Every finding on record at Swan Health at Overland Park

Based on observations, record review, and interviews, the facility failed to conduct a complete investigation to rule out abuse or neglect for a right leg fracture of unknown origin for Resident (R) 1. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented a diagnosis of anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen for too long). The Annual Minimal Data Set (MDS), dated 04/25/2026, documented R1 was in a persistent vegetative state. R1 had impairment of her bilateral upper and lower extremities. R1 was dependent on staff for bed mobility. The Quarterly MDS, dated 07/26/2026, documented R1 was in a persistent vegetative state. R1 had impairment of her bilateral upper and lower extremities. R1 was dependent on staff for bed mobility. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 05/04/2026, documented R1 was at risk for pressure ulcers due to immobility and she had no pressure ulcers at that time. R1's Care Plan, dated 05/04/2025 and revised 07/30/2026, documented R1 had an activity of daily living (ADL) self-care performance deficit related to severe contractures (abnormal permanent fixation of a joint or muscle) to her bilateral upper extremities, decreased range-of-motion to her bilateral lower extremities, and a comatose state. R1 experienced muscle spasms and tremors. The Care Plan documented an intervention, dated 07/30/2026, that R1 was dependent on staff for rolling left and right. The facility's Investigation, not dated, documented on 07/31/2026 at approximately 12:08 PM, staff notified Administrative Nurse D that R1 had bruising and swelling on her knee. The facility's conclusion documented that R1 had an acute impacted supracondylar distal femoral fracture (a break in the thigh bone just above the knee joint), and the provider gave orders to send R1 to the emergency room where they confirmed the fracture. Chart review and investigation showed that R1 was bed bound with contractures to bilateral upper and lower extremities. R1 was totally dependent on enteral feedings (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) for her entire admission. Her laboratory results showed a decline in her serum calcium levels during her stay leading to the demineralization (the progressive loss of minerals, primarily calcium and phosphate, from bone tissue, leading to reduced bone density and increased fragility) of the bone causing the bones to become brittle. The facility held an in-service immediately for all staff on abuse, neglect, and exploitation and an in-service with care staff on safe turning and repositioning. The facility's investigation concluded there were no findings of abuse and neglect. The facility's investigation did not include any witness statements from staff who worked around the time of the incident to rule out abuse or neglect as the cause of the injury of unknown origin. The investigation did not include any resident statements or interviews to rule out any possible patterns of abuse or neglect in the facility. Upon request, the facility did not have any staff witness statements regarding R1's right femur fracture of unknown origin to rule out abuse or neglect as the potential cause. R1's EMR revealed the following: A Health Status Note on 07/29/2026 at 10:54 PM, documented Licensed Nurse (LN) H noticed R1 had swelling from her right knee to her mid-thigh area that was warm to the touch with a small amount of redness over her kneecap, without bruising. R1 had an elevated heart rate and temperature. LN H notified the provider and received an order for blood work and an x-ray of her right femur (thigh bone) and right knee. A Radiology Report, dated 07/30/2026, documented R1 had an acute impacted supracondylar distal right femoral fracture with soft tissue swelling and bony demineralization of her right femur. A Transfer to Hospital Summary on 07/31/2026 at 03:52 PM, documented R1 had an x-ray of her right femur on 07/30/2026. The x-ray showed an acute impacted supracondylar distal femoral fracture and soft tissue swelling without dislocation. A Nurses Notes on 07/31/2026 at 10:30 PM, documented ambulance personnel picked up R1 and transferred her to the hospital. On 08/24/2026 at 02:01 PM, R1 laid in bed with her eyes closed. There was a sheet over her upper and lower body with an outline of her legs visible. Her left leg was contracted inward at the knee, with her foot appearing at the level of her right thigh. Her right leg was straight, with her right foot contracted. On 08/24/2026 at 11:12 AM, Administrative Nurse D stated she had interviewed the nurse who reported the bruising to R1's right knee and the CNA who worked with R1. She stated the nurse reported they were unsure how the bruising happened, but the bruising was on the outer aspect of R1's right knee and her left leg/foot contracted up to her right knee. Administrative Nurse D stated staff reported that if R1's protective boots were off, they had found her left foot on her right knee in the past. She stated she talked to the night shift staff to see if they noticed anything with R1 and they had not. She stated she had the staff demonstrate how they repositioned R1 to make sure they were not using her right knee to move her. Administrative Nurse D stated the CNA reported during the demonstration that if staff did not hold her left leg just right, the left leg would kind of pop back and hit her right knee. Administrative Nurse D stated R1's x-ray showed demineralization of the bone, so she pulled R1's labs and noted her calcium had been decreasing. On 08/24/2026 at 03:18 PM, Certified Nurse Aide (CNA) M stated that sometimes, R1's left foot did touch her right knee depending on how staff repositioned her. On 08/24/2026 at 03:30 PM, LN G stated she worked on 07/31/2026 and did rounds with LN H when Administrative Nurse D went into R1's room. She stated they assessed R1's right leg which had bruising and swelling on her inner right leg and R1 appeared to be in pain. She stated she did not recall any incidents happening with R1 to have caused the injury. On 08/24/2026 at 03:44 PM, Administrative Nurse D stated on 07/31/2026, staff told her they found some bruising and swelling on R1's right knee. She entered R1's room to assess her. She stated while they waited for the x-ray results, she asked staff if anybody noticed any injury to R1's right knee and nobody did. Administrative Nurse D stated she reviewed R1's previous skin assessments and there was no bruising documented. She stated once they had the x-ray results, they sent R1 to the hospital. Administrative Nurse D stated based on the five staff she talked to, the x-ray report, and R1's labs, she ruled out any abuse. She stated she should have interviewed every staff member that took care of R1 in the last five days of the incident and got statements from them. She stated she did not interview any residents. On 08/24/2026 at 04:07 PM, LN H stated on 07/29/2026, he noticed R1's right leg had swelling, and she had a fever that night. He stated he talked to R1's provider and she ordered labs and an x-ray. LN H stated he did not see any bruising on R1's right leg/knee that night. He stated 07/31/2026, R1's right knee had small dots of discoloration and red skin. He stated R1's x-ray came back as a fracture, but no staff had reported any incidents to him about R1. The facility's Abuse, Neglect, and Exploitation policy, dated 07/01/2026, directed an immediate investigation was warranted when suspicions or reports of abuse, neglect, or exploitation occurred. The policy directed the written procedure for investigations included: identifying staff responsible for the investigation; exercising caution when handling evidence that could be used in a criminal investigation; identifying different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred with the extent and cause; and providing complete and thorough documentation of the investigation.

Based on record review and interviews, the facility failed to ensure staff provided the necessary assistance with activities of daily living for Resident (R) 1 when staff failed to wash his face, provide baths, and trim his nails. Findings included:- R1's Electronic Medical Record (EMR) documented the following diagnoses of acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), epilepsy (brain disorder characterized by repeated seizures), spastic quadriplegic cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), seborrheic dermatitis (a common, chronic skin condition that primarily affects areas rich in sebaceous glands, such as the scalp, face, and trunk), and dysphagia (swallowing difficulty). R1's admission Minimum Data Set (MDS) dated [DATE] documented a staff assessment for mental status that showed a score of three, indicating severely impaired cognition. R1's MDS documented he was dependent on staff with all activities of daily living (ADL). R1 was at risk of developing a pressure ulcer and had moisture associated skin damage (MASD). The MDS documented a turning and repositioning program, nutrition and hydration interventions to manage skin problems, and applications of ointments/medications other than to the feet. R1's Activities of Daily Living Self-Care Care Plan initiated on 06/08/2026 directed that R1 was totally dependent on staff for dressing and personal hygiene and oral care. The plan of care further directed that R1 required a skin inspection every shift to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. R1's Care Plan lacked direction of care with grooming related to R1's personal hygiene preference to have his face washed and cocoa butter applied daily or addressing trimming of the fingernails. Review of R1's Bath Sheets documented the following:05/31/2026 documented no concerns.06/03/2026 documented no concerns.06/08/2026 documented no concerns.06/14/2026 documented no concerns. There was no evidence that R1 received any baths other than those listed above, indicating that between admission [DATE]) and discharge (06/30/2026), 32 days total, R1 only received five baths. Review of R1's Progress Notes from 05/29/26 through 06/30/26 lacked documentation that addressed R1's facial care, fingernails, or refusals for bathing/personal care. Review of R1's Admission paperwork from his admission to the acute hospital dated 06/30/2026 documented R1 admitted with very long fingernails. Review of the admission photograph revealed R1's right hand had fingernails that extended over the top of all five of R1's fingertips. On 07/20/2026 at 03:13 PM, R1's representative stated he had asked both facility staff and facility administration about R1 needing to have his nails trimmed. R1's representative stated he had asked the facility staff to wash R1's face and put on some cocoa butter cream every day. On 07/21/2026 at 11:11 PM, Certified Nurse Aide (CNA) N stated that she would let the nurse know if a resident needed their nails trimmed. CNA N further stated she did not trim fingernails because she did not feel comfortable doing that. On 07/21/2026 at 11:00 AM, Licensed Nurse (LN) H stated that when the residents needed their nails trimmed, she notified Administrative Nurse E. LN H revealed that she did not see clipping fingernails as part of her job but said if a resident's nails appeared to be too long and needed to be trimmed due to being at risk of harming themselves, she would trim them. On 07/21/2026 at 12:10 PM, Administrative Nurse E stated that if a resident needed their nails trimmed, she would be notified, and she would trim the resident's nails. Administrative Nurse E further stated that CNAs and LNs could trim residents' nails, but if a resident was diabetic, only an LN could trim that resident's nails. Administrative Nurse E stated that R1's representative had come into R1's room and thrown away all of the creams that were ordered for R1. Administrative Nurse E stated R1's representative informed them the creams did not work and directed staff to use the cream that R1's representative had supplied. On 07/21/2026 at 12:58 PM, Consultant HH confirmed that regardless of what a family member requested, the facility still needed to address ADLs and fingernails. The facility's Nail Care policy, implemented on 07/01/26, documented the purpose of the procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health. The policy further directed that staff would routine cleaning and inspections of nails would be provided during Activities of Daily Living care on an ongoing basis. The policy identified routine nail care, to include trimming and filing, which would be provided on a regular schedule, and nail care would be provided between scheduled occasions as the need arose. The facility's Activities of Daily Living (ADLs) policy, implemented on 07/01/26, documented a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on record review and interviews, the facility failed to provide adequate care and services related to skin issues when staff failed to address and treat Resident (R) 1's seborrheic dermatitis (a common, chronic inflammatory skin condition causing oily patches, stubborn dandruff, and yellow or white scales) on his face and scalp. Findings included:- R1's Electronic Medical Record (EMR) documented the following diagnoses of acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), epilepsy (brain disorder characterized by repeated seizures), spastic quadriplegic cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), seborrheic dermatitis (a common, chronic skin condition that primarily affects areas rich in sebaceous glands, such as the scalp, face, and trunk), and dysphagia (swallowing difficulty). R1's admission Minimum Data Set (MDS) dated [DATE] documented a staff assessment for mental status that showed a score of three, indicating severely impaired cognition. R1's MDS documented he was dependent on staff with all activities of daily living (ADL). R1 was at risk of developing a pressure ulcer and had moisture associated skin damage (MASD). The MDS documented a turning and repositioning program, nutrition and hydration interventions to manage skin problems, and applications of ointments/medications other than to the feet. R1's Activities of Daily Living Self-Care Care Plan initiated on 06/08/2026 directed that R1 was totally dependent on staff for dressing and personal hygiene and oral care. The plan of care further directed that R1 required a skin inspection every shift to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. R1's Care Plan lacked direction of care for seborrheic dermatitis. R1's Clinical Update from the hospital dated 05/18/2026 documented he had a history of seborrheic dermatitis and to monitor for worsening tachypnea (rapid shallow breathing), secretion burden, and fevers. The seborrheic dermatitis management per dermatology recommended Vanicream (a mild corticosteroid used topically to reduce inflammation, redness, and itching associated with skin conditions such as dermatitis) twice a day as needed, Ketoconazole (an antifungal medication used to treat dandruff and seborrheic dermatitis) two percent shampoo two to three times per week as needed, and ketoconazole cream to the red areas on R1's face. R1's Discharge Orders provided to the facility for R1's admission dated 05/29/2026 documented Vanicream apply topically to affected area if needed for dry skin, ketoconazole two percent cream apply topically to affected area two times a day as needed for itching or rash. R1's Orders tab documented the following orders:Ketoconazole external shampoo two percent, apply to scalp topically as needed for dandruff to scalp on bath days, ordered on 05/29/26.Ketoconazole external cream two percent, apply to affected areas topically as needed for itching or rash, ordered on 05/29/2026, discontinued on 06/02/2026. The Orders Note dated 05/29/2026 at 03:22 PM documented the Vanicream cream was discontinued, and A&D ointment (an over-the-counter skin protectant and emollient used to treat and prevent diaper rash, minor cuts, scrapes, and chafed skin) was ordered verbally. Review of R1's May Medication Administration Record (MAR) revealed no signatures indicating R1 had received Ketoconazole external cream or Ketoconazole external shampoo. Review of R1's May Treatment Administration Record (TAR) revealed no signatures indicating R1 had received A&D ointment. Review of R1's June MAR revealed no signatures indicating R1 had received Ketoconazole External Cream or Ketoconazole external shampoo. Review of R1's June TAR revealed no signatures indicating R1 had received A&D ointment. Review of R1's Face Sheet revealed R1 was photographed on 06/02/2026 with no reddened areas to his face, and his forehead appeared shiny in the photograph. Review of R1's Bath Sheets documented the following:05/31/26 documented no concerns.06/03/26 documented no concerns.06/08/26 documented no concerns.06/14/26 documented no concerns. Review of R1's Progress Notes documented throughout that R1's skin was warm and pink with brisk capillary refill (less than three seconds) with no edema (swelling resulting from an excessive accumulation of fluid in the body tissues) present. The Skilled Assessments flow into the progress notes and reflected the same documentation. R1's Progress Notes lacked any identification of rashes or flaky skin during his stay at the facility. Review of R1's Admission paperwork from his admission to the acute hospital dated 06/30/2026 documented R1 admitted with significantly worse fungal facial rash than when R1 had originally been discharged on 05/29/2026. On discharge, 05/29/2026, R1 had some small areas, but this was well-controlled with the daily application of antifungal ointment and facial hygiene. Review of the admission photograph of R1 revealed a reddened area that spanned out from around R1's nose; multiple raised, reddened, circular areas throughout R1's face with an increase in areas on his chin and forehead. R1 had yellowed flakes at the bridge of his nose near both eyes. R1 had whitish-yellow areas under the base of his nose, and white flakes on his lips and circling his chin. In a second photograph of R1's right ear, a darker reddened circular outline with dry yellow flakes on the inside was visible on the outside of R1's ear near his canal. On the underside of R1's earlobe, there was a similar reddened area at the base that had patches of dry yellow flakes throughout that reddened area. On 07/20/2026 at 03:13 PM, R1's representative stated he had asked the facility staff to wash R1's face and put on some cocoa butter cream every day. R1's representative further stated that he had asked both facility staff and facility administration about getting R1 in to see a dermatologist (physician specializing in skin conditions). On 07/21/2026 at 11:10 AM, Certified Nurses Aide (CNA) M stated that when he gave a resident a bath, he would check over the resident's skin and let the nurse know if there were any skin concerns. CNA M stated that R1 had dry, flaky skin and hair. CNA M stated he had notified the nurse. On 07/12/2026 at 11:11 AM, CNA N stated that R1 had irritated skin and the nurse was notified about the concern. On 07/20/2026 at 02:43 PM, Administrative Nurse E, the wound care nurse, stated that R1's order for the Vanicream was just for dry skin with no specifications as to where it needed to go. Administrative Nurse E stated she spoke with the nurse practitioner and asked to discontinue the order. Administrative Nurse E revealed she did not know what that cream was used for, and when asked if she would call to clarify the order with the discharging facility, Administrative Nurse E stated she would not call because R1 was their patient once admitted and not the discharging hospital's. Administrative Nurse E stated that R1's father had come into the facility and thrown all of R1's topical creams away. On 07/20/2026 at 02:50 PM, Administrative Nurse D stated that she had provided cares for R1 and noticed red blotches on his skin, but did not think that it was a rash but more of a color variance. Administrative Nurse D stated R1 had reddened areas on his face since he was admitted to the facility. The facility's Skin Integrity-Foot Care policy, implemented on 07/01/26, documented it was the policy of the facility to ensure residents received proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health.

