Every finding on record at Salem Health & Rehabilitation

Based on staff interview and clinical record review, the facility staff failed to ensure residents receive treatment and care in accordance with a medical provider orders for (1) one of (3) three sampled residents, Resident #2. The findings included:For Resident #2, the facility staff failed to administer the medication Ertapenem for (7) seven days as ordered by a medical provider. Ertapenem is a potent antibiotic used to treat serious bacterial infections, including urinary tract infections. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to spina bifida, paraplegia, weakness, neuromuscular dysfunction of bladder, and type 2 diabetes mellitus. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 2/17/26 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of Resident #2's April 2026 orders disclosed a medical provider order with a start date of 4/19/26 which read in part, .Ertapenem Sodium Injection Solution.1 (one) GM (gram).Inject 1 gram intramuscularly one time a day for uti (urinary tract infection) for 7 (seven) days.please give first dose now. The order had an end/completed date of 4/26/26. A review of the April 2026 MAR (medication administration record) disclosed the following:4/19/26 - was coded as (9) = Other / See Progress Note4/20/26 - was coded as (2) = Drug Refused4/21/26 - medication was administered4/22/26 - medication was administered4/23/26 - medication was administered4/24/26 - medication was administered4/25/26 - medication was administered4/26/26 - was marked with (X) not administered A review of Resident #2's progress notes did not disclose a progress note to include why ertapenem was not administered on 4/19/26. A follow-up visit medical provider progress note dated 4/20/26, which read in part, .was seen today due to refusal of IM (intramuscular) antibiotics for urinary tract infection.Per nursing staff.had refused.dose of ertapenem.when asked why.refusing.stated that.does not want a shot.Upon further review.IM ertapenem is the only medication.is susceptible to that is not via IV (intravenous).is not susceptible to any oral antibiotics at this time. After education regarding the importance of completing antibiotic therapy and that ertapenem is the only susceptible option available.agreed to comply with IM ertapenem daily for (7) seven days, with the course ending 4/26/26. A review of Resident #2's comprehensive person-centered care plan disclosed a focus which read in part, .UTI.The resident has developed a urinary tract infection. An intervention associated with the focus read in part, .Medications as ordered. On 5/6/26 at 10:34 AM, the Director of Nursing (DON) was interviewed and agreed a progress note for 4/19/26 could not be located for why the ertapenem was not administered to Resident #2. The DON stated another provider saw Resident #2 on 4/20/26 and the resident agreed to receive the medication for (7) seven days. The DON agreed Resident #2 received only (5) five doses of ertapenem and stated an order should have been obtained to extend the length of the medication administration. This concern was discussed on 5/6/26 at 11:19 AM at the pre-exit meeting with the Administrator, Director of Nursing, Regional Director of Clinical Services, Assistant Director of Nursing, and the Regional MDS Director. Requested and received a facility policy titled, Non-Controlled Medication Orders with a revision date of 08/2020 which read in part, .Medications are administered.upon receipt of a clear, complete, and signed order.Medication orders specify.Quantity or duration (length) of therapy. No further information was provided prior to exit on 5/6/26.

Based on observation, Resident interview, staff interview and facility document review the facility staff failed to ensure call bell was accessible for 1 of 7residents, Resident #5.The findings included:For Resident #5 the facility staff failed to ensure the resident's call bell was within reach.Resident #5's face sheet listed diagnoses which included but not limited to idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness.Resident #5's most recent minimum data set with an assessment reference date of 06/18/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Surveyor observed Resident #5 on 08/26/25 at 2:30 pm. Resident was resting in bed with eyes closed. Call bell was observed lying on the floor next to bed. Surveyor observed resident on 08/27/25 at 9:45 am. Resident was sitting up in bed, call bell was observed in floor beside bed. Surveyor observed resident on 08/27/25 at 1:20 pm. Resident was seated in wheelchair at bedside. Call bell was lying on opposite side of bed out of reach of resident. Surveyor asked resident if they could reach the call bed, and resident stated, I guess I could get to it if I really had to. Surveyor observed resident on 08/28/25 at 8:35 am. Resident was sitting up in bed, call bell in floor beside bed. Surveyor spoke with the director of nursing (DON) on 08/28/25 at 1:00 pm regarding call bell placement. DON stated that call bells should be placed within reach of the resident whether they are in bed or sitting in chair. Surveyor requested and was provided with a copy from Mosby's Textbook for Long-Term Care Assistants which read in part, Always keep the call light within the person's reach--in the room, bathroom, and shower or tub room.The concern of not maintaining the resident's call bell within reach was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services on 08/28/25 at 4:00 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of a room change prior to the change for 1 of 10 sampled residents (Resident #3). The findings included: For Resident #3, the facility staff failed to provide the resident with written notification of a room change including reason for the change prior to moving the resident to another room in the facility. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Malignant Neoplasm of the Frontal Lobe and Spondylosis with Radiculopathy of Cervical Region.The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/10/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. According to Resident #3's clinical record, he changed rooms within the facility on 1/23/25. The resident's clinical record included a Room Change Notification form dated 1/23/25 completed by a facility social worker, Other Staff Member (OSM) #4. The form indicated Resident #3's Power of Attorney (POA) was notified of the room change on 1/23/25 at 11:00 AM and gave consent for the change. The form documented the reason for the change as Medical Management. On 8/27/25 at 2:50 PM, surveyor spoke with OSM #4 who stated she notified Resident #3 and the family verbally of the room change. OSM #4 further stated that now they provide written notification of room changes and have been doing so for several months but Resident #3 was not provided with written notification. Surveyor spoke with OSM #4 again on 8/28/25 at 1:16 PM regarding the Room Change Notification form dated 1/23/25. Question number 10 on the form read Resident and/or RP [responsible party] were provided with a copy of notification and yes was checked. OSM #4 stated she marked yes in error on the form. Surveyor requested and received the facility policy titled Bed Management/Room Changes dated 9/30/22 which read in part .4. Provide timely and efficient room changes through internal transfers with proper documentation using the Room Change Assessment Notification form.On 8/28/25 at 4:00 PM, the survey team met with the Administrator, Administrator in Training, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff failing to provide written notification of a room change for Resident #3.No further information regarding this concern was presented to the survey team prior to the exit conference on 8/28/25.

