Every finding on record at Springs of Richmond, The

Based on interview, observation, and record review, the facility failed to timely implement wound care orders and interventions for a resident resulting in the deterioration of a sacral wound (Resident 6) and failed to thoroughly complete admission skin assessment for a resident's wound (Resident 2) for 2 of 2 residents reviewed for pressure ulcer management. Findings include: 1. During an observation and interview, on 2/9/2026 at (time not documented), Resident 6 indicated the facility was not changing his wound dressings as they should. He had big wounds on his bottom that he got at home. He reported his wound was severe and that he goes to wound care. Resident 6 did not feel the facility was taking care of his wounds as it should; there were issues with his dressing, protein shakes, turning, and cushions multiple times since he had been there.The clinical record for Resident 6 was reviewed on 02/12/2026 at 2:31 PM. The resident's diagnoses included, but were not limited to, rhabdomyolysis (rapid breakdown of skeletal muscle tissue), a pressure wound to the sacral region (wedge shaped bone located at the base of the lumbar spine), and a pressure area to the ischium (lower-back bone of the pelvic girdle).An admission MDS, dated [DATE], indicated Resident 6 was admitted on [DATE]. The resident was cognitively intact. Resident 6 did not have any behaviors of rejecting care. Resident 6 needed substantial to maximum help with rolling left and right, sitting to lying, and lying to sitting. Resident 6 was dependent on toileting needs and showering. The resident used a manual wheelchair and was dependent on staff for all locomotion needs. A pressure-reducing device was used for the bed and chair; the resident received pressure injury/ulcer care and application of non-surgical dressings and ointments/medications. Resident 6 was at risk for pressure injuries based upon formal and clinical assessment. The resident had one unstageable wound due to a deep pressure injury and one unstageable wound due to eschar/slough.A nursing admission assessment, dated 1/5/2026, indicated Resident 6 was at low to moderate risk for further skin impairments.A current physician's order, dated 1/5/2026, indicated the resident was to have a pressure-reducing cushion in the wheelchair.A wound care plan, dated 1/6/2026, indicated Resident 6 had a pressure ulcer to the sacrum and right buttock with a wound vac (a specialized, medical device used to accelerate healing for wounds). The interventions included, but were not limited to, a pressure-reducing cushion for the chair, a pressure-reducing mattress, providing treatment per MD order, and notifying the MD if treatment was not effective.A letter of pressure ulcer unavoidability was completed by the Director of Nursing Services (DNS) on 1/6/2026. The letter indicated the resident was a high risk for skin breakdown despite preventative measures. A current physician's order, dated 1/5/2026, indicated staff were to encourage the resident's turning and repositioning while in bed.A facility wound assessment, dated 1/6/2026, indicated Resident 6 had a pressure area to the right buttocks. The area was unstageable with measurements of 8 cm x 5 cm x immeasurable depth, with the presence of slough.A facility wound assessment, dated 1/6/2026, indicated Resident 6 had a pressure area to the sacrum. The area was unstageable with measurements of 12 cm x 10.5 cm x 5 cm. There was undermining of 4 cm, without the location of the undermining indicated.A current physician's order, dated 1/7/2026, indicated: indicated staff were to observe the resident's (sacrum and right ischium) dressing to open areas every shift for drainage on dressing and dislodgement.A physician's order, dated 1/7/2026 through 1/14/2026, indicated staff were to cleanse the resident's sacrum and right ischium with normal saline, pat dry, apply normal saline wet-to-moist (placing normal saline-soaked gauze into the wound bed to maintain moisture), and secure with dry dressing as needed for soiling and dislodgement.A physician's order, dated 1/9/2026 through 1/14/2026, indicated staff were to change the resident's negative pressure dressing (an advanced healing system that used a vacuum pump) every Monday, Wednesday, and Friday.The treatment administration record for Resident 6 indicated a change of negative pressure therapy to the sacral wound on 1/12/2026. This administration was left blank.The treatment administration record for Resident 6 indicated the wound vac was in place and functional on 1/12/2026.A facility wound assessment, dated 1/13/2026, indicated Resident 6 had a pressure area to the right buttocks. The area was unstageable with measurements of 7 cm x 5 cm x immeasurable depth, with the presence of slough.A facility wound assessment, dated 1/13/2026, indicated Resident 6 had a pressure area to the sacrum. The assessment included a note that it was unable to be completed due to the wound vac being in place. The assessment did indicate the area was unstageable with measurements of 12 cm x 10.5 cm; no depth was indicated.A physician's order, dated 1/14/2026, indicated the resident's negative pressure setting was at 125 mm Hg continuous therapy three times a day.A current physician's order, dated 1/14/2026, indicated to cleanse the sacrum wound with normal saline, pat dry, and apply normal saline wet-to-moist and secure with dry dressing as needed if unable to apply negative pressure therapy.A physician's order, dated 1/14/2026 through 1/23/2026, indicated to change the resident's negative pressure dressing every Monday, Wednesday, and Friday.A physician's order, dated 1/15/2026, indicated for the resident to have a specialized, air-filled medical seat cushion designed to prevent pressure ulcers (ROHO cushion) .place cushion on wheelchair when it comes in.A wound center provider note, dated 1/15/2026, indicated Resident 6 had two pressure areas. The primary wound was an unstageable pressure area to the sacrum measuring 13.7 cm x 10.3 cm x 2.5 cm. The area had slough with tunneling of 3.6 cm from the 0900-1100 aspect (clock method for describing wound tunneling uses an imaginary clock face over the wound, with 12:00 at the resident's head and ^:00 at the resident's feet). Debridement was provided during the visit, with a resulting wound size of 13.8 cm x 10.4 cm x 2.5 cm. The layer of exposure was necrosis of the muscle. The second wound was an unstageable pressure area to the right ischium measuring 3.5 cm x 4 cm x 0.1 cm. Debridement was provided to the ischium during the visit, with a resulting wound size of 3.6 cm x 4.1 cm x 0.2 cm, with a fat layer exposed. A notation from the visit indicated, .[Resident 6] comes in today with [Brand 1] vac with a [Brand 2] canister and [Brand 3] very small piece of foam.Resident needs a .ROHO [air filled seating] cushion for wheelchair-still has a standard cushion. The plan of care indicated wounds were anticipated to heal in 2-4 months. Wound care orders from the visit included, but were not limited to, .Patient's current wheelchair cushion is inadequate. Please obtain ROHO cushion for patient. and to keep pressure therapy on. If the dressing seal to the sacrum were to be broken and the transparent dressing came loose, reinforce with strips of dressing as needed. If negative pressure wound therapy malfunctions or becomes non-occlusive for more than 2 hours, remove the dressing, clean the wound with normal saline, apply a moistened gauze with saline and then dry gauze, and change twice a day until negative pressure wound therapy can be put back on. If the dressing becomes non-occlusive or malfunctions, call your healthcare provider and wound care during business hours on weekdays.A physician's order, dated 1/15/2026, indicated for the resident to have a specialized, air-filled medical seat cushion designed to prevent pressure ulcers .place cushion on wheelchair when it comes in.A physician's order, dated 1/16/2026, indicated wound care to the right ischium was to cleanse wound with normal saline, pat dry, apply Hydrofera Blue transfer (cut to size of wound and hydrate dressing with NS before applying), cover with ABD, and secure with tape.A physician's order, dated 1/16/2026, indicated wound care to the right ischium was to cleanse wound with normal saline, pat dry, apply Hydrofera Blue transfer (cut to size of wound and hydrate dressing with NS [normal saline] before applying), cover with ABD [abdominal pad], and secure with tape, as needed for soiling or dislodgement.A facility wound assessment, dated 1/20/2026, indicated Resident 6 had a pressure area to the right buttocks. The area was unstageable with measurements of 3.6 cm x 4 cm x 0.1 cm, with the presence of slough in the wound bed.A facility wound assessment, dated 1/20/2026, indicated Resident 6 had a pressure area to the sacrum. The area was unstageable with measurements of 13.5 cm x 10.5 cm x 2.5 cm. There was tunneling of 3.5 cm at the 0900-1100 aspect. The note indicated Resident 6 was at times noncompliant with dressings and turning.The treatment administration record for Resident 6 indicated the negative pressure therapy change to the sacral wound scheduled for 1/21/2026 was not administered, with the reason noted as .Discontinued.The treatment administration record for Resident 6 indicated negative pressure therapy to the sacral wound was not in place due to .discontinued. twice on 1/21/2026.A wound center provider note, dated 1/22/2026, indicated Resident 6 had two pressure areas. The primary wound was an unstageable pressure area to the sacrum measuring 13.1 cm x 11 cm x 2.2 cm. The area had slough with tunneling of 3.4 cm from the 0900-1200 aspect. Debridement was provided during the visit, with a resulting wound size of 13.2 cm x 11.1 cm x 2.3 cm. The layer of exposure was bone involvement without evidence of necrosis. The second wound was an unstageable pressure area to the right ischium measuring 3.7 cm x 2.9 cm x 0.1 cm. Debridement was provided to the ischium during the visit, with a resulting wound size of 3.8 cm x 3 cm x 0.2 cm, with a fat layer exposed. A notation from the visit indicated, .[Family Member 11] notes vac started beeping Monday. Alarm turned off but continued to alert until Tuesday when vac removed. Dressing in place today was a Hydrofera Blue transfer folded in half and covering about 25% of the wound.There is now exposed bone, and deep tissue injury of intact skin of proximal aspect.Has a new foam cushion on top of original foam cushion. Needs ROHO cushion or equivalent, as previously requested. Wound care orders, dated 1/22/2026, indicated .Patient's current wheelchair cushion is inadequate. Please obtain ROHO cushion for patient. Please no foam cushions.Wound must have dressing on at all times. Patient did not have dressing on the sacrum wound today. Patient's undermining has increased depth. Increased pressure injury noted at 12:00 aspect of sacral wound. Bone exposure noted. Wound care orders indicated to keep pressure therapy on. If the dressing seal to the sacrum were to be broken and the transparent dressing came loose, reinforce with strips of dressing as needed. If negative pressure wound therapy malfunctions or becomes non-occlusive for more than 2 hours, remove the dressing, clean the wound with normal saline, apply a moistened gauze with saline and then dry gauze, and change twice a day until negative pressure wound therapy can be put back on. If the dressing becomes non-occlusive or malfunctions, call your healthcare provider and wound care during business hours on weekdays.A physician's order, dated 1/23/2026 through 1/26/2026, indicated to change the resident's negative pressure dressing every Sunday, Tuesday, and Thursday.The treatment administration record for Resident 6 indicated the order for [Sacrum]: Cleanse wound with normal saline, pat dry, apply NS [Normal Saline] wet to moist and secure with dry dressing PRN [as needed] if unable to place wound vac . was ordered on 1/14/2026 with no end date. There were no signed off administrations of this on the treatment record. The treatment administration record for Resident 6 indicated .