Every finding on record at The Ching Villas

Based on observation and interview, the facility failed to ensure that food items stored in the walk-in refrigerator were labeled properly and old food discarded. This deficient practice places residents in the facility at risk for foodborne illness.Findings Include:During an initial walkthrough of the kitchen with the Dietary Manager (DM) on 01/13/26 at 09:00 AM, in the walk-in refrigerator, observed meatloaf stored beyond the discard date of 12/24, and turkey beyond the discard date of 01/11. A tray of Salisbury steak was observed with an open date of 11/24 and no discard date. Concurrent interview with the DM noted that these items should have been thrown out to prevent serving expired food and residents risking foodborne illness.

Based on observations, interviews, and record review, the facility failed to ensure five out of 10 residents (Resident (R), 112, R182, R177, R179, and R180) sampled for receiving specialized services, received physical therapy (PT) treatments according to their prescribed treatment plan. PT treatments help to assist the residents to restore his/her highest level of physical functioning. This deficient practice affects the resident's ability to meet their therapy goals. Findings Include: Observation and interview with R182 in her room on 01/13/26 at 2:00 PM. R182 said she fell on her front stairs at home and fractured her foot. She said she was getting therapy, but she wasn't supposed to put weight on her foot. Observed R182 lying in her bed, with a blue colored cast on her lower right leg. R182 added that she is concerned about her therapy, because she knows that she will only be allowed for a couple of weeks of therapy then she is supposed to go home. She said her house has stairs, and a narrow hallway, she said she didn't think the wheelchair would fit. When asked if she felt like she was making progress she added that she wasn't sure because each time she had therapy, she is doing different exercises and didn't feel like the exercises were consistent. Electronic Health Record (EHR) reviewed on 01/14/26. R182 is a [AGE] year-old female admitted to the facility on [DATE] for rehabilitative services. Minimum data set (MDS) admission assessment dated [DATE]. Functional status: Substantial/ Max assist. PT evaluation & plan of treatment note reviewed. Certification Period: 1/5/2026 - 2/3/2026 Start of Care: 1/5/2026. Reason for Referral: Patient is a [AGE] year-old female who presented to the hospital following a fall on her right side. She was unable to WB (weight bear) following a fall. She was found to have right fibula fracture. She underwent surgeries to repair the fractures on 12/26 and 12/30. Present level of function: Lives with family in a 2-story house. Assessment summary. Reason for therapy. Patient requires PT services to facilitate independence with all functional mobility.Plan of treatment. Therapeutic exercises.Frequency: five times per week, for 30 days, daily. Potential for achieving rehab goals: Patient demonstrates good rehab potential as evidenced by ability to follow 2 step directions, able to make needs known, motivated to participate and motivated to return to prior level of living. Anticipated help needed upon discharge: Patient will likely require assist from caregiver or family upon discharge. Physician orders reviewed. 01/05/26 – 02/03/26 PT evaluate and treat 5x/week for 30 days. Treatment may include therapeutic exercises, therapeutic activities. Reviewed progress notes for PT visits on 01/16/26. Noted missed PT visit for week 01/05/26 to -1/10/26. Resident encountered four of five PT visits. Requested documentation for missed PT appointment from the Director of Rehab (DOR). Received and reviewed the Service Log Matrix with date range of 01/01/2026 to 01/31/2026. Confirmed R182 had four visits from 01/05/26 to 01/10/26. Reviewed PT missed visit details dated 01/10/26 Reason for missed session: Cancelled. Signed by PT 15 at 01/12/26 at 3:14 PM. The DOR stated that PT15 wasn't working and not available for interview to determine why the appointment was cancelled. 2) R112 was an [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to hyponatremia (low sodium level in the blood) and general weakness. On 01/13/26 at 09:23 AM, an interview was conducted with R112 in her room. Queried R112 about her PT services at the facility. R112 said she has not had any PT sessions since 01/09/26. When asked how often she was getting PT before 01/09/26, R112 said she used to get PT every day and was not sure why it stopped. Review of R112's Electronic Health Record (EHR) was conducted. Scanned document titled Physical Therapy, PT Evaluation & (and) Plan of Treatment dated 12/16/25 stated under Plan of Treatment a frequency for PT services of five times a week for 30 days. On 01/16/26 at 11:22 AM, concurrent interview and record review was conducted with the DOR in the conference room. PT service log for January 2026 indicated that R112 did not have PT for five consecutive days from 01/09/26 to 01/13/26 and was seen only two times for the week of 01/11/26 to 01/17/26. The DOR confirmed the frequency of PT services was not met for the current week and will further investigate. On 01/16/26 at 1:01 PM, the DOR presented a document titled Physical Therapy Missed Visit Detail that stated, 01/12/26 Reason for Missed Session: Scheduling Conflict. No other information to explain the scheduling conflict was noted. The document was electronically signed on 01/16/26. 3) On 01/13/26 at 2:26 PM, observed R177 in bed, with his family member at the bedside and voiced that he should be receiving PT daily but has not been getting it daily and is waiting for his next treatment. R177 noted that he was evaluated by someone but had only one treatment since then. On 01/16/26 at 12:33 PM, record review of R177's Electronic Health Record (EHR) noted that R177's PT evaluation was completed on 01/07/26. The PT plan of care indicated that R177 should be receiving PT at the frequency of five times/week for 30 days. The PT service log noted that R177 did not receive PT treatment on 01/12/26. On 01/16/26 at 01:50 PM, interview with the DOR who confirmed that R177 did not receive a PT treatment on 01/12/26 and did not meet the 5x a week for the week of 01/08/26-01/14/26. The DOR further stated that the treatment was missed due to a scheduling conflict but was not sure of what it was. The PT missed visit details noted that it was just signed by the DOR on 01/16/26 at 4:50 PM. 4) On 01/14/26 at 10:14 AM, observed R179 in his room sitting down on his wheelchair eating breakfast. When asked if he had any concerns, he stated that he has had only one PT treatment and that he should be getting it at least four times a week. R179 also stated that the facility was supposed to provide him with a walker, but until now, they have not provided it. On 01/15/26 at 10:18 AM, record review of R179's EHR noted that he had his PT evaluation on 01/07/26. The PT treatment plan indicated that R179 should be getting PT treatments five times a week for 30 days. R179's PT service logs showed that he did not receive PT treatment on 01/13/25, which would have been his fifth treatment for the week of 01/07-01/13/26. The PT missed visit detail report noted the reason for the missed session was due to dialysis. R179 is getting dialysis treatments three times a week on a Tuesday, Thursday, Saturday schedule. 01/13/26 was a Tuesday, R179's regular scheduled dialysis day. The facility was able to accommodate R179's PT treatments on his other regular scheduled dialysis days the previous week. On 01/14/26 at 1:50 PM, interview with the DOR noted that she was not sure why the PT treatment was not done on 01/13/26 and stated the physical therapist assigned was off that day so she was not available for an interview. 5) On 01/14/26 at 11:03 AM, observed R180 on her wheelchair waiting for lunch. When asked if she had any concerns, R180 voiced that she is not where she wants to be. She elaborated that she is still not able to walk up any steps yet, which she would have to do at home. R180 was told that she would be discharged sometime this week but feels she needs more PT to be able to function at home. On 01/16/2026 at 12:19 PM, record review noted on PT evaluation and treatment plan that resident should be receiving PT treatments five times a week. During week of 01/5-1/10/26, R180 only had four treatments, with 01/10 not being done. The missed treatment rationale indicated cancelled. Interview with the DOR could not elaborate on the reason why it was cancelled and stated Physical Therapist assigned to complete treatment was not available for an interview.