Based on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide activities of daily living (ADL) care to 1 of 10 dependent residents, Resident #5.The findings included:For Resident #5 the facility staff failed to provide nail care. Resident #5's face sheet listed diagnoses which included but not limited to idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness.Resident #5's most recent minimum data set with an assessment reference date of 06/18/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #5's comprehensive care plan was reviewed and contained a plan for the resident requires assistance with ADL's (activities of daily living).Surveyor spoke with Resident #5 on 08/27/25 at 9:45 am. Resident was sitting up in bed, alert and oriented. Surveyor observed resident's nail to be long, jagged and with brownish debris underneath. Surveyor asked resident if nails being long bothered him, and resident stated that it does. Surveyor asked resident if staff trimmed their nails, and resident stated, I chew them. Surveyor spoke with resident on 08/27/25 at 1:20 pm regarding fingernails, and resident stated, I have asked to have them cut, but nobody ever does it. Surveyor spoke with Resident #5 on 08/28/25 at 8:35 am regarding fingernails. Resident stated they would like to have their fingernails cut. Surveyor told resident they would let staff know, and resident stated they would appreciate it.Surveyor spoke with director of nursing (DON) on 08/27/25 at 11:15 am. Surveyor asked DON who is responsible for providing nail care to resident, and DON stated usually certified nurse's aides (CNA), but nurse's do it as well.Surveyor spoke with CNA #6 on 08/27/25 at 1:15 pm regarding nail care. CNA #6 stated they provide nail care every day and trim residents' nails as needed. Surveyor asked CNA #6 if they worked with Resident #5, and CNA #6 stated they do not. Surveyor spoke with CNA #5 on 08/28/25 at 9:00 am regarding resident's nail care. CNA #5 stated they do nail care at least once a week including trimming, cleaning, and filing. Surveyor asked CNA #5 if they worked with Resident #5, and CNA #5 stated they have but not this week. Surveyor requested and was provided with a facility policy entitled Nursing Care and Services which read in part, Nursing staff will provide nursing care and services following current standards of practice recognized by state boards of nursing as informed by national nursing organizations and by hiring individuals who graduate from an approved nursing school and/or nurse aide curriculum and have or will have successfully passed a licensing and/or certification examination. 1. The center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skills & Techniques by [NAME], [NAME], and Ostendorff, as a reference for nursing services and skill not otherwise provided in the Policies and Procedures Manuals.The concern of not providing nail care for Resident #5 was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing and regional director of clinical services on 08/28/25 at 4:00 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 10 sampled residents. Resident #6.The findings included:For Resident #6, the facility staff failed to check blood glucose levels and failed to administer the medication Novolog as ordered by a medical provider. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, Muscle Weakness, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Cerebral Infarction, Anxiety Disorder, Depression, Cognitive Communication Deficit, and Chronic Pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/14/25, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A medical provider orders with a start date of 4/25/25 read in part, .Novolog FlexPen Subcutaneous (situated or applied under the skin) Solution Pen-injector 100 UNIT/ML (units/milliliters).Inject 15 unit subcutaneously before meals and at bedtime for T2DM (Type 2 Diabetes Mellitus). A medical provider order with a start date of 4/25/25 read in part,.Novolog FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML.Inject as per sliding scale: if 0-60=0 If asymptomatic give Med Plus as ordered. If symptomatic give Glucagon as ordered from stat box; 61-199=0; 200-249=4 Units; 250-299=6 Units; 300-349=8 Units; 350-399=10 Units; 400-499=12 Units; 450-499=14 Units; 500+ = 16 Units.subcutaneously before meals and at bedtime. A review of the August 2025 MAR (medication administration record) revealed Resident #6 did not have any blood glucose checks documented or any evidence of Novolog being administered, refused, or held on the following dates and times: 8/15/25-6AM, 4PM, and 9PM8/16/25-6AM8/20/25-6AM8/24/25-6AM8/25/25-6AM A review of the person-centered comprehensive care plan had a focus which read in part, .DIABETES MELLITUS: The resident is at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with: insulin use. An intervention related to the focus read in part, .administer medications as ordered. Further review of the plan of care disclosed another focus which read in part, .HYPOGLYCEMIC: the resident is at risk for complications related to the use of hypoglycemic medications. Interventions related to the focus read in part, .monitor of signs/symptoms of hypoglycemia.vitals as needed. On 8/27/25 at 12:57 PM, surveyor spoke with the director of nursing and reviewed the August 2025 MAR for Resident #6. The director of nursing stated she would look for evidence of why the medication was not administered. The director of nursing informed surveyor she could not find any evidence of the Novolog being held, given, or refused by the resident on the days that were blank on the August 2025 MAR. This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00PM with the administrator, administrator-in-training, director of nursing, assistant director of nursing and regional director of clinical services. Surveyor requested and received a facility policy titled, Administration Procedures for All Medications which read in part, .III .1 .a. Check the MAR .for the order .d. Check for vital signs or other tests to be done during or prior to medication administration . No further information regarding this concern was presented to the survey team prior to exit on 8/28/25.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide care and treatment to promote healing of pressure ulcers for 1 of 10 residents, Resident #5.The findings included:For Resident #5 the facility staff failed to provide care and treatment to promote healing of pressure ulcers as evidenced by failing to follow infection control procedures during a dressing change.Resident #5's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, gangrene, and acute osteomyelitis.Resident #5's most recent minimum data set with an assessment reference date of 06/16/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section M, Skin Conditions, coded the resident as having one stage 1 pressure ulcer and three unstageable pressure ulcers.Resident #5's comprehensive care plan was reviewed and contained a plan for The resident is at risk for pressure ulcers . and The resident has a chronic wound or pressure ulcer. Interventions for these care plans included Enhanced barrier precautions.Surveyor observed registered nurse (RN) #2, with assistance from licensed practical nurse (LPN) #2, performing wound care/dressing change on 08/28/25 at 10:50 for Resident #5. RN #2 performed hand hygiene, donned gloves and gown, cleaned the overbed table with disinfectant, placed a barrier on the table, placed treatments and dressings on the barrier. RN #2 removed gloves, performed hand hygiene, and donned new gloves. RN #2 asked LPN #2 to retrieve bandage scissors from their (RN #2) pocket. LPN #2 did so, and handed scissors to RN #2, then performed hand hygiene and donned gloves. RN #2 proceeded to remove old bandage from Resident #5's wound, without cleaning scissors prior to using them. RN #2 placed scissors on barrier on table. After removing old bandage and placing in trash, RN #2 removed gloves, performed hand hygiene and donned new gloves. RN #2 cleaned wound to Resident #5's lateral right foot, placed betadine gauze over wound, removed gloves, returned to treatment cart to retrieve gauze wrapping, donned gloves without performing hand hygiene, wrapped wound with wrapping, placed dated and initialed tape to secure wrapping. RN #2 then removed gloves, performed hand hygiene, donned clean gloves, cleaned wound to resident's right heel, applied treatment, applied dressing and wrapping, without changing gloves or performing hand hygiene.Surveyor spoke with the facility infection preventionist (IP) on 08/28/25 at 11:15 am. Surveyor asked IP what their expectations are for cleaning scissors and hand hygiene during wound care. IP stated scissors should be cleaned after each use and hand hygiene should be performed with each glove change. Surveyor asked IP if RN #2 should have changed gloves and performed hand hygiene after cleaning wound, but prior to applying treatment dressing, and IP stated they should have.Surveyor requested and was provided with a facility policy entitled Handwashing Requirements which read in part, A. Hand Hygiene. 