Based on record review and interviews, the facility failed to provide foot care to Resident (R) 1, who was dependent on staff for foot care and whose toenails were long. Findings included:- R1's Electronic Medical Record (EMR) documented the following diagnoses of acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), epilepsy (brain disorder characterized by repeated seizures), spastic quadriplegic cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), seborrheic dermatitis (a common, chronic skin condition that primarily affects areas rich in sebaceous glands, such as the scalp, face, and trunk), and dysphagia (swallowing difficulty). R1's admission Minimum Data Set (MDS) dated [DATE] documented a staff assessment for mental status that showed a score of three, indicating severely impaired cognition. R1's MDS documented he was dependent on staff with all activities of daily living (ADL). R1 was at risk of developing a pressure ulcer and had moisture associated skin damage (MASD). The MDS documented a turning and repositioning program, nutrition and hydration interventions to manage skin problems, and applications of ointments/medications other than to the feet. R1's Activities of Daily Living Self-Care Care Plan initiated on 06/08/2026 directed that R1 was totally dependent on staff for dressing and personal hygiene and oral care. The plan of care further directed that R1 required a skin inspection every shift to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. R1's Care Plan lacked direction of care for his toenails or feet. Review of the Podiatrist list for June lacked R1's name on the list of residents that were seen. Review of R1's Bath Sheets documented the following:05/31/26 documented no concerns.06/03/26 documented no concerns.06/08/26 documented no concerns.06/14/26 documented no concerns. Review of R1's Progress Notes from 05/29/26 through 06/30/26 lacked documentation that addressed R1's feet or toenails. Review of R1's Admission paperwork from his admission to the acute hospital dated 06/30/2026 documented R1 admitted with very long toenails. Review of the admission photograph revealed R1's right foot had a thick big toenail that appeared to extend past the top of his big toe considerably. R1's second toe and pinky toe also appeared to have toenails extending past the top of his toes considerably. On 07/20/2026 at 03:13 PM, R1's representative stated he had asked both facility staff and facility administration about R1 being seen by a podiatrist (doctor who specializes in foot care) for his toenails. On 07/21/2026 at 11:11 PM, Certified Nurses Aide (CNA) N stated that she would let the nurse know if a resident needed their nails trimmed. CNA N further stated she did not trim toenails and fingernails because she did not feel comfortable doing that. On 07/21/2026 at 11:00 AM, Licensed Nurse (LN) H stated that when the residents needed their nails trimmed, the podiatrist handled that, or she would notify Administrative Nurse E. LN H revealed that she did not see clipping toenails as part of her job. LN H stated if a resident's toenails appeared to be too long and needed to be trimmed due to being at risk of harming themselves, she would trim them. LN H further revealed that she could only trim a resident's toenails as long as the resident was not a diabetic. On 07/21/2026 at 12:10 PM, Administrative Nurse E stated that if a resident needed their toenails trimmed, she would be notified, and she would trim the resident's nails unless it was something that the podiatrist needed to attend to. Administrative Nurse E stated she could not recall if she trimmed R1's toes but felt that she had, stating it would be in the progress notes. Administrative Nurse E further stated that CNAs and LNs could trim residents' nails, but if a resident was diabetic, only a LN could trim that resident's nails. The facility's Skin Integrity-Foot Care policy, implemented on 07/01/2026, documented it was the policy of the facility to ensure residents received proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. The policy directed that the facility would provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions. The policy further directed that if necessary, the facility would assist the resident in making appointments with a qualified person and arranging for transportation to and from such appointments. The policy directed staff that nursing assistants would inspect skin during baths and would report any concerns to the resident's nurse immediately after the task.