Based on record reviews and staff interview, the facility failed to ensure the risk and benefits of using psychotropic medications were explained and documented for two of five Residents (R) 162 and R181 or their representatives sampled for unnecessary medications. This deficient practice affect's the residents' ability to understand the risks or benefits of treatment. Findings include:1) R162 was a [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to Alzheimer's disease, delirium due to known physiological condition, restlessness and agitation, and dementia.Review of R162's Electronic Health Record (EHR) was done. Cognitive screening was done on 01/05/26 and noted R162 had BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. R162 had orders for Olanzapine (antipsychotic medication) 5 mg (milligrams) and Trazadone (antidepressant medication) 50 mg once a day. Review of the consent form completed on 01/02/26 revealed that verbal consent was obtained for the use of both medications. The consent form did not include the name of the consenting individual, their relationship to the resident and the date consent was obtained and there was no documentation in the progress notes. 2) R181 was an [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services. R181 has a medical history that included, but not limited to, dementia and Alzheimer's disease, and delirium due to known physiological condition.Review of R181's EHR was conducted and noted that R181's BIMS score on 01/08/26 was 3, indicating severe cognitive impairment. R181 had a medication order for Quetiapine (antipsychotic medication) 50 mg at bedtime. Review of the consent form for the antipsychotic medication dated 01/07/26 revealed that verbal consent was obtained, however, the name and relationship to the resident of the consenting individual and date it was obtained were not documented. No progress notes that identified who the facility obtained consent from were found in the EHR.On 01/16/2026 at 12:26 PM a concurrent interview and record review was conducted with the Resident Care Manager (RCM) 6 at the nurses' station. Reviewed the consent forms for the use of psychotropic medications for both R162 and R181. Queried the RCM who would the facility get consent from if the residents are not able to due to cognitive impairment. RCM said they would ask the family members or authorized representatives to sign the consent. RCM acknowledged that the consents for both R162 and R181 were documented as verbal but does note who gave the verbal consent. RCM added, It's hard to validate if the name is not there, staff must type the name in the consent form. Review of the facility policy titled Use of Psychotropic Medications(s) with a revision date of 02/13/25 stated, .Prior to initiating or increasing psychotropic medication, the resident/guest, family, and/or resident/guest representative must be informed of the benefits, risks and alternatives for the medication .

Based on observations, interviews, and record review, the facility failed to develop a plan of care to include oxygen (O2) therapy for one of two Resident's (R) 178 sampled for O2 therapy; and failed to implement the care plan for bilateral heel protectors for one of one resident, R173 sampled for having bilateral lower extremity (BLE) edema and cellulitis. This deficient practice puts the residents at risk for not achieving their treatment goals.Findings Include:On 01/13/26 at 10:40 AM, observed R178 with 02 at one liter (L) via nasal cannula (NC). R178 said the 02 is helping him with his breathing but feels he would be ok without it. R178 was admitted on [DATE] with a primary diagnosis of postprocedural complications and disorders of the digestive system and has a history of diaphragmatic hernia. On 01/13/26 at 1:30 PM, observed R178 without 02 and no signs or symptoms of respiratory distress. On 01/14/26 at 09:00 AM, observed R178 with 02 at 1L via NC, but denied having any breathing issues.On 01/14/2026 at 10:00 AM, record review of R178's Electronic Health Record (EHR) noted a physician's order for continuous O2 supplementation 1-4 liters per minute (LPM) via NC for shortness of breath (SOB) or Sp02 (oxygen concentration) <90%, dated 01/12/26. On 01/14/26 noted orders to wean O2 as tolerated every shift. Review of R173's care plan did not include any problems, goals, and interventions for O2 therapy.On 01/16/26 at 08:30 AM, interview with Assistant Director of Nursing (ADON) confirmed that there was no O2 therapy in R178's care plan and that it should have been included. The ADON also acknowledged that the care plan is important as it directs the care provided to the residents. Review of the facility's Oxygen Administration policy, dated 10/01/2024, on 01/16/26, in the Procedures section, it notes, 16. The resident's care plan will identify the interventions of oxygen therapy, based upon the resident's assessment and orders.2) 01/14/2026 9:48 AM, observed R173 in bed with BLE edema, redness, and dry scaly skin. BLE exposed with no socks or heel protectors applied. R173 stated her skin is very sensitive and complained of pain at an 8 out of 10 on the pain scale. She said they have been giving her pain meds with relief and applying cream every day for the dryness. At 11:00 AM, observed R173 in bed, with BLE still exposed and no heel protectors applied.At 2:50 PM, observed R173 in bed, with BLE still exposed and no heel protectors applied.At 3:00 PM, record review of R173's EHR noted physician's orders to have bilateral heel protectors in place. Review of the care plan noted to ensure heels are offloaded by floating heels while in bed.AT 2:57 PM, interview with Registered Nurse (RN) 1 confirmed that the heel protectors should have been reapplied to R173's feet after her physical therapy (PT) and shower. RN1 acknowledged that this is to protect resident from further skin breakdown. On 01/16/26 at 01:00 PM, review of the facility's Comprehensive Care Plan policy, dated 10/01/24, in the Policy Statement it notes, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident/guest.that includes measurable objectives and timeframes to meet a resident/guest's medical, nursing,.that are identified in the resident/guest's comprehensive assessment.

The facility failed to securely store a medication patch for one of one resident sampled for medication storage; and 2) discard a medication injectable for a resident who was no longer residing in the facility in one medication room of two medication rooms sampled; and 3) label a medication bottle without an open date in one medication cart of six carts in the sample. The deficient practice increases the risk of a medication diversion.Findings include: During an observation in Resident (R) 58's room on 01/14/2026 at 09:12 AM, an opened and labeled lidocaine patch was placed on the resident's mattress at the foot of the bed. R58 was lying in bed awake. Asked R58 if she is having any pain and she said, not now. I did have pain earlier. At 09:23 AM asked Licensed Practice Nurse (LPN) 30 if R58 was supposed to get a lidocaine patch during the medication rounds. LPN30 looked in the Electronic Health Record (EHR) and said oh no, I went into the room to put it on then I got called out of the room for something else and forgot to go back and put it on. I should have put it on first. 2) Observation on 01/15/2026 at 08:20 AM in the Fifth-floor medication room with the Infection Preventionist (IP). Inspection of the medication refrigerator revealed an insulin pen. Review of the label revealed Toujeo Max Solostar (Insulin), the label appeared worn and the name of the resident was not legible. Asked the IP if she could identify the name of the resident and if so, if they were still residing in the facility. The IP looked in the EHR for the resident and said she thought they were discharged and would get back to the surveyor. At 09:35 AM the IP confirmed the resident was discharged and the insulin pen should have been discarded. 3) On 01/15/26 at 08:31 AM, concurrent inspection of medication cart two and interview with LPN3 was done. Observed an opened, one-quart bottle of Lactulose (prescription laxative) in the third drawer of the medication cart. The bottle was approximately two-thirds full, and open date was not noted on the bottle. LPN3 acknowledged that the bottle did not have an open date and added it should have been written on the bottle. Queried LPN3 how long are the medications good after opening. LPN3 responded, It is good for one year after opening but would not be able to tell if there is not an open date.

Based on observations, interviews, and record review, the facility failed to ensure that one of one resident sampled for quality of care received treatment and care in accordance with professional standards of practice and the comprehensive care plan.Findings Include:On 01/14/26 at 09:55 AM, observed Resident (R) 173 in bed with oxygen (O2) on 3L (liter) via nasal cannula (NC). R173 stated her breathing was okay and she had no shortness of breath (SOB), despite having a moist cough.Record review of R173's Electronic Health Record (EHR) on 01/14/26, noted a physician's order for continuous O2 at 1-2 LPM (liters per minute) via NC, Sp02 (oxygen concentration) goal: 88-92%, and to notify Physician (MD) if condition worsens or if requiring additional O2. Review of the progress notes did not indicate the need for O2 to be increased to 3L. During an interview with RN1 on 01/14/26 at 12:30 PM, RN1 verified that R173's 02 was set on 3L. Requested RN1 to review R173's O2 orders in the medical record. RN1 confirmed the current order is 1-2L and there were no orders to increase O2 level to 3L. RN1 stated that the evening shift RN2 endorsed to her that R173's O2 level be on 3L but confirmed that there was no documentation in the progress notes by RN2 of R173 needing to increase O2 level. RN1 also acknowledged that there was no physician notification made to increase O2 level and verbalized the importance of documentation and notifying the physician of any changes to the resident's status.Facility's Oxygen Administration policy dated 10/01/2024 was reviewed on 01/16/26. In the Policy Statement section, it notes, Oxygen is administered to a resident who needs it, consistent with professional standards of practice, the comprehensive care plan. In the Procedure section, it notes, 6. Notify the physician of any changes in the resident's condition, including significant changes in.oxygen concentration.16. The resident's care plan will identify the interventions for oxygen therapy, based on the resident's assessment and orders. Review of the facility's Change in a Resident's Condition or Status policy, dated 12/01/2024, in the Policy Statement section, it notes, This facility's policy is to promptly notify.Attending Physician.of changes in the resident's/guest's medical/mental condition and/or status. In the Procedure section, it notes, The nurse will notify the resident's/guest's Attending Physician or physician on call when there has been I. Specific instruction to notify the Physician of changes in the resident's/guest's condition.2.A significant change of condition is a major decline.the resident's/guest's status that: requires interdisciplinary team review and/or revision to the care plan. Review of the facility's Documentation in Medical Record policy with a revision date of 03/18/2025, in the Policy Statement in notes, Each resident/guest's medical record shall contain an accurate representation of the actual experiences of the resident/guest and include enough information to provide a picture of the resident/guest's progress through complete, accurate, timely documentation. In the Procedures section, it notes, 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care serviced occurred.