1. The following is a list of some situations that require hand hygiene: j. before and after changing a dressing. r. After removing gloves for aprons. t. After any contact with potentially contaminated materials (used wound/treatment dressings). (2) Hands must be washed prior to and after using gloves.Surveyor was also provided with a policy entitled Nursing Care and Services which read in part, Nursing staff will provide nursing care and services following current standards of practice recognized by state boards of nursing as informed by national nursing organizations and by hiring individuals who graduate from an approved nursing school and/or nurse aide curriculum and have or will have successfully passed a licensing and/or certification examination. 1. The center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skills & Techniques by [NAME], [NAME], and Ostendorff, as a reference for nursing services and skill not otherwise provided in the Policies and Procedures Manuals.Surveyor was provided with an excerpt from Clinical Nursing Skills & Techniques for applying a dressing, which read in part, 1. Perform hand hygiene and apply clean gloves. 2. Gently remove tape, bandages, or ties .5. Fold dressings with drainage contained inside and remove gloves inside out over dressing. Dispose of gloves and soiled dressing according to agency policy .8. Clean wound. a. Perform hand hygiene and apply clean gloves. Use gauze or cotton ball moistened in saline or antiseptic swab for each cleaning stroke or spray wound surface with wound cleaner. 9. Apply antiseptic ointment (if ordered) with sterile cotton-tipped applicator or gauze along wound edges. Dispose of gloves. Perform hand hygiene. 10. Apply dressing.The concern of RN #2 failing to provide care and treatment to promote healing of a pressure ulcer was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services on 08/28/25 at 4:00 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 10 sampled residents. Resident #4 and Resident #6.The findings included:1. For Resident #4, the facility staff failed to accurately document the correct foot containing a wound on a skin assessment on 1/22/25 and failed to document treatment for a wound on the correct foot. The wound was on Resident #4's right foot and the facility staff documented the wound was on the left foot. Resident #4's diagnosis list indicated diagnoses that included, but were not limited to, Dislocation of Right Ankle Joint, Hypertension, Anxiety, Depression, Edema, Neuropathy, Insomnia, History of Falling, Diabetes Mellitus Type 2, Sleep Apnea, and Difficulty Walking. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/24/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A medical provider orders dated 1/22/25 read in part, .Left foot wound care (below the toes) every day shift.Cleanse with wound cleanser, pat dry, apply xeroform (an occlusive petroleum impregnated fine mesh gauze dressing which provides a microbial barrier and is mildly deodorizing) and bordered gauze. A review of a medical provider's progress note dated 1/22/25 read in part, .Patient seen today per nursing request for a wound on the bottom of her right foot. She states the wound has been there for several weeks but had started to heal until she went to the hospital for her ankle fracture.Wound nurse came in during visit and addressed wound concern.Plan.Wound to right foot.Wound care consult in place to treat wound. A review of a Wound Assessment Report dated 1/22/25 read in part, .Left foot.skin tear/laceration.present on admission.Treatment.Dressing Change Frequency: Daily.Clean Wound With: Cleanse with wound cleanser.Primary Treatment: Xeroform.Other Dressings: Bordered Gauze. A review of the January 2025 TAR (treatment administration record) read in part, .Left foot wound care (below the toes).order date 1/22/25. Treatment was documented as being provided on 1/23/25. On 8/27/25 at 2:12 PM, surveyor spoke with the director of nursing, and she stated the wound nurse incorrectly documented the foot as the left foot and not the right foot. On 8/27/25 at 2:31 PM, surveyor interviewed the wound nurse who performed the wound assessment on 1/22/25 via phone conversation and she stated she could not recall Resident #4. This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00 PM with the administrator, administrator-in-training, director of nursing, assistant director of nursing, and regional director of clinical services.Surveyor requested, but did not receive a facility policy for accurate documentation on the clinical record.No further information regarding this concern was presented to the survey team prior to exit on 8/28/25. 2.For Resident #6, the facility staff failed to document administration of scheduled oxycodone medication on the August 2025 MAR (medication administration record) on 8/15/2025, 8/16/2025, 8/20/25, 8/24/25, and 8/25/25. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, Muscle Weakness, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Cerebral Infarction, Anxiety Disorder, Depression, Cognitive Communication Deficit, and Chronic Pain. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/14/25, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A medical provider orders with a start date of 4/28/25 read in part, .oxycodone HCI Oral Tablet 5 MG (milligrams).Give 1 tablet by mouth every 6 hours for pain. A review of the MAR (medication administration record) for August 2025 revealed no documentation for administration of scheduled oxycodone on the following dates and times: 8/15/25 at 12:00 AM, 6:00 AM, or 6:00 PM8/16/25 at 12:00 AM or 6:00 AM8/20/25 at 6:00 AM8/24/25 at 6:00 AM8/25/25 at 12:00 AM or 6:00 AM On 8/27/25 at 12:57 PM, surveyor spoke with the director of nursing and reviewed the August 2025 MAR for Resident #6. The director of nursing stated she would check. The director of nursing provided surveyor with a copy of a Controlled Drug Administration Record that revealed Resident #6 received the scheduled doses of oxycodone on the dates/times in question. The director of nursing stated the nurses did record the medications were given on the NARC log (controlled drug administration record), but the nurses failed to document the administration on the MAR. This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00PM with the administrator, administrator-in-training, director of nursing, assistant director of nursing and regional director of clinical services. Surveyor requested and received a facility policy titled, Administration Procedures for All Medications which read in part, .III .1 .a. Check the MAR .for the order .IV .7. document administration in the MAR . No further information regarding this concern was presented to the survey team prior to exit on 8/28/25.