[Sacrum and right ischium] dressing to open area(s) every shift for draining on dressing and dislodgement. An associated nurses note stated, .not administered: Other wet to moist on Wound center today . A facility wound assessment, dated 1/27/2026, indicated Resident 6 had a pressure area to the right buttocks. The area was unstageable with measurements of 3 cm x 4 cm x 0.1 cm, with the presence of slough in the wound bed.A facility wound assessment, dated 1/27/2026, indicated Resident 6 refused to allow the facility to measure his wounds.A wound center provider note, dated 1/30/2026, indicated Resident 6 had two pressure areas. The primary wound was an unstageable pressure area to the sacrum measuring 13.6 cm x 10 cm x 2 cm. The area had slough with tunneling of 3 cm from the 0900-1100 aspect. Debridement was provided during the visit, with a resulting wound size of 13.7 cm x 10.1 cm x 2.1 cm. The layer of exposure was bone involvement without evidence of necrosis. The second wound was an unstageable pressure area to the right ischium measuring 4.7 cm x 2.7 cm x 0.2 cm. Debridement was provided to the ischium during the visit, with a resulting wound size of 4.8 cm x 2.8 cm x 0.3 cm, with a fat layer exposed. A notation from the visit indicated Resident 6 .just received a new cushion, which feels like a one-piece block of foam. Resident 6 needed a ROHO or equivalent cushion, as previously requested, and Family Member 11 indicated the facility told Family Member 11 that a ROHO had been ordered. Wound care orders indicated Resident 6's cushion was inadequate, requested no foam cushions, and indicated to keep negative pressure therapy on. If the dressing seal to the sacrum were to be broken and the transparent dressing came loose, reinforce with strips of dressing as needed. If negative pressure wound therapy malfunctions or becomes non-occlusive for more than 2 hours, remove the dressing, clean the wound with normal saline, apply a moistened gauze with saline and then dry gauze, and change twice a day until negative pressure wound therapy can be put back on. If the dressing becomes non-occlusive or malfunctions, call your healthcare provider and wound care during business hours on weekdays.A facility wound assessment, dated 2/3/2026, indicated Resident 6 had a pressure area to the right buttocks. The area was unstageable with measurements of 2.7 cm x 3.5 cm x immeasurable depth, with the presence of slough.A facility wound assessment, dated 2/3/2026, indicated Resident 6 had a pressure area to the sacrum. The area was unstageable with measurements of 13 cm x 10 cm x 0.2 cm. There was undermining of 4 cm at the 0900-1200 aspect.A wound center provider note, dated 2/5/2026, indicated Resident 6 had two pressure areas. The primary wound was an unstageable pressure area to the sacrum measuring 12.6 cm x 9.5 cm x 1.8 cm. The area had slough with tunneling of 2.2 cm from the 0900-1100 aspect. Debridement was provided during the visit, with a resulting wound size of 12.7 cm x 9.6 cm x 1.9 cm. The layer of exposure was bone involvement without evidence of necrosis. The second wound was an unstageable pressure area to the right ischium measuring 4 cm x 2.5 cm x 0.1 cm. Debridement was provided to the ischium during the visit, with a resulting wound size of 4.1 cm x 2.6 cm x 0.2 cm, with a fat layer exposed. A notation from the visit indicated Resident 6 needed a ROHO or equivalent cushion, as previously requested, and Family Member 11 indicated the facility told Family Member 11 that a ROHO had been ordered. Wound care orders indicated Resident 6's cushion was inadequate, requested no foam cushions, and indicated to keep negative pressure therapy on. If the dressing seal to the sacrum were to be broken and the transparent dressing came loose, reinforce with strips of dressing as needed. If negative pressure wound therapy malfunctions or becomes non-occlusive for more than 2 hours, remove the dressing, clean the wound with normal saline, apply a moistened gauze with saline and then dry gauze, and change twice a day until negative pressure wound therapy can be put back on. If the dressing becomes non-occlusive or malfunctions, call your healthcare provider and wound care during business hours on weekdays.A facility wound assessment, dated 2/10/2026, indicated Resident 6 had a pressure area to the right buttocks. The area was unstageable with measurements of 2.5 cm x 3.5 cm x immeasurable depth, with the presence of slough.A facility wound assessment, dated 2/10/2026, indicated Resident 6 had a pressure area to the sacrum. The area was unstageable with measurements of 12 cm x 9.5 cm x 0.2 cm. There was undermining of 4 cm at the 0900-1200 aspect.An order sheet provided by ADNS, dated 12/10/2025 at 2:45, indicated the cushion provided to Resident 6 was a .Pressure Retribution Foam Cushion with Cutout.During an interview, on 12/10/2026 at 2:45 PM, ADNS indicated Resident 6 was on the foam cushion (pressure Retribution Foam cushion) from 1/12/2026 until the air filled cushion was delivered on 2/3/2026. The facility received a call after Resident 6's wound care appointment on 2/5/2026 and it was disclosed to cushions that were still not adequate, so they had the air filled dry floating low profile cushion same day delivered on 2/6/2026.During an interview, on 2/11/2026 at 11:17 AM, LPN 7 indicated she had taken care of Resident 6 multiple times before. When she took care of him prior to sending to wound care, she would make sure he had his antibiotic, breakfast, and dressing was in place. The LPN indicated the resident was sent to wound care on a 3 to 4 inch thick foam cushion with a U-shape cut out. Resident 6 received an air cushion over the weekend, but was on strict bedrest, so he had not used it yet to her knowledge.During an interview, on 2/11/2026 at 12:10 p.m., LPN 9, indicated on 1/21/2026 she received in report Resident 6's wound vac was on hold due to frequent stools. She was not sure if she worked 8 hours or 12 hours with him that day, but Resident 6 had a wet to moist dressing on both wounds. She changed the dressings once during her shift with a wet to moist but did not attempt to reapply the wound vac. LPN 9 was unsure how long it had been off. LPN 9 confirmed she did not notify the physician or wound care because she believed the previous nurse had.During an interview on 2/12/2026 at 12:07 PM, Physician 10 indicated she had seen Resident 6 for treatment of his wounds. Resident 6 had substantial wounds to his coccyx with bone and muscle involvement. The interventions had not been implemented for Resident 6's care. The cushion Resident 6 came to his appointments on had been inadequate. The facility continued to use foam cushions, even sending the resident with two foam cushions to the last two wound care visits. The cushions being provided were not sufficient for the severity of the ulcer he had. On 1/15/2026, she recalled the wound vac (negative pressure wound therapy) that was in place was a mismatch of wound vac pieces and utilized the wrong type of foam. It was not likely detrimental to the wound, but it was not effective in healing. On 1/22/2026, Resident 6's sacral wound looked .much worse. Family Member 11 said that the vac had stopped working and been left in place for at least 24 hours. Resident 6 had a .small dinner-plate-sized wound and now had bone exposure in the central aspect. that had not been noted previously. There was no dressing in place for the sacral wound except for a folded piece of Hydrofera Blue over the exposed bone. Case Manager 15 called the facility on 1/23/2026 to report concerns, including the need for a Hoyer sling, ROHO cushion, and the wound not being covered. Case Manager 15 also clarified wound care orders included the importance of compliance with wound vac treatment. On 1/30/2026, Physician 10 saw Resident 6 in the office. Resident 6 had a double foam cushion in his wheelchair. Resident 6 reported the facility did not provide his protein supplement or turn him often. Physician 10 indicated she last saw him on 2/5/2026 and the dressing was a little bit not on point. Every time Resident 6 came to wound care, except for 1/22/2026 when no vac was in place, the foam had not been applied completely. Resident 6 had an improper cushion and reported interventions were not consistent. Case Manager 15 had reached out several times to the facility, including 1/23/2026 and 2/5/2026. It was her opinion that the wound will heal, but Resident 6 was .fragile, so that is a difficult part. They [the facility] have to optimize nutrition and minimize pressure to the area if he [Resident 6] has any hope. The physician indicated the inadequate cushion could impact the wound even if just when going to the appointment. As severe as the wound was, even coming across the road on the wrong cushion can be detrimental. When asked to describe a Roho cushion or adequate alternative, she indicated Resident 6 needed a air-cell-based cushion and should not be on a foam cushion.During an interview on 2/13/2026 at 8:20 AM, Family Member 11 indicated when she had visited the resident in the facility the wound vac (treatment to the coccyx) was not observed to be functional.During an interview on 2/13/2026 at 9:35 AM, Physician 10 reported the wound vac was noted to be applied inappropriately during the visit on 2/13/2026. The bulb (where the hose attached to the dressing to apply the negative pressure) was placed directly over the bone, but it should have been bridged. Bridging was a closure technique that extends foam from a wound bed across intact skin not over a boney prominence to connect the bulb. The wound had resulted in deterioration of the exposed bone, which was now crumbling.During an interview, on 2/13/2026 at 11:02 AM, LPN indicated she cared for Resident 6 prior to going to wound care on 1/22/2026. Prior to going to wound care, she reapplied a wet to moist dressing to both of Resident 6's wounds. She did not attempt to reapply the wound vac because he would be getting it changed in just a couple of hours at wound care. She could not remember what dressing she removed that day. When Resident 6 was transferred on 1/22/2026, he was sent out on a foam cushion with a U-shaped cut out.During an interview, on 2/13/2025 at 1:03 PM, ADON indicated Resident 6's wound VAC should be bridged.An article by the National Institute of Health, last updated September 4, 2023, defined negative pressure wound therapy (NPWT) as a broad term used to describe a unique and versatile system that aids the optimization of wound healing through the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue. This is also referred to as a wound VAC (vacuum assisted closure).2. During an interview, on 2/9/2026, Family Member 12, indicated Resident 2 had pressure wounds and ulcers.The clinical record for Resident 2 was reviewed on 02/13/2026 9:57 AM. The admission MDS Assessment, dated 11/30/2025 indicated that Resident 2 was cognitively intact and needed partial/moderate staff assistance with hygiene care. A cognition screening, completed on 2/10/2026, indicated Resident 2 was cognitively impaired. A nursing skin note from admission, dated 2/6/2026, indicated a skin assessment was completed. The nurse noted an open area on the left buttock measured 6 cm x 4 cm, open areas on the right buttock measured 2 cm x 1 cm and 1 cm x 1 cm, and the right heel had a deep purple maroon discoloration measured at 4.5 cm x 0.75 cm. The resident had two other skin alterations listed to the left lower extremity. A wound management assessment, completed 2/6/2026, indicated Resident 2 had an unstageable deep tissue pressure ulcer to the right heel measured at 1 cm x 4 cm x immeasurable depth, an unstageable deep tissue pressure ulcer to the right buttock measured 4.5 cm x 2 cm x immeasurable with no open areas, and an unstageable pressure area to the left buttock measuring 5 cm x 5 cm x immeasurable depth with eschar. During an interview, on 02/12/2026 at 1:19 PM, ADON indicated the admitting nurse could not assess staging because she was an LPN. There was no depth listed for the wound on admission so that was why none was listed, the admitting nurse had some measurements inverted, and there was no description other than open areas to the pressure areas to the buttocks.A policy entitled, Pressure/Stasis/Arterial/Diabetic Wound Guidelines, was provided by the DNS on 2/11/2026 at 11:30 AM. The policy indicated .If skin alteration is noted upon admission, admitting nurse should complete progress note assessment.Documentation descriptions of wound using: a. Length - 12 o'clock to 6 o'clock, b. Width - 3 o'clock to 9 o'clock, c. Depth - deepest area of wound bed, d. Exudate, e. Color, f. Odor, g. Wound margins, h. Surrounding tissue, t. Tunneling and/or undermining if applicable. 3.1-40