Based on observation, interview and record reviews, the facility failed to ensure the indwelling urinary catheter bag was placed in a sanitary position off the floor for one Resident (R) 65 sampled with an indwelling urinary catheter. The deficient practice increased R65's risk of preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter. Findings include:On 01/13/26 at 12:26 PM, observed R65 lying in bed with his eyes closed. R65 was using an air mattress and had an indwelling urinary catheter. R65's bed was set at the lowest setting. The urinary catheter line was connected to a urine collection bag on the left side of the bed. The urinary catheter line and urine collection bag were on the floor. Registered Nurse (RN) 9 was in the hallway by the medication cart. Asked RN9 to check on R65's urine collection bag. RN9 confirmed that the bag was on the floor and that it was supposed to be placed in a basin to act as a barrier so that it is not touching the floor.Review of R65's Electronic Health Record (EHR) conducted. R65 was a [AGE] year-old resident admitted for short-term rehabilitation services. Diagnoses included, but not limited to, sepsis (a life-threatening, emergency response to infection where the immune system damages the body's own tissues and organs), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and urinary tract infection. Review of the care plan dated 12/07/25 noted one of the interventions for the indwelling urinary catheter stated, Do not allow tubing or any part of the drainage system to touch the floor.Review of the facility policy titled Indwelling Urinary Catheter Care with a revision date of 10/05/25 stated, . Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review, the facility failed to ensure two of three residents sampled for accidents were free from accidents. Resident (R) 185 had a fall and R58 received a skin tear when transferred with a mechanical device to a wheelchair. The deficient practice placed the residents at risk for injury. Findings include: During an observation of R58 in her room and interview with family members (FM) 1 and FM2 who were at the bedside on 01/14/2026 at 11:55 AM assisting R58 to eat lunch. FM1 stated that the staff need to be more careful when they use the Hoyer lift to transfer R58 because her skin tears easily. She has had problems with skin tears, and it happens when she is transferred. Observed R58 with the Geri sleeves on both of her arms. Reviewed the Resident Grievance/ Complaint Form dated 7/22/25. The FM stated that one Certified Nurse Aide (CNA) was being too fast during guests transfer from bed to wheelchair. The CNA stated she was only holding the Hoyer sling to help navigate the guest's position during the transfer. Corrective action was taken and FM1 was reassured that the staff mentioned will be educated on proper handling when transferring guests. Performance correction notification form reviewed. Verbal correction provided to the CNA on 07/22/25. Resolved on 07/22/25. Electronic Health Record (EHR) reviewed for R58 on 01/14/26. R58 is an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis includes and is not limited to unspecified dementia, Hemiplegia and hemiparesis (weakness on one side) following cerebral infarction (stroke) affecting right dominant side. Nursing progress note dated 01/12/26 at 11:39 AM reviewed. Skin tear to left elbow noted after transferring back to bed. 1 by 0.7 centimeters (cm). Normal Saline (NS), Medi-honey and dry dressing applied. Family made aware, no concerned (sp) verbalized at this time. Physician (MD) made aware via MD binder. Interview with Registered Nurse (RN) 55 on 01/16/2026 at 1:03 PM in the third-floor medication room. Asked about the shower schedule for R58 and what the nursing staff are doing to prevent skin tears during transfers to the wheelchair. RN55 said the CNA's have a schedule for R58's ADL's, her showers are four times per week. We have the preventions in place; she wears the Geri sleeves. Most of the time when transferring her with the Hoyer lift, she screams, it's her behavior. During an interview with the Director of Nursing (DON) on 01/16/2026 at 1:17 PM. Asked him about the care plan interventions for R58's Activities of Daily Living (ADL's) and asked him what the nursing staff are doing to address her hand hygiene and her most recent skin tears. The DON responded that they have made a lot of considerations for R58 at the request of the family. We have increased her shower schedule from 3 times per week to 4 times per week at the request of the family. We are considering trimming her nails. The DON later confirmed that the family was called to inquire about having R58's nails trimmed and declined to have the staff trim them. 2) On 10/16/25 at 4:00 PM, the Department of Health, Office of Healthcare Assurance (OHCA) received a complaint from R185's FM3 that R185 sustained a fall at the facility on 10/03/25. R185 was sent to the hospital post fall and admitted with a diagnosis of a mild fracture of L2 (lumbar 2) that was worsened by the fall. FM3 was contacted by the Charge Nurse (CN) 1 and was told that R185 was up in the wheelchair (w/c) in the hallway for lunch and that resident was left unattended due to CN1 and Certified Nurse Aide (CNA)1 was the only two people on the floor and they were busy assisting another resident. On 01/16/26 at 08:00 AM, record review of R185's EHR was conducted. R185 is a [AGE] year-old female that was admitted on [DATE] to the facility with primary diagnosis of other fracture of second lumbar vertebra, with a history of first lumbar vertebra but not limited to, syncope, and unspecified dementia. R185's care plan noted that she is at risk for falls due to decreased mobility, pain, debility, and advanced dementia. One approach noted in the care plan to address falls was to observe R185 frequently and place her in a supervised area when she is out of bed. Review of the facility's investigation summary and witness statements confirmed that R185 was placed in the hallway in her w/c for the afternoon meal with other residents. According to CN1's witness statement dated 10/6/25, R185 was last seen by CNA1 at 16:40 PM. At about 16:45 PM, CN1 was inside the Resident Care Manager's (RCM) office when they heard a visitor from 225A rushing to help R185. Per visitor R185 was found on the floor on her left side curled up. On 01/16/26 at 09:30 AM, interview with CN1 confirmed her statement and acknowledged that R185 was a high risk for fall due to her dementia and should not have been left alone or unsupervised. CN1 stated that prior to her meeting with RCM, CNA1 was in the hallway watching R185 and other residents. CNA1 proceeded to help another resident in their room, thus leaving R185 unsupervised in the hallway. When asked if this fall could have been prevented, CN1 responded yes and that CNA1 should have called for help before leaving hallway and losing sight over R185 and the other residents. CN1 further stated that CNA1 is a part-timer and was not familiar with the residents on the second floor. On 01/16/26 at 1:30 PM, review of the facility's Fall Prevention and Management Program Guidelines, in the Key Elements of the Fall Prevention and Management Program, it notes, E. Re-assessment, implementation and evaluation of treatment plan. In the Details of Key Elements section E of the Dynamic Treatment Plan, it states, 2. As information is updated, it needs to be communicated to the staff.a. Staff. 3. Individual care plan developed, communicated with staff and implemented.