Based on observation, staff interview and facility document review the facility staff failed follow established infection control procedures for 2 of 7 residents, Resident #5 and Resident #10The findings included:For Resident #5 the facility staff failed to follow established infection control procedures during a dressing change. Resident #5's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, gangrene, and acute osteomyelitis. Resident #5's most recent minimum data set with an assessment reference date of 06/16/25 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section M, Skin Conditions, coded the resident as having one stage 1 pressure ulcer and three unstageable pressure ulcers. Resident #5's comprehensive care plan was reviewed and contained a plan for The resident is at risk for pressure ulcers . and The resident has a chronic wound or pressure ulcer. Interventions for these care plans included Enhanced barrier precautions. Surveyor observed registered nurse (RN) #2, with assistance from licensed practical nurse (LPN) #2, performing wound care/dressing change on 08/28/25 at 10:50 for Resident #5. RN #2 performed hand hygiene, donned gloves and gown, cleaned the overbed table with disinfectant, placed a barrier on the table, placed treatments and dressings on the barrier. RN #2 removed gloves, performed hand hygiene, and donned new gloves. RN #2 asked LPN #2 to retrieve bandage scissors from their (RN #2) pocket. LPN #2 did so, and handed scissors to RN #2, then performed hand hygiene and donned gloves. RN #2 proceeded to remove old bandage from Resident #5's wound, without cleaning scissors prior to using them. RN #2 placed scissors on barrier on table. After removing old bandage and placing in trash, RN #2 removed gloves, performed hand hygiene and donned new gloves. RN #2 cleaned wound to Resident #5's lateral right foot, placed betadine gauze over wound, removed gloves, returned to treatment cart to retrieve gauze wrapping, donned gloves without performing hand hygiene, wrapped wound with wrapping, placed dated and initialed tape to secure wrapping. RN #2 then removed gloves, performed hand hygiene, donned clean gloves, cleaned wound to resident's right heel, applied treatment, applied dressing and wrapping, without changing gloves or performing hand hygiene. Surveyor spoke with the facility infection preventionist (IP) on 08/28/25 at 11:15 am. Surveyor asked IP what their expectations are for cleaning scissors and hand hygiene during wound care. IP stated scissors should be cleaned after each use and hand hygiene should be performed with each glove change. Surveyor asked IP if RN #2 should have changed gloves and performed hand hygiene after cleaning wound, but prior to applying treatment dressing, and IP stated they should have. Surveyor requested and was provided with a facility policy entitled Handwashing Requirements which read in part, A. Hand Hygiene. 1. The following is a list of some situations that require hand hygiene: j. before and after changing a dressing. r. After removing gloves for aprons. t. After any contact with potentially contaminated materials (used wound/treatment dressings). (2) Hands must be washed prior to and after using gloves. The concern of staff failing to follow established infection control procedures was discussed with the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services on 08/28/25 at 4:00 pm. No further information was provided prior to exit. 2. For Resident #10, the facility staff failed to maintain infection control measures during the use of a multiuse bottle of Dakins Solution. On 8/28/25 at 3:20 PM, surveyor observed Licensed Practical Nurse (LPN) #10 perform a dressing change to the left ischium for Resident #10. LPN #10 transported a multiuse bottle of Dakins Solution into the resident’s room in a clean plastic bag and then removed the Dakins Solution container and placed it directly on the resident’s overbed table. LPN #10 had not cleaned the overbed table prior to sitting the container down. Following the dressing change, LPN #10 picked up the Dakins Solution and then sat the bottle directly on Resident #10’s roommate’s fabric chair seat cushion while she washed her hands. LPN #10 then returned the bottle of Dakins Solution to the unit treatment cart and placed the container in the bottom cart drawer among other items without sanitizing the bottle. On 8/28/25 at 3:45 PM, surveyor spoke with the facility Infection Preventionist (IP) and discussed the observations regarding the bottle of Dakins Solution. IP stated the Dakins Solution should have been placed in a zip lock bag in the treatment cart and he would discard the Dakins Solution and get a new bottle for Resident #10 and place it in the treatment cart. On 8/28/25 at 4:00 PM, the survey team met with the Administrator, Administrator in Training, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the infection control concerns with LPN #10 actions regarding the multiuse bottle of Dakins Solution. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/28/25.

Based on observation, staff interview, and facility document review, the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 15 sampled resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The findings included:1. room [ROOM NUMBER]’s air conditioning/heating wall unit (p-tac) had a large amount of thick dust and debris visible in the unit’s grates; the bathroom ceiling light cover was missing and the light bulb was exposed, the bathroom ceiling vent had a thick layer of dust present with visible rust, the bathroom door had multiple areas of soiling on both sides around the doorknob and door edges, and a nightstand had multiple areas of a light-brown dried substance. On 8/27/25 at 10:42 AM, surveyor entered room [ROOM NUMBER] and observed the p-tac unit with a large amount of thick dust in between the grates and down in the unit. There was also torn paper/wrapper in the unit. room [ROOM NUMBER]’s bathroom ceiling light did not have a cover, and the light bulb was exposed. The bathroom vent was rusted and had a thick layer of dust present. Each side of the bathroom door was soiled around the edges and the doorknob. A nightstand beside an unoccupied bed had several areas of a light-brown dried substance resembling enteral feeding formula. Surveyor returned to room [ROOM NUMBER] on 8/28/25 at 10:15 AM and the previous observations remained unchanged. On 8/27/25 at 11:23 AM, surveyor spoke with the Environmental Services Director who stated resident rooms and bathrooms were cleaned daily following the facility policies. He stated when housekeeping finds an item in need of repair, they notify him, and he turns in a work order to maintenance. On 8/27/25 at 12:17 PM, surveyor spoke with the Maintenance Director who stated p-tacs were cleaned using a shop-vac every three months and the filters were changed with the change of the seasons. He stated the wardroom p-tacs were cleaned more often due to the residents placing items on top of the units. Surveyor requested and received the facility policy titled “Daily Resident/Patient Room Cleaning” which read in part “…The room cleaning tasks should be performed in the following order…2…Dust all flat surfaces with a cloth and disinfectant, clean the air vent covers, and spot clean all necessary areas…” On 8/28/25 at 4:00 PM, the survey team met with the Administrator, Administrator in Training, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed observations concerning room [ROOM NUMBER]. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/28/25. 2. room [ROOM NUMBER]’s air conditioning/heating wall unit (p-tac) had a large amount of thick dust, debris, food crumbs, and two dead bugs visible in the unit’s grates, the window curtains had fallen down in the middle and several curtain hooks were present in the window sill, the curtains had multiple areas of dark staining visible, an overbed table had leg supports that were soiled with a white substance, and the room had two broken overbed tables in resident use. On 8/27/25 at 11:10 AM, surveyor entered room [ROOM NUMBER] and observed the p-tac unit with a large amount of thick dust, debris, food crumbs, and two dead bugs visible in the unit’s grates. The left side of the window curtains had fallen in the middle and there were several sharp ended curtain hooks in the windowsill and there were multiple areas of dark staining visible on the window curtains. The leg support of an overbed table was soiled with a dried white substance. On 8/27/25 at 12:17 PM, surveyor spoke with the Maintenance Director who stated p-tacs were cleaned using a shop-vac every three months and the filters were changed with the change of the seasons. He stated the wardroom p-tacs were cleaned more often due to the residents placing items on top of the units. Surveyor and Maintenance Director observed room [ROOM NUMBER]’s p-tac and he stated maintenance would clean it. Surveyor returned to room [ROOM NUMBER] on 8/28/25 at 10:30 AM and the previous room observations remained unchanged apart from the window curtains which had been re-hung. The p-tac had not been cleaned. It was also noted the room had two broken overbed tables in resident use. One table would not raise or lower and had two wheels which would not roll and the other overbed tabletop was unstable and wobbled up and down when touched. Surveyor requested and received the facility policy titled “Daily Resident/Patient Room Cleaning” which read in part “…The room cleaning tasks should be performed in the following order…2…Dust all flat surfaces with a cloth and disinfectant, clean the air vent covers, and spot clean all necessary areas…” On 8/28/25 at 4:00 PM, the survey team met with the Administrator, Administrator in Training, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed observations concerning room [ROOM NUMBER]. No further information regarding this concern was presented to the survey team prior to the exit conference on 8/28/25. 