip alarm before the incident of 3/11/11. On 4/4/11 at 11:05 AM, Staff B (Licensed Practical Nurse) stated she/he stood with Staff G (Certified Nursing Assistant) in the hallway by the medication cart. The resident's roommate propelled self into the hallway in a wheelchair waving arms and stating, "We need help in here". Staff B told staff G to go assist the resident. Staff G requested Staff B obtain vital sign equipment. Staff B grabbed the equipment and went to the resident ' s room and found the resident lying on the bathroom floor on right side. Vitals were taken and the resident complained of pain to the right arm. Staff B stated the resident had alarms on at 1 PM when this nurse performed safety checks. The resident ' s roommate could turn the alarms off. On 4/4/11 at 8:55 PM, Staff G was interviewed and stated he/she had provided cares for Resident #1 and roommate. Staff G stated he/she saw Resident #1 in a wheelchair and the intact alarm was clipped to the back of shirt. About 15 minutes, after this observation, he/she was called to the resident's room and observation revealed the resident lying on the bathroom floor. The alarm did not sound. Staff G believed when Resident #1 leaned forward to get out of the wheelchair the roommate unclipped the alarm. Resident #1 has another type of alarm since the fall which caused a fractured shoulder. On 4/4/2011 at 11:30 A.M. Staff C was interviewed. Staff C stated had taken care of Resident #1 and the roommate. Staff C stated before the resident fell on [DATE], the resident required 1 staff assistance but now needed 2 staff assistance. Prior to the fall, the resident had alarms on the wheelchair, bed, recliner and floor mat and unable to turn the alarms off but the resident ' s roommate could disable the alarms. The roommate had been told not to disable the alarms. Now, after the resident ' s fall with a fracture, the alarms are kept out of reach so the roommate cannot disable them. During an interview on 4/4/11 at 11:45 AM with Staff D, Staff D stated has provided cares services to Resident #1 along with his/her roommate. Before Resident #1's fall on 3/11/11, the resident required 1 staff assistance and now requires 2 staff to transfer. Resident #1 had alarms on the wheelchair, bed, recliner and floor mat alarm. The resident could not turn off the alarms but the roommate could. Staff D stated she/he has told the roommate, quite a few times, to not turn off the alarms. After Resident #1 fell and acquired a fracture, the alarms were placed so the roommate can no longer disable the alarms. Staff E was interviewed 4/4/11 at 12 noon and stated has provided cares and services to Resident #1 and roommate. Staff E stated before the fall the resident required 1 staff person assistance and now requires 2 staff persons. Resident #1 could not shut off the alarms on the bed, wheelchair, recliner or floor but the roommate could shut the alarms off. Now, after the resident's fall with a fracture, the alarms are out of the roommate's reach. This last weekend the roommate rolled his wheelchair on the floor mat alarm and it went off. Staff E stated she/he went to the room and the roommate was looking around trying to shut the alarm off but could not. Staff E shut the alarm off and cautioned the roommate if he/she wheels onto the floor mat the alarm will go off. Staff F was interviewed on 4/4/11 at 2 PM and stated she/he has taken care of Resident #1 and the roommate. Resident #1 had a chair and bed alarm prior to the fall on 3/11/11. Prior to the fall required 1 person assistance and now requires 2 person assistance after the fall. The roommate was able to disconnect alarms prior to fall and now cannot disable the alarms. When the alarms come on now the roommate goes to the hallway and waves his/her arms. Staff is very aware of the alarm situation with Resident #1 and the roommate and everyone is checking this room. During an interview with Staff A on 4/4/11 at 10:20 AM. Staff A stated she/he has taken care of Resident #1 and roommate. Resident #1 has alarms to prevent falls and was not able to take the alarms off but the roommate did take the alarms off. On the bed pad alarm, the roommate would place books on the pad so the alarm did not sound. There is a pad alarm on the recliner and the roommate could turn the alarm off by just pushing the button on the alarm. An interview with Resident #1's roommate was conducted on 3/30/11 at 1:30 PM. The roommate stated Resident #1 broke his/her arm when they fell in the bathroom and could not remember about how the alarm was removed prior to the fall. The roommate stated he/she had nothing to do with it. The roommate stated he/she would push the call light if needed help. Observation of Resident #1 on 3/30/11 at 1:30 PM revealed the resident seated in a recliner with a call light clipped to a blanket which covered the resident ' s lap and had the right arm in a sling. The resident was resting and unable to answer questions.