Based on interview and record review, the facility failed to ensure call lights were answered timely for 5 of 6 residents reviewed for accommodations of needs. (Resident 92, Resident 6, Resident 61, Resident 55, and Resident 26) Findings include:During an interview for Resident Council on 2/11/26 at 1:03 p.m., Resident 61, Resident 55 and Resident 26 indicated the residents were unable to get their call lights answered to get assistance. It would take the staff from 20 to 30 minutes to answer a call light. Review of the resident council meetings, dated October 2025, November 2025, December 2025, and February 2026, indicated the residents had concern of call lights not being answered timely. During an interview with Resident 92 on 2/9/26 at 1:37 p.m., the resident indicated he had to wait for assistance with toileting. It took up to thirty minutes for his call light to be answered, especially during mealtimes. During an interview with Resident 6 on 2/9/26 at 2:14 p.m., the resident indicated when the resident pushed his call light for help, it took up to thirty minutes for it to get answered. The staff would sometimes come in and shut it off and then would not return. During a confidential interview, from 2/9/26 to 2/13/26, the confident indicated they had timed it and it had taken up to thirty minutes for the call light to be answered and sometimes the staff did not come at all during the night. The resident had to lay in urine for long periods of time. During an interview with the Executive Director (ED) on 2/12/2026 at 10:31 a.m., The ED indicated call lights should be answered as soon as possible. The facility did not have a way to track call light time responses. During an interview with the Activity Director on 2/12/26 at 11:05 a.m., the Activity Director indicated call light wait times had been a concern in resident council. The resident council had reported a concern about call light wait time in January 2026, but she did not document it. January 2026 was the first time she had conducted a resident council meeting. The call light policy provided by the ED, on 2/12/26 at 11:40 a.m., indicated call lights should be answered as quickly as possible. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to set up follow up appointments with the optometrist (eye doctor) as recommended for 1 of 1 resident reviewed for vision (Resident 51). During an observation and interview with Resident 51 on 2/10/2026 at 9:55 a.m., the resident had a book in her hand and was moving her glasses around to read it. The resident indicated she had not had her glasses very long but had to move her glasses around to see out of them to read. The resident would rather read then watch television. The resident needed different glasses and she did not care if it was reading glasses, whatever worked so she could see to read. The resident was observed to have 7 books and magazines on her night stand. Review of the clinical record of Resident 51 on 2/11/2026 at 9:54 a.m., indicated the resident's diagnosis included, but was not limited to, bilateral changes in retinal vascular appearance (abnormal alterations in the blood vessels of both eyes). The significant change Minimum Data Set (MDS) assessment for Resident 51, dated 12/11/25, indicated it was very important to the resident to have books, newspaper and magazines to read. The quarterly MDS assessments for Resident 51, dated 1/22/26, indicated the resident was cognitively intact. The resident was reasonable and consistent. The resident required corrective lenses for vision. The optometrist appointment for Resident 51, dated 3/13/25, indicated the resident was to have a follow up in 1 to 3 months for electroretinography (ERG) (measures the electrical responses of light sensitive cells and test for retinal disorders). The optometrist appointment for Resident 51, dated 10/17/25, indicated the resident was to have a follow up in 1 to 3 months for a dilated fundus exam (diagnostic procedure). Review of the physician's order for Resident 51, dated February 2026, indicated the resident may see an optometrist as needed. During an interview with the Social Service Director (SSD), on 2/11/26 at 11:02 a.m., indicated nursing were responsible to schedule residents for their follow up appointment with the eye doctor. The SSD would review Resident 51's record to see if she had her follow up appointments between April 2025 to June 2025 as ordered by the eye doctor and November 2025 to January 2026 as ordered by the eye doctor. During an interview with the SSD, on 2/11/2026 at 2:18 p.m., the SSD indicated Resident 51 did not have the eye doctor appointments/test in the time frame they were suppose to be completed. During an interview with Director Of Health Services (DOHS), on 2/12/26 at 2:19 p.m., the DOHS indicated it was nursing staffs' responsibility to schedule the follow up eye doctor appointments for Resident 51. The facility did not have a policy for ancillary services. 3.1-39(a)(1)

Based on observation, interview, and record review, the facility failed to provide a resident with prescribed prn (as needed) Imodium when experiencing loose stools (Resident 62) and assess a resident with increased frequency and urgency of urination (Resident 72) for 2 of 2 residents reviewed for bowel and bladder Incontinence/UTI. Findings include: 1.The clinical record for Resident 62 was reviewed on 2/10/2026 at 12:41 p.m. The resident's diagnoses included, but were not limited to, diverticulosis (condition of small bulging pouches in the digestive track lining, primarily the colon, caused by high pressure), muscle weakness, diarrhea (loose stool), and urinary incontinence. The resident was alert and oriented. An admission Observation and Data Collection report, dated 2/1/26, indicated Resident 62 was incontinent with bowel and bladder, had weakness in bilateral lower extremities, no skin impairments identified upon skin assessment, and was at risk for pressure ulcers. Dated 2/2/26, the resident was alert and oriented A plan of care, dated 2/2/26, indicated Resident 62 had diverticulosis. The interventions included, but were not limited to, administering medications as ordered by the physician, and recording the duration and frequency of diarrhea. A plan of care, dated 2/2/26, indicated Resident 62 was at risk for skin breakdown related to decreased mobility. The interventions included, but were not limited to, keeping as clean and dry as possible and minimizing skin exposure to moisture. A progress note, dated 2/4/26 at 9:52 p.m., indicated the provider put in a referral for the resident to be seen by a gastroenterologist (medical doctor specializing in digestive systems) for loose stools. The physician's order, dated 2/4/26, indicated Resident 62 was prescribed Imodium (over the counter medication to treat loose stools) A-D 2 mg (milligram), one tablet oral, every four hours as needed for diarrhea. The physician's order, dated 2/5/26, indicated Resident 62 was prescribed Imodium A-D 2 mg, one to three tablets three times a day as needed. A progress note, dated 2/9/26 at 1:38 p.m., indicated Resident 62 was complaining of buttock pain, was having frequent soft/loose stools, and the resident's coccyx was red with blanching and noted shearing to upper coccyx area. A review of the February Medication Administration Record (MAR) indicated no prn Imodium was given to Resident 62 since the order was received on 2/4/26. A progress note, dated 2/10/26 at 9:45 a.m., indicated Resident 62 had complaints of discomfort in the groin area. Moisture-Associated Skin Damage (MASD - inflammation and skin erosion caused by prolonged exposure to fluids like urine, stool, or wound exudate, often resulting in painful, burning, and itchy skin) noted to the groin area. During an interview on 2/10/2026 at 10:36 a.m., Resident 62 indicated their private area was all red and excoriated from lying in their urine and feces all the time. The staff had put powder on the red area that morning. A progress note, dated 2/11/26 at 1:46 p.m., indicated the nurse practitioner was notified of Resident 62 having loose stools, she would be in to assess the resident, and gave a referral for the resident see a gastroenterologist. A progress note, dated 2/11/26 at 5:22 p.m., indicated the nurse practitioner changed the Imodium order to 2 mg, one tablet by mouth, three times a day. During an interview with the Assistant Director of Health Services (ADHS) on 2/12/26 at 1:20 p.m., they indicated MASD was caused by moisture, sweating, or incontinence. It was the facilities expectation that residents were checked for incontinence during every two-hour rounding (checking and changing) or when the resident called for assistance with care. The expectation was to keep them clean and dry. During an interview with Resident 62 on 2/13/2026 at 9:51 a.m., the resident indicated no one had offered them any Imodium when they were having diarrhea. The first time the resident received an Imodium was within the last couple days and the Imodium had helped a lot. During an interview with the DHS on 2/13/26 at 10:55 a.m., they indicated it was their expectation that if a resident was experiencing diarrhea and had an order for Imodium, the nurse would offer it. The facility did not have a policy for following the physician orders. The floor nurse was responsible to provide Resident 62 with her Imodium medication if needed for her diarrhea. A Perineal Care for Incontinence policy was provided by the DHS on 2/12/26 at 10:18 a.m. It indicated .to provide incontinence care that will keep skin from being exposed to prolonged periods of urine and feces. 2. During an observation and interview with Resident 72 on 2/09/2026 at 12:19 p.m., the resident was in the bathroom with the door shut. The resident ambulated out of the bathroom to her chair independently. The resident indicated the last 3 to 4 days she had been running to the bathroom constantly and sometimes she could urinate and sometimes she could not. The resident felt like she needed a bedside commode next to her recliner because she was going so frequently to the bathroom, almost every 10 minutes. The resident had reported her concerns to the staff member today that had provided her with her routine medications, but was unsure of her name. During an interview with LPN 2 on 2/10/2026 at 12:58 p.m., the LPN indicated she did not care for Resident 72 on 2/09/26 she was off work. LPN 2 asked QMA 4 if Resident 72 had reported to her anything on 2/9/26. QMA 4 indicated the resident reported to her that she was experiencing urgency with urination, but could not always urinate. QMA 4 reported it to LPN 3. LPN 2 verified there was no documentation of an assessment, the change in condition with urination or a urinalysis labs completed for the resident on 2/9/26. LPN 2 indicated an event should have been opened for the resident and the facility nurses would follow up on the resident for 72 hours. An event was opened up for anything new like the urgency with urination. There was no event started for the resident. LPN instructed QMA 4 to put a urine collection container in the resident's toilet so they could test her urine for a UTI and to start encouraging fluids. During an interview with the Director of Nursing Services (DNS) on 2/10/2026 at 2:15 p.m., the DNS indicated she would expect LPN 3 to follow up with Resident 72 after QMA 4 had reported to her the resident's concerns. Review of the record of Resident 72 on 02/12/2026 at 1:53 p.m., indicated the resident's diagnoses included, but were not limited to, history of urinary tract infection. The physician's order for Resident 72, dated 1/22/26, indicated staff may dip the resident's urine for signs and symptoms of a UTI. The care plan for Resident 72, dated 1/22/26, indicated the resident was at risk for a UTI. The care plan for Resident 72, dated 1/22/26, indicated the resident was continent, but was at risk for incontinence related to decreased mobility. The interventions included, but were not limited to, observe continence status and report changes as needed. The admission Minimum Data Set (MDS) assessment for Resident 72, dated 1/26/26, indicated the resident required supervision for ambulation and toileting. The resident was occasionally incontinent of urine. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to provide dependent residents with nail care and failed to provide timely incontinent care for 3 of 3 residents reviewed for Activities of Daily Living (ADL) care (Resident 91, Resident 28 and Resident 62). Findings include:1.During an observation and interview with Resident 91 on 2/9/26 at 12:41 p.m., the resident's fingernails were long. The resident indicated the staff had not assisted him with trimming his fingernails. During observation and interview with Resident 91 on 2/10/26 at 1:20 p.m., the resident's fingernails were long on both hands. The resident indicated his fingernails had been long since he was admitted . He had asked Certified Resident Care Assistant (CRCA) 1 and CRCA 6 to trim them for him, but they never showed up to trim them. The resident had a stroke and was unable to trim them himself, he had never let his fingernails get long like they were now before he had the stroke. The resident was afraid he would scratch himself with them being so long. Review of the clinical record of Resident 91 on 2/11/2026 at 2:54 p.m., indicated the resident's diagnosis included, but was not limited to, Cerebral Vascular Accident (CVA) (stroke). The Occupational Therapy (OT) cognitive assessment for Resident 91, dated 2/5/26, indicated the resident was cognitively intact for daily decision. The care plan for Resident 91, dated 2/6/26, indicated the resident had functional impairment due to left side hemiparesis (weakness) and stroke. The interventions included, but were not limited to, provide nail care on shower days and as needed. 2. The clinical record for Resident 28 was reviewed on 2/10/26 at 12:43 p.m. The resident's diagnosis included, but was not limited to, congestive heart failure. The admission Minimum Data Set (MDS) assessment, dated 12/28/26, indicated Resident 28 was severely cognitively impaired, required partial/moderate assistance with personal hygiene, and had no behaviors toward others or rejection of care. During an observation and interview with Resident 28 on 2/9/26 at 2:26 p.m., the resident's fingernails were long and appeared dirty. Resident 28 indicated his nails needed to be trimmed. During an observation and interview with Resident 28 on 2/10/26 at 1:58 p.m., his nails were long, specifically both thumbs, and both middle fingers had jagged, sharp edges to them. During an observation and interview with Resident 28 on 2/11/26 at 10:39 a.m., his nails continued to be long, specifically both thumbs and both middle fingers were rough and jagged. Resident 28 indicated no staff had gotten around to trimming his nails yet. During an interview with the Director of Health Services (DHS) on 2/13/26 at 10:35 a.m., they indicated residents should be offered nail care and trimming on their shower days and nursing was who was responsible to ensure nail care was provided to residents. 3. The clinical record for Resident 62 was reviewed on 2/10/2026 at 12:41 p.m. The diagnoses included, but were not limited to, spinal stenosis, muscle weakness, diarrhea (loose stools), and urinary incontinence. The resident was alert and oriented. An admission Observation and Data Collection report, dated 2/1/26, indicated Resident 62 was incontinent with bowel and bladder and had weakness in bilateral lower extremities. A bowel and bladder plan of care, dated 2/2/26, indicated Resident 62 experienced periods of incontinence due to debility and weakness. The interventions included, but were not limited to, offer and assist with toileting as needed and per resident request, and provide incontinence care as needed. During an interview with Resident 62 on 2/10/26 at 10:20 a.m., the resident indicated they would lay in bed soiled for up to a half hour waiting for help. A progress note, dated 2/10/26 at 9:45 a.m., indicated Resident 62 had complaints of discomfort in the groin area. Moisture-Associated Skin Damage (MASD - inflammation and skin erosion caused by prolonged exposure to fluids like urine and stool) noted to the groin area. During an observation on 2/10/26 at 1:15 p.m., Resident 62 was yelling, will someone help me, help me, someone help me. During an interview with Resident 62 on 02/10/2026 at 1:47 p.m., the resident indicated they pushed their call light because they were incontinent and needed to be changed. Someone came in and said I'll go get someone to help you and never come back. I had to yell out for help.over thirty minutes waiting on someone, so I had to yell out for help. During an observation and interview with Resident 62 on 02/11/2026 at 10:44 a.m., the resident indicated they turned their call light on because they were incontinent and needed cleaned up. CNA 13 was observed to enter the resident's room and assisted the resident with incontinence care. Resident 62's vaginal area was red, raw, and excoriated from the vaginal area up to the buttocks. Resident 62 moaned out in discomfort during cleaning. An observation on 2/11/26 at 11:01 a.m., Resident 62 was heard moaning and yelling for help from the doorway. Resident 62's call light was on. Family Member 14 was standing at the doorway saying, she needs help, she went again and whistling for someone's attention. No staff were observed down either hallway. During an interview with Family Member 14 on 2/11/2026 at 1:33 p.m., he indicated he came into the facility twice a day to see Resident 62 and nearly every day that he came in, Resident 62 would push her call light for help getting cleaned up. Staff would come in, turn off the call light, say someone would be back in to help, and no one would come back. Family Member 14 indicated Resident 62 would tell him how uncomfortable she was and how much it burned to have that left on her skin for any period-of-time. Lunchtime was the worst with trying to get help. He had even stood in the doorway looking for help or trying to flag someone down. An interview with the Executive Director (ED) on 2/12/2026 at 10:31 a.m., the ED indicated staff should answer call lights as soon as possible. A Perineal Care for Incontinence policy was provided by the DHS on 2/12/26 at 10:18 a.m. It indicated .To provide incontinence care that will keep skin from being exposed to prolonged periods of urine and feces. The DHS indicated 3.1-38(a)(3)(A) 3.1-38(a)(3)(E)