3. For room [ROOM NUMBER] the facility staff failed to ensure the bathroom toilet was clean. On 8/26/25 at 2:00 PM, this surveyor conducted an initial tour and observation of the facility. During a tour of the facility on 8/26/25 at 2:20 PM this surveyor entered room [ROOM NUMBER] bathroom. The toilet bowl was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand. On 8/27/25 at 8:16 AM, surveyor observed the bathroom in room [ROOM NUMBER] and the toilet bowl in the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand. On 8/27/25 at 12:05 PM, surveyor spoke with other staff #8 (OS#8) via phone conversation and she stated she does not clean the resident rooms every day. On 8/27/25 at 11:05 AM, surveyor observed the bathroom in room [ROOM NUMBER] and the toilet bowl in the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand. On 8/27/25 at 3:10 PM, surveyor asked the administrator what time housekeeping left for the day and the administrator informed surveyor they were leaving now. On 8/27/25 at 3:15 PM, surveyor observed the bathroom in room [ROOM NUMBER] and the toilet bowl in the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand. On 8/28/25 at 8:24 AM, surveyor and the DON observed room [ROOM NUMBER]’s bathroom and the toilet bowl in the bathroom was observed to have a large, brown smear of feces on the outside of the right side of the toilet bowl (surveyor’s right side). The smear was approximately the size of an average woman’s hand. The DON stated she would let them know. This concern was discussed at the pre-exit meeting on 8/28/25 at 4:00 PM with the administrator, AIT (administrator-in-training), director of nursing, assistant director of nursing, and regional director of clinical services. Surveyor requested and received a facility policy titled, “Daily Resident/Patient Room Cleaning”, which read in part, “…Required Items…Quaternary disinfectant (a chemical used in cleaning products to kill germs on non-porous surfaces)…Bowl brush, cleaning rags…spot clean all necessary areas…” No further information was provided to the survey team prior to exit on 8/28/25.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer or discharge to the resident and the resident's representative(s) and failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for two (2) of seven (7) sampled residents and/or residents' representatives, (Resident #3 and Resident #4). The findings include: 1. For Resident #3, the facility staff failed to provide the resident or the resident's representative written notice of the reason(s) of transfer/discharge to the hospital on [DATE] and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge on [DATE], 11/23/24 and 12/5/24. Resident #3's diagnosis list indicated diagnoses that included, but were not limited to, Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Hypertension, Post Traumatic Stress Disorder, Iron Deficiency Anemia, Chronic Kidney Disease-Stage 3 (three), Depression, Presence of Coronary Angioplasty Implant and Graft, Cognitive Communication Deficit, Diabetes Mellitus Type 2 (two), Bipolar Disorder, Anxiety Disorder, and Gastrointestinal Hemorrhage. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/31/24, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record indicated Resident #3 was transferred to the hospital on [DATE], 11/23/24, and 12/5/24. Written notifications of reason for transfer or discharge were provided to Resident #3 and the residents representative for the discharges/transfers on 11/5/24 and 12/5/24, but a written notification for reason of transfer/discharge could not be located for the transfer/discharge that occurred on 11/23/24. Surveyor requested evidence of a written notification for reason of transfer/discharge for 11/23/24 to the resident and resident representative and evidence the ombudsman was provided with written notification for reason for discharges on 11/5/24, 11/23/24, and 12/5/24. This concern was discussed at the pre-exit meeting on 2/26/25 at 1:44 PM with the administrator, director of nursing, regional director of clinical services, and assistant director of nursing. On 2/26/25 at 2:09 PM, regional director of clinical services informed surveyor that social worker could not locate evidence the local long-term care ombudsman received notification for any of Resident #3's discharges/transfers to the hospital and no evidence could be located of the resident and resident representative receiving written notice for the reason of transfer/discharge on [DATE]. Surveyor requested and received a facility policy, titled, Notice of Transfer/Discharge with an effective date of 1/6/20, that read in part, .4. Provide proper advance written notification of the transfer/discharge to the patient and family member/legal representative .notification shall be made as soon as reasonably possible .7. Provide designated copies of the completed .Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman .8. Scan a copy of the Notice of Transfer/Discharge into the patient's medical record .9. Once the document has been scanned .complete a Social Work and Discharge Planning Progress Note confirming the following: a. Date Patient and/or RP (resident representative) were given notice and the method in which they received notice. b. Date the notice was sent to the Ombudsman and method by which it was sent . No further information regarding this concern was presented to the survey team prior to the exit on 2/26/25. 2. For Resident #4, the facility staff failed to provide written notice to the Office of the State Long-Term Care Ombudsman of the reason for transfer/discharge on [DATE]. Resident #4's diagnosis list indicated diagnoses that included, but were not limited to, Encephalopathy, Pressure Ulcer of Right Hip-Stage 4 (four), Malnutrition, Type 1 (one) Diabetes Mellitus, Hypertension, Atrial Fibrillation, Alzheimer's Disease, Insomnia, and Depressive Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/31/24, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of the clinical record indicated Resident #4 was transferred to the hospital on 9/13/24. On 2/26/25 at 10:12 AM, surveyor interviewed other staff #4 (OS#4) and she stated she could not find evidence of the ombudsman being notified of Resident #4's transfer/discharge on [DATE]. This concern was discussed at the pre-exit meeting on 2/26/25 at 1:44 PM with the administrator, director of nursing, regional director of clinical services, and assistant director of nursing. Surveyor requested and received a facility policy, titled, Notice of Transfer/Discharge with an effective date of 1/6/20, that read in part, .7. Provide designated copies of the completed .Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman .8. Scan a copy of the Notice of Transfer/Discharge into the patient's medical record .9. Once the document has been scanned .complete a Social Work and Discharge Planning Progress Note confirming the following .b. Date the notice was sent to the Ombudsman and method by which it was sent . No further information regarding this concern was presented to the survey team prior to the exit on 2/26/25.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow the medical provider's orders for 1 of 10 sampled residents (Resident #10). The findings included: For Resident #10, the facility staff administered Vitamin D3 10 mcg instead of the provider ordered Vitamin D 50 mcg. Resident #10's diagnosis list indicated diagnoses, which included, but not limited to Osteoarthritis of Knees and Right Shoulder, Congestive Heart Failure, and Moderate Protein-Calorie Malnutrition. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/28/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 2/26/25 at 8:33 AM, surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #10's medications. The administered medications included a Vitamin D3 10 mcg tablet. A review of Resident #10's medical provider orders revealed no order for Vitamin D3; however, the resident did have an order for Vitamin D 50 mcg to be administered at 9:00 am daily. Resident #10 did not receive Vitamin D during the medication administration observation. On 2/26/25 at 10:42 AM, surveyor spoke with LPN #2 regarding the Vitamin D3 and Vitamin D. LPN #2 looked in the medication cart and verified the cart contained a house stock bottle of Vitamin D3 but did not include Vitamin D for administration. During the six-minute medication administration observation for Resident #10, LPN #2 was interrupted on two separate occasions with medication deliveries from another staff member, one delivery included controlled medications and narcotic count records. Surveyor requested and received the facility policy titled General Guidelines for Medication Administration with a revision date of 8/2020 which read in part .4. At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away .II. Administration .6. Medications are administered without unnecessary interruptions . On 2/26/25 at 1:45 PM, the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the concern of Resident #10 receiving Vitamin D3 instead of Vitamin D. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/26/25.