Based on interviews and record reviews, the facility failed to notify the physician that two of three residents (R)1, and R2 sampled had a change of condition that required administration of oxygen. The deficient practice of not notifying the physician of a change of condition could affect any resident, and places them at risk for not getting the appropriate treatment that may result in a negative outcome. Findings include:R1's electronic medical record (EMR) reviewed. R1 was an [AGE] year-old male admitted to the facility on [DATE] for rehabilitation after hospitalization for an acute stroke. As a result of his stroke, he had dysphagia (difficulty swallowing), expressive aphasia (communication disorder due to stroke that affects person's ability to speak, write, and understand). R1 had mild cognitive impairment and was alert and oriented (A&O) x1 (aware who he was, but not aware of location, time, or situation), was dependent on staff for all activities of daily living and required 1:1 feeding assistance. R1 had an order for Difficulty breathing: Oxygen (O2) 1-4 LPM (liters per minute) via nasal cannula for SOB (shortness of breath) or SpO2 <90% (peripheral capillary oxygen saturation measuring percentage of oxygen in the blood. (Normal 95%-100%)); Frequency as needed (PRN). Review of R1's nursing notes revealed R1 did not have any difficulty breathing or signs/symptoms (i.e. wheezing, low oxygen saturation level) that would indicate the need for oxygen, until 09/15/25. On 09/15/25 nursing note charted at 09:53 PM read: .Guest had SOB around 15:30 (03:30 PM), O2 (Sp02) 87-89 (%), breathing even and unlabored, lung sounds clear, applied Oxygen 2L, O2 92-94%, did routine checks on guest, O2 was 97-98%, started to wean guest off oxygen by going to 1L, O2 94-95%, breathing even and unlabored. Endorsed to oncoming noc (night) shift nurse. There was no documentation that R1's Provider was notified of this change of condition that required prn oxygen administration. In addition, there was no documentation how long R1 required the oxygen. On 10/09/25 at 01:00 PM, during an interview with the Director of Nursing (DON), after review of R1's records, he said he could not determine when R1 was taken off the oxygen on 09/16/2025, and that there was no documentation the physician was notified. The DON confirmed this met the criteria for a condition change, and the provider should have been notified. Interview with Registered Nurse (RN) 1 on 10/09/25 at 10:30 AM revealed that the facility uses a binder (communication book) to write notes in, to inform the Providers (Physicians and Advance Practice Registered Nurse (APRN)) of non-emergent concerns and needs for the residents, i.e. medical appointments, increase and decrease in medication dosage and things that can be addressed the next day. RN1 said this decreased the number of calls made to physicians/APRNS. It is utilized by the nurses, physicians, APRNs, Speech Therapist (ST), Occupational Therapist (OT), and Physical Therapist (PT). The RNs are to check this communication book at the beginning of their shift and if they need clarification on what has been noted, they will call the respective disciplines. RN1 further stated that physicians will look at the book on a Monday, Wednesday, Friday, the days they are scheduled to see their assigned residents and document their responses. The APRNs are scheduled on the Tuesday, Thursday schedule. RN1 noted that there are no physicians/APRNs that come on the weekends, so if there are any issues that come up and cannot wait till the following Monday, they would page the on-call physician. Record review of the facility's communication book on 10/09/25 at 01:30 PM noted that on 09/27/25 (Saturday, time not specified) R2 complained of shortness of breath (SOB). RN 2 assessed R2's lungs and noted them to be clear to auscultation bilaterally and oxygen saturation (SPO2) at 96%. RN2 elevated head of bed and administered oxygen at one liter (L) with positive effect and SPO2 increased to 98%. Physician's response in the MD's response column of the communication book noted ok (time and reviewed date not indicated).Record review of R2's EMR on 10/09/25 at 01:45 PM revealed the nursing progress notes had no documentation of R2's complaints of having shortness of breath on 09/27/25, and no documentation of notification to the on-call physician. There was no previous documentation noted of R2's complaints of having any SOB. A Physician's order was entered on 09/21/25 for Oxygen 1-4 L via nasal cannula for SOB or SPO2<90%, with special instructions to notify MD if 02 is applied or increased.Interview with the DON on 10/09/25 at 02:00 PM confirmed the order to notify MD and said for resident's who required 02 for the first time, a call to the physician should have been made, including at night, when the O2 was needed and administered, as it is considered a change in condition. The facility's Change in a Resident's Condition or Status policy, with a revised date of 05/19/23 was reviewed on 10/09/25. It notes The facility shall notify resident, his or her Attending Physician.of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a .d. significant change in the resident's physical.condition.e. need to alter the resident's medical treatment.2. A significant change.a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Based on medical record review, document review and interviews, the facility failed to ensure the medical records of three Resident's (R)1, R2 and R3 were complete and accurate. 1) R1 and R2's records did not include complete, accurate documentation of oxygen administration. 2) R1's records included a nursing progress note of an assessment on a different resident and in error, entered into the wrong record. 3) R3's discharge notice included inaccurate information regarding her current condition.Findings include:R1's electronic medical record reviewed (EMR). R1 was an [AGE] year-old male admitted to the facility on [DATE] for rehabilitation after hospitalization for an acute stroke. As a result of his stroke, he had dysphagia (difficulty swallowing), expressive aphasia (communication disorder due to stroke that affects person's ability to speak, write, and understand). R1 had mild cognitive impairment and was A&O1x (aware who he was, but not aware of location, time, or situation), was dependent on staff for all activities of daily living and required 1:1 feeding assistance. Review of R1's nursing progress notes revealed the following entry on 09/13/25 at 10:01 PM: Guest was admitted for PT/OT (physical/occupational therapy), primary diagnosis (Dx): Acute cholecystitis (inflammation of the gallbladder), abdominal pain RUQ (right upper quadrant) and RLQ (right lower quadrant), acute cystitis (inflammation of bladder) without hematuria, respiratory Acidosis pacemaker .Guest is alert and oriented x4.she is able to eat independently . was entered into R1's electronic medical record (EMR) in error, which was not identified prior to the survey. R1 had an order for Difficulty breathing: Oxygen (O2) 1-4 LPM (liters per minute) via nasal cannula for SOB (shortness of breath) or SpO2 <90% (peripheral capillary oxygen saturation measuring percentage of oxygen in the blood. (Normal 95%-100%)); Frequency as needed (PRN). Review of R1's nursing notes revealed R1 did not have any difficulty breathing or signs/symptoms (i.e. wheezing, low oxygen saturation level) that would indicate the need for oxygen, until 09/15/25. Further review revealed the facility utilized three separate methods to document the administration of oxygen for R1, (nursing notes, vitals Report, and respiratory Administration Record.) Review of these documents revealed they are not systematically organized and did not provide accurate documentation of oxygen use. The notes included following: Nursing note findings: On 09/15/25 nursing note charted at 09:53 PM read: .Guest had SOB around 15:30 (03:30 PM), O2 (Sp02) 87-89 (%), breathing even and unlabored, lung sounds clear, applied Oxygen 2L, O2 92-94%, did routine checks on guest, O2 was 97-98%, started to wean guest off oxygen by going to 1L, O2 94-95%, breathing even and unlabored. Endorsed to oncoming noc (night) shift nurse. 09/16/25, there was no day shift nursing note. 09/17/25 at 08:01 AM: Late entry: Received guest asleep on 1LPM NC (nasal cannula). O2 was 96% on 1LPM. 09/17/25 at 11:09 PM: Respirations unlabored, SPO2 94-96% on RA (room air) with fluctuations down to 91% while asleep. Lungs CTA (clear to Auscultation). These nursing notes are incomplete because 1) there was no day shift assessment 09/16/25, 2) no lung assessment 09/17/25 day shift, and 3) 09/17/25 at 11:09 PM, it was documented R1 was on RA, but there is no documentation when he was taken off the prn oxygen. Respiratory Administration Record (RAR) reviewed from admission to 09/18/25. This record is for documentation of the PRN administration of oxygen. Page one of the form had three areas per day to document each PRN administration, and page two provides an area to document the date, time and reason/comments for each separate use. Review of the RAR revealed one entry on page 1 for prn administration on 09/16/2025, charted time 22:47 (10:47 PM). Page 2 included the following two entries: PRN 1 Reason: SOB (shortness of breath) around 15:30 (03:30 PM), administered O2 (oxygen) @ 15:40 (3:40 PM) for 2LPM PRN 1 Result-Follow-up: Effective. Comment: guest O2 95-97% on 2L wean to 1L O2 94-95%. This document does not coincide with nurse's notes, which indicated the first PRN O2 was administered on 09/15/25. The Vitals Report should include O2 Saturation % and note if oxygen is being administered. Reviewed the report from 09/15/2025 to 09/18/2025, which included the following entries: 09/15/2025 at 16:51-17:20 (04:51 PM-05:20 PM): Vitals taken, but did not include O2 saturation, or if R1 was on oxygen. Per nurse notes, placed on O2 at approximately 03:30 PM 09/16/2025 00:55 AM: O2 Saturation 93% Oxygen Use: No. 09/16/2025 10:32 AM: O2 Saturation 97% Oxygen Use: No. 09/16/2025 03:38 PM: O2 Saturation 97% Oxygen Use: No. 09/16/2025 10:43 PM: O2 Saturation 87% Oxygen Use: No. 09/16/2025 10:52 PM: O2 Saturation 91% Oxygen Use: Yes - Liter flow 1 09/17/2025 07:01 AM: O2 Saturation 96% Oxygen Use: Yes - Liter flow 1 09/17/2025 02:40 PM: O2 Saturation 94% Oxygen Use: No. The Vitals Report did not include the prn O2 noted in progress note 09/15/25 a 03:30 PM. It also indicated R1 was not on O2 the day or evening shift of 09/16/25, until 10:52 PM. This would mean the O2 was removed after the initial administration on 09/15/25 and required a second prn administration, which is not clearly reflected in documentation. On 10/09/25 at 12:30 PM, during an interview with the Resident Care Manager (RCM), discussed and reviewed R1's documentation of oxygen administration. At that time, she said the nursing staff should document an assessment before and after oxygen administration in nurse notes. She went on to say when a PRN order for oxygen is used, it is considered a change of condition and would trigger alert charting, which requires staff to document a focused assessment every shift related to oxygen administration and lung assessment. The RCM confirmed there was no day shift assessment on 09/16/2025 and the documentation in the three areas (i.e. forms) of the chart did not provide the information needed to determine the accurate use of the prn oxygen. On 10/09/25 at 01:00 PM, during an interview with the Director of Nursing (DON), after review of R1's records, he said he could not determine when R1 was taken off the oxygen on 09/16/2025. He confirmed the Vitals Record should include the oxygen and O2 saturation, if it is being administered when the vitals are taken. The DON agreed the records were incomplete. 2) Review of the facility's unit communication book (binder located on the unit) revealed an entry on 09/27/25 (Saturday, time not specified) R2 complained of SOB. Registered Nurse (RN) 2 assessed lungs and noted it to be clear to auscultation bilaterally and oxygen saturation at 96%. RN elevated head of bed and administered oxygen at one liter with positive effect and SPO2 increased to 98%. Physician's response in the MD's response column of the book noted ok (time and date reviewed not indicated).Record review of R2's Nursing Notes revealed there were no progress notes entered by RN2 of R2's complaints of SOB on 09/27/25. The nursing progress notes documented on 09/27/25 at 00:07 AM stated Guest alert and oriented x2, slurred speech, left facial drooping. Breathing even and unlabored, denied SOB (shortness of breath)/chest pain.SPO2 at 92% at RA (Room Air) entered by RN3.Interview with DON on 10/09/25 at 02:00 PM confirmed that RN2 should have documented in the progress notes R2's complaint of SOB and application of 02. 3) On 09/30/25 at 11:30 AM, the State Agency received a complaint from R3's family member (FM)1. In the complaint FM1 noted that the facility shutoff R3's health care insurance and then a week later got a Notice of Discharge from Administrator indicating that R3 was well enough to go home. FM1 also stated that on the Notice of Discharge, it noted the residents' health has improved sufficiently so the resident no longer needs services.Review of the Notice of Resident Discharge/Transfer Form furnished to FM1 on 10/07/25 at 10:00 AM noted in the discharge/transfer to section indicated: Home. The option marked for discharge reason was The discharge/transfer is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.Initial PT assessment notes from 09/18/24-10/17/24 noted that R3's mobility score was =1 (ranges from 0-12, 12 being the highest function). R2 was also noted to be able to understand the ability to express ideas and wants and follows 1-step directions independently, had the decision-making ability for routine activities and was independent in cognition. In the PT certification period from 04/21/25-06/01/25, R3's mobility score =2, with LE ROM (lower extremity range of motion) impaired, RLE ROM (right lower extremity range of motion) with severe pain. R3 was noted to only sometimes have the ability to express ideas and wants, sometimes understands the ability to understand others, and for 1-step directions, R3 needed prompts and cues, and cognition was severely impaired. PT discharge recommendations/status was Skilled Nursing Facility (SNF).Initial OT certification period from 09/18/24-10/17/24, noted R3's Self-care function score at 10 (ranges from 0-12, 12 being the highest function) with R3's decision making ability for routines activities to be independent. In the OT certification period notes from 04/21/25-06/01/25, R2's self-care score decreased to 4, with decision making ability for routine activities to be severely impaired. OT discharge recommendations/status was SNF.Interview with the Social Worker (SW) on 10/07/25 at 01:25 PM in her office confirmed that they had been working with R3's family to find long-term care (LTC) placement, but due to various reasons i.e. bed availability and family preference, they had not been successful. SW also agreed that LTC placement would be the best option for R3, as her condition had not improved. Interviewed the Administrator on 10/07/25 at 02:50 PM, at which time she disclosed that she generated the Notice of Resident Discharge form to expedite the discharge process for R3, as it has been a year of ongoing discharge planning. Administrator noted that she entered Home because it is what FM2 wanted but felt that the resident's needs would be better taken care of in a LTC facility, and that it was not safe for R3 to be discharged home. Administrator was also unsure of what to mark for discharge reason but marked The discharge/transfer is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, despite knowing that the R3's health condition had not improved but declined from baseline. She agreed it did not accurately reflect R3's condition. Reviewed the facility's Documentation policy on 10/08/25 at 10:00 AM, which noted, Medical records documentation primarily is a means of communication. and serves as a legal document.Documentation must be timely, accurate, objective, thorough, and complete, and must present the appropriate facts to substantiate the following requirements.1.Clearly reflects the condition of the patient, 2.Clearly reflects the skilled services provided.