Based on observation, interview, and record review the facility failed to ensure residents had fluids available at bedside for 3 of 3 residents reviewed for hydration. (Resident B, Resident D and Resident E) Findings include:1. During an interview, on 1/28/26 at 12:48 p.m., Resident B's family member indicated she visited her family member daily and the resident never had fluids in the room. The resident reported that the only fluids they received were with meal trays. The family member indicated ever day they had to provide fluids for Resident B. Review of the clinical record of Resident B on 1/28/26 at 10:28 a.m., indicated the resident's diagnoses included, but were not limited to, stroke (sudden disruption of blood flow to the brain causes brain cells die leading to permanent neurological damage), chronic kidney disease (long term progressive loss of kidney function), and urinary tract infection. The plan of care for Resident B, dated 9/18/25, indicated the resident was at risk for dehydration. The interventions included, but were not limited to, staff were to offer fluids with meals, medication pass and activities. The plan of care for Resident B, dated 9/18/25, indicated the resident received a high risk medication diuretic. The intervention included, but were not limited to, staff were to encourage fluids if not contraindicated. The plan of care for Resident B, dated 12/4/25, indicated the resident was at risk for constipation. The intervention included, but were not limited to, staff were to encourage fluids. The admission Minimum Data Set (MDS) assessment for Resident B, dated 9/24/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. 2. The clinical record for Resident D was reviewed on 1/29/26 at 9:47 a.m. The resident's diagnoses included, but were not limited to, congestive heart failure (heart muscle is too weak or stiff to pump blood efficiently) and iron deficiency anemia (body lacks sufficient iron to produce adequate hemoglobin). The admission Minimum Data Set (MDS) assessment, dated 1/22/26, indicated Resident D was cognitively intact for daily decision making. During an interview and observation, on 1/28/26 at 10:45 a.m., Resident D had a Styrofoam cup with a small amount of water in it. He indicated they had not brought him any water today, but he had not asked yet. Sometimes he had to ask and sometimes they brought it. During an observation and interview with Resident D, on 1/28/26 at 1:30 p.m., Resident D had a cup of water sitting in front of him. He indicated he just got fresh water about twenty minutes ago for the first time that day. A plan of care, dated 1/19/26, indicated Resident D was at risk for dehydration. The interventions included, but were not limited to, staff were to offer fluids. 3. The clinical record for Resident E was reviewed on 1/29/26 at 1:58 p.m. The resident's diagnoses included, but were not limited to, severe sepsis with septic shock (body's overwhelming response to infection causes organ dysfunction) and acute respiratory failure with hypoxia (inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function). The admission Minimum Data Set (MDS) assessment, dated 1/15/26, indicated Resident E was moderately cognitively impaired and was on a controlled carbohydrate diet with a 2 gram sodium restriction. During an interview and observation with Resident E, on 1/28/26 at 10:55 a.m., the resident had an empty Styrofoam cup with no date on it. The resident indicated she always had to ask for water. During an interview and observation with Resident E, on 1/28/26 at 1:45 p.m., the resident had a Styrofoam cup with no date on it, it was empty and had ice in it. The resident indicated that was what came on her lunch tray and the facility still had not passed water. A plan of care, dated 1/12/26, indicated Resident E was at risk for dehydration. The interventions included, but were not limited to, staff were to offer fluids. During an interview with the Administrator, on 1/29/26 at 3:03 p.m., the Administrator indicated the facility does not have a policy in regards to hydration and his expectation was to keep residents hydrated and the resident's water cups were passed once per shift. This Federal citation relates to intake 2707905. 3.1-3(v)(1)

Based on interview and record review the facility failed to notify a resident's family of a large bruised area to the resident's back for 1 of 3 residents reviewed notification of injury. (Resident B) Finding include: During an interview, on 1/28/26 at 12:48 p.m., Resident B's family member indicated they were not notified of a large bruise on the resident's back. The family member indicated when the resident was admitted to the hospital, on 12/21/25, the bruise was observed. The resident reported to the family member that a week before she went to the hospital she had a fall during a transfer with staff. The family member was not aware the resident had a fall or had the bruising. Review of the clinical record of Resident B on 1/28/26 at 10:28 a.m., indicated the resident's diagnosis included, but was not limited to, stroke (lack of oxygen causing brain cells to die, potentially leading cause of long-term disability and death). The resident's record did not indicate the resident had a fall. The admission Minimum Data Set (MDS) assessment for Resident B, dated 9/24/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable.The progress note for Resident B, dated 12/21/25 at 2:23 p.m., indicated the dark areas to the resident's back had worsened and was getting darker. The area increased in size. An event was opened to ensure the wound nurse was aware. The Nurse Practitioner was notified. The documentation did not indicate the resident's family had been notified. During an interview with the Director Of Nursing Services (DNS) on 1/28/26 at 2:06 p.m., the DNS indicated when an event was created in the computer they were turned into incident reports that were an internal document. No further information or documentation was provided by the DNS. The notification policy provided by the DNS on 1/28/26 at 2:25 p.m., indicated the purpose was to ensure the resident's responsible party was notified of a change in condition timely. The responsible party would be notified immediately of a change in condition. This citation relates to Intake 2707905. 3.1-5(a)(2)