Based on observation, the facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment and help prevent the development and transmission of infections for 1 of 10 residents (Resident #10). The findings included: For Resident #10, the nurse dropped an oral medication tablet on top of the medication cart and then administered the medication to the resident. On 2/26/25 at 8:37 AM during a medication pass and pour observation, surveyor observed Licensed Practical Nurse (LPN) #2 remove a Finasteride 5 mg tablet from a blister pack and the tablet inadvertently landed directly on top of the medication cart. LPN #2 donned a glove and picked up the tablet from the medication cart and placed it in the medication cup along with the resident's other medications. LPN #2 then administered the medications, including the Finasteride to Resident #10. On 2/26/25 at 1:45 PM, the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff administering an oral medication that had been in contact with the top of the medication cart. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/26/25.

Based on observations, interviews, and the review of documents, the facility staff failed to ensure menus were followed for two (2) of approximately 11 - 13 resident tray carts (each tray cart was used to transport multiple residents' trays to nursing units); this observation occurred for the lunch meal on 5/30/24. (The dietary staff members working on the food service line during the lunch meal on 5/30/24 indicated the last two (2) resident tray carts were the smallest carts to be sent out; the dietary staff members indicated each cart contained trays for approximately 20 residents.) The findings include: The facility staff failed to ensure all residents had the opportunity to receive the schedule menu items for the lunch meal on 5/30/24. The facility staff ran out of two (2) menu items prior to all the residents receiving their meals. The facility staff ran out of the pork loin with garlic and fresh herbs and the facility staff ran out of the roasted red potatoes. On the afternoon of 5/30/24, the facility's food service staff were observed to be preparing trays to be sent to residents who were having their midday meal on their nursing unit. On 5/30/24 at approximately 1:00 p.m., the Dietary Manager was observed to be cooking additional pork loin. On 5/30/24 at 1:10 p.m., the Dietary Manager was noted to place three (3) frozen pork tenderloin into the steam/oven to cook. The dietary staff had used all the pork loin that had initially been prepared for the 5/30/24 lunch. On 5/30/24, the Administrator reported the pork loin may have been used up due to residents asking for additional servings. On 5/30/24 at 1:30 p.m., the dietary staff were noted to be running out of the roasted potatoes. The Dietary Manager was noted to be preparing additional roasted potatoes. The facility's Region Director of Operations (Staff Member (SM) #17) with the dietary contract company stated they had contacted their dietitian and obtained approval for mashed potatoes to substitute for roasted potatoes. On 5/30/24 at 1:40 p.m., SM #17 stated they had obtained dietitian approval for use of pulled pork to substitute for pork loin. On 5/30/24 at 2:15 p.m., the cook (Staff Member (SM) #19), for the 5/30/24 lunch, reported they cooked the wrong size pork loin; SM #19 reported they felt they had cooked enough potatoes for the meal in question. On 5/30/24 at 2:25 p.m., SM #17 reviewed the facility's meal information for the 5/30/24 lunch. SM #17 reported six (6) pork loins should have been cooked but only four (4) were cooked. SM #17 reported that one too few bags of potatoes had been cooked. On 6/4/24 at 11:10 a.m., the survey team met with the facility's Administrator, Director of Nursing, and Regional Nurse Consultant. During this meeting, the surveyor discussed the facility staff running out of two (2) items on the menu for the 5/30/24 lunch meal.

Based on observation facility staff failed to ensure hand rails were intact on 4 of 4 nursing units. During initial tour and throughout the course of the facility, surveyors observed residents utilizing hand rails for stabilization while ambulating and as an anchor to pull themselves down the halls while in wheelchairs. On 6/3/24, the surveyor checked handrails throughout the building and found a number of missing handrail segments or end caps which left sharp edges exposed posing a risk of injury: On the front hallway, there were no end caps between the elevator and dining room and no end cap or corner segment by the ladies' restroom. On Unit 1, a segment of the hand rail was missing near the door to the unit manager's office. End caps were missing by rooms 14, 17, 23, 25, and 26. On unit 2, the rail by the pantry was missing an end cap. On Unit 3, end caps were missing by the MDS office and room [ROOM NUMBER]. On 6/3/24, the administrator, director of nursing, MDS corporate consultant, regional nurse consultant, and a consulting administrator were notified of the concern during a summary meeting. No additional information was offered to surveyors prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to screen for a mental disorder or intellectual disability prior to admission for 1 of 38 sampled residents. Resident #154. The findings include: For Resident #154 (R154), the facility staff failed to obtain a Level I Screening for Mental Illness, Intellectual Disability (ID), or Related Conditions, to determine if the resident had or may have had a MD (Mental Disorder), ID, or related condition prior to admission. R154's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Legal Blindness, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Parkinson's Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/27/24, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. On 5/30/24, during the clinical record review, surveyor could not locate a PASARR (Preadmission Screening and Resident Review) on R154's clinical record. On 5/30/24, 5/31/24 and 6/3/24, surveyor requested evidence of a PASARR for R154 from the director of nursing. On 6/3/24 at 1:28 PM, surveyor interviewed Discharge Planning Director #1 (DPD#1) about R154's PASARR history. DPD#1 stated she could not locate the PASARR on R154. She stated it was done on paper and she had reached-out to the screeners. DPD#1 stated R154 had come from [name omitted] and she requested a medical record request to the hospital on 5/30/24 and again today (6/3/24). DPD#1 stated they (hospital) may find it (PASARR), or they may not, so she did a new PASARR and provided surveyor with a copy of R154's PASARR dated 6/3/24. On 6/3/24 at 4:15 PM, the survey team met with the Administrator #1, Director of Nursing, Regional Director of Clinical Services, Regional MDS and Administrator #2, and discussed the concern of the facility staff failing to obtain a PASARR for R154 prior to admission. Surveyor requested and received a facility policy titled, Level I PASRR{sic}-Virginia, which read in part, .Prior to arrival of a planned admission the Social Worker and Discharge Planner will collaborate with the Admissions Director to preview the .Level 1 PASRR (Level 1 Screening for Mental Illness, Intellectual Disability, or Related Conditions) and/or initiate completion of the Level 1 PASRR if not completed .to predetermine if the transferring patient meets SNF/NF (skilled nursing facility/nursing facility) criteria and to screen the patient for indicators of serious mental illness, mental retardation, developmental disabilities or related conditions prior to being admitted in the SNF/NF Center, as required by Federal Regulation .if the Level 1 PASRR is missing from the preadmission paperwork, collaborate with admissions .in order to initiate completion of the Level 1 PASRR internally . No further information regarding this concern was presented to the survey team prior to the exit conference on 6/4/24.