Based on interviews and record review, the facility failed to ensure the nursing staff provided the standard of quality care to one of three Residents (R)1 sampled. 1.) R1 had a peripheral intravenous access (PIV) in his right arm for three days, with no order. 2) Staff used R1's hospital weight as his baseline weight upon admission, and 3) Licensed Staff (LS)4 did not document a neurological assessment and monitoring as required, to ensure there was no change of condition. The deficient practice placed R1 at an increased risk of infection at the catheter site; an increased the risk of his nutritional needs not being met; and an increased risk of acquiring an unidentified medical condition that may result in a negative outcome. Findings include:R1's electronic medical record (EMR) reviewed. R1 was an [AGE] year-old male admitted to the facility on [DATE] for Physical and Occupational Therapy after hospitalization for a stroke. As a result of his stroke, he had dysphagia (difficulty swallowing), and expressive aphasia (communication disorder that affects the ability to speak, write, and understand). R1 had mild cognitive impairment and was alert and oriented (A&O) x1 (aware who he was, but not aware of location, time, or situation). He was dependent on staff for all activities of daily living, required 1:1 feeding assistance and was at risk for malnutrition and dehydration. Review of R1's nursing progress notes revealed an entry recorded as Late Entry on 09/06/2025 at 08:02 AM. Guest was newly admitted on [DATE] .Received him asleep in bed with even and unlabored respirations. Guest made a moaning sound when I tried to wake him, but he never opened his eyes. Unable to do final Glasgow Coma Scale or CVA (stroke) Neurocheck (neurological assessment) under Observations (location in record details). Note left in MD binder (used to communicate non urgent information to providers).Frequent visual checks and rounding for added safety. (No time documented in the note). The next progress note entry was 05:22 PM that day. No documentation found about R1's condition on rounding, or evidence that the licensed staff attempted to reassess R1's neurological status during the shift after he was unable to be woken. During an interview with the Director of Nursing (DON) on 09/17/25 at 01:15 PM, he said the facility had developed a stroke program, and all staff were required to attend education on the care of Residents post stroke. The DON agreed the neuro assessment should have been completed and documented. Reviewed the content of the stroke education provided by the DON, which included the three components of the Glasgow Coma Scale; motor, verbal and eye opening, and directed staff to Don't be afraid to stimulate these patients, describe what you see .Be vigilant to changes, Recognize subtle clues . 2) On 09/03/25 at 11:18 AM, RN6 completed the admission assessment (admission Observation), which included in the Skin Status section that R1 had a RUA IV (catheter for peripheral intravenous (PIV)) for the administration of fluids in the right upper arm). On 09/05/25 at 07:10 AM, RN7 documented .the aide found that guest had pulled out his R PIV. Guest bleeding from his arm. Cleansed w/NS (with normal saline) and applied gauze . Reviewed R1's orders, which revealed there was no order for the PIV.3) Reviewed R1's admission assessment, where Facility Staff (FS)4 documented R1's weight on 09/02/25 at 09:00 PM as 195.8 pounds (lbs.). Reviewed Vitals Report, that documented on 09/03/2025 at 11:09 PM, his weight was 174.8 lbs. (21 lb. loss), and on 09/04/25 at 09:38 PM, the weight was 156.8 lbs. (39 lb. total weight loss since admission). There was no repeat weight to confirm accuracy and there was no documentation either day that Nursing Staff or the Provider was notified. Reviewed the Observation Detail List Report, Nutrition admission Assessment recorded on 09/08/25 at 02:38 PM. The report included Questionable wts. (weights) of 156.8# and 195# on 9/4/25 and 9/2/25 not used d/t (due to) wt. error. Son made aware of wt. discrepancy; son states likely error d/t guest's UBW (usual body weight) 180-185#. Daily weights requested for closer monitoring.On 10/09/25 at approximately 01:00 PM, interviewed Facility Staff (FS) 4 in the conference room. At that time reviewed R1's medical records and FS4 confirmed he/she documented the admission weight of 195.8 lbs. FS4 said he/she had been told by the nurse on duty to take the weight off the hospital records and record as the admission weight. On 10/09/2025 at approximately 01:15 PM, interviewed the DON, who said the facility policy and expectation was to take the admission weight on the facility scale. He also said if there was a significant loss like this, the staff should repeat the weight to ensure accuracy and report the loss to the nursing staff.