Based on record review, observations, and interviews, the facility failed to provide the necessary care and services related to indwelling catheter care for Resident (R) 1 when staff removed the catheter, failed to reinsert a catheter and monitor to ensure adequate urine output. Additionally, staff failed to obtain physician involvement. R1 subsequently developed a change in condition and was diagnosed with urine retention, urinary tract infection, and acute kidney injury. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of conversion disorder (a mental condition in which a person experiences blindness, paralysis, or other nervous system symptoms that cannot be explained by illness or injury) with seizures (violent involuntary series of contractions of a group of muscles) or convulsions (involuntary series of contractions of a group of muscles), encephalopathy (a broad term for any brain disease that alters brain function or structure), and cerebrovascular disease (a group of conditions that affect the blood vessels supplying blood to the brain). The Quarterly Minimum Data Set (MDS) dated 03/31/2026, documented the Brief Interview for Mental Status (BIMS) was not conducted as R1 was rarely or never understood. The MDS documented R1's short-term and long-term memory were not assessed. The MDS documented R1's cognitive skills for daily decision making were severely impaired. The MDS documented R1 was dependent on staff for activities of daily living (ADL). The MDS documented R1 had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). The MDS further documented R1 had no speech and recorded rarely or never for R1's ability to make himself understood.The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 06/28/2025, documented R1 had a tracheostomy (trach- opening through the neck into the trachea through which an indwelling tube may be inserted) and had decreased communication. The CAA documented R1 was able to follow simple, one step commands with occasional cues. The Urinary Incontinence and Indwelling Catheter CAA dated 06/28/2025, documented R1 had a catheter due to neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). R1's 11/25/2024 Care Plan documented R1 had an indwelling catheter due to neurogenic bladder and documented the following interventions:11/25/2024 - R1 had Foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door.11/25/2024 - Staff was directed to check tubing for kinks each shift.11/25/2024 - Staff was directed to monitor and document for pain or discomfort due to catheter.11/25/2024 - Staff were directed to monitor, record, or report to provider for signs and symptoms of urinary tract infection (UTI-an infection in any part of the urinary system): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R1's 11/25/2024 Care Plan documented R1 had an ADL self-care performance deficit related to cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with left sided weakness and documented the following interventions:11/25/2024 -R1 was totally dependent on staff to provide bed bath twice/week and as necessary.11/25/2024 -R1 was totally dependent on staff for personal hygiene and oral care.11/25/2024-R1 was totally dependent on staff for and turning in bed every two hours and as necessary.R1's Care Plan lacked documentation regarding R1's chronic UTIs. A N Adv Skilled Evaluation note dated 05/23/26 (at 10:49 PM) documented under the genitourinary (GU) section staff were unable to replace R1's catheter, provider was aware. The note lacked evidence of provider's response. The B&B - Bladder Elimination task, dated 05/23/2026 at 03:37 PM, documented an incontinent episode for R1. The task lacked further urine output documentation on 05/23/26. The Monitor Output in Foley Catheter task, dated 05/23/2026 at 03:37 PM, documented not applicable. The task lacked further urine output documentation on 05/23/26. A N Adv Skilled Evaluation note dated 05/23/2026 at 10:49 PM, documented under the genitourinary (GU) section staff were unable to replace R1's catheter, provider was aware. The note lacked evidence of provider's response. The Monitor Output in Foley Catheter task dated 05/24/26 at 10:13 AM, documented not applicable. A separate entry on 05/24/2026 at 09:46 PM recorded 2000 (milliliters) under amount. The task lacked further urine output documentation on 05/24/2026. The B&B - Bladder Elimination task, dated 05/24/2026, documented an incontinent episode for R1 at 10:13 AM and 09:46 PM. The task lacked further urine output documentation on 05/24/2026. A N Adv Skilled Evaluation note dated 05/24/2026 at 11:24 AM, revealed blank documentation under the GU section. The note lacked evidence of staff intervention related to R1's Foley catheter. The note lacked evidence that the provider was contacted. A N Adv Skilled Evaluation note dated 05/24/26 at 11:48 PM, revealed blank documentation under the GU section. The note lacked evidence of staff intervention related to R1's catheter. The note lacked evidence that the provider was contacted. The Monitor Output in Foley Catheter task, lacked documentation on 05/25/2026. The B&B - Bladder Elimination task, lacked evidence of documentation on 05/25/2026. A N Adv Skilled Evaluation note dated 05/25/2026 at 01:21 PM, revealed blank documentation under the GU section. The note lacked evidence of staff intervention related to R1's catheter. The note lacked evidence that the provider was contacted. A N Adv Skilled Evaluation note dated 05/25/2026 at 01:23 PM, revealed blank documentation under the GU section. The note lacked evidence of staff intervention related to R1's catheter. The note lacked evidence that the provider was contacted. A N Adv Skilled Evaluation note dated 05/26/2026 at 10:22 AM, revealed blank documentation under the GU section. The note lacked evidence of staff intervention related to R1's catheter. The note lacked evidence that the provider was contacted. A Monitor Output in Foley Catheter task, dated 05/26/2026 at 11:02 AM, documented not applicable. A separate entry on 05/26/2026 at 09:37 PM documented not applicable. The task lacked further urine output documentation on 05/26/2026. A B&B - Bladder Elimination task, dated 05/26/2026, documented an incontinent episode for R1 at 11:02 AM and 09:38 PM. The task lacked further urine output documentation on 05/26/2026. A Monitor Output in Foley Catheter task, dated 05/27/2026 at 11:15 AM, documented not applicable. The task lacked further urine output documentation on 05/27/2026. A B&B - Bladder Elimination task, dated 05/27/2026, documented an incontinent episode for R1 at 11:15 AM. The task lacked further urine output documentation on 05/27/2026. A N Adv Skilled Evaluation note dated 05/27/2026 at 12:17 AM, revealed blank documentation under the GU section. The note lacked evidence of staff intervention related to R1's catheter. The note lacked evidence that the provider was contacted. An eINTERACT SBAR Summary for Providers note dated 05/27/2026 at 01:02 PM, documented the change in condition reported was urinary incontinence. The note revealed blank documentation under the GU/Urine status evaluation section. The note recorded under the primary care provider feedback section to send R1 to the hospital. A No Type Specified note dated 05/2720/26 at 02:16 PM, documented R1 was discharged to the hospital for catheter replacement at 02:20 PM on a stretcher and was escorted by two medical transport personnel. A No Type Specified note dated 05/27/2026 at 07:41 PM, documented the emergency room (ER) physician contacted the facility for more details on what, when, and how the Foley catheter was discontinued. The note documented that the nurse was unable to give a relevant reason. The note further documented no progress note was placed at the time of the incident. R1's EMR lacked evidence of any notes, documented between 05/23/2026 at 10:49 PM and 05/27/2026 at 01:02 PM, that showed any staff intervention related to R1's Foley catheter being out, any documentation of staff contacting the provider, or orders given from the provider. Review of R1's hospital discharge records revealed a History Physical- Adult note dated 05/27/2026 at 06:57 PM. The note documented R1 had a known history of CVA with residual aphasia (condition with disordered or absent language function), trach, percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach) dependence, and was bed-bound. The note further documented R1 came to the ER for urinary retention. The note documented R1 had a chronic Foley catheter, due to comorbidities. The note further recorded R1's family visited him at the facility and noted R1 did not have a Foley in place. Per documentation, nursing was notified and could not get the catheter placed after six attempts. The note recorded R1 had possibly been without the catheter for two to three days. Hospital documentation recorded R1 was seen by urology and a catheter was placed. The note documented R1 did have urine flowing from his catheter, but it was bloody with no clots noted. The note further recorded R1 was noted to have an acute kidney injury (AKI - a sudden and temporary loss of kidney function, causing toxins and waste to build up in the blood) and a UTI. Review of R1's hospital discharge records revealed an Infect Disease Consult Note dated 05/29/2026 at 12:41 PM. The note documented R1 presented to the ER for Foley catheter placement. The note recorded R1's family noted R1 did not have a catheter at the facility. The note further recorded the Foley catheter was placed by urology which required urethral dilation (a minor medical procedure used to stretch and widen a narrowed urethra) due to stricture (an abnormal narrowing or constriction of a bodily passage, tube, or hollow organ). The note recorded that more than two liters of urine was drained following placement. The note documented R1 was diagnosed with a UTI. Review of R1's Treatment Administration Record (TAR) dated 05/01/2026 to 05/31/2026, revealed staff documented performing a flush of R1's Foley catheter on 05/25/2026. Review of R1's Treatment Administration Record (TAR) dated 05/01/2026 to 05/31/2026 revealed staff documented performing urinary catheter care on 05/24/2026 for AM and PM shifts, 05/25/2026 for AM and PM shifts, and on 05/26/2026 for AM shift. The order for urinary catheter care was discontinued on 05/26/2026 at 04:54 PM. Review of the record with Administrative Nurse D confirmed staff identity initials recorded on the TAR, from 05/24/2026 to 05/26/2026, for staff that documented performing catheter care and Foley flush during the time R1's catheter was not in place. On 06/09/2026 at 04:29 PM, R1 rested in bed in his room. R1 had trach and Foley catheter in place. The Foley catheter bag was covered and hung from the side of R1's bed. On 06/09/2026 at 03:08 PM, Licensed Nurse (LN) G confirmed she had worked at least one shift between 05/24/2026 and 05/27/2026. LN G stated she came in the morning after R1's catheter came out. She stated it came out on the previous night shift. LN G stated the night nurse said they could not get it back in place and left it for day shift. LN G stated she went and got LN J to assist her with replacing R1's catheter. She stated neither of them were able to replace the catheter. She stated R1's sister came in and asked about R1's catheter being out, and she told her what had happened. LN G stated she told R1's sister R1's urethra was damaged and they could not put the catheter back in. She stated R1's sister asked if R1 could see a urologist. LN G stated she told R1's sister yes. LN G stated she was then off for several days and when she came back R1 was in the hospital, and his catheter had been replaced. LN G stated she contacted the provider and asked if they could not get the catheter back in if they should send R1 out. She stated she got orders for a condom catheter and that is what they used. LN G stated she made a nurses note under the progress note section related to her contacting the provider and what the provider's response was. LN G stated she did not know why catheter care was documented on her shift. She stated she did not perform catheter care during the shifts she worked, as R1 did not have a catheter in place. She stated she cleaned him up good, but he did not have a catheter to do catheter care on. On 06/09/2026 at 03:16 PM, LN H stated she had worked on the 05/26/2026 and 05/27/2026. She stated she was the nurse that contacted the provider to send the resident to the ER. She stated she had received in report that R1's Foley catheter had come out several days before on night shift. LN H stated it may have been out four to five days but was not for sure exactly how many days. LN H stated R1's sister was at the facility and saw the catheter was no longer in and asked about it. She stated the sister had spoken to the administrator and was concerned that R1's wound may worsen if the catheter was not replaced due to incontinence. She stated she attempted to put his catheter in but was unsuccessful. She stated she was told by other staff that two other nurses had also previously attempted to replace R1's catheter but were unable to. She stated R1's sister wanted R1 sent out if they were unable to replace the catheter. LN H stated she was unsure as to how or why R1's catheter came out due to there not being any progress notes recorded related to the incident. She stated the ER doctor contacted her and asked about R1's catheter and she was unable to give him any details due to there being no documentation from previous staff. She stated it made staff look foolish that she was unable to provide information to the ER doctor due to lack of documentation. She stated everything she knew about what happened with R1's catheter prior to her shifts was hearsay from other staff as there were no notes to read and she could not confirm what had been done previously. LN H confirmed her initials were recorded on the TAR as providing catheter care on 05/26/2026. She stated if she charted that it must have been a mistake. She stated R1 did not have a Foley in either day she worked, and she could not have done catheter care. She stated R1 had been incontinent on her shift twice and she cleaned him up after each time but did not perform catheter care as he did not have one. LN H stated she got the order for catheter care discontinued because there was no point in documenting against catheter care when R1 did not have a catheter in place. On 06/09/2026 at 03:30 PM, LN I stated she had worked a night shift between 05/24/2026 and 05/27/2026. She stated she was not that familiar with R1. She stated she did not know if R1 had an order for a continuous catheter. She stated she was not 100% sure if R1 had a catheter, and she was only providing general information. She stated she did know that R1 had a history of urinary retention. On 06/09/2026 at 03:37 PM, LN J confirmed his initials and stated he worked a shift between 05/24/2026 and 05/27/2026. LN J stated LN G asked him to assist her with replacing R1's catheter. He stated R1's catheter had come out on the previous night shift and LN G had difficulty getting it put back in place. He stated when he tried, there was a lot of resistance, and he did not want to force it. He stated he recommended LN G contact the doctor to see if R1 could be sent out to have a specialist do it. LN J stated he was unsure if LN G contacted the doctor, but stated he believed she did. LN J stated he did not remember documenting that he had done catheter care on R1 when he worked his shift. He stated he did not have that assignment, and he did not do catheter care on R1 that day a R1 did not have one in place. LN J stated LN G should have put in a note documenting that information if she contacted the doctor. LN J stated it would be difficult for staff to know what was going on with a resident if other staff were not documenting when they contacted providers. He stated unless he had the resident himself, he would have a hard time knowing what had occurred on previous shifts if there was no documentation. On 06/09/26 at 04:00 PM, LN K confirmed she had worked a night shift between 05/24/2026 and 05/27/2026. She stated she had only heard about R1's situation in passing. She stated she knew R1 had gone out to the hospital. She stated if her initials were documented as performing catheter care then it must have been her. She stated she did not recall anything out of the ordinary with him the night she worked. LN K stated she did not recall if R1 had a catheter or not the night she worked. LN K stated when she documented doing catheter care, she must have considered it as regular peri care and clicked it. On 06/09/2026 at 04:49 PM, Administrative Nurse D stated she was on vacation from 05/21/2026 to 06/01/2026. Administrative Nurse D stated R1's catheter came out; staff tried to put it back in and were unable to. She stated from what she understood, R1's Foley came out on night shift, they notified the nurse practitioner, and no new orders were given. Administrative Nurse D stated R1 was sent out on 05/27/2026 and returned on 05/30/2026. Administrative Nurse D stated R1 had urinary retention and neurogenic bladder. Administrative Nurse D stated she reviewed the TAR for the dates of 05/2420/26 through 05/26/2026 and saw where staff had documented performing catheter care over those days. She stated staff should not have documented performing catheter care if R1 did not have a catheter in place. She stated staff should have contacted the doctor and should have put a progress note in after documenting that if he did not have it in place. Administrative Nurse D stated if there was an order to hold the catheter and monitor, then that should have been put in. She further stated staff should be putting in notes if no new order was given, or any order given. She stated they should document any change in conditions and notes documenting family was notified. Administrative Nurse D stated if the catheter was out, staff should have notified the MDS coordinator to have them change the Foley catheter output task. She stated staff should have monitored urine output through a different task if the catheter was no longer in place. Administrative Nurse D stated R1 was found to have had a UTI at the hospital. She stated she believed R1 may have had a history of chronic UTIs. Administrative Nurse D stated it would be difficult for other nurses to know what was going on with a resident fi there was no documentation from previous shifts. The facility's Urinary Continence and Incontinence- Assessment and Management policy, with a revision date of August 2022, documented the staff and practitioners will appropriately screen for and manage individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. If an indwelling catheter is needed, staff will monitor and report complications such as evidence of a symptomatic infection.