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to follow the medical provider orders for 2 of 38 sampled residents (Residents #84 and #160). The findings included: 1. For Resident #84, the facility staff failed to follow the recommendations of the orthopedic specialist for compression stockings. Resident #84's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Asthma, Chronic Kidney Disease Stage 3, Heart Failure, Paroxysmal Atrial Fibrillation, and Displaced Bicondylar Fracture of Left Tibia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 5/30/24 at 3:20 PM, surveyor spoke with Resident #84 who complained of swelling in their feet stating it was painful while participating in physical therapy. The resident removed their left sock revealing a large amount of swelling in the left foot. The resident stated they have been requesting a fluid pill for the edema but there has been no follow up. Resident #84 was not wearing compression stockings, only regular grip socks. The resident stated they have not had any compression stockings while at the facility. Surveyor reviewed Resident #84's clinical record and was unable to locate documentation of the resident's lower extremity edema or request for a diuretic. During a meeting with the facility management team on 5/30/24 at 3:25 PM, surveyor discussed the resident's edema and their desire for a diuretic. Resident #84's clinical record included a nursing progress note dated 5/13/24 11:57 AM which read in part Patient returned from follow up ortho appointment with recommendations to start .Compression stockings and LE [lower extremity] elevation . On 6/03/24 at 8:15 AM, surveyor spoke with the Director of Nursing (DON) and requested the ortho consult report from 5/13/24. On 6/03/24 at 12:40 PM, surveyor spoke with Resident #84 who stated some improvement with swelling today and was wearing bilateral compression stockings. According to the clinical record, the provider order for compression stockings was entered on 6/03/24 at 12:00 PM. On 6/03/24 at 2:34 PM, surveyor spoke with the DON who stated they reviewed the ortho consult today and noted the recommendation for compression stockings and spoke with the provider and added them today. On 6/03/24 at 4:18 PM, the survey team met with the Administrator, DON, and Regional Nurse Consultant and discussed the concern of Resident #84 not receiving compression stockings until today when they were recommended by the orthopedic specialist on 5/13/24. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/04/24. 2. For Resident #160, the facility staff failed to follow the provider orders for the administration of Amlodipine Besylate and Metoprolol Tartrate used to treat high blood pressure. Resident #160's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Vascular Dementia, Dysphagia, Cerebral Infarction, Heart Failure, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/16/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #160's provider orders included an order dated 12/07/23 for Amlodipine Besylate 10 mg one time a day for hypertension hold if systolic blood pressure (SBP) less than 100 or diastolic blood pressure (DBP) less than 60. The resident's orders also included an order dated 12/07/23 for Metoprolol Tartrate 25 mg two times a day for hypertension hold if heart rate less than 60. Surveyor reviewed Resident #160's clinical record and was unable to locate evidence of staff checking the resident's blood pressure prior to the administration of Amlodipine Besylate or heart rate prior to the administration of Metoprolol Tartrate. Surveyor requested and received the facility policy titled General Guidelines for Medication Administration with a revision date of 8/2020 which read in part .II. Administration .2. Medications are administered in accordance with written orders of the prescriber . On 6/03/24 at 4:18 PM, the survey team met with the Administrator, Director of Nursing, and the Regional Nurse Consultant and discussed the concern of staff failing to administer Amlodipine Besylate and Metoprolol Tartrate according to the provider orders. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/04/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment in accordance with the provider orders to promote pressure ulcer wound healing for 1 of 38 sampled residents (Resident #184). The findings included: For Resident #184, the facility staff failed to treat an unstageable/Stage 4 pressure ulcer to the mid back as ordered. Resident #184's diagnosis list indicated diagnoses, which included, but not limited to Sepsis due to Methicillin Susceptible Staphylococcus Aureus, Sacral Pressure Ulcer, Generalized Muscle Weakness, Osteoarthritis, and Macular Degeneration. The minimum data set (MDS) with an assessment reference date (ARD) of 11/11/23 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating Resident #184 was severely cognitively impaired. The resident was coded as having one unstageable pressure ulcer with slough and/or eschar present upon admission. Resident #184's comprehensive person-centered care plan included a focus area stating the resident has a skin impairment pressure ulcer to mid back (Stage 4) . with an intervention for treatment as ordered. Resident #184 was admitted to the facility with an unstageable pressure ulcer to the mid back. The resident was seen by the Wound Nurse Practitioner (WNP) on 11/10/23, the progress note read in part .There is an unstageable pressure injury to the mid-thoracic spine that is covered in slough. There is a surrounding band of purple tissue that is slightly indurated .9 cm x 8 cm x 0.3 cm .100% slough .Treatment Recommendations: 1. Cleanse with wound cleanser 2. Apply Medical grade honey fiber to base of wound 3. Secure with Bordered foam 4. Change daily . A Skin Observation Tool - V2 dated 11/10/23 read in part .Rsd [resident] noted to have large wound to mid back, copious amount of yellow and bloody drainage. Wound cleansed with wound cleanser; pat dry applied honey fiber covered with bordered foam. New orders for the same TX [treatment] to be done daily . According to Resident #184's November 2023 Treatment Administration Record (TAR) the treatment of medical grade honey fiber was not initiated as directed by the WNP. Instead, a treatment order to cleanse the wound with wound cleanser, apply 0.25% Dakin's solution moistened fluffed gauze and cover with bordered foam daily began on 11/11/23. Resident #184 was seen by the WNP again on 11/14/23, the progress note documented a decrease in the wound measurements to 6 cm x 4 cm x 0.3 cm with 100% slough present. The wound status was described as improving without complications. The progress note read in part .Treatment Recommendations: 1. Cleanse with wound cleanser 2. Apply Medical grade honey fiber to base of wound 3. Secure with Bordered foam 4. Change daily .Performed sharp debridement to mid back pressure injury .I anticipate as the slough is removed that the wound will have a hole with a high chance of exposed structures but am unable to tell at this time . According to Resident #184's November 2023 TAR, the previous treatment order of Dakin's solution continued despite the WNP's direction for medical grade honey fiber. The resident was reassessed by the WNP on 11/21/23, the progress note read in part .Wound Status: Improving despite measurements .6.2 cm x 3.2 cm x 1.5 cm .undermining from 5 o'clock to 6 o'clock .100% slough .Treatment Recommendations: 1. Cleanse with 0.25% Dakins solution 2. Apply Dakins moistened fluffed gauze to base of wound. 