Based on an interview and record review, the facility failed to identify and report a medication error to the Administrator or Director of Nursing (DON) for review and appropriate action as required by facility policy. Resident (R) 1 was ordered Lisinopril (to treat high blood pressure) 2.5 mg (milligrams) orally and hold the medication if the resident's Systolic Blood Pressure (SBP) was less than 120 millimeters (mm) of mercury (Hg). Although R1's SBP was documented as 113 mm Hg, the Lisinopril was administered, when it should have been held. Findings Include: R1's Electronic Medical Record (EMR) reviewed on 10/09/25. The physician orders documented an order for Lisinopril 2.5 mg, to be given once an evening, hold for systolic blood pressure (SBP) less than 120 (started on 09/03/25, ended 09/16/25). R1's September 2025 Medication Administration Record (MAR) reviewed. On 09/12/25 R1's SBP was documented to be 113, lower than the required parameter for administering the medication. The medication order was not followed, and the resident was administered Lisinopril 2.5 mg. On 10/09/25 at 11:15 AM, conducted an interview and concurrent review of R1's MAR for 09/12/25 with the DON. He confirmed R1's SBP was 113 and the Lisinopril should have been held. Also, the DON confirmed the facility did not identify this medication error prior to this interview and no report was done.

Based on interview and record review, the facility failed to ensure safe handling and disposal of a soiled bed pad/brief for one Resident (R)1. R1 was transferred to the hospital from the facility on 09/18/25. The resident's belongings were collected from R1's room, bagged, and placed at the nursing station until it was picked up by R1's Family Member (FM)3 on 09/22/25. FM3 discovered a soiled bed pad/brief in a bag marked as the resident's belongings. Findings Include: On 09/25/25 at 07:50 PM, the State Agency (SA) received a complaint via email that a soiled (with urine and feces) bed pad/ brief was found in a bag given to them as part of the resident's belongings. The bag was labeled with R1's name and room number. Pictures of all the resident's belongings bags (five bags; one gift bag with a balloon, two blue personal belongings bags, and two clear bags). In a picture (P1), in one of two Clear Bags (CB)1, any reasonable person could identify blue material (bed pad/brief), inside the bag just by looking at it. A second picture (P2) documented the inside of CB1, which contained a visibly soiled item with brown material (feces/urine) at the bottom of the bag. On 10/08/25 at 11:42 AM conducted a concurrent interview and observation of R1's assigned room with Certified Nurse Aide (CNA)45 and CNA3. Both staff confirmed they packed all of the resident's belonging in bags and placed it in the nursing station for the resident's family.On 10/08/25 at 01:40 PM, conducted an interview and review of the picture of the bags with CNA45. Showed CNA45 P1, then inquired if staff recognized the bags as R1's belongings. CNA45 confirmed and recognized all five bags mentioned above as R1's belongings. CNA45 attested to packing the two blues belonging bags but confirmed he/she did not pack any clear bags. On 10/08/25 at 01:43 PM, conducted an interview and review of the picture of the bags with CNA3. CNA3 reviewed P1 and confirmed all five bags in the pictures were identified as R1's belongings. Inquired with CNA3 about the clear bag (with the bed pads visible at the bottom). CNA3 confirmed bed pads were visible at the bottom and identified R1's boots at the top of CB1. CNA3 could not recall which bags he/she packed but insisted that he/she would not have knowingly put the resident's belongings in with a soiled bed pad/brief. On 10/08/25 at 02:03 PM, conducted an interview and review of facility video surveillance with the Administrator and two other surveyors present. The Administrator presented video surveillance of the Unit Clerk (UC) handing off R1's belonging to FM3. In the video, FM3 and UC are seen looking through two of the blue belongings bag and did not look through CB1 identified in P1, which contained the soiled bed pad/brief.Reviewed CB1, P1, and P2 with the Administrator. Administrator confirmed bed pads/ briefs, and the protection boots are visible through CB1, and that same bag was in the video as part of R1's belongings sent home with FM3. Also, the Administrator confirmed the bed pad/briefs were soiled. After reviewing the video surveillance and pictures, the Administrator confirmed the bag which contained soiled bed pads/briefs was given to R1's FM3 as part of the resident's belongings.

Based on observation and interview, the facility failed to ensure the ice and water equipment for the residents were kept in clean and sanitary conditions in accordance with professional standards for food service safety. Residents risk serious complications from foodborne illness as a result of their compromised health status. Unsanitary food handling and/or equipment maintenance practices represent a potential source of pathogen exposure for all residents receiving ice or water on the affected floor. Findings include: On 12/10/24 at 12:15 PM, an inspection of the resident nourishment room on the 4th floor was done. Observed a buildup of hardened brown sediment/material around the bottom edge of the plastic chute dispensing water and ice for the residents. A concurrent interview was done with Registered Dietician (RD)1 who was present in the nourishment room. RD1 stated that Maintenance was responsible to clean the ice and water machine. While RD1 could not say what the brown buildup was or if it was acceptable, RD1 did agree that the ice/water dispenser should be cleaned regularly and confirmed that it was used daily to provide hydration to the residents on the 4th floor. On 12/10/24 at 12:29 PM, interviews were done in the 4th floor nourishment room with Maintenance Associate (MA)2 and the Facilities Coordinator (FC). MA2 stated that he cleans the ice/water dispenser every Saturday, so it had just been cleaned three days ago. When asked to see the maintenance log, MA2 reported that he does not keep a log of the weekly cleaning. Concurrent observations were done with MA2 and FC of the brown buildup on the plastic chute. Both agreed that while calcium deposits could not be entirely avoided, those deposits are white in appearance and did not explain brown sediment. They also agreed that a buildup of brown sediment/material should be avoided.

Based on observation, interview, and record review, the facility failed to identify, support, and honor the preferences of 3 of 11 Residents (R) sampled for Choices. Specifically, the facility failed to honor R60's and R79's preference to be informed of a time range that rehabilitation therapy services would occur and failed to honor R21's preference to be assisted outside periodically for fresh air. As a result of this deficient practice, these residents did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: 1) R60 is a [AGE] year-old female admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of her Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 10/30/24 noted R60 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/10/24 at 04:08 PM, an interview was done with R60 at her bedside. When asked about the right to make choices in her daily life that were important to her, R60 stated that not only does she not get to choose her therapy time, but she is also often not informed when it will happen since there is no scheduled time. R60 stated that she informed the facility from the beginning that she likes to go to therapy before lunch. She feels more energized in the morning and wants to do therapy before she is tired out from the day. R60 explained that at times the therapists will come in at 03:00 PM, with no prior notice that they were coming, and she has to tell them no because she simply does not have the energy. R60 reported that it is very upsetting to not know when therapy will happen. A review of R60's comprehensive care plan (CP) revealed the following: Resident has DX: [diagnosis of] Anemia and is at increased risk for activity intolerance . Adjust the intensity of activities to accommodate energy level and tolerance. Resident has depressed mood over current medical conditions . Allow resident to have control over situations, if possible. [R60] . has a preference to plan her own daily activities of their choice . Also noted during the review that there was no care plan created for her therapy preferences prior to 12/10/24. On 12/13/24 at 01:01 PM, an interview was done with the Director of Rehabilitation (DOR) in her office. During a concurrent review of R60's electronic health record (EHR), DOR confirmed that there was documentation that R60 had notified the therapy team on 11/06/24 that she preferred to have therapy in the morning only. DOR stated that in general, there is no schedule for when therapy will happen, but if a resident states their preference to be informed or for a particular time, the therapy team can work with the resident to create a schedule. DOR acknowledged that prior to 12/13/24, the team had not developed a therapy schedule for R60, despite her communicated preferences. 2) R79 is a [AGE] year-old male admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of his MDS Admission Assessment with an ARD of 10/29/24 noted R79 was determined to have a BIMS score of 15, indicating no cognitive impairment. On 12/11/24 at 09:15 AM, an interview was done with R79 at his bedside. During the interview, a therapist popped his head in to inform R79 that he would be having therapy soon. After the therapist left, R79 expressed how frustrating it is that he never knows when therapy will show up. Stated he would like to be informed earlier what time they will be coming by so that he can prepare himself. On 12/13/24 at 10:53 AM, an interview was done with Resident Care Manager (RCM)4 in the 4th floor activity room. RCM4 confirmed that she does receive a lot of complaints from residents wanting to know what time they will be having therapy. Stated that when she receives a complaint, she lets the therapy team know. A review of R79's CP noted no care plan created regarding therapy preferences. 3) R21 is a [AGE] year-old male admitted to the facility on [DATE] for wound care, therapy, and skilled nursing services. A review of his MDS Admission Assessment with an ARD of 08/07/24 and his Quarterly Assessment with an ARD of 11/03/24 noted R21 was determined to have a BIMS score of 15, indicating no cognitive impairment. On 12/10/24 at 01:59 PM, an interview was done with R21 at his bedside. When asked about the right to make choices in his daily life that were important to him, R21 stated that he is frequently cold and often wishes he could go outside for some fresh air and sunlight. R21 reported that he stays in bed in his room every day and confirmed that the facility has not assisted him in going outside. A review of R21's CP revealed the following care plan, initiated on 08/02/24, identifying R21's activity preferences: [R21] . has a preference to plan his own daily activities . He enjoys . going outside for fresh air .