The facility identified a census of 37 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent further weight loss for Resident (R) 1. R1 was admitted to the facility on [DATE] and had a weight loss of 3.85% by 07/02/25 with no documented intervention or response to the loss. R1's weight further declined to a significant loss of 8.85% by 08/01/25 (more than 7.5% in three months) with no documented intervention or response from the facility until 08/14/25. This deficient practice resulted in a total significant weight loss of -11.15% for R1 from 06/06/25 to 08/20/25. Findings included:- R1's Electronic Medical Record (EMR) documented a diagnoses of nontraumatic subarachnoid hemorrhage (SAH- bleeding in the space just outside the brain), conversion disorder (a mental condition in which a person experiences blindness, paralysis or other nervous system symptoms that cannot be explained by illness or injury), dysphagia (swallowing difficulty), cerebral edema (abnormal accumulation of fluid in the brain, which causes it to swell), and dependence on a respirator, or ventilator (the inability to breathe on one's own, requiring mechanical ventilation to support or replace normal breathing function). The admission Minimum Data Set (MDS), dated 06/12/25, for R1 noted the Brief Interview for Mental Status (BIMS) assessment was not completed as R1 was rarely or never understood. The MDS documented R1's short-term and long-term memory was not assessed. The MDS further documented R1 had severely impaired cognitive skills for daily decision making. The MDS documented R1 was dependent on staff for activities of daily living (ADL). The MDS documented R1 had functional limitation in range of motion to his upper and lower extremities, with impairment on both sides. The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA), dated 06/12/25, documented R1 had decreased ability to make himself understood. The CAA documented R1 had confusion, disorientation and/or forgetfulness. The CAA further documented R1 was alert and able to answer simple yes or no questions by nodding or shaking his head. The Nutritional Status CAA dated 06/12/25, documented R1 had contractures (abnormal permanent fixation of a joint or muscle), partial or total loss of arm movement, functional limitation in range of motion, and hemiplegia (paralysis of one side of the body) and, or hemiparesis (muscular weakness of one half of the body). The CAA documented R1 had poor memory. The CAA documented R1 was to have nothing by mouth due to dysphagia, and all nutrition and or hydration were given via percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). R1's Care Plan, with an initiated date of 06/17/25, documented the following:R1 had an ADL self-care performance deficit related to being bedbound. R1 was bedfast all or most of the time. R1 was totally dependent on staff for transferring. R1 was totally dependent on staff for personal hygiene and oral care. R1 had a tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) related to respiratory failure. R1 required tube feeding related to dysphagia. R1 would maintain adequate nutritional and hydration status as evidenced by stable weight, no signs or symptoms of malnutrition, or dehydration through the review date. R1 was dependent on tube feeding and water flushes. The intervention directed staff to see the doctor's orders for the current feeding orders. R1's EMR revealed the following orders:An order, with an ordered date of 06/05/25, directed staff to weigh R1 monthly. An order, with a start date of 06/05/25 and a discontinue date of 06/16/25, documented the resident required enteral feed (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) six times a day. Staff were to give 200 milliliters (ml) of Jevity (a liquid nutrition with fiber providing complete nutrition) 1.5 by bolus feed and 180 ml water flush with each bolus feed six times a day via PEG.An order, with a start date of 06/16/2025 and a discontinue date of 08/11/25, documented the resident required enteral feed six times a day. Staff were to give 230 mL of Jevity 1.5 by bolus feed and 220 ml water flush with each bolus feed six times a day via PEG. An order, with a start date of 08/11/25 and a discontinue date of 08/15/25, documented an enteral feed order for the resident, every shift. Give Jevity 1.5 at 60 ml per hour plus water flush 220 ml every four hours continuously via PEG for nutritional management.An order, with a start date of 08/15/25 and a discontinue date of 08/22/25 documented the resident required enteral feeding every shift. Staff were to give Jevity 1.5 at 65 ml per hour plus water flush 220 ml every four hours continuously via PEG for nutritional management.An order, with a start date of 08/20/25, directed staff to obtain a Hoyer (total body mechanical lift) weight every two weeks. An order, with a start date of 08/22/25, documented the resident required an enteral feed every shift. Staff were to give Jevity 1.5 at 70 ml per hour plus a water flush of 250 ml every four hours continuously via PEG for nutritional management.R1's EMR lacked evidence of changes to R1's enteral feed orders from 06/16/25 to 08/11/25. R1's EMR lacked evidence of any changes in weight monitoring from 06/05/25 to 08/20/25. R1's EMR documented the following weights: 130.0 pounds (lbs.) on 06/06/25125.0 lbs. on 07/02/25 118.5 lbs. on 08/01/25 117.5 lbs. on 08/15/25 115.5 lbs. on 08/20/25 117.6 lbs. on 09/02/25 120.5 lbs. on 09/17/25 R1 had a weight loss of 3.85% from 06/06/25 to 07/02/25 and R1's EMR lacked evidence of any interventions from the facility. R1 had a significant loss of 8.85% from 06/06/25 to 08/01/25. R1's EMR lacked evidence of interventions from the facility until 08/11/25. R1 had a loss of 9.62% from 06/06/25 to 08/15/25. R1 had a total significant loss of 11.15% from 06/06/25 to 08/20/25. A Mini Nutrition note dated 06/05/25 documented R1 had a moderate decrease in food intake in the last three months. The note documented the resident had a weight loss greater than three kilograms (kg) (6.6 lbs.) in the last three months. R1 was bed or chair-bound and had suffered psychological stress or acute disease in the past three months. The resident has mild dementia. A Nutrition Therapy Progress Note with a date of 08/14/25, documented R1 had a history of recent nausea, with one emesis (vomit) on 08/06/25, and weight loss over the past month. R1 had continual overall weight loss since SAH on 04/02/25. The order changed from bolus feeds six times a day to continuous enteral feeding via PEG with continued strict nothing-by-mouth orders due to dysphagia. R1 admitted on a bolus order of Jevity 1.5 200 ml six times per day with 180 ml water six times per day plus Prosource (nutrition product designed for patients with malnutrition or protein deficiencies) 15 grams (g) a day. The resident's weight on 05/26/25 prior to admission to the facility was 143 lbs. and 1.3 ounces. The note further documented the resident's weight on 08/02/25 of 118.5 lbs., was discussed with R1's primary care provider. The provider changed the resident to continuous infusion with a smaller volume of the meal supplement infused continuously. The resident required increased kilocalories (kcals- a unit of energy measurement used in nutrition) to about 100 kcals per day. Staff were to monitor the resident for gastrointestinal (GI) symptoms. Per the note, R1 lost 23 lbs. from 04/03/25 to 06/06/25 (the resident admitted to facility on 06/05/25). A Nutrition/Dietary Note dated 08/22/25, documented the resident with 3 lb. weight loss this week. A Certified Nurse Aide reported the resident had infrequent urine output. R1 indicated he was thirsty. R1's weight on 08/01/25 was 118.5 lbs., and on 08/15/25 weight was 117.5 lbs. The note documented an increase in the resident's enteral feed rate, but not water flush. On 08/20/25 the resident's weight was 115.5 lbs. No new labs were ordered. R1 had no edema or no skin breakdown. A new order was placed to increase the resident's water flush from 220 ml to 250ml every four hours, along with an increase in enteral feed rate of Jevity 1.5 from 65 to 70 ml per hour. The note documented speculation R1 had higher metabolic needs than typical, possibly due to increased activity, or fidgeting, and a history of asthma with episodes of coughing. The note documented for staff to monitor R1's tolerance to the feedings, hydration, weights every two weeks, labs, and skin integrity. R1's goal weight over the next six months was 125 lbs. to 135 lbs. A Nutrition/Dietary Note dated 09/02/25, documented R1's Hoyer weight was 117.6 lbs., which was up 2 lbs. since 08/20/25 with a weight of 115.5 lbs. The note documented a planned weight increase to a goal weight from 125 lbs. to 135 lbs. over the next six months, with noted muscle atrophy. The note documented weights every 14 days through October 2025 and longer as needed to achieve weight trending toward weight goals and stability. The note further documented R1 reported tolerance to continuous enteral feed without GI symptoms or issues with Jevity 1.5 at 70 ml per hour with a water flush of 250 ml every four hours via PEG tube. Feeds would provide 2520 kcals, 107 grams of protein, and 2776 ml of water. The note documented for staff to continue to monitor weights, tolerance, labs, hydration, GI issues, and medical progress. R1's EMR lacked evidence of dietary notes or dietary assessments from 06/05/25 to 08/14/25. A Dietary Profile dated 06/06/25, documented R1 required a strict nothing by mouth directive, and on was on bolus gravity PEG feeds six times a day. The Dietary Profile documented R1 had a tracheostomy, ventilator, and had a subarachnoid hemorrhage. The Dietary Profile documented R1 had a PEG tube for nutritional support due to dysphagia. The resident required increased volume and water flushes due to resident's hunger and continued weight loss. R1's usual weight was 153 lbs. on 04/02/25 at the onset of SAH, and he had a current admit weight of 130 lbs. on 06/06/25. The resident's goal weight was from 140 lbs. to 150 lbs., and the goal weight in the next three to six months would be 135 lbs. to 145 lbs. The Dietary Profile documented R1 was tolerating PEG feeds well and had no GI symptoms. A Dietary Profile dated 09/08/25 documented R1 was on a strict nothing-by-mouth directive and was on continuous enteral feed via PEG tube. The Dietary Profile documented R1's family was concerned about R1's weight decline post SAH on 04/02/25. The Dietary Profile documented R1's weight was 153 lbs., and noted he had a severe weight loss prior to admitting to the facility. The Dietary Profile documented R1's weight was 130 lbs. on 06/06/25 (admission weight) with a current weight of 117.6 lbs. R1 was on a planned weight increase plan. R1's EMR lacked evidence of any other Dietary Profile assessments. On 09/18/25 at 02:11 PM, R1 received a continuous enteral feeding via an enteral feeding pump (a medical device used to deliver liquid nutrition directly into a patient's digestive tract via a feeding tube), as he rested in his bed. On 09/18/25 at 03:35 PM, Licensed Nurse (LN) G stated if a resident had a significant loss, he would reweigh them to make sure the weight was correct. LN G stated he would report the noted loss to the Director of Nursing (DON), the PCP, and the dietician. LN G stated he would also put in a progress note documenting the loss. He stated the dietician would usually adjust the rate of a feeding if a resident was not getting enough calories. LN G stated he believed the facility weighed residents once per month, or every two weeks. LN G stated one of the nursing aides told him they thought R1 lost weight and R1's family reported R1 lost weight as well. LN G stated R1 was on bolus feeding and he stated he asked Dietary BB about changing R1's feedings to continuous instead of bolus, as he stated he was concerned R1 may not have been getting fed consistently. LN G stated he was not sure what other staff did on other shifts. He stated he knew what he did on his shifts, but was not sure what others did related to R1's scheduled bolus feedings. LN G stated the only thing he suspected was R1 may not have been receiving them consistently. LN G stated staff would know if R1 was being fed if the order was changed to consistent instead of bolus. On 09/18/25 at 03:54 PM, Dietary BB stated R1 was 153 lbs. prior to admitting to the facility and had lost weight prior to arriving at the facility. Dietary BB stated R1 admitted with a weight of 130 lbs. Dietary BB stated she could see R1's weight was already declining prior to admission, so she changed R1's enteral feeding orders to increase his calories. Dietary BB stated she gave R1 a big increase in calories when he came in and his loss slowed down compared to what he had lost prior to admitting to the facility. She stated in July, when R1 lost 3.85% in the first month at the facility, R1 was having a lot of stools and some reported nausea. She stated she was not sure if a further increase would cause more nausea or vomiting, and she wanted to give him time to adjust to the increase in calories. She stated sometimes, if they moved too fast and the resident started vomiting, they could move backwards and decline. Dietary BB stated she had the order changed to small volume continuous feeding on 08/11/25 instead of bolus and R1 tolerated the change well with no reported nausea. Dietary BB stated she would normally intervene and make adjustments when a noted loss occurred and before it became significant. Dietary BB stated the facility normally did monthly weights for residents, but they changed R1 to every two weeks. Dietary BB stated she should have changed R1 to weekly weights sooner than she did once R1 started having some loss in the facility, as he was still on monthly at that time. Dietary BB further stated there should have been interventions put into place in July when the initial loss of 3.85% was documented in the first month, even though the loss slowed when compared to pre-admission loss. Dietary BB stated they probably should have started continuous feeding in July and increased how often he was weighed then. Dietary BB R1 did not have any reported nausea with the continuous feeding, only when he had the bolus feedings. Dietary BB stated there were no dietary assessments done for R1 in July when the loss was first documented. Dietary BB stated she probably should have followed up and done an assessment during that time. Dietary BB stated the biggest error was not increasing how often R1 was weighed to stay on top of changes. On 09/18/25 at 05:05 PM, Administrative Nurse D stated the facility obtained weights monthly, and results were given to the dietitian to review. Administrative Nurse D stated the dietician reviewed weights and PEG tub feedings and then made adjustments based on the findings and contacted the doctor. Administrative Nurse D stated it could be difficult to track loss based on weights obtained from a hospital, prior to admission to the facility, but if there was notable loss in the facility, interventions should be in place to prevent the loss from worsening. Administrative Nurse D stated if a loss was noted for a resident, it would be appropriate to change how often the resident was weighed to more closely monitor changes. On 09/18/25 at 05:25 PM, Administrative Staff A stated she believed residents were weighed weekly when admitted and then changed to monthly. Administrative Staff A stated Dietary BB was responsible for monitoring weight loss in the facility. Administrative Staff A stated Dietary BB would monitor loss and make dietary adjustments as needed to help prevent weight loss. Administrative Staff A stated she believed a resident's weight could go from some noted loss to significant within a month's time if not monitored. Administrative Staff A stated she was not a clinician, but it would make sense to check and monitor a resident's weight more frequently than once a month if there was some documented loss. The facility's Enteral Nutrition policy, with a revision date of November 2018, documented the dietician, with input from the provider and nurse, estimates calories, protein, nutrients, and fluid needs, determines whether the resident's current intake is adequate to meet his or her needs, recommends special food formulations, and calculates fluids to be provided. The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. The facility's Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy, with a revision date of September 2012, documented the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

The facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care. Findings included: - A review of the facility's submitted Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 through 03/31/25 indicated the facility triggered for no RN coverage on 12 occasions (04/05/24, 4/12/24, 04/19/24, 06/08/24, 07/20/24, 07/21/24, 08/03/24, 08/17/24,11/11/24, 11/17/24, 11/23/24, and 12/09/24). Upon review of the facility's working schedules and daily posted staffing revealed that no accounted RN hours for eight of the twelve days triggered (04/05/24, 04/12/24, 04/19/24, 06/08/24, 07/20/24, 07/21/24, 08/03/24, and 08/17/24). The facility was not able to provide documentation for the eight missing days of RN coverage as requested on 05/06/25. On 05/06/25 at 10:35 AM, Administrative Nurse D stated that both Administrator A and she came in to cover call-offs and weekend shifts for nursing. She stated the hours may not have been reflected correctly on the PBJ documentation. On 05/06/25 at 10:35 AM, Administrator A stated she was not able to pull punches or timecards for the missing days due to the changeover to a newer system and had no way to pull the needed data for the coverage. The facility's Department Supervision, Nursing policy, revised 08/2022, indicated the facility was to ensure a registered nurse was on duty at least eight consecutive hours every 24 hours, seven days a week.

The facility identified a census of 32 residents. The sample included 12 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 32 residents residing in the facility. Findings Included: - On 05/05/25, Administrative Staff A provided a Facility Assessment updated 03/01/25. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs for days, nights, and weekend shifts. On 05/05/25, a review of the facility's Payroll Based Journaling (PBJ - Staffing Data Report) from 04/01/24 to 03/31/25 revealed excessively low weekend staffing triggered in all four quarters. On 05/06/25 at 01:30 PM, Administrative Nurse D stated the facility assessment did not separate the hours required by shift but just showed the required hours as a total. She stated the facility assessment was updated annually to reflect the yearly changes the Centers for Medicare and Medicaid Services (CMS) put out. The facility's Facility Assessment policy, revised 10/2018, indicated the facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents during day-to-day operations.

The facility reported a census of 32 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staffing. Findings included: - A review of the facility's submitted PBJ data from 04/01/24 through 03/31/25 indicated the facility triggered for excessively low weekend staffing for Fiscal Year (FY) Quarter Three 2024, FY Quarter Four 2024, FY Quarter One 2025, and FY Quarter Two 2025. A review of the facility's working schedule, time sheets/punches, and posted staffing hours indicated no gaps or loss of hours. An inspection of the working schedule revealed weekend call-offs documented with administrative nurse coverage. On 05/05/25, a review of the Facility Assessment updated 03/01/25 revealed the facility did not differentiate the required nursing hours for day, evening, and weekend shifts for staffing. On 03/12/25 at 11:34 AM, Licensed Nurse (LN) I stated the facility staffing was fine on evenings and weekends. She stated the facility usually had extra staff on duty to assist with resident care and the occasional call-off. On 03/12/25 at 01:30 PM, Administrative Nurse D stated that the facility was staffed heavily on weekends and at times outside of the regular nursing hours. She stated the facility had occasional call-offs, but the administrative nurses covered the shifts. The facility's Reporting Direct Care Staffing Information (PBJ) policy, revised 08/2022, indicated the facility was to report complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS).