Based on interview and record review the facility failed to complete a thorough and accurate assessment of a large bruised area to a resident's back for 1 of 3 residents reviewed for Quality of Care. (Resident B) Findings include: The hospital note for Resident B, dated 1/21/26 (no time), indicated the resident had a traumatic wound on admission to the right side of her back measuring 22 centimeters (cm) by 9 cm. The area was purple and red with erythema (superficial reddening of the skin as result of an injury or irritation causing dilation of the blood capillaries). Review of the clinical record of Resident B on 1/28/26 at 10:28 a.m., indicated the resident's diagnosis included, but was not limited to, stroke (lack of oxygen causing brain cells to die, potentially leading to lasting damage, paralysis, or speech impairment, leading cause of long-term disability). The resident's record did not indicated the resident had a fall. The progress note for Resident B, dated 12/21/25 at 2:23 p.m., indicated the dark areas to the resident's back worsened, was getting darker, and increasing in size. An event was opened to ensure wound nurse aware. The Nurse Practitioner was notified. The documentation had no further assessments of the area to the resident's back. Review of the wound management for Resident B on 1/28/26 at 10:28 a.m., indicated the resident had no bruising assessment for the resident's back or any other assessment of the resident's back. During an interview with the Director Of Nursing Services (DNS) on 1/28/26 at 2:06 p.m., indicated the when an event was created in the computer they were turned into incident reports that were an internal document. No further documentation or assessments were provided by the DNS during the survey process. During an interview, on 1/28/26 at 12:48 p.m., Resident B's family member indicated they were not notified of a large bruise on the resident's back. The resident indicated she had a fall during a transfer with staff at the facility and hit the side of her bed. The family member was not aware the resident had a fall or had the bruising. The bruising policy provided by the DNS on 1/28/26 at 2:25 p.m., indicated the procedure was to complete an bruise incident in the electronic health record along with a template/assessment progress note. This citation relates to Intake 2707905.3.1-37(a)

Based on interview and record review, the facility failed to report Resident B received Resident D's morning medication in error to the local hospital that Resident B was being transferred, to ensure continuity of care 1 of 3 residents reviewed for Discharge Process. (Resident B). Findings include:Review of the clinical record of Resident B on 11/12/25 at 10:50 a.m., indicated the resident's diagnoses included, but were not limited to, chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, dependence on renal dialysis and pulmonary edema.The progress note for Resident B, dated 10/26/25 at 10:37 a.m., indicated the wrong resident's medication, error occurred. Nursing supervisor made aware immediately. Director of Health Services (DHS) notified. The Nurse Practitioner (NP) made aware and completed an in person assessment. Orders were given to combat potential side effects include midodrine (medication used to treat low blood pressure) 5 milligrams (mg) by mouth every 8 hours as needed for systolic blood pressure below 100, a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) to be drawn today and repeat on 10/27/2025, and check vital signs every 4hours for 24 hours. Vitals completed at the time of incident and multiple times since then. No signs and symptoms of adverse effects noted at this time. Vitals would continue to be taken minimal every 4 hours for the next 24 hours. The resident was made aware and a message was left for his wife with no return communication at this time. The facility census for Resident B, dated 10/27/25, indicated he was discharged to the local hospital from the facility.The physician recapitulation for Resident B, dated October 2025, indicated the resident was ordered the following morning medications: carvedilol (treatment for hypertension) 12.5 milligrams (mg), cetirizine (treatment for allergies) 10 mg, gabapentin (anticonvulsant) 300 mg, monocal (calcium supplement) 22.75-625 mg, senna (laxative) 8.6 mg and sertraline (antidepressant) 25 mg. The physician recapitulation for Resident D, dated October 2025, indicated the resident was ordered the following morning medications: amlodipine (treatment for hypertension) 5 mg, atorvastin (treatment for high cholesterol) 20 mg, vitamin D3 25 micrograms (mcg), duloxetine (antidepressant) 60 mg, Eliquis (blood thinner) 5 mg, furosemide (diuretic) 30 mg, gabapentin 800 mg, multivitamin, potassium chloride 20 milliequivalent (meq), sotalol (antiarrhythmic agent) 120 mg and atenolol (treatment for hypertension) 50 mg.The local hospital note for Resident B, dated 10/27/25 to 11/2/25, indicated the facility had no documentation of the resident receiving the wrong medication at the facility provided with the resident, on 10/26/25, prior to admission to the hospital. During an interview with Resident B's family member, on 11/13/25 at 10:00 a.m., indicated when the resident was transferred to the local hospital from the facility on 10/27/25, the facility did not tell the hospital that he had received medications in error on 10/26/25. The family member went to the facility, on 10/28/25, and got a list of the medications that the resident received in error and provided it the resident's nurse at the hospital. The resident's nurse at the hospital then reported it to the physician that was caring for Resident B. During an interview with the NP, on 11/13/25 at 11:00 a.m., the NP indicated it was important for the facility to report to the local hospital that Resident B received the wrong medication, on 10/26/25, for his treatment and care at the hospital. During an interview with the Director of Health Services (DHS), on 11/13/25 at 11:18 a.m., indicated it was the facilities expectation that the nurse transferring Resident B to the local hospital should have reported to the hospital that the resident had received the wrong medications. During an interview with the DHS, on 11/13/25 at 12:50 p.m., verified Resident B did not receive his scheduled morning medications on 10/26/25 and verified the resident received Resident D's morning medications on 10/26/25. There was no documentation that the hospital was notified of the medication error when Resident B was transferred to the hospital on [DATE]. During an interview with Clinical Support, on 11/13/25 at 12:00 p.m., indicated the facility did not have a policy for continuity of care of what the nurse should report to the hospital on when a resident is transferred to the hospital. This citation relates to Intake 2658401. 3.1-12(a)25(A)3.1-12(a)25(B)

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error when Resident B received Resident D's morning medication for 1 of 3 residents reviewed for medication error (Resident B). Finding include:Review of the clinical record of Resident B on 11/12/25 at 10:50 a.m., indicated the resident's diagnoses included, but were not limited to, chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, dependence on renal dialysis and pulmonary edema.The facility baseline care plans, for admission, were in place for Resident B from 10/24/25 to 10/27/25. The plan of care for Resident B, dated 10/27/25, indicated the resident was at risk for dehydration/fluid imbalance. The interventions included, but were not limited to, administer medications as ordered. The plan of care for Resident B, dated 10/27/25, indicated the resident was at risk for pain related to pulmonary fibrosis, diabetes, congestive heart failure, neuropathy, tubular adenoma, colon cancer, intractable back pain, intervertebral disc aspiration, spinal stenosis, cardiomyopathy, lymphadenopathy and pulmonary edema. The interventions included, but were not limited to, administer medications as ordered. The resident was sent to the local hospital on [DATE].The laboratory values for Resident B were reviewed. The resident had the following laboratory values: dated 6/29/24, creatinine level was high at 5.5; dated 6/1/25, creatinine level was high at 6.1; dated 10/12/25, creatinine level was critical at 8.5; dated 10/13/25, the creatinine level was critical at 8.2; dated 10/17/25, the creatinine level was critical at 7.9; dated 10/22/25, the creatinine level was high at 6.4. The progress note, dated 10/26/25 at 10:37 a.m., indicated Resident B received the wrong resident's medication, a medication error occurred (Resident B had received Resident D's medication). Nursing supervisor made aware immediately. Director of Health Services (DHS) notified. The Nurse Practitioner (NP) made aware and completed an in-person assessment. Orders were given to combat potential side effects include midodrine (medication used to treat low blood pressure) 5 milligrams (mg) by mouth every 8 hours as needed for systolic blood pressure below 100, a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) to be drawn today and repeat on 10/27/2025, and check vital signs every 4-hours for 24 hours. Vitals completed at the time of incident and multiple times since then. No signs and symptoms of adverse effects noted at this time. Vitals would continue to be taken minimal every 4 hours for the next 24 hours. The physician recapitulation for Resident B, dated October 2025, indicated the resident was ordered the following morning medications: carvedilol (treatment for hypertension) 12.5 milligrams (mg), cetirizine (treatment for allergies) 10 mg, gabapentin (anticonvulsant) 300 mg, monocal (calcium supplement) 22.75-625 mg, senna (laxative) 8.6 mg and sertraline (antidepressant) 25 mg. Resident D's medication record was reviewed on 11/13/25 at 10:15 a.m. The physician recapitulation for Resident D, dated October 2025, indicated the resident was ordered the following morning medications: amlodipine (treatment for hypertension) 5 mg, atorvastin (treatment for high cholesterol) 20 mg, vitamin D3 25 micrograms (mcg), duloxetine (antidepressant) 60 mg, Eliquis (blood thinner) 5 mg, furosemide (diuretic) 30 mg, gabapentin 800 mg, multivitamin, potassium chloride 20 milliequivalent (meq), sotalol (antiarrhythmic agent) 120 mg and atenolol (treatment for hypertension) 50 mg.The medications Resident B received had the following potential side effects: Amlodipine -swelling of the extremities, nausea, stomach pain, dizziness, drowsiness, excessive tiredness, flushing, and muscle stiffness or tremors.Atorvastin - diarrhea, heartburn, gas, joint pain, memory loss, and confusion.Duloxetine - nausea, vomiting, diarrhea, constipation, decreased appetite, dry mouth, sweating, and tiredness.Eliqis - bleeding gums, nosebleeds, coughing up or vomiting blood, swelling or joint pain, headache, vomiting, rash, chest paint, swelling of the face or tongue, trouble breathing, wheezing, and feeling dizzy or faint. Furosemide - frequent urination, blurred vision, headache, constipation, and diarrhea.Gabapentin - drowsiness, tiredness, dizziness, headache, uncontrollable shaking of a part of your body, blurred vision, unsteadiness, anxiety, memory problems, unwanted eye movements, nausea, vomiting, heartburn, diarrhea, and swelling of extremities.Potassium chloride - upset stomach, vomiting, and diarrhea.Sotalol - warning alert indicated the following: may cause QT prolongation (an irregular heart rhythm that can lead to fainting, loss of consciousness, seizures, or sudden death). For the first three days you take sotalol, you will have to be in a facility where your heart can be monitored. Tell your doctor if you or anyone in your family has or has ever had long QT syndrome (an inherited condition in which a person is more likely to have QT prolongation) or if you have or have ever had or you have or have ever had low levels of potassium in your blood, slow or irregular heartbeat, heart failure, or kidney disease. Your doctor may tell you not to take sotalol. Make sure you have discussed any medications you are currently taking or plan to take before taking sotalol with your doctor and pharmacist. If you experience any of the following symptoms, call your doctor immediately: fast, pounding, or irregular heartbeat; fainting; or loss of consciousness.Atenolol - dizziness, lightheadedness, tiredness, lack of energy, drowsiness, depression, nausea, diarrhea, and rash.During an interview with RN 1, on 11/12/25 at 1:46 p.m., the RN indicated on 10/26/25 Resident B was given Resident D's morning medication in error. During an interview with Resident B's family member, on 11/13/25 at 10:00 a.m., they indicated the resident received several medications in error on 10/26/25 while residing at the facility. During an interview with the NP, on 11/13/25 at 11:00 a.m., she indicated Resident B did receive Resident D's morning medications in error on 10/26/25. The NP indicated none of medications given in error was life threatening and did not cause him any harm. The NP indicated she assessed him within 30 minutes of him receiving the wrong medications and 24 hours after he received the wrong medications. Resident B was not experiencing any side effects from being given the wrong medications. The resident was sent to the hospital related to his history of orthostatic hypotension (low blood pressure). The NP indicated she ordered midodrine and called the dialysis center related to hypotension and midodrine. The dialysis center had not returned a call back within an hour, so the resident was sent to the hospital related to dialysis and hypotension monitoring. The resident had a history of an allergy sensitivity to medication that caused a rash. At the time of the assessments the resident did not have any rash. The hospital Admission/Discharge note indicated the resident's admission diagnosis was symptomatic bradycardia (slow heartrate) dated 10/27/25. The resident's discharge diagnoses, dated 11/2/25, were sinus bradycardia, end-stage renal disease on dialysis, pseudobradycardia secondary to frequent PVC's confirmed. The hospital admission face sheet, dated 10/27/25, indicated Resident B had an allergy to Atorvastatin Calcium with reactions of dizziness and rash. The resident had the following laboratory values: dated 10/27/25, the creating level was critical at 9.3. (a normal creatinine level ranges from 1.8 to 1.9 mg/dl but can vary depending on individuals age and overall health) During an interview with the DHS, on 11/13/25 at 12:50 p.m., she verified Resident B did not receive his scheduled morning medications on 10/26/25 and verified the resident received Resident D's morning medications on 10/26/25 in error. The medication administration policy provided by Clinical Support on 11/13/25 at 11:55 a.m., indicated the five rights of passing medication were the right resident, right drug, right dose, right route, and right time. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration. Residents are identified before medication is administered. Methods of identification include checking photograph attached to the medical record, call resident by name, have the resident verify their last name and if necessary, verifying resident identification with other facility personnel. This citation relates to Intake 2658401. 3.1-48(c)(2)