Based on observation and interview, the facility failed to provide privacy for one resident (Resident (R)274) and failed to protect the confidentiality of another resident's (R113) electronic health record. These failed practices have the potential to negatively impact the psychosocial well-being of the affected residents. Findings Include: 1) On 12/12/24 at 02:30 PM, while exiting the 3rd floor recreation room, made observations into room [ROOM NUMBER] at the end of the hall. Observed Certified Nurse Aide (CNA)3 assisting Resident (R)274 from the bathroom, located just inside the room entrance, back to her bed located next to the window. R274 was wearing a top that ended above her hips and an adult incontinence brief. CNA3 glanced at the State Agency (SA), observing from down the hall, yet neglected to attempt to preserve R274's privacy in any way, such as providing her with a towel or gown to cover, or by closing a door or privacy curtain. On 12/13/24 at 08:29 AM, an interview was done with CNA5 outside R274's room. CNA5 validated that R274 likes to wear only a top with her brief. CNA5 stated that when she assists R274 to the bathroom, she has R274 wear a gown and she will either hold the back of the gown closed for her, or she will shut a door to protect her privacy. On 12/13/24 at 08:40 AM, an interview was done with Resident Care Manager (RCM)5 at the 3rd floor Nurses' Station. RCM5 validated that staff should protect residents from being exposed by either providing a cover up, closing a door, or pulling the privacy curtain. 2) On 12/12/24 at 09:32 AM, an observation was made after exiting the elevator on the 5th floor. The medication cart to the immediate left of the elevators (medication cart #1), in front of room [ROOM NUMBER], had a laptop on it that was open and displaying the electronic health record for Resident (R)113. There were no staff members around the cart. At 09:34 AM, Registered Nurse (RN)8 returned to the medication cart from down the long hall. RN8 acknowledged she should not have left the laptop displaying protected information open and unattended.

Based on record review and interview the facility failed to provide Resident (R)107's completed Interact Nursing Home to Hospital Transfer Form to the hospital R107 was sent to when his condition changed and he became unstable, requiring a transfer and admission to an acute hospital. Findings Include: Record Review (RR) was done of R107's Electronic Health Record (EHR). On 11/17/24 Registered Nurse (RN) 25 documented R107 was sent to the emergency room (ER) because R107 complained of shortness of breath and could not breath and his Oxygen (O2) saturations were in the 70's. R107 was sent to the ER by 911 ambulance. Progress note dated 11/17/24 stated R107 was admitted to the hospital for diagnosis of AFib (Atrial fibrillation (AFib) is an irregular and often very rapid heart rhythm.). On 12/12/24 at 10:59 AM met with and interviewed Resident Care Manager (RCM) 5. Inquired where the documents are kept that were sent to the ER with R107. RCM5 stated the form is under the observation tab and labeled Interact Nursing Home to Hospital Transfer form. During this interview a concurrent RR was performed with RCM5 who confirmed this form was not filled out for this resident when he went to theER on [DATE]. RCM5 agreed this form would normally be filled out and sent with the resident to the hospital. RCM5 stated It's a communication for the change of condition, which includes care at facility along with point of contacts for the resident (R107). On 12/12/24 at 02:31 PM interviewed Registered Nurse (RN)25. Inquired about R107 who was transferred to theER on [DATE]. RN25 stated this was an emergency situation and she sent the resident with other documents the CCD, face sheet, and no POLST because he didn't have one. RN25 also stated she gave report to the hospital ER nurse. Inquired about filling out the form (Interact Nursing Home to Hospital Transfer form) and faxing it to the ER and RN25 confirmed she did not do this, she agreed she could have done this. RN25 stated the form is new, started about two months ago. On 12/13/24 at 08:46 AM met with and interviewed RCM5 and Nurse Educator (NE)1 who stated training on filling out the Interact Nursing Home to Hospital Transfer form is on new hire orientation and throughout the year during huddles. NE1 also explained a binder is left at all the nurse's station for nurses to use as a reference when sending a resident to the ER/hospital. Reviewed huddle rosters and did not see RN25's name on them. Inquired with NE1 and RCM5 if this is a new form and both denied this, NE1 stated the form is new for new staff. Requested for NE1 to check for training date for RN25. On 12/13/24 NE1 left a copy of the In-Service Attendance Record dated 09/13/24 for surveyor. The record stated SEND OUT: please ensure completion of the following: SBAR - Interact Transfer Form (send a copy or fax to ER ASAP if not completed before guest left and roster was signed by RN25. Review of facility provided documents revealed facility provided training to nurses on Transfer to emergency room which states If guest is leaving via 911 you may not have enough time to complete the transfer form. Print all other paperwork and send with guest. You can always fax over the transfer form later (Obtain fax number from ER nurse). In-Service Attendance Record dated 07/22/24 states 4) SENT OUT NOTES: Document provider update, responsible party/ in case of Emergency notification, order, Name of hospital (EMS or AMR transport), sent out Dx (diagnosis), & list of what were sent with guest (EX: MAR, CCP, Transfer Form, POLST etc).

Based on interview and record review, the facility failed to ensure the involvement of one resident (Resident (R)79) in the development of his comprehensive care plan (CP). As a result of this deficient practice, staff did not have all the information necessary to assist R79 in meeting his highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: R79 is a [AGE] year-old male admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of his Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 10/29/24 noted R79 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/11/24 at 09:21 AM, an interview was done with R79 at his bedside. When asked about his participation in his care planning, R79 stated that he had not been invited nor had he participated in any care planning meetings. R79 expressed uncertainty what his current plan of care was, or how much longer he would be staying. Review of R79's electronic health record (EHR) revealed no documentation of an interdisciplinary team (IDT) discussion held since R79's admission. On 12/13/24 at 10:51 AM, an interview and concurrent record review was done with Resident Care Manager (RCM)4 in the 4th floor activity room. When asked about care planning, RCM4 stated that there is usually an IDT meeting done on admission, then once a quarter. RCM4 stated that the meeting and all discussed is usually documented in a progress note that is recorded by Social Services. RCM4 was unable to locate a progress note documenting IDT discussion but reported there was an Attendance Record, dated 11/15/24, indicating that an IDT meeting occurred. Referred State Agency (SA) to Social Services regarding what was discussed. On 12/13/24 at 02:32 PM, an interview was done with the Social Service Manager (SSM) in the 5th floor conference room. SSM confirmed that social services staff should have documented the IDT discussion in a progress note. SSM could not explain why the progress note was not created but confirmed that all social services staff were trained and expected to document the IDT discussion in a progress note. After further questioning, SSM acknowledged that it was possible the IDT meeting did not occur as planned.

Based on record review, the facility failed to implement a comprehensive person-centered care plan to meet the medical, physical, and psychosocial needs for two of two Residents (R) 36 and R228 in the sample. The deficient practice has the potential to diminish both resident's quality of life. Findings Include: Cross reference to F698. Physical medicine and rehabilitation note 12/09/24 17:14 reviewed. R36 is a [AGE] year-old female admitted to the facility on [DATE] for subacute rehab services for decline in Activities of Daily Living (ADL's) and functional mobility after hospitalization . Care plan dated 11/15/24 reviewed. Approach: Check bruit and thrill. Assess site for bleeding. If bleeding, call the physician. Review of the medical record revealed there was no documentation of bleeding to the access site, or that it was reported to the physician (cross reference to F697). 2) Cross reference to F697, F684. Electronic medical record face sheet 11/29/24 reviewed. R228 is a [AGE] year-old female admitted to the facility on [DATE] for rehab services after a stroke. R228 receives pain management for leg and neck pain. Care plan reviewed. Problem: Resident has complaints of acute pain related to (R/T) Acute Cerebrovascular Accident (CVA), (stroke) and left sided weakness. Start Date 11/30/24 Approach: Monitor and record any complaints of pain: location, frequency, intensity, effect on function, alleviating factors, aggravating factors. Start Date 11/30/24 Approach: Assess effects of pain on the resident (disturbances in sleep, activity, self-care, appetite, psychosocial, etc.). Start Date 11/30/24 Review of the care revealed there were no interventions for the management of R228's pain.