The facility identified a census of 32 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for residents in the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from May 2024 through April 2025, lacked evidence of tracking and identification of possible infection outbreaks at the facility. The infection log lacked identification of the facility-acquired infections. On 05/06/25 at 09:06 AM, Administrative Nurse D, the facility's Infection Preventionist, stated she did not track the antibiotic use in the facility to monitor for a possible infection outbreak. The facility's Infection Prevention Plan policy, dated 2025, documented the Infection Prevention and Control Program was designed to improve the quality of care for patients while reducing the risk of acquired Healthcare-Associated Infections (HAIs) for patients, staff, and visitors. The Infection Prevention Program coordinates prevention, surveillance, investigation, and control of infectious agents and reports information to external agencies as required. Infection prevention was a collaborative effort by all departments, services, and personnel throughout the facility to optimize patient safety and reduce the risks for disease transmission to patients, visitors, and staff.

The facility reported a census of 32 residents. Based on observations, record review, and interviews, the facility failed to ensure safe medication storage with three of the five medication carts. This deficient practice placed the residents at risk for diversion and ineffective medication regimen. Findings Included: - On 05/04/25 at 10:00 AM, an inspection of the facility revealed three unlocked and unsupervised medication carts on the facility's 200 hallway. An inspection of the medication carts revealed resident medications, stock medications, and medicated ointments stored in the carts. On 05/04/25 at 10:06 AM, Licensed Nurse (LN) G stated she was away from the medication cart for only five minutes, but stated she should have locked them before leaving them. She secured the medication carts. On 05/04/25 at 10:07 AM, LN I stated all the carts were to be locked when staff were away from them. LN I secured the other two carts and returned to the nurse's desk. On 05/06/25 at 01:32 PM, Administrative Nurse D stated staff were expected to lock the medication and treatment carts when not in use or supervised. The facility's Medication Labeling and Storage policy, dated 02/2023, indicated the facility was expected to store and ensure all medications and biologicals remained locked and secured to prevent tampering or exposure to the environment.

The facility identified a census of 32 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 19 and R8 remained free from unnecessary psychotropic (alters mood or thought) medications and chemical restraint (use of medication to control behaviors). This deficient practice placed both residents at risk for sedation and chemical restraint. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle weakness, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R19's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS noted she had bilateral (both sides) upper and lower extremity impairments. The MDS noted she was dependent on staff assistance for transfers, bathing, bed mobility, dressing, toileting, and personal hygiene. The MDS noted she had no psychiatric or mood disorders. The MDS indicated she did not take antianxiety (a class of medications that calm and relax people) or antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. R19's Psychotropic Drug Use Care Area Assessment (CAA) completed 02/04/25 noted she took psychotropic medications and was at risk for side effects. The CAA noted she took antipsychotic drugs and noted that care plan interventions were implemented. R19's Care Plan initiated on 02/27/25 indicated she was totally dependent on staff assistance for all her activities of daily living (ADL) related to her medical diagnoses. The plan noted she took medications with Black Box Warnings (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The plan instructed staff to monitor for medication side effects and adverse reactions to the medications. The plan noted that the pharmacy would make medication recommendations and follow up as indicated. The plan noted she would be monitored by her medical provider, and the pharmacist would consider dosage reduction when clinically appropriate for her psychotropic medications. R19's EMR under Physician Orders indicated an order (dated 01/28/25) for staff to administer 12.5 milligrams (mg) of Seroquel (antipsychotic medication) via her gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The EMR revealed she had the medication upon her admission on 01/28/25. R19's EMR under Physician Orders indicated an order (dated 01/28/25) for staff to administer Lorazepam (an antianxiety medication), one milligram every six hours as needed for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The order lacked a stop date and was documented as indefinite. A review of R19's Medication Regimen Review (MRR) completed 03/14/25 revealed the Consultant Pharmacist (CP) notified the facility that R19's Lorazepam medication required a duration of use past the 14-day period. The medical provider responded to the note with a 30-day duration for anxiety on 03/21/25. R19's Lorazepam received no other orders for the continuation past the 30-day stop period. A review of R19's Medication Regimen Review (MRR) completed 03/14/25 revealed the CP notified the facility that R19's Seroquel medication could not be used for depression. The medical provider noted R19 failed a gradual dose reduction. The MRR did not acknowledge that depression was not an accepted CMS indication for antipsychotic medications. On 05/06/25 at 07:00 AM, R19 rested in her bed. R19 received her morning medication without issue. On 05/6/25 at 01:20 PM, Licensed Nurse (LN) I stated that antipsychotic medication should not be given for depression. She stated the medication was to be given for mental disorders. She stated PRN psychotropic medications required a 14-day stop date and a physician's rationale for continued use. She stated that nursing staff were expected to monitor the orders and report irregularities to the medical provider and the director of nursing. She stated the pharmacy was expected to also find these issues and report them. On 05/06/25 at 01:32 PM, Administrative Nurse D stated all PRN psychotropic medications should have the initial 14-day stop date. She stated the durations were not usually put into the orders due to the pharmacy setting the durations for the medications. She stated that antipsychotic medications were not meant to be used for depression. She stated that antipsychotics were to be used for behavioral and mood disorders. The facility's Psychotropic Medication Use policy, revised 07/2022, indicated the facility was not to give psychotropics unless necessary to treat a specific condition and deemed beneficial to the resident. The policy noted that the facility would identify the risks versus benefits of the medication's use and utilize non-pharmacological interventions. The policy noted that the facility would ensure continual medication monitoring and adjust the dosage to meet the therapeutic needs of the resident. The policy noted that PRN psychotropic medication would be given a 14-day stop date and renewed only upon physician evaluation. 41037 - R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of paraplegia (the loss of muscle function, sensation, or both) and insomnia (inability to sleep). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R8 had received hypoglycemic (a class of medication used to lower blood sugar) medication, opioid (a class of controlled drugs used to treat pain) medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. R8's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/15/25 documented R8 received antipsychotic medication related to his diagnosis of paraplegia. R8's Care Plan, dated 03/26/25, documented the nursing staff would request the physician to review and evaluate R8's medications. R8's EMR under the Orders tab revealed the following physician orders: Diazepam (antipsychotic) oral tablet two milligram (mg) (valium) give one tablet by mouth every eight hours as needed (PRN) for mild muscle spasms (involuntary muscular contraction) dated 02/10/25. The as needed antipsychotic medication lacked a 14-day stop date or a physician-ordered specific duration. Diazepam oral tablet, give two mg tablets (four mg) by mouth as needed for moderate muscle spasms. May have four mg at bedtime as needed, dated 02/10/25. The as needed antipsychotic medication lacked a 14-day stop date or a physician-ordered specific duration. Quetiapine (antipsychotic) fumarate tablet 25mg (Seroquel) give 12.5 mg tablet by mouth at bedtime for insomnia dated 03/10/25. Review of R8's EMR under the Misc tab revealed Monthly Medication Review (MMR) dated 01/16/25 with a recommendation for R8's as needed Valium needed a clinical rationale documentation in R8's clinical record for the continuance of the medication with a duration the medication should be continued. The physician response dated 02/11/25 rationale was chronic spasticity para status and the duration was lifetime. MMR dated 03/17/25 documented R8 had received antipsychotic medication Seroquel that lacked an acceptable indication for use. The physician's response dated 03/21/25 documented a diagnosis of psychosis (any major mental disorder characterized by a gross impairment in reality perception). The facility was unable to provide physician documentation for the use of an antipsychotic medication with a non-approved indication upon request. On 05/06/25 at 07:46 AM, R8 laid on his right on his bed. Staff delivered his breakfast tray to his room. R8 consumed a drink from his tray to swallow his pain medication without difficulty. On 05/6/25 at 01:20 PM, Licensed Nurse (LN) I stated that antipsychotic medication should not be given for insomnia. She stated the medication was to be given for mental disorders. She stated PRN psychotropic medications required a 14-day stop date and a physician's rationale for continued use. She stated nursing staff were expected to monitor the orders and report irregularities to the medical provider and the director of nursing. She stated the pharmacy was expected to also find these issues and report them. On 05/06/25 at 01:32 PM, Administrative Nurse D stated that all PRN psychotropic medications should have the initial 14-day stop date. She stated the durations were not usually put into the orders due to the pharmacy setting the durations for the medications. She stated that antipsychotic medications were not meant to be used for insomnia. She stated that antipsychotics were to be used for behavioral and mood disorders. The facility's Psychotropic Medication Use policy, revised 07/2022, indicated the facility was not to give psychotropic unless necessary to treat a specific condition and deemed beneficial to the resident. The policy noted that the facility would identify the risks versus benefits of the medication's use and utilize non-pharmacological interventions. The policy noted that the facility would ensure continual medication monitoring and adjust the dosage to meet the therapeutic needs of the resident. The policy noted that PRN psychotropic medication would be given a 14-day stop date and renewed only upon physician evaluation.

The facility identified a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to complete the Care Area Assessment (CAA) analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for two residents, Residents (R) 12 and R20, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. This placed these residents at risk for impaired care and decreased quality of life due to unidentified care needs. Findings included: - R12's Admission MDS dated [DATE] 23 triggered the CAA for functional abilities (self-care mobility), urinary incontinence and indwelling catheter, pressure ulcer, and nutritional status. All triggered CAA's lacked completion with an analysis of findings. R20's Admission MDS dated [DATE] triggered the CAA for functional abilities (self-care mobility), urinary incontinence and indwelling catheter, pressure ulcer, psychotropic (alters mood or thought) drug use, falls, and nutritional status. All triggered CAA's lacked completion with an analysis of findings. On 05/06/25 at 09:03 AM, Administrative Nurse E was unavailable for interview by phone. On 05/06/25 at 10:30 AM, Administrative Nurse D stated she was not able to answer the question about R12 and R20's MDS lacking the analysis of their CAAs. The Facility's MDS Assessment Coordinator policy, last revised November 2019, documented a registered nurse (RN) would be responsible for conducting and coordinating the development and completion of the resident assessment (MDS).

The facility identified a census of 32 residents. The sample included 12 residents, with five sampled residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist's (CP) recommended a Centers for Medicare and Medicaid (CMS) approved indication related to Resident (R) 19's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. This deficient practice placed R19 at risk of unnecessary medication administration and related complications. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), muscle weakness, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R19's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS noted she had bilateral upper and lower extremity impairments. The MDS noted she was dependent on staff assistance for transfers, bathing, bed mobility, dressing, toileting, and personal hygiene. The MDS noted she had no psychiatric or mood disorders. The MDS indicated she did not take antipsychotic medications. R19's Psychotropic (alters mood or thought) Drug Use Care Area Assessment (CAA) completed 02/04/25, noted she took psychotropic medications and was at risk for side effects. The CAA noted she took antipsychotic drugs and noted that care plan interventions were implemented. R19's Care Plan initiated on 02/27/25 indicated she was completely dependent on staff assistance for all her activities of daily living (ADL) related to her medical diagnoses. The plan noted she took medications with Black Box Warnings (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The plan instructed staff to monitor for medication side effects and adverse reactions to the medications. The plan noted that the pharmacy would make medication recommendations and follow up as indicated. The plan noted she would be monitored by her medical provider, and the pharmacist would consider dosage reductions when clinically appropriate for her psychotropic medications. R19's EMR under Physician Orders indicated an order (dated 01/28/25) for staff to administer 12.5 milligrams (mg) of Seroquel (antipsychotic medication) via her gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) at bedtime for depression. The EMR revealed she had the medication upon her admission on 01/28/25. A review of R19's Medication Regimen Review (MRR) completed 03/14/25 revealed the CP notified the facility that R19's Seroquel medication could not be used for depression. The medical provider noted R19 failed a gradual dose reduction. The MRR did not acknowledge that depression was not an accepted CMS indication for antipsychotic medications. On 05/06/25 at 07:00 AM, R19 rested in her bed. R19 received her morning medication without issue. On 05/06/25 at 01:20 PM, Licensed Nurse (LN) I stated that antipsychotic medication should not be given for depression. She stated the medication was to be given for mental disorders. She stated that nursing staff were expected to monitor the orders and report irregularities to the medical provider and the director of nursing. She stated the pharmacy was expected to also find these issues and report them. On 05/06/25 at 01:32 PM, Administrative Nurse D stated that antipsychotic medications were not meant to be used for depression. She stated that antipsychotics were to be used for behavioral and mood disorders. She stated the pharmacist was expected to make recommendations about which medications were appropriate related to psychotropic medication use. The facility's Medication Regimen Review policy, revised 01/2021, indicated the facility's CP was to complete monthly medication reviews for each resident and report irregular findings. The policy indicated the CP was to make recommendations to the facility for medication findings based on medication indications, durations, side effects, potential complications, or adverse reactions.