3. Secure with Bordered foam 4. Change Daily .I performed sharp debridement to the wound and there is now an open hole as anticipated. I can see exposed muscle and I am reclassifying this as a stage 4 pressure injury. I am making new treatment recommendations. There is still a significant amount of necrotic tissue that is too adhered for debridement today. I anticipate that the wound will continue to grow in size and depth as this is removed. I am listing the wound as improved despite measurements since there is less necrotic tissue and anticipated the size would grow as this layer came off . According to Resident #184's November 2023 TAR, the previous treatment order to cleanse wound with wound cleanser, apply 0.25% Dakins solution moistened fluffed gauze and cover with bordered foam continued, despite the new order directing the area be cleansed with 0.25 % Dakins solution. Resident #184 was last seen by the WNP on 11/28/23, the progress note described the wound as measuring 7.2 cm x 3.2 cm x 1.7 cm with undermining from 12 o'clock to 1 o'clock. The wound base was described as 25% granulation tissue and 75% slough. The progress note read in part .The wound is stable today. There is less necrotic tissue but the measurements are larger. I anticipated this would happen as the necrotic tissue was removed from the wound .Recommended continuing current treatment. I anticipate the open hole in the wound will grow in size as necrotic tissue continues to improve. According to Resident #184's November and December 2023 TAR, the wound continued to be cleansed with wound cleanser instead of the WNP ordered treatment to cleanse with 0.25% Dakins solution. Surveyor attempted to interview the WNP, and the facility wound nurse, however, they were no longer employed by the facility. On 6/03/24 at 2:34 PM, surveyor spoke with the Director of Nursing (DON) regarding the identified treatment error to the resident's pressure ulcer. The DON stated they would have to check on it; however, no additional information was provided. Surveyor requested and received the facility policy titled Wounds/Skin Impairments with an effective date of 1/29/24 which read in part Any wounds and/or skin impairments will be routinely assessed and treated as ordered . On 6/04/24 at 11:09 AM, the survey team met with the Administrator, DON, and Regional Nurse Consultant and discussed the concern of staff failing to follow the WNP treatment orders for Resident #184. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/04/24.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident who is fed by enteral means receives the appropriate provider ordered hydration for 1 of 4 sampled residents dependent on enteral feeding (Resident #160). The findings included: For Resident #160, the facility staff failed to provide water flushes as ordered on seven (7) separate occasions during the month of May 2024. Resident #160's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Vascular Dementia, Dysphagia, Heart Failure, Cerebral Infarction, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/16/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #160 was coded for the presence of a feeding tube in which they received 501 cc/day or more of average fluid intake. Resident #160's current comprehensive person-centered care plan included a focus area stating, the resident is at risk for complications related to the need for an enteral tube feeding with an intervention to administer tube feedings and flushes per order. On 5/30/24 at 9:15 AM, surveyor spoke with Resident #160 who stated they felt hungry at times and craved water. The resident's lips appeared dry with a white coating present. Resident #160's provider orders included an order dated 3/26/24 to flush feeding tube with 200 cc of water every 4 hours. A review of the resident's May 2024 Medication Administration Record (MAR) revealed omissions for the water flushes on the following occasions: 5/11/24 10:00 AM, 5/11/24 2:00 PM, 5/11/24 10:00 PM, 5/12/24 10:00 AM, 5/12/24 2:00 PM, 5/21/24 2:00 PM, and 5/28/24 10:00 PM. Resident #160 had a provider order present to have nothing by mouth. Surveyor requested and received the facility policy titled Enteral Feeding Tubes with an effective date of 1/29/24 which read in part .Care and Management .3. Provide irrigation after feeding and/or routinely per provider order to ensure patency, and document in medical record . On 6/03/24 at 4:18 PM, the survey team met with the Administrator, Director of Nursing, and Regional Nurse Consultant and discussed the concern of the water flush omissions for Resident #160. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/04/24.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications for 1 of 4 sampled residents dependent on enteral feeding (Resident #384). The findings included: For Resident #384, the facility staff failed to follow the medical provider orders for enteral feeding. Resident #384's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Malignant Neoplasm of Brain, Malignant Neoplasm of Lung, Pneumonitis, Dysphagia, Cerebral Edema, and Seizures. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/28/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #384 was coded for the presence of a feeding tube. Resident #384's current comprehensive person-centered care plan included a focus area stating, the resident is at risk for complications related to the need for an enteral tube feeding with an intervention to administer tube feedings and flushes per order. On 5/29/24 at 1:21 PM and 5/30/24 at 9:26 AM, surveyor observed Resident #384 receiving Osmolite 1.5 continuously via pump running at 55 ml/hour. The resident's current medical provider orders included an order dated 5/28/24 for Osmolite 1.5 at 250 ml via bolus five (5) times a day at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. On 5/30/24 at 3:25 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Regional Nurse Consultant (RNC) and discussed the concern of Resident #384 not receiving enteral feedings as ordered. On the morning of 5/31/24, the RNC provided the surveyor a written statement indicating the tube feeding pump had been removed from Resident #384's room. On 5/31/24 at 1:20 PM, surveyor spoke with the Registered Dietitian (RD) who stated the enteral feeding was changed to bolus because Resident #384 was taking a medication which required the feeding to be held with administration. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/04/24.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the provider orders for 1 of 38 sampled residents (Resident #84). The findings included: For Resident #84, the facility staff failed to administer supplemental oxygen as ordered by the provider. Resident #84's diagnosis list indicated diagnoses, which included, but not limited to Chronic Respiratory Failure, Asthma, Chronic Kidney Disease Stage 3, Heart Failure, Paroxysmal Atrial Fibrillation, and Displaced Bicondylar Fracture of Left Tibia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #84's comprehensive person-centered care plan included a focus area stating, the resident is at risk for respiratory complications secondary to respiratory failure with an intervention to administer oxygen as ordered. On two separate occasions, 5/29/24 at 12:30 PM and 5/31/24 at 8:56 AM, surveyor observed Resident #84 in bed receiving oxygen via nasal cannula at the delivery rate of 3 liters per minute (l/m) per the oxygen concentrator setting. The oxygen concentrator was located on the left side of the bed out of the resident's reach at each observation. Resident #84's current medical provider orders included an order dated 3/29/24 for oxygen at 2 l/m via nasal cannula. On 5/31/24 at 9:00 AM, surveyor spoke with Licensed Practical Nurse (LPN) #10 who verified the resident's oxygen was ordered for 2 l/m. The Unit Manager (UM) accompanied the surveyor to Resident #84's room and acknowledged the oxygen concentrator was set at 3 l/m and changed the setting to 2 l/m. Surveyor requested and received the facility policy titled, Respiratory Care & Oxygen Equipment with an effective date of 1/29/24 which read in part Oxygen therapy will be administered per provider's order . On 6/03/24 at 4:18 PM, the survey team met with the Administrator, Director of Nursing, and Regional Nurse Consultant and discussed the concern of Resident #84 receiving oxygen at the incorrect delivery rate. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/04/24.