Based on interview and record review, the facility failed to protect and promote patient's rights for 1 of 26 residents sampled (Resident (R)60) by ensuring that she was treated with respect and dignity. This deficient practice has the potential to affect all residents in the facility. Findings Include: R60 is a [AGE] year-old female admitted to the facility on [DATE] for wound care, and antibiotic and rehabilitative therapy. A review of her Minimum Data Set (MDS) Admission Assessment with an Assessment Reference Date (ARD) of 10/30/24 noted R60 was determined to have a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 12/10/24 at 04:17 PM, an interview was done with R60 at her bedside. R60 described an incident where she fired a traveling nurse for repeatedly waking her for things that could have waited, such as unscheduled pain medication, and for not listening to R60 regarding the proper way to complete her dressing change. R60 reported she felt that Registered Nurse (RN)2 made her feel bullied, and was cocky. On 12/13/24 at 11:00 AM, an interview was done with Resident Care Manager (RCM)4 in the 4th floor activity room. RCM4 reported that she was made aware of a problem R60 had with RN2. RCM4 stated that as a result of the complaint from R60, she ensured that RN2 would not be assigned to R60 again and completed a grievance form. Review of the Resident Grievance/Complaint Form completed by RCM4 on R60's behalf on 12/06/24 noted the following: Guest with complaints of how nurse [RN2] provided wound care and felt she did not complete correctly. Guest did not appreciate how the nurse addressed her concern. RCM4 had initially described the nature of the grievance/complaint as complaints of nurse's bedside manner, then crossed out bedside manner and finished with wound care approach. The resulting staff education done to resolve the complaint did not address bedside manner, how to approach a resident, or cultural competency.

Based on document review and interviews, two certified nurse assistants (CNA)2, and CNA3 did not possess the competencies and skill sets necessary to provide services to safely meet two residents (R)1 and R4's needs in a manner that promotes physical, mental and psychological well-being. CNA2 roughly assisted R1 with the urinal causing harm, an abrasion on his penis. In addition, when CNA3 found R4 unresponsive with cords wrapped around her neck in an attempted suicide, after undoing the cords, CNA3 left R4 alone and went to the nursing station to inform the nurse. As a result of these behaviors R1 suffered harm, and the initial staff response to assess and treat R4 was delayed, and put her at risk of further potential of self-harm when alone. Findings include: 1) On 06/08/2022 the Office of Healthcare Assurance ([NAME]) received a completed report from the facility regarding a staff to resident(s) event. The report included: On the morning of 6/6/2022, oncoming day CNA (certified nursing assistant)1 reported to the nurse manager that she was doing her guests and three guests reported that the CNA NOC (night shift) was being rough with them. No specifics were given at the time. The AP (alleged perpetrator-CNA2) was off of night shift at the time report was made. CNA2 was removed from the schedule and would not return pending further investigation. The Executive Director of the facility contacted the agency to report situation due to CNA2 was from an agency. All three guests (residents (R)) were interviewed on 6/6/2022. Guest (R1) indicated that the CNA who assisted him on the night of 6/5/2022 was very rough and was the worst he ever had.R1 explained that when placing his penis into the urinal bottle, the rims of the urinal bottle caused him some skin tears. R1 reported that his attending physician visited him on 6/6/ and prescribed some medication to be applied on the abrasion.Guest (R2) was interviewed and stated she does not recall any issues with any staff but stated she was waiting awhile for her call light to be responded to for a brief change. Otherwise, guest stated no problems, everything was okay.Guest (R)3 was interviewed and stated she does not recall having any issues with nursing staff and denied any issues with previous night's CNA. She had no concerns. Based on the information received, although 2 of the guests (R2 and R3) denied any issues, the first guest (R1) above was caused injury although it may not have been intentional. Review of R1's provider notes dated 06/08/2022 included: R1 is an [AGE] year old male post hospitalization from ,d+[DATE]- 05/19/2022 for severe C1-C4 (cervical vertebrae) central canal stenosis (narrowing) with cord compression. C1-C4 decompression and fusion on 05/16/2022 . Patient admitted to the facility on [DATE] for [sic] SNF PT/OT (skilled nursing facility physical/occupational therapy). Patent being seen for discharge as well as scant amount of blood at urethral meatus noted today and checking tests for patients complaint of continued urinary frequency. Urine testing culture still pending.Examined penis and noted a small abrasion to right of the tip of the penis and ordered to apply [MEDICATION(S)] to the affected areas as needed 3 times daily. Review of R1's nursing progress notes revealed the following entries: 06/05/2022 at 11:56 PM: . Kept cervical collar on . Cervical and spine precaution observed during render of care. Continent to bowel and bladder, needs 1 person assist for transferring and toileting. 06/06/2022 at 07:17 AM by Director of Nursing (DON): Guest voiding in urinal and at 04:30 (AM) CNA1 alerted this writer that there was small amount of blood in the urinal and noted at head of penis. Upon assessment, noted scant to small amount of fresh blood at urethral meatus (opening) along with small spot of bright red blood in his brief.Asked guest if he was having any dysuria/pain with urination. He stated this last time there was some pain when voided.No trauma noted to penis or meatus. Endorsed to on-coming RN. 06/07/2022 12:56 PM: New order from physician (MD)1-collect U/A (urinalysis), dx (diagnosis) Hematuria (blood in urine) 06/07/2022 02:47 PM: New order from NP (Nurse Practioner) -Cleanse urethral meatus with NS (normal saline), apply [MEDICATION(S)] to site BID (twice a daily). 06/07/2022 09:06 PM: .[MEDICATION(S)] to urethral meatus applied, slight redness to area. Endorsed from day shift RN that UA was collected to rule out infection due to tear of area. Endorsed from SW (Social Worker) that guest has lateral transfer tomorrow, . 06/08/2022 04:26 PM: D/C (discharge) note . U/A collected from yesterday gave [sic] back abnormal with incr (increased) in WC (white count). Updated NP and MD, no new orders or changes since C/S (culture and sensitivity to determine appropriate antibiotic) not completed yet, . On 10/12/2022 at 04:45 PM during an interview with CNA1, she said R1 had called several times to go to the bathroom, and mentioned CNA2 was rough with him when it came to the urinal. Inquired if R1 could position the urinal himself, and CNA1 said no, we had to do it for him because of the neck brace and just had surgery. She went on to say she noticed R1 was bleeding and he said the girl (CNA2) was rough. CNA1 said R1's roommate overheard the conversation and said she (CNA2) was rough, I could hear him saying stop being so rough. CNA1 went on to say during her morning rounds, R2 also reported she was being treated roughly on the overnight shift, and that when CNA2 would change her, she would be rough and didn't want her in the room anymore. She said later when she went to check on R1 again, there was more blood on his brief. When asked what kind of urinal the facility uses, she said it was plastic and could hurt someone if not careful. On 10/13/2022 at 11:30 AM, during an interview the NP, who examined P1 the morning of 06/06/2022, she said she was not aware at the time of her examination that there had been any concern expressed by P1 about rough treatment during the noc shift when staff assisted him. The NP reviewed her progress note and confirmed she identified an abrasion on P1's penis and ordered [MEDICATION(S)] ointment. She said she did not order a urinalysis at that time because she identified the source of the blood and did not have reason to believe it was a urinary infection. On 10/13/2022, examined the urinal used by the facility, which was a plastic type material. The body of urinal was somewhat flexible, but the hole to place the penis in was not. If staff are not careful when placing the urinal, it could cause pain/injury. 2) On 10/04/2022, [NAME] received an event report from the facility that on 09/28/2022, R4 had a failed attempt of suicide by wrapping call light and telephone cord wrapped around her neck. She was found by CNA3 and subsequently transferred by ambulance to a hospital where she was admitted for further care. R2 was a [AGE] year old female new admission to the facility on [DATE] after acute hospital stay for [CONDITION(S)], pneumonia (PNA) and urinary tract infection ([CONDITION(S)]). Past medical history included [CONDITION(S)] ([CONDITION(S)]), chronic kidney disease, hypertension, and [CONDITION(S)]. R2 used oxygen by nasal cannula at night for comfort. R2 did not have a history of psychiatric illness, or depression. Review of the Nursing notes included, but not limited to the following entries: 09/28/2022 at 04:38 PM: Received guest via gurney at 12:40pm in stable condition from hospital (H)1. Guest is FULL code, .here for PT/OT (physical/occupational therapy).Guest (P4) is