The facility identified a census of 32 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician was notified of blood sugars outside the physician ordered parameters for Resident (R) 12 and the facility failed to ensure antihypertensive (medication used to treat high blood pressure) medication was administered per the physician ordered parameters for R16. These deficient practices placed these residents at risk for unnecessary medication administration and possible adverse reactions. Findings included: - R12's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R12 had received diuretic (a medication to promote the formation and excretion of urine) medication and anticoagulant (a class of medications used to prevent the blood from clotting) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R12 had received diuretic medications, anticoagulant medications, and insulin (medication to regulate blood sugar) during the observation period. R12's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/14/24 lacked completion with analysis of findings. R12's Care Plan, dated 03/26/25, documented nursing staff would review the pharmacy consult recommendations and follow up as indicated. R12's EMR under the Orders tab revealed the following physician orders: Blood glucose monitoring four times a day for DM. Notify the physician if blood sugar was less than (<) 30 or greater than (>) 350 dated 02/11/25. Novolog (insulin) flex pen subcutaneous solution pen injector 100 units/milliliters (ml) (insulin aspart) inject 10 units subcutaneously with meals for blood sugar 250 and greater dated 02/28/25. Review of R12's Medication Administration Record (MAR) from 02/01/25 to 05/05/25 (94 days) his blood sugar was outside the physician ordered parameters on the following 12 dates: 02/20/25, 02/27/25, 03/03/25, 03/08/25, 03/25/25, 03/26/25, 04/03/25, 04/06/25, 04/13/25, 04/18/25, 05/04/25, and 05/05/25. R12's clinical record lacked documentation of physician notification. On 05/06/25 at 07:37 AM, R12 laid asleep on his bed with no distress noted. On 05/26/25 at 01:20 PM, Licensed Nurse (LN) I stated the physician should be notified of any blood sugars outside the ordered parameters LN I stated a note should be entered into the resident's EMR of the notification and their response to the notification. On 05/06/25 at 01:23 PM, Administrative Nurse D stated she expected the physician to be notified of any blood sugars that were outside the ordered parameters. Administrative Nurse D stated that a note should be in the residents' EMR of the physician notification and the physician's response. The facility was unable to provide a policy related to following a physician's order. 45668 - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of chronic respiratory failure, hypoxia (inadequate supply of oxygen), hypertension (high blood pressure), and muscular dystrophy (MD - group of inherited disorders that involve muscle weakness and loss of muscle tissue and worsen over time). R16's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of eleven, indicating intact cognition. The MDS noted no upper or lower extremity impairments. The MDS noted he required substantial to moderate assistance from staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS noted he had a diagnosis of hypertension. The MDS noted that he received oxygen therapy services. R16's Functional Abilities Care Area Assessment (CAA) completed 06/11/24 indicated he required moderate to substantial staff assistance with his activities of daily living. The CAA noted staff were to anticipate his needs and care plan interventions were implemented to minimize the risks of falls, weight loss, incontinence, and skin breakdown. R16's Care Plan initiated on 11/26/24 indicated he required staff assistance for dressing, bathing, transfers, toileting, and personal hygiene. The plan noted he took medications with Black Box Warnings (BBW - the highest safety-related warning that medications can have assigned by the Food and Drug Administration). The plan instructed staff to monitor for medication side effects and adverse reactions to the medications. The plan noted he had hypertension. R16's EMR under Physician's Orders revealed an order for staff to administer 25 milligrams of Metoprolol (antihypertensive medication) by mouth two times daily for hypertension. The parameters instructed staff to hold the medication if systolic blood pressure (SBP - relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was less than (<) 110 millimeters of mercury (mmHg). A review of R20's Medication Administration Record (MAR) from 03/01/25 to 05/06/25 revealed that Metoprolol was given outside the ordered parameters on ten occasions (03/14/25, 03/16/25, 03/18/25, 03/24/25, 03/26/25, 03/30/25, 04/27/25, 04/30/25, 05/01/25, and 05/03/25). The EMR lacked documentation showing why the medication was given outside of parameters. On 05/06/25 at 01:20 PM, Licensed Nurse (LN) I stated blood pressure medication parameters should be followed for each medication. She stated medication should be held if outside the parameters, and document the reason why the medication was held or given. On 05/06/25 at 01:32 PM, Administrative Nurse D stated that staff were expected to follow the physician's orders related to the parameters. She stated medications should not be given outside the parameters unless instructed by the physician. She stated staff should provide documentation if given orders to give it out of parameters in the progress notes. The facility's Medication Monitoring policy, revised 04/2019, indicated that medications would be given per the physician's orders and instructions. The policy noted that the pharmacy was to report irregular medication findings, and the facility was to take action to correct potential errors.

The facility identified a census of 32 residents, with one resident on puree textured diets. Based on observations, interviews, and record review, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals. This deficient practice placed one resident at risk for complications related to nutritional impairment. Findings included: - On 05/05/25 at 10:59 AM, Dietary Staff CC placed one serving of cooked parmesan chicken into the food processor machine and then started the machine. Dietary Staff CC then poured water into the food processor with the chicken. Dietary Staff CC checked the consistency. Dietary Staff CC washed the food processor bowl. Dietary Staff CC placed one serving of cooked spaghetti with marinara sauce into the food processor and then started the machine. Dietary Staff CC then poured water into the food processor with the spaghetti and then added the thickener into the processor bowl. Dietary Staff CC washed the food processor bowl, then placed one serving of cooked peas into the food processor and started the machine. Dietary Staff CC then poured water into the food processor with the peas, checked the consistency, and then added the thickener into the food processor with the peas. Dietary Staff CC washed the food processor bowl. On 05/05/25 at 11:09 AM, Dietary Staff CC stated he did not follow the recipes because he had prepared the altered diets for a long time. On 05/06/25 at 10:55 AM, Dietary Staff BB stated water should never be used as an additive in the food when the food texture was altered. Dietary Staff BB stated that AM Dietary Staff CC should have followed the recipe when he prepared the pureed diet for the residents. The facility was unable to provide a policy related to altered diet preparation.

The facility identified a census of 32 residents. The sample included 12 residents. Based on record review and interview, the facility failed to update its daily posted staffing form to provide accurate daily staffing information. Findings included: - On 05/04/25 at 10:05 AM, an inspection of the facility revealed posted staffing documentation on the wall in the cafeteria area. An inspection of the documentation revealed the document was dated 04/29/25. At 10:05 AM, Licensed Nurse (LN) H stated the form should be updated daily by the nursing administrators, but had not been updated since last week. On 05/05/25 at 0745 AM, an inspection of the posted staffing form revealed a date of 04/29/25. On 05/06/25 at 01:32 PM, Administrative Nurse D stated the form was to be updated daily with the correct information on it. She stated that Administrator A updated and posted the forms daily. On 05/06/25 at 01:32 PM, Administrator A stated she had been off since last week and wasn't able to update the forms. The facility's Posting Direct Care Daily Staffing Numbers policy, revised 08/2022, indicated that staffing hours must be maintained for facility records for a minimum of 18 months and posted daily. The policy indicated the records must be made available upon request.

The facility identified a census of 29 residents. The sample included three residents reviewed for feeding tubes. Based on record review and interviews, the facility failed to prevent the neglect of Resident (R) 1 when staff did not provide adequate monitoring and timely care and attention to R1's percutaneous endoscopic gastrostomy (PEG tube- feeding tube through the abdominal wall directly into the stomach) site, which became infected, her abdomen became swollen and inflamed, and her right lower abdomen developed darkening, which staff documented as bruising. On [DATE] at 05:34 AM, R1 had a swollen abdomen and a large palpable mass around the PEG tube, with pus noted coming from the site. Staff notified Consultant GG, who assessed R1, and a note at 08:40 AM documented R1 had cellulitis (skin infection caused by bacteria) surrounding her PEG tube site with the skin indurated (hardened, firm) and erythematous (redness). Six days later, on [DATE] at 12:13 PM, Licensed Nurse (LN) G documented R1's PEG tube balloon appeared displaced and noted bruising around R1's right lower abdomen. LN G documented a new PEG tube was placed with a KUB (Kidney, Ureter, Bladder) x-ray ordered. LN G documented leaving a message for Consultant GG with the KUB results. On [DATE] at 05:59 AM, LN H documented R1 continued on an antibiotic for bacterial infection, R1's right side of her abdomen remained very swollen, inflamed, had blisters, the PEG tube stoma (surgically created opening of an internal organ on the surface of the body) size increased and the inflated balloon was visible. At 06:52 AM, LN H notified Consultant GG that no new orders were received. On [DATE] at 10:15 AM, LN I documented R1's PEG site was very inflamed with bruising noted from the PEG tube site across R1's left breast and down her left side to her hip. LN I notified Consultant GG and received an order to send R1 out to the hospital. R1 died at the hospital the same day. The facility's failure to ensure R1 remained free from neglect placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of encounter for attention to gastrostomy (G-tube: tube surgically placed through an artificial opening into the stomach) and anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen for too long). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 was in a persistent vegetative state. R1 had impairment on both sides of her upper and lower extremities and was dependent on staff for her activities of daily living (ADL). R1 had a feeding tube and received 51% or more total calories and 501 cubic centimeters (cc) or more of fluids through tube feeding daily. The Quarterly MDS dated [DATE], documented R1 was in a persistent vegetative state. R1 had impairment on both sides of her upper and lower extremities and was dependent on staff for her activities of daily living (ADLS). R1 had a feeding tube and received 51% or more total calories and 501 cc or more of fluids through tube feeding daily. The Feeding Tube Care Area Assessment (CAA) dated [DATE], lacked an analysis of findings. R1's Care Plan dated [DATE], documented R1 required tube feeding related to dysphagia (difficulty swallowing). The plan directed staff to check for tube placement and gastric contents/residual volume per facility protocol; staff were to monitor, document, and report as needed (PRN) any signs and symptoms of aspiration, fever, shortness of breath, tube dislodgement, infection at tube site, tube dysfunction or malfunction, abnormal breath sounds, abnormal lab values, abdominal pain, abdominal distention, abdominal tenderness, constipation or fecal impaction, diarrhea, nausea and vomiting, and dehydration. The plan directed staff to provide local care to the resident's G-tube site as ordered and monitored for signs and symptoms of infection, and staff provided tube feedings and water flushes. R1's EMR documented an order with a start date of [DATE] for enteral feedings (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) every shift with Osmolite (enteral formula) 1.2 at 50 milliliters (mL) per hour with 40 mL water flushes every four hours. R1's EMR documented an order with a start date of [DATE] for amoxicillin-potassium clavulanate (Augmentin- an antibiotic used to treat infections) ,d+[DATE] milligrams (mg) every 12 hours for bacterial infection for 10 days. R1's clinical record revealed the following: A N (Nursing) Adv (Advantage) Skilled Evaluation note on [DATE] at 12:11 AM documented R1's abdomen was distended and tender. An Orders - Administration Note on [DATE] at 12:36 AM documented the nurse held R1's tube feeding. A Health Status Note on [DATE] at 05:34 AM documented at the beginning of the shift, R1 had a swollen abdomen with a huge palpable mass predominantly around the PEG tube side extending towards the right side of her abdomen. The area was inflamed, warm, and tender to touch with pus noted from the PEG tube site. R1's vital signs included a pulse of 110 beats per minute (bpm) and a temperature of 101.2 degrees Fahrenheit (F). Staff administered as needed (PRN) Tylenol (medication used to treat pain and fever) 650 mg and turned off R1's tube feeding that shift. Staff notified Consultant GG who stated he would see R1 soon. Staff notified R1's representative and oncoming nurse. A Medical Doctor (MD) note on [DATE] at 08:40 AM documented R1 was in a persistent vegetative state with total care provided by facility staff for her PEG tube and noted the resident had cellulitis surrounding the PEG tube. R1 had a low-grade fever with no evidence of an abscess (cavity containing pus and surrounded by inflamed tissue) on examination but the area surrounding the PEG tube was indurated and erythematous. Consultant GG initiated Augmentin to cover the usual skin cellulitis organisms. A N Adv Skilled Evaluation note on [DATE] at 12:13 AM documented R1 had new, generalized pain in her abdomen with facial expressions as indicators of pain. R1's abdomen was tender and distended. A Health Status Note on [DATE] at 06:27 AM documented R1 continued Augmentin for bacterial infection. R1's abdomen was still swollen, inflamed, and blistering. R1's heart rate fluctuated with lows of 41 bpm. R1 had no adverse reactions from antibiotics noted or reported that shift. A N Adv Skilled Evaluation note on [DATE] at 06:03 PM documented R1 had unchanged generalized abdominal pain with facial expressions as indicators of pain. A N Adv Skilled Evaluation note on [DATE] at 02:33 AM documented R1 had unchanged generalized abdominal pain. A N Adv Skilled Evaluation note on [DATE] at 05:25 PM documented R1 had unchanged generalized abdominal pain. The record lacked any progress notes after [DATE] at 05:25 PM until [DATE] at 12:13 PM. R1 ' s KUB x-ray results on [DATE] at 11:56 AM documented R1's bowel gas pattern was normal without any obstruction or free air. There was a moderate amount of stool in R1's colon and rectum. The x-ray did not address the PEG tube placement. A Communication - with Physician note on [DATE] at 12:13 PM documented R1's PEG tube balloon appeared to not be in place with noted bruising around her right lower abdomen. Staff placed a new PEG tube and ordered a KUB x-ray. LN G documented a new PEG tube was in place, and he left a message for Consultant GG with the x-ray results. LN G documented R1's right lower abdomen was firm with discoloration and bruising. A Communication - with Family/Next of Kin (NOK)/Power of Attorney (POA) note on [DATE] at 03:02 PM documented R1's family member visited and was aware of KUB results. A Communication - with Family/NOK/POA note on [DATE] at 03:14 PM documented R1's representative was notified of KUB results and provided an update on R1. A N Adv Skilled Evaluation note on [DATE] at 12:15 AM documented R1's abdomen was distended and tender. A Health Status Note on [DATE] at 05:59 AM documented R1 continued Augmentin for bacterial infection. R1's right side of her abdomen was still very swollen, inflamed, and blistered. R1's stoma had increased in size and the inflated balloon was visible. R1 had hypoactive (less than normal activity in the body or its organs) bowel sounds present in all quadrants and her PEG tube was in place. R1 had a temperature of 99.9 degrees F and received Tylenol 650 mg. The nurse notified the oncoming nurse. A Health Status Note on [DATE] at 06:52 AM documented staff notified Consultant GG with no new orders at that time. A eInteract SBAR Summary for Providers note on [DATE] at 07:04 AM documented R1's gastrostomy tube had a blockage or displacement. R1 had a distended abdomen and skin discoloration. Consultant GG ordered a KUB x-ray. A No Type Specified note on [DATE] at 10:15 AM documented upon assessment that morning, R1's PEG tube site was very inflamed, and she had bruising from her PEG tube site across her left breast and down her left side to her hip. LN I notified Consultant GG who gave the order to send R1 to the hospital. LN I notified R1's representative at 07:10 AM. The ambulance arrived at 07:45 AM to transfer R1 to the hospital. Per request, the facility obtained hospital records for R1's visit on [DATE] which revealed the following: An Emergency Provider Report on [DATE] at 09:38 AM documented R1 was sent to the emergency department (ED) for an issue with her PEG tube. Emergency Medical Services (EMS) stated R1 had redness around her PEG tube and was sent to the hospital for a concern it was in the wrong place. The assessment revealed R1's PEG tube was present with the area medial (towards the middle) to the tube drained [NAME] (clinically evident) pus. There was erythema (redness or inflammation of the skin) that extended from the right abdomen all the way around to the flank (side of the body between the rib cage and the hip). A Computed Tomography [CT scan - test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessel] Abdomen and Pelvis with Contrast on [DATE] at 10:50 AM documented R1's gastrostomy tube with the balloon was outside of the stomach in the anterior (front) abdominal wall. The results documented an abnormal appearance of the gastrostomy tract with a suspected herniation of the stomach through the abdominal muscle with a recommendation for a surgical consultation. A History and Physical on [DATE] at 11:13 AM documented R1 presented with an anterior abdominal wall infection. CT scan revealed feeding tube was outside of the peritoneum (membrane that lines the abdominal cavity) with a large fluid collection in the subcutaneous (beneath the skin) tissues. The assessment revealed widespread cellulitis across R1's right abdomen extending to the feeding tube. An Attestations noted on [DATE] at 01:00 PM documented the provider responded to the ED for a concern of drainage around R1's PEG tube. A quick examination revealed an obviously dislodged PEG tube with a large amount of erythema, induration, and foul-smelling drainage coming from around the PEG tube. R1's representative initially wanted everything done but needed to talk to other family. The provider called R1's representative back 45 minutes later for follow-up and discussed the surgery would be extensive debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) of all infected abdominal wall tissues and removal of the current tube. R1 would need to return to the operating room every two to three days for ongoing debridement which the provider expected would go on for several weeks with months of ongoing wound care. R1's representative wanted to talk to further family members before agreeing. The provider talked to R1's representative a third time and she expressed she did not want to cause any further pain or suffering to R1. R1 was transferred to the Intensive Care Unit (ICU) where the PEG tube was removed with approximately 400 mL of purulence (pus) mixed with tube feedings and debris was evacuated with gentle pressure applied. At 07:00 PM, R1's representative and family arrived, and they wished to proceed with comfort care. At 07:30 PM, R1's experienced an acute rhythm change and the provider let R1's family know she was getting ready to pass away. R1's time of death was at 07:33 PM. On [DATE] at 01:36 PM, Certified Nurse Aide (CNA) M stated she did not usually care for R1 but would do R1's hair for her. She stated she was not sure of the date but maybe, a couple of weeks prior, R1's abdomen was swollen and red on one side. She stated she reported it to LN G who stated he was aware of it. On [DATE] at 01:51 PM, LN J stated she worked the last week R1 was in the facility and did not see any issues with R1. She stated that R1's PEG tube site was not swollen when she changed the dressing. She stated she checked PEG tube placement by auscultating (listening with a stethoscope) for air, aspirating for gastric return, and palpating around the site for protrusions. LN J stated if a PEG tube needed to be replaced, the nurses could replace the PEG tube in the facility with a two-nurse verification process to check for placement. On [DATE] at 01:57 PM, Administrative Nurse D stated to her knowledge, R1 had not had any problems until the day before she went to the hospital when she was notified by LN G of R1's PEG tube issues and bruising on her abdomen. She stated LN G replaced the PEG tube and auscultated the tube for placement along with obtaining a KUB x-ray. She stated the nurses were able to replace the PEG tubes with a two-nurse placement verification with a KUB and documented it in the nurses' notes. Administrative Nurse D stated the x-ray would indicate if the PEG tube was not in the correct place. She stated LN G called Consultant GG with the results of the KUB and received no new orders. Administrative Nurse D stated the next morning on [DATE], Consultant GG gave orders to send R1 to the hospital for evaluation. She stated she knew Consultant GG started R1 on Augmentin for cellulitis on [DATE]. On [DATE] at 11:25 AM, LN K stated she notified the doctor and Administrative Nurse D for any changes in condition. LM K said if she received any new orders, she wrote the orders up. She stated if a PEG tube needed to be replaced, two nurses verified placement and an x-ray confirmed placement. On [DATE] at 11:30 AM, LN L stated she notified the doctor for any change in condition or if she saw anything that looked different then she documented it. The facility's Physician Notification of Change in Condition policy, dated [DATE], directed if any change in condition occurs that necessitated a transfer to a higher level of care, an order must be written or received by the physician. Patients can be transferred immediately to a higher level of care with the approval of CCO or designee if the physician cannot be immediately reached, and it was felt a higher level of care was immediately necessary to safeguard a patient's health and safety. The facility's Enteral Nutrition policy, dated [DATE], directed staff monitored for signs and symptoms of enteral feed intolerance every four hours which included abdominal distention, abdominal pain/cramping, vomiting, and/or new onset diarrhea. The facility's Abuse/Neglect/Exploitation of Children/Elderly and Vulnerable Adults policy, last revised February 2020, defined neglect as when a resident was deprived of or allowed to do without necessary food, clothing, shelter, or medical treatment. The facility failed to ensure R1 remained free from neglect when they failed to provide the necessary monitoring and treatment for R1's PEG tube complications which included abdominal distention, redness and swelling at the PEG tube site, and discoloration of R1's abdomen. R1 transferred to the hospital on [DATE] where she died the same day. This deficient practice placed R1 in immediate jeopardy. The facility received the Immediate Jeopardy [IJ] Template on [DATE] at 04:42 PM. The facility submitted a removal plan to the state agency which included the following: The facility educated all LN in an in-service provided by Administrative Nurse D prior to their next scheduled shift on PEG tubes, notification of changes, and abuse/neglect/exploitation. Administrative Nurse D rounded on all 23 residents with PEG tubes on [DATE] to ensure proper placement. Administrative Nurse D or designee rounded daily using the PEG Tube Nursing Audit Tool. Administrative Nurse D reviewed the information from the audits and reported findings to the Quality Committee Quarterly. The surveyor verified the implementation of the IJ removal plan while onsite on [DATE] at 10:00 AM. The deficient practice remained at a scope and severity of G to represent the actual harm to R1.