Based on interview and record review, the facility failed to timely follow up on hemolyzed lab results for a resident at risk for complications related to a cancer diagnosis for 1 of 3 residents reviewed for laboratory services. This deficient practice resulted in hospitalization for treatment of acute on chronic anemia with the need for multiple transfusions of blood products. (Resident D) Findings include: The clinical record for Resident D was reviewed on 6/3/2025 at 1:43 p.m. The medical diagnoses included malignant melanoma and encephalopathy. An admission Minimum Data Set assessment, dated 4/24/2025, indicated Resident D was cognitively impaired. A care plan for Resident D addressing his cancer diagnosis, revised 4/21/2025, included providing interventions as ordered and to include Resident D in care decisions. A care plan for Resident D addressing his potential for bleeding, revised 4/28/2025, indicated Resident D was at risk for bleeding and to monitor laboratory results as ordered. A physician order, dated 4/21/2025, indicated Resident D to have weekly laboratory tests, including a complete blood count, completed and faxed to his oncologist [Oncologist 13]. Per the National Health Institute in a June 8, 2024, publication entitled, Normal and Abnormal Complete Blood Count with Differential, a complete blood count (CBC) is a laboratory blood test which monitors red blood cells, including hematocrit and hemoglobin, white blood cells, and platelets. A laboratory result, dated 4/28/2025, indicated Resident D had a hemoglobin of 7.2, which was indicated as low. The Administration Record for Resident D indicated a CBC was completed on 5/5/2025. A laboratory report, entitled Rejected Labs, was ran on 6/4/2025 at 1:09 p.m. The report indicated Resident D's labs from 5/5/2025 were appraised on 5/6/2025. The labs were noted to be hemolyzed with text to, . please enter a new order and recollect. Per the Center for Disease Control in an April 24, 2024, publication entitled, Reference Tool to Determine Hemolysis Status, hemolyzed samples are samples which have hemolyzed, or red blood cells have been observed to be broken down, which may lead to inaccurate lab results. Review of progress notes did not address the 5/5/205 hemolyzed laboratory results. A nursing progress note, dated 5/9/2025, indicated obtaining a CBC for Resident D related to confusion. A laboratory result, dated 5/9/2025, indicated Resident D had a hemoglobin of 5.5, indicated as critical, with the results called into the Nurse Practitioner. A nursing progress note, dated 5/9/2025, indicated Resident D was transferred to the emergency room for a critical hemoglobin result. Hospital documentation, dated for a day of 5/9/2025 through 5/21/2025, indicated Resident D was admitted through the emergency department with a critically low hemoglobin on 5/9/2025. During Resident D's hospital stay, Resident D received transfusions to treat acute on chronic anemia. During an interview with Family Member 12, on 6/2/2025 at 11:35 a.m., Family Member 12 indicated Resident D was at the facility for care, including management of his cancer diagnosis. Family Member 12 stated the facility, .did not monitor [Resident D's] labs. A few days before Resident D went to the hospital, he was so out of it, and we [Resident D's family] kept telling the nurses, but no one seemed to care. One of the nurses told [Family Member 14] that Resident D's body was just shutting down. Come to find out, they were not even doing his labs, his oncologist [Oncologist 13] told me they had not received any labs for a week prior to his hospitalization . During an interview with Oncologist 13's office manager on 6/5/2025 at 1:55 p.m., Office Manager 15 indicated they had not received any CBC results from the facility regarding Resident D between May 5th and May 9th, 2025, nor did they give the order to not redraw lab results. During an interview with Corporate Nurse on 6/4/2025 at 2:10 p.m., he indicated they did not have a specific policy for hemolyzed samples. Routine labs were usually sent through their facility's laboratory results, such as Resident D's labs that were drawn on 5/5/2025, and those results were then integrated into the system. It was the responsibility of the interdisciplinary team to review the results; the nursing staff would redraw the lab and/or reach out to the provider. During an interview with the Director of Nursing on 6/4/2025 at 2:27 p.m., she indicated she was unsure why the labs were not redrawn or if a provider was notified about the laboratory results. This citation relates to Complaint IN00459458 and IN00460139. 3.1-37(a)

Based on interview and record review, the facility failed to accurately reflect the behaviors, including refusal of care and verbal aggression, for 1 of 5 residents reviewed for abuse. (Resident C) Findings include: The clinical record for Resident C was reviewed on 6/3/2025 at 11:40 a.m. Medical diagnosis included infection to the left knee related to internal prosthetic. A nursing admission assessment, dated 5/12/2025, indicated Resident C was alert and oriented to person, place, time, and situation. During an interview on 6/2/2025 at 12:45 p.m., Resident C indicated while he was at the facility, two staff came into his room before he left. One of them, he believes was a nurse, kept trying to change the wound dressing on his leg. He had to tell her twice to leave him alone before he kicked her out of his room. He had his son pick him up and he left against medical advice. During an interview on 6/2/2025 at 10:52 p.m., Licensed Practical Nurse (LPN) 19 indicated she took care of Resident C while he was here. Resident C was a .very frustrated person .and he was agitated . During an interview on 6/2/2025 at 11:12 p.m., Certified Resident Care Associate (CRCA) 18 indicated she went into Resident C's room one time during his stay with the QMA (Qualified Medication Aide) on duty. When the staff were in the room, Resident C .cussed them out . and refused to let me empty his full urinal because he said he was leaving and going to pour it on the floor when he was going . During an interview on 6/4/2025 at 1:55 p.m., LPN 20 indicated Resident C was resistive to assistance, cussed at her, fought everything we tried, and kicked her out of his room. Review of the medical record did not indicate documentation of these refusals of care or verbally aggressive behaviors. During an interview on 6/4/2025 at 2:35 p.m., Corporate Nurse indicated they did not have a specific policy for documenting behaviors, but it would be the expectation refusals of care would be documented in the chart. This citation relates to Complaint IN00459544. 3.1-50(a)(1) 3.1-50(a)(2)

2. The clinical record of Resident B was reviewed on 6-2-25 at 10:30 a.m. Her diagnoses included, but were not limited to, aftercare following joint replacement surgery, cerebral ischemia and hypertensive heart disease. Her admission Minimum Data Set assessment, dated 3-26-25, indicated she was cognitively intact. In an interview with Resident B, on 6-2-25 at 4:04 p.m., she indicated the response time for her call light to be responded to varied from a few minutes up to 45 minutes; usually well over 15 minutes. I had nothing to do other than watch the clock to see how long it took. I am at an age that when I need to use the bathroom, it is immediate. Having to wait for someone to come and help can be very uncomfortable. In an interview with the Corporate Nurse, on 6-4-25 at 2:25 p.m., he indicated it was hard to put a numeric value on call light response time, as there are multiple variables, such as the volume of call lights, the circumstances of what each resident's care needs were and the situation of the floor in general. If I were to put a numeric value, the goal would be to respond in under 15 or 20 minutes. On 6-4-25 at 2:11 p.m., the Corporate Nurse provided a copy of policy with a review date of 12-17-24, and entitled, Guidelines for Answering Call Lights. This policy indicated its purpose as, To respond to the resident's request and needs. It indicated, Answer the call light as quickly as possible. This citation relates to Complaints IN00459458, IN00459544, and IN00460166. 3.1-3(t) Based on interview and record review, the facility failed to promote the dignity of 2 of 3 residents reviewed for the need of assistance. (Resident B and Resident C) Findings include: 1. The clinical record for Resident C was reviewed on 6/3/2025 at 11:40 a.m. Medical diagnosis included infection to the left knee related to internal prosthetic. A nursing admission assessment, dated 5/12/2025, indicated Resident C was alert and oriented to person, place, time, and situation. During an interview on 6/2/2025 at 12:45 p.m., Resident C indicated he was unable to get assistance while he was at the facility. Resident C stated, I hit my call light one time and told the CNA [Certified Nurse Aide] what I needed, but it was over two hours before someone came back. I ended up hitting my call light again and waited 45 minutes before someone answered it. I am used to not needing anyone to help me. I felt helpless having to ask multiple times, and having to wait so long made it even worse . During an interview on 6/3/2025 at 11:30 p.m., CRCA (Certified Resident Care Associate) 17 indicated staffing in the building was bad. She routinely had 37 patients to herself, and she cannot get things done. When asked if she was able to get routine care done, like passing ice water and providing showers, she indicated, .that is the least of my worries. No, I cannot get them done all the time, but I am also not able to get my call lights answered as quickly as I like. There have been times that residents tell me their lights are on for thirty minutes or more, and these are long term care residents, they know when it is just me over there, but I am only one person. There are some residents which I need the nurse to help me with, leaving no one to answer lights or help with other residents .