The facility identified a census of 29 residents and 11 residents with trust accounts. The sample included three residents who were reviewed for misappropriation. Based on observation, record review, and interviews, the facility failed to ensure residents with trust accounts managed by the facility remained free from misappropriation when Administrative Staff B misappropriated funds from the resident trust fund account. This deficient practice placed all residents with trust accounts managed by the facility at risk for misappropriation, financial instability, and impaired rights. Findings included: - The facility's undated RFMS [Resident Funds Management Systems] Investigation, documented on 12/11/24 the facility initiated an investigation after finding credit card fraud on the company credit card attributed to Administrative Staff B. The facility noted several large checks from the resident funds account written to Administrative Staff B with withdrawals not matching up with the written checks. On 12/16/24, Administrative Staff C flew in to assist with the audit of the facility's RFMS account. On 12/17/24, the facility identified several withdrawals from Resident (R) 2, R3, and R4's accounts without receipts signed by the residents. The facility also noted several checks written out of the RFMS account that were not attached to any specific resident. On 12/18/24, Administrative Staff B came to the facility to give an account of discrepancies. She stated she could not remember details but stated the money was accounted for. The facility placed Administrative Staff B on suspension pending further investigation. On 12/19/24, the facility implemented new policies and procedures related to withdrawals from the resident trust account. On 12/30/24, Administrative Staff B resigned from the facility effective immediately. On 01/16/25, the facility reimbursed the missing funds to the resident trust account. On 01/16/25, the facility notified the State Agency (SA) of the issues. On 01/22/25, the facility notified law enforcement. The following checks were written by and made out to Administrative Staff B, from the resident trust account: Check #1831 on 12/14/23 was written and cashed/deposited for $500.00. The For line listed resident petty cash. Check #1835 on 05/01/24 was written and cashed/deposited for $400.00. The For line listed resident petty cash. Check #1838 on 06/28/24 was written and cashed/deposited for $150.00. The For line was left blank. Check #1840 on 07/16/24 was written and cashed/deposited for $500.00. The For line listed resident petty cash. Check #1841 on 07/23/24 was written and cashed/deposited for $450.00. The For line was left blank. Check #1843 on 08/12/24 was written and cashed/deposited for $250.00. The For line was left blank. Check #1844 on 08/19/24 was written and cashed/deposited for $300.00. The For line was left blank. A review of R2's RFMS Statement, Withdrawal Receipts, and Withdrawal Record revealed the following: A transaction on 03/07/24 for $136.60 for personal needs items. A Withdrawal Receipt dated 03/06/24, for $136.60 was not signed by R2 or Administrative Staff B and lacked evidence of a Withdrawal Record for 03/06/24. A transaction on 05/28/24 for $4.00 for personal needs items but lacked evidence of a Withdrawal Receipt or a Withdrawal Record for the transaction. A transaction on 10/31/24 at $150.00 for personal needs items. A Withdrawal Receipt dated 10/30/24, for $150.00 was not signed by R2 or Administrative Staff B. A Withdrawal Record dated 10/30/24, was signed by Administrative Staff B but was not signed by R2. A transaction on 11/20/24 at $100.00 for personal needs items. A Withdrawal Receipt dated 11/19/24, for $100.00 was not signed by R2 or Administrative Staff B. A Withdrawal Record dated 11/19/24, was signed by Administrative Staff B but was not signed by R2. A review of R3's RFMS Statement, Withdrawal Receipts, and Withdrawal Records revealed the following: A transaction on 06/03/24 for $1200.00 for personal needs items. A Withdrawal Receipt dated 05/29/24, for $1200.00 was not signed by R3 or Administrative Staff B. A RFMS Withdrawal Record dated 05/29/24, for $1200.00 was not signed by R3 or Administrative Staff B. A transaction on 07/01/24 for $50.00 for personal needs items. A Withdrawal Receipt dated 06/28/24, for $50.00 was not signed by R3 or Administrative Staff B. A Withdrawal Record dated 06/28/24, was not signed by R3 or Administrative Staff B. A transaction on 07/25/24 for $450.00 for personal needs items. A Withdrawal Receipt dated 07/24/24, for $450.00 was not signed by R3 or Administrative Staff B. A RFMS Withdrawal Record dated 07/24/24, was signed by Administrative Staff B but not by R3. A review of R4's RFMS Statement, Withdrawal Receipts, and Withdrawal Record revealed the following: A transaction on 08/29/24 for $120.00 for personal needs items. A Withdrawal Receipt dated 08/28/24, was not signed by R4 or Administrative Staff B. A Withdrawal Record dated 08/28/24, was not signed by R4 or Administrative Staff B. On 02/27/25 at 04:53 PM, R3 lay in bed and yelled out for help. On 02/27/25 at 04:55 PM, R4 lay in bed and pulled the blanket down from his face to converse with the surveyor. On 02/27/25 at 04:58 PM, R2 lay in bed and watched television. On 02/27/25 at 04:17 PM, Administrative Staff A stated in November 2024, Accounts and Receivables asked her to help balance the corporate credit card. She stated she asked Administrative Staff B to make a spreadsheet with receipts for the purchases, but Administrative Staff B never made the spreadsheet. Administrative Staff A stated she asked Administrative Staff B to review the receipts with her before Administrative Staff B went on vacation on 12/09/24, but she left for the day before it was done. She stated she went to Administrative Staff DD and discovered Administrative Staff B had charged personal lunches and dinners on the corporate credit card. She stated she wondered if the corporate credit card was off, what else could have been off? Administrative Staff A stated she started an investigation on 12/11/24 and had Administrative Staff C fly out to help with the investigation. She stated on 12/17/25, the facility noticed there were several large checks written out to Administrative Staff B that did not match any resident's account and the resident funds were compromised. Administrative Staff A stated that Administrative Staff B came in on 12/18/24 to give a statement and stated that the records were all there and that the facility did not know what they were looking at. Administrative Staff A stated she placed Administrative Staff B on suspension on 12/18/24 and the facility started writing new policies on 12/19/24. She said the facility wanted to give Administrative Staff B another chance to account for the funds, but she had no further statement and quit on 12/30/24. Administrative Staff A stated the facility reported the incident to the SA on 01/16/25. She stated she believed Administrative Staff B did bad bookkeeping but since there were no traces of where the money went, the facility paid the money back. She stated the withdrawal receipts should have had the resident and Administrative Staff B's signature on each transaction. On 02/27/25 at 04:27 PM, Administrative Staff C stated during the investigation, the facility reimbursed any transaction that was withdrawn without the resident's signature. She stated it took a while to look at everything and she wanted to get everything for an audit from Social Security. Administrative Staff C stated after the audit, the facility reported the incident to the SA. She stated there was some withdrawn money without receipts and checks that were cashed with nothing to back them up. On 03/03/25 at 11:38 AM, Administrative Staff DD stated the facility currently had Administrative Staff C helping with resident funds remotely and, if a resident needed money, she told Administrative Staff C who sent a receipt from their account and then Administrative Staff DD and Administrative Staff A gave the money to the resident and had them sign the receipt then they both signed it as well. The facility's Abuse/Neglect/Exploitation of Children/Elderly and Vulnerable Adults policy, last revised February 2020, defined exploitation when a person who stood in a position of trust and confidence with a person and knowingly by deception or intimidation, obtained or used or endeavored to obtain or use, a vulnerable person's funds, assets, or property with the intent to temporarily or permanently deprive a vulnerable person of the use, benefit or possession of the funds, assets or property for the benefit of someone other than the vulnerable person. The facility's Resident Trust/Personal Need Fund Notification and Authorization policy, revised 04/01/24, directed requests for less than $100.00 were honored the same day, and requests for $100.00 or more were honored within three banking days. No funds were disbursed without the appropriate written authorization of the resident or legal representative, if applicable. The facility failed to prevent misappropriation of resident trust funds from the resident trust account and from R2, R3, and R4's trust accounts. This deficient practice placed all residents with trust accounts managed by the facility at risk for misappropriation, financial instability, and impaired rights.

The facility identified a census of 29 residents. Based on record review and interviews, the facility failed to notify Resident (R) 1's representative of the plan of care changes. This deficient practice had the risk of miscommunication between R1, their representative, and the facility. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of encounter for attention to gastrostomy (G-tube: tube surgically placed through an artificial opening into the stomach) and anoxic brain damage (brain injury that occurs when the brain is deprived of oxygen for too long). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a feeding tube and received 51% or more total calories and 501 cubic centimeters (cc) or more of fluids through tube feeding daily. The Quarterly MDS dated [DATE], documented R1 had a feeding tube and received 51% or more total calories and 501 cc or more of fluids through tube feeding daily. The Feeding Tube Care Area Assessment (CAA) dated 10/14/24, lacked an analysis of findings. R1's Care Plan dated 12/17/24, documented R1 required tube feeding related to dysphagia (difficulty swallowing). The plan directed staff to check for tube placement and gastric contents/residual volume per facility protocol; staff monitored, documented, and reported as needed (PRN) any signs and symptoms of aspiration, fever, shortness of breath, tube dislodgement, infection at tube site, tube dysfunction or malfunction, abnormal breath sounds, abnormal lab values, abdominal pain, abdominal distention, abdominal tenderness, constipation or fecal impaction, diarrhea, nausea and vomiting, and dehydration; staff provided local care to G-tube site as ordered and monitored for signs and symptoms of infection; and staff provided tube feedings and water flushes. R1's EMR documented an order with a start date of 02/18/25 for amoxicillin-potassium clavulanate (Augmentin- an antibiotic used to treat infections) 875-125 milligrams (mg) every 12 hours for bacterial infection for 10 days. R1's clinical record revealed the following: A Nursing (N) Advanced (Adv) Skilled Evaluation note on 02/18/25 at 12:11 AM documented R1's abdomen was distended and tender. A Orders- Administration Note on 02/18/25 at 12:36 AM documented the nurse held R1's tube feeding. A Health Status Note on 02/18/25 at 05:34 AM documented at the beginning of the shift, R1 had a swollen abdomen with a huge palpable mass predominantly around the percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach) side extending towards the right side of her abdomen. The area was inflamed, warm, and tender to touch with pus noted from the PEG tube site. R1's vital signs included a pulse of 110 beats per minute (bpm) and a temperature of 101.2 degrees Fahrenheit (F). Staff administered PRN Tylenol (medication used to treat pain and fever) 650 mg and turned off R1's tube feeding that shift. Staff notified Consultant GG who stated he would see R1 soon. Staff notified R1's representative and oncoming nurse. A Medical Doctor (MD) note on 02/18/25 at 08:40 AM documented R1 had a persistent vegetative state with total care for PEG tube and had cellulitis surrounding the PEG tube. R1 had a low-grade fever with no evidence of an abscess (cavity containing pus and surrounded by inflamed tissue) on examination but the area surrounding the PEG tube was indurated and erythematous. Consultant GG initiated Augmentin to cover the usual skin cellulitis organisms. R1's EMR lacked evidence the facility notified R1's representative of the new Augmentin order for her PEG tube site cellulitis. On 03/03/25 at 11:25 AM, LN K stated she notified the doctor and Administrative Nurse D for any changes in condition and if she received any new orders, she wrote the orders up. She stated she notified the resident's representative or family on new orders, the doctor's plan, and changes in condition. LN K stated she documented the notification in a nurse's note and passed the information on to the next nurse. On 03/03/25 at 11:30 AM, LN L stated she notified the doctor for any change in condition or if she saw anything that looked different then she documented it. She stated she notified the resident's representative and Administrative Nurse D of any change in condition. On 03/03/25 at 12:06 PM, Administrative Nurse D stated she expected staff to notify the family of any medication changes, changes in conditions, mental status changes, or anything outside the resident's baseline. She stated she expected the notification to be documented under family notification in the EMR. The facility's Physician Notification of Change in Condition policy, dated June 2014, directed if any change in condition occurs that necessitated a transfer to a higher level of care, an order must be written or received by the physician. Patients can be transferred immediately to a higher level of care with the approval of CCO or designee if the physician cannot be immediately reached, and it was felt a higher level of care was immediately necessary to safeguard a patient's health and safety. The policy did not address representative or family notification or changes. The facility failed to notify R1's representative of plan of care changes. This deficient practice had the risk of miscommunication between R1, their representative, and the facility.

The facility's census totaled 46 residents with 3 sampled of the 25 ventilator (a machine that artificially and rhythmically inflates and deflates the lungs as in normal breathing) dependent residents. Based on observation, interview, and record review, the facility failed to provide service to one ventilator for over three years and 7 months. The ventilator was used for life sustaining with resident (#1) and was found not functioning. The resident was found unresponsive and not breathing. This deficient practice placed this resident in immediate jeopardy. Findings included: - Resident #1's Physician order [REDACTED]. The annual Minimum Data Set assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident's cognitive status was intact and able to make his/her needs known. The MDS further documented the resident was totally dependent on staff with toilet use and personal hygiene, extensive assistance on staff with bed mobility and dressing, and limited assistance on staff with eating. The MDS documented the resident required oxygen therapy, suctioning, tracheotomy (an opening though the neck into the trachea through which an indwelling tube may be inserted), and a ventilator. A significant change MDS dated [DATE] documented the resident was in a persistent vegetative state with no discernible consciousness. The resident required total dependence on staff with bed mobility, toilet use, dressing, eating, and personal hygiene. The MDS documented the resident required oxygen therapy, suctioning, tracheotomy care, and a ventilator. The revised care plan dated [DATE] documented the resident required assistance with cares related to the [DIAGNOSES REDACTED]. The approaches included extensive to total assist of one or two staff members with bed mobility and positioning, the resident was able to feed him/herself with set up help and would require assistance at times. The care plan reviewed on [DATE], [DATE] and [DATE] documented the resident was ventilator dependent and required the ventilator on 24 hours a day/7 days a week with the oxygen level set at 30 percent. The care plan instructed the staff to monitor the equipment functions, such as appropriate configuration of ventilator circuit, alarm function, cleanliness of filter, power level of batteries, and cleanliness of self-inflating manual resuscitator. The staff was to monitor the equipment for related problems, such as: failure of the ventilator, malfunction of equipment, inadequate warming or humidification of the inspired gases, inadvertent changes in ventilator settings, accidental disconnection of ventilator, and accidental decannulation (removal of the tracheotomy tube). The POS dated [DATE] documented the resident required 24 hour ventilation dependence. The nurses' notes documented on [DATE] at 3:00 P.M. staff started cardiopulmonary resuscitation (CPR) (restoring of life of someone who is in cardiac or [MEDICAL CONDITION]). Staff called the doctor who ordered the resident to be sent to the hospital. The hospital history and physical dated [DATE] documented the resident had a cardiopulmonary arrest at the nursing home when there was an interruption in electrical power, which most likely led to the ventilator problem. Computed tomography (CT scan) (test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) was reviewed and indicated an infarct (death of tissue) in the right cerebral hemisphere of the brain. The facility stated there was not an electrical power shortage at the facility at any time that day. If there would have been a power outage the backup generators would start up. Review of the Customer Service Report dated [DATE] documented the last preventative service provided on the ventilator used by resident #1 was on [DATE] which was 3 years and 7 months prior to the malfunction of the ventilator. The maintenance service report provided on [DATE] documented the backup battery was dead. The 700 Series Ventilator Operator's Manual documented the facility should provide preventative maintenance every 2 years for the entire ventilator. Review of the checklist revealed the battery check was not on the list. On [DATE] at 1:13 P.M. the resident was in bed, unresponsive, and with the ventilator functioning. An interview on [DATE] at 12:30 P.M. with administrative staff A stated the resident's ventilator had slipped through the cracks and the ventilator had not been maintained/serviced since 2011. An interview on [DATE] at 1:13 P.M. with licensed nursing staff I stated the resident was responsive to making his/her needs known before the ventilator failure and since the ventilator failure and return from the hospital, he/ she had been unresponsive and no longer able to make his/her needs known. An interview on [DATE] at 8:15 A.M. with licensed nursing staff H stated when a ventilator alarm goes off staff would check the resident, try and trouble shoot for any problems, make sure resident was all right, and call the respiratory staff for them check the ventilator. An interview on [DATE] at 11:15 A.M. with direct care staff O stated the resident was almost total care before the ventilator failure but he/she was able to mouth what he/she wanted and he/she could also feed him/herself with just set up help. The resident was now total care with all activities of daily living. An interview on [DATE] at 12:05 P.M. with direct care staff P stated about 1:30 P.M. on [DATE] the afternoon of the ventilator failure another aide asked him/her to help pull the resident up in bed. After he/she helped pull the resident up in bed, the resident asked for the respiratory therapist. Direct care staff P told respiratory therapy the resident wanted him/her and ,[DATE] minutes later he/she heard the staff call a code blue (emergency assistance was needed). An interview on [DATE] at 1:15 P.M. with activity staff Z stated he/she made rounds to all of the rooms. He/she started walking around 2:00 P.M. and when he/she went to resident #1's room, the resident appeared asleep. When activity staff Z left the room, he/she saw the ventilator screen was black and had a message on. The ventilator screen was usually very bright. Activity staff Z immediately went to the respiratory staff, which they went right to the room, and when he/she saw them go to the room he/she stayed out of the way. An interview on [DATE] at 1:45 P.M. with physician S stated all the residents were terminal due to multiple diagnoses, but the malfunction of the ventilator did cause him/her to be coded and he/she was sent to the hospital. He/she was without oxygen for a short time because of the ventilator malfunction. He/she might have not had a change in condition if the ventilator had not malfunctioned. We are not sure if he/she will come back to his/her prior function as the lack of oxygen did cause irreversible harm. His/her condition regarding anoxia [MEDICAL CONDITION] (lack of oxygen to the brain) was discussed with the family. An interview on [DATE] at 2:03 P.M. with respiratory staff V he/she went to the resident's room on [DATE] and the ventilator screen was black with a small message but not sure what the message was but the ventilator was "not ventilating". Respiratory staff V saw the resident was not breathing, so called for a code blue (emergency assistance is needed), three respiratory therapists and 2 nurses came to the room. We provided 2 rounds of CPR and the Emergency Medical Technician (EMTs) showed up and the EMTs took over. On [DATE] at 2:30 P.M. respiratory therapist U provided a list of ventilators with the last date the ventilators were serviced. Respiratory therapist U reported he/she had an email from the company that serviced the ventilators but was unable to find the email. The handwritten list revealed another ventilator was last serviced on [DATE]. The ventilator went three years without preventative maintenance /service. Respiratory therapist U provided additional log titled "Ventilator Inventory" which documented all of the facilities 25 ventilators were serviced on [DATE], [DATE], and [DATE] and the 11 rental ventilators were serviced in the last 6 months. The ventilators were not serviced until the ventilator failure that resulted in leaving a resident with irreversible harm. The 2015 facility policy "Medical Equipment Management Plan" documented the objective of the policy was to ensure that all life critical equipment was operating at all times. The director of respiratory therapy assured that scheduled testing of all life support equipment was performed within the "service month . Reports of the completions rate of the scheduled inspection and maintenance were presented to the safety committee each quarter. The facility failed to ensure the respiratory staff monitored the life critical equipment for proper functioning which caused this resident to go into [MEDICAL CONDITION] and sent to the hospital which placed this resident in immediate jeopardy. The resident was alert and oriented prior to the ventilator failure and when he/she returned from the hospital he/she had experienced irreversible harm and was now in a vegetative state. The Immediate Jeopardy was abated on [DATE] after the facility had all 25 ventilators serviced and maintenance done, revised their policy for monitoring the life critical equipment annually, and provided in-service to all staff that are responsible for checking the proper functions of the ventilators and batteries. The deficiency remains at a scope and severity of a "G".