Based on interview and record review, the facility failed to assess a resident for safe self-administration of medication for 1 of 3 residents reviewed for medication compliance. (Resident C) Findings include: The clinical record for Resident C was reviewed on [DATE] at 11:40 a.m. Medical diagnosis included infection to the left knee related to internal prosthetic. A nursing admission assessment, dated [DATE], indicated Resident C was alert and oriented to person, place, time, and situation. A nursing progress note, dated [DATE], indicated Resident C's son brought in his home medications for tonight's dosage and his intravenous antibiotic. Resident C and his son .administered dose . and Resident C .took all medications including narcotics from home . Review of the clinical record did not indicate a Self-Administration of Medication assessment was completed or a physician order to reflect such. During an interview on [DATE] at 12:45 p.m., Resident C indicated while he was at the facility, the facility did not have his medication when he admitted so he had to have his son bring in his medication the night of admission. He stated his pain was, out of control, a 10/10 . I had my son bring in my medications and took my oxys [oxycodone] .I take three [oxycodone] . During an interview on [DATE] at 10:52 p.m., Licensed Practical Nurse (LPN) 19 indicated she took care of Resident C while he was here. Resident C was a .very frustrated person .and he was agitated . The night Resident C was admitted , he had his son bring in his medication, and LPN 19 went to the bedside, where she witnessed Resident C remove pills from a vial. When asked to elaborate, she indicated a container with multiple unlabeled medications. She then had Resident C verify the medications, and she checked them against the physician orders. When asked how she was able to verify what the medications were, she stated she couldn't, but just .had the resident verbally tell me since he [Resident C] knew his medications . When asked if she completed a self-administration of medication assessment, she stated she had not and she was unsure of the self-administration of medication policy within the building because she was .new . During an interview on [DATE] at 1:55 p.m., LPN 20 indicated when a resident brings in medications from home, they were to be in the original pill bottles from the outside pharmacy with .the correct name, label, and cannot be expired . The nursing staff will then verify the medication by what was on the bottle. Medications were to be counted, and a medication slip filled out in front of the resident to verify the number of medications. LPN 20 admitted Resident C and stated she .did not complete a Self-Administration assessment . A policy entitled, Guidelines for Safe Self-Administration of Medications, was provided by the Corporate Nurse on [DATE] at 2:45 p.m. The policy indicated, .Residents requesting to self-medicate or has self-medication as a part of their place of care shall be assessed using the observation Trilogy- Self Administration of Medication within the electronic health record . This citation relates to Complaint IN00459544. 3.1-11(a)

Based on interview and record review, the facility failed to ensure 1 of 4 residents reviewed for accurate and timely receipt of medications, received their medications as ordered by their physician. (Resident B) Findings include: In an interview with Resident B on 6-2-25 at 4:04 p.m., she indicated she kept track of the medications received while she was a resident of the facility. She indicated several days before she discharged from the facility, I got to feeling real dizzy in the afternoon, and realized no one had given me my morning meds, which included several BP [blood pressure] pills. She did not indicate she had made the facility aware of this at the time of occurrence. In an interview with the Executive Director (ED) on 6-4-25 at 11:05 a.m., he indicated on the date of Resident B's discharge from the facility, 5-6-25, the facility learned of a medication error in which Registered Nurse (RN) 3 had not administered Resident B's morning medications on 5-1-25. In a second interview on 6-4-25 at 1:02 p.m., with the ED, he reiterated the facility did not learn of this until 5-6-25. He added the resident, nor her family member, mentioned any negative impacts the lack of medications caused. A review of the medication administration record (MAR), for 5-1-25, for Resident B indicated the following medications were designated as Not Administered: Resident Unavailable: -amlodipine 5 mg (milligrams) once daily (for high blood pressure), -aspirin 81 mg once daily (a nonsteroidal anti-inflammatory medication which also has an anti-platelet effect, sometimes used for prevention of blood clots and reducing the risk of heart attacks or strokes), -biotin 1 mg once daily (supplement), -citalopram 20 mg once daily (for depression), -isosorbide extended release 60 mg once daily (for angina), -metformin 500 mg twice daily (for diabetes), and -metoprolol tartrate 25 mg twice daily (for high blood pressure). In an interview with the ED on 6-4-25 at 1:02 p.m., he indicated RN 3 was a relatively new staff member and that he, the Director of Nursing, the Assistant Director of Nursing had each checked in with RN 3 at least twice on 5-1-25, to see if she had any questions, concerns or needed assistance. He indicated RN 3 did not indicate she was encountering any problems or concerns at that time. The ED indicated he could see where it might have been difficult to locate this resident at that point in her stay, as she was involved in therapy services and very involved in the activities of the building. But we could have helped her locate the resident. The clinical record of Resident B was reviewed on 6-2-25 at 10:30 a.m. Her diagnoses included, but were not limited to, aftercare following joint replacement surgery, cerebral ischemia and hypertensive heart disease. Her admission Minimum Data Set assessment, dated 3-26-25, indicated she was cognitively intact. A review of the progress notes indicated a late entry dated, 5-6-25, for 5-2-25 (sic), indicated Resident B had a missed am [morning] med administration, due to the resident was unavailable, and the nurse practitioner had been informed of this with no new orders received. In an interview with the Corporate Nurse on 6-4-25 at 2:25 p.m., he indicated if a resident does not receive their medications, ideally the nursing staff should let their supervisor know what was going on to see if the supervisor can offer any help. Additionally, the staff member should let the medical provider know the resident did not receive their medications, as well as notification to the resident if they were able to comprehend or that resident's responsible party. This citation relates to Complaints IN00459458 and IN00459544. 3.1-25(a) 3.1-25(b)(9)

Based on observation, interview, and record review, the facility failed to ensure a resident was deemed appropriate to self-administer a nebulizer (a device that converts liquid medicine to mist to inhale it) medication for 1 of 5 residents reviewed for medication administration. (Resident 207) Findings include: An observation was conducted of medication administration for Resident 207 with Licensed Practical Nurse (LPN) 2 on 2/13/25 at 8:08 a.m. LPN 2 prepared Resident 207's morning medications and after the resident took the medications by mouth, she requested a nebulizer treatment. LPN 2 obtained a vial of a medication and dispensed such into the nebulizer medicine cap connected to the nebulizer machine. LPN 2 secured the medicine cup to the face mask and handed the face mask to Resident 207. Resident 207 proceeded to hold the face mask to administer the nebulizer medication at 8:28 a.m. LPN 2 proceeded to leave Resident 207's room to prepare medications for Resident 209. At 8:45 a.m., LPN 2 returned to the medication cart and the nebulizer machine was still on in Resident 207's room. LPN 2 indicated Resident 207 preferred to turn the nebulizer machine off herself. Resident 207 was observed to have a sling in place to her right arm and the nebulizer machine was located on the nightstand located on the right side of her bed. The clinical record for Resident 207 was reviewed on 2/13/25 at 9:32 a.m. The diagnoses included, but were not limited to, humerus (long bone of the upper arm) fracture. A care plan for functional status, start date of 2/6/25, indicated Resident 207 had functional impairment related to a right humerus fracture. A progress note, dated 2/12/25 at 5:34 p.m., indicated Resident 207 returned from an orthopedic appointment and was non weight bearing to the right upper extremity with the utilization of a sling. A care plan, start date of 2/13/25, indicated Resident 207 desired to self-administer medications. The goal was for Resident 207 to self-administer medications safely. The approach listed assessing the safety and efficacy of self-administration of medications that included to assess and require return demonstration to ensure safety and provide support to the resident as needed. There was no care plan or assessment in the electronic health record (EHR) to deem Resident 207 could self-administer her nebulizer treatments prior to 2/13/25. A policy entitled Guidelines for Self Administration of Medications, review date of 12/17/24, was provided by the Executive Director on 2/13/25 at 11:15 a.m. The policy indicated the following, .1. Residents requesting to self-medicate or has self-administration as a part of their plan of care shall be assessed using the observation .within the electronic health record 3.1-11(a)

Based on observation, interview, and record review, the facility failed to date oxygen tubing for 1 of 1 resident reviewed for respiratory care needs. (Resident 253) Findings include: The clinical record for Resident 253 was reviewed on 2/13/25 at 9:14 a.m. Diagnoses included, but were not limited to, acute kidney failure and falls. A physician's order, dated 2/9/25, indicated Resident 253 was to be on continuous oxygen of two to three liters per minute. During an observation on 2/11/25 at 12:42 p.m., Resident 253 had oxygen tubing at the bedside not dated when it was initiated. During an observation on 2/12/25 at 11:38 a.m., Resident 253 had oxygen tubing on that was not dated. During an observation on 2/13/25 at 9:41 a.m., Resident 253 had oxygen tubing on that was not dated. During an interview on 2/13/25 at 12:29 p.m. with the Assistant Director of Health Services (ADHS), she indicated oxygen tubing was dated but it kept rubbing off, so we ordered labels to date and time the oxygen tubing. The ADHS indicated they date and time the tubing, then a couple hours later it would be rubbed off. The ADHS indicated the policy was to date the tubing when it was initially placed on a resident. An Administration of Oxygen Policy provided by the Executive Director (ED), on 2/13/25 at 11:18 a.m., indicated, .14. Date the tubing for the date it was initiated .a. Tubing should be changed monthly and PRN [as needed] . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure a gastric tube (g-tube) feeding and water flushes were administered as ordered by the physician for 1 of 4 residents reviewed for nutrition. (Resident 299) Findings include: The clinical record for Resident 299 was reviewed on 2/11/25 at 2:45 p.m. The diagnoses included, but were not limited to, encounter for orthopedic aftercare following surgical amputation, severe sepsis with septic shock, and dysphagia. A care plan for tube feeding, initiated on 2/5/25 and revised on 2/11/25, indicated Resident 299 required tube feeding related to dysphagia. The approaches indicated providing a diet as ordered, providing water flushes as ordered, and provide tube feedings as ordered. A review of the physician orders indicated, effective on 02/11/25 09:50 a.m., Resident 299 was to receive Jevity 1.5 (brand of tube feed) at 60 mL/hr (milliliters per hour) and flush with 180 mL of water every four hours. The previous order for the g-tube was for Jevity 2.0 at 50mL/hr with 150 mL every four hours of water flushes and the order was discontinued on 2/11/25. Observations of Resident 299's feeding pump (device to monitor the infusion of the feeding), on 2/11/25 at 2:25 p.m. and 2/12/25 at 11:20 a.m., was observed running at 50ml/hour of Jevity 2.0 with 150 mL of water flushes every four hours. An interview conducted with the Director of Health Services (DHS), on 2/14/25 at 2:40 p.m., indicated the Assistant Director of Health Services (ADHS) entered the order change regarding the g-tube feedings and flushes after the Registered Dietitian gave the order. The ADHS should have followed up with the nursing staff to ensure communication the g-tube feeding order was changed. A policy entitled Tube Feedings, revised on 5/10/24, was provided by the Executive Director on 2/13/25 at 11:15 a.m. The policy indicated the following, .1. Residents requiring tube feeding are assessed by Registered Dietitian (RD) or the Nutrition & Dietetics Technician, Registered (NDTR) per MDS [Minimum Data Set] guidelines and suggested monthly monitoring. The assessment includes the estimated calorie, protein, and fluid needs for resident 3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure a resident's bowel movements were documented and followed up when a resident went over three days without having a bowel movement for 1 of 1 resident reviewed for constipation. (Resident G) Findings include: The clinical record for Resident G was reviewed on 2/13/25 at 12:31 p.m. The diagnoses included, but were not limited to, constipation. An Admission Minimum Data Set (MDS) assessment, dated 12/16/24, indicated Resident G was cognitively intact and always continent of bowel. A bowel and bladder care plan, start date of 12/11/24, indicated Resident G was continent of bowel. The approach was to notify the charge nurse of a change in bowel and bladder patterns as needed and report signs and symptoms of constipation. An interview conducted with Family Member (FM), on 2/12/25 at 11:00 a.m., indicated Resident G went 13 days without a bowel movement after her admission to the facility. The electronic health record, under the Vitals section, noted the following bowel movements documented for Resident G: - No bowel movements documented from 12/10/24 until 12/14/24, - No bowel movements documented from 12/19/24 until 12/23/24 as a small, - No bowel movements documented from 12/26/24 until 12/29/24, - No bowel movements documented from 12/30/24 until 1/2/25 as a small, - No bowel movements documented from 1/6/25 until 1/11/25, - No bowel movements documented from 1/12/25 until 1/16/25, - No bowel movements documented from 1/18/25 until 1/23/25, - No bowel movements documented from 1/29/25 until 1/31/25 as a small, and - No bowel movements documented from 2/9/25 until 2/12/25 as a small. On 2/14/25 at 8:50 a.m., the Executive Director indicated there was no facility policy regarding monitoring of bowel movements. The National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/NBK513291/, was retrieved on 2/14/25 at 4:30 p.m., updated 11/12/23, indicated the following, . Constipation . Characterized by infrequent and often difficult bowel movements . Introduction . Constipation is a symptom or condition characterized by difficult and infrequent bowel movements, typically 3 or fewer times a week 3.1-38(a)(2)(C)

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 1 of 2 residents reviewed for homelike environment. (Resident 14). Findings include: The clinical record of Resident 14 was reviewed on 2/11/25 at 2:45 p.m. The diagnoses included, but were not limited to, acute respiratory disease, heart failure, and obesity. During an observation on 2/11/25 at 2:34 p.m., Resident 14's corner molding was off the wall exposing where the dry wall connected at the corner. The molding was leaning up against the opposite wall. There were areas where the paint was missing on the wall behind the head of the bed. Observations were conducted of Resident 14's room and the molding was observed to be off of the wall exposing the dry wall on 2/12/25 at 11:12 a.m. and 2/12/25 at 1:45 p.m. During a tour on 2/14/25 at 2:15 p.m., the Executive Director (ED) indicated he was not aware of the molding being off the wall and areas where the paint was missing behind the bed. He stated this had been an issue in the past due to Resident 14 being in a motorized wheelchair. An interview with the Executive Director, on 2/14/25 at 3:38 p.m., indicated the facility's expectation was to promote a safe, clean, and homelike environment for all residents. 3.1-19(f)(5)

Based on observation, interview and record review the facility failed to implement pressure relieving boots for a resident who had a unstageable pressure ulcer to the right heel and was experiencing pain from the right heel pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident C). Finding include: Review of the record of Resident C on 1/21/2021 at 3:00 p.m., indicated the resident's [DIAGNOSES REDACTED]. The physician order [REDACTED]. The Admission Minimum Data Set (MDS) assessment for Resident C, dated 1/12/2021, indicated the resident had the ability to be understood and understand others. The resident was independent for daily decision making. The resident's decisions were consistent and reasonable. The resident required extensive assistance of two staff for bed mobility and transfers. The resident was at risk for developing pressure ulcers. The resident was admitted with one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar). The wound assessment for Resident C, dated 1/12/2021 at 9:26 a.m., indicated the resident had an unstageable pressure ulcer with heavy exudate that was yellow or tan, cloudy and thick. The wound was covered with slough and/or eschar. The wound measured 5 centimeters (cm) long and 4 cm in width. The skin surrounding the wound was dark purple with [DIAGNOSES REDACTED] and redness. The wound assessment for Resident C, dated 1/19/2021 at 6:15 p.m., indicated the resident had an unstageable pressure ulcer with heavy exudate that was yellow or tan, cloudy and thick. The wound was covered with slough and/or eschar. The wound measured 5 centimeters (cm) long and 4 cm in width. The skin surrounding the wound was dark purple with [DIAGNOSES REDACTED] and redness. During an observation and interview with Resident C on 1/21/2021 at 3:25 p.m., indicated he had a sore on his right heel that caused him pain. The resident rated his current pain as a 9 on the 1-10 pain scale. The resident was observed to be laying in bed with both calves on a pillow and no pressure relieving boots in place. Both of the resident's heels were laying on the mattress. The resident indicated he did not mind wearing the pressure relieving boots and had never refused to wear them. At 3:45 p.m., CNA 1 came into the resident's room and searched the resident's room for the pressure relieving boots and was unable to locate them. CNA 1 indicated she had never seen Resident C wearing pressure relieving boots before. Resident C yelled out this heel is really hurting me. The resident was moaning and had facial grimacing. CNA #1 indicated she was going to go report the resident's pain to the nurse. At 3:50 p.m., LPN 2 came into the resident's room and searched for the resident's pressure relieving boots and was unable to locate them. Resident C reported to the nurse he had not had the pressure relieving boots for about a week. LPN 2 indicated the resident received Tylenol as need and routine [MEDICATION NAME]. During an interview with the Wound Nurse on 1/21/2021 at 3:55 p.m., indicated Resident C's pressure relieving boots were in the laundry. Reported to the Wound Nurse that the resident had not seen the pressure relieving boots for approximately a week and his pain was a 9. The Wound Nurse indicated she would follow up on the resident's pain. During an observation and interview with Resident C on 1/22/2021 at 9:45 a.m., Resident C was in his electric wheelchair going down the hallway into his bedroom, the resident did not have on pressure relieving boots. Resident C had on non skid slipper socks and had direct pressure on his right heel sitting on the hard leg rest on his electric wheelchair. The resident indicated he did not know where his pressure relieving boots were and his pain in his right heel was a 4 on the 1-10 pain scale. The resident stated it was no wonder why the right heel hurt, having pressure on it was what caused the pain. Observation one of the resident's pressure relieving boots were laying on a pile of sheets and pillows on the resident's table. At 9:50 a.m., RN 3 came into the resident's bedroom and indicated she did not know why the resident did not have his pressure relieving boots on, the CNA may have forgot to put them on. RN 3 located the second pressure relieving boot under the pile of sheets and pillows on the table. CNA 4 placed both pressure relieving boots on the resident without difficulty. CNA 4 did assist get the resident up this morning, but did not finish his care. CNA 4 was unsure why the resident did not have his pressure relieving boots on, the other CNA may have forgot. During observation on 1/22/2021 at 10:05 a.m., Resident C was in the Therapy Gym receiving therapy with his pressure relieving boots in place. During an interview with Physical Therapy Assistant (PTA) 5 on 1/22/2021 at 10:30 a.m., indicated Resident C had complained of right heel pain during therapy on 1/21/2021. PTA 5 indicated he thought the resident was having pain because his right foot was swollen and he had attempted to put shoes on the resident. PTA 5 indicated he did not believe the resident had on pressure relieving boots on 1/21/2021, but was unsure. PTA 5 indicated he was unsure if the resident normally wore pressure relieving boots, because the resident was covered up with a blanket most of the time. During an observation on 1/22/2021 at 11:12 a.m., the Wound Nurse completed Resident C's pressure ulcer dressing. The resident's old dressing had brown drainage on it. The wound was black with white/tan slough on the edges of the wound. The surrounding skin of the wound was pink/red. The resident moaned and indicated the wound was tender when the Wound Nurse was cleaning the wound with Normal Saline. The pressure wound guidelines policy provided by the Director Of Health Services on 1/22/2021 at 3:20 p.m., indicated the purpose was to provide weekly documentation of wound measurements and condition. The Pain Management policy provided by Director Of Health Services on 1/22/2021 at 3:20 p.m., indicated the purpose was to ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual. During an interview with the Director Of Health Services on 1/22/2021 at 3:30 p.m., the facility did not have any other pressure ulcer policies. This Federal Tag relates to Complaint IN 323. 3.1-40

Based on interview and record review, the facility failed to supervise a resident to prevent a fall, resulting in a fall with a fracture, for 1 of 3 residents reviewed for accidents. (Resident H) Findings include: Resident H's record was reviewed on 6/13/18 at 12:37 p.m. Her [DIAGNOSES REDACTED]. Medications included an anti-coagulant ([MEDICATION NAME]) with special instructions to monitor for any signs and symptoms of bleeding. Treatments included a sling to her left upper extremity. Resident H's Admission Minimum Data Set (MDS) assessment dated [DATE], indicated she required extensive assistance of 2 for toileting and extensive assistance of 1 to walk in her room or corridor. She had a fall with fracture prior to admission. A physician's history and physical note for Resident H documented 5/25/18, indicated Resident H had been admitted to the facility following hospitalization for a left humerus fracture. An Occupational Therapy (OT) progress note for Resident H dated 5/30/18, indicated her current level of functioning for toileting had been she was able to safely perform all toileting task utilizing grab bars requiring overall moderate assistance (26-75% assist). She had made functional gains, however, continued to require assistance during all daily activities to ensure safety and skill performance. Precautions included fall risk, confusion, and left humerus fracture with a sling in place. A Physical Therapy (PT) progress note for Resident H dated 5/31/18, indicated she had remaining functional deficits with activity tolerance, reduced standing balance, and reduced safety awareness. Precautions included fall risk, confusion, and left humerus fracture with a sling in place. Progress notes for Resident H indicated the following: On 6/3/18 at 11:24 a.m., she had been assisted to the commode. Staff had left the bathroom to straighten her bed linens and heard her fall. She had been assessed and had 2 lacerations on her forehead and a golf ball size hematoma above her right eye. She explained she had tried to move her housecoat from underneath herself and fell on the floor hitting her head. On 6/5/18 at 3:38 a.m., she complained of neck pain and had been treated with pain medication. On 6/5/18 at 3:24 p.m., her blood pressure had been trending up and she complained of soreness to the neck and head. She complained of not feeling well or feeling right in the head. She also complained of confusion at times. She requested to been seen by a physician as soon as possible and was sent to a local emergency room . She returned from the emergency roiagnom on [DATE] at 7:40 p.m., with a C-collar around her neck and orders to be seen by a Neurosurgeon. On 6/6/18 at 3:15 a.m., she remained in her room lying in bed with signs and symptoms of anxiety from her recent visit to the ER which she returned wearing a C-collar and had orders to see a Neurosurgeon for a fracture to her cervical spine. During an interview with Certified Resident Care Associate (CRCA) 4 on 6/13/18 at 10:44 p.m., she indicated she had assisted Resident H to the bathroom on 6/3/18, and she had left Resident H in the bathroom to straighten the bed linens. Resident H had explained at that time she had been trying to fix her gown and fell off the commode. CRCA 4 felt Resident H had been safe to sit on the commode by herself. During an interview with Resident H's daughter on 6/14/18 at 9:24 a.m., she indicated she had observed a staff member walk her mother to the bathroom prior to her mother's fall on 6/3/18. Her mother hadn't walked very well at that time. She felt her mother hadn't been physically able to be left on the commode by herself when she fell on [DATE]. During an interview with PT 2 on 6/14/18 at 10:19 a.m., she indicated she had evaluated Resident H after she was admitted to the facility. Resident H could sit on the toilet independently but would need supervised. Resident H had issues with safety awareness. Resident H could understand what she was told but would not always follow the safety instructions. PT 2 had attended a meeting to discuss Resident H's care on 6/4/18, and discussed the need for more therapy for balance. Resident H had balance issues because she could not use her left arm related to a fracture. During an interview with OT 1 on 6/14/18 at 10:41 a.m., she indicated she had evaluated Resident H after she was admitted to the facility. Resident H had safety awareness deficits and needed supervision and physical assistance with her daily activities. This Federal tag relates to Complaint IN 695. 3.1-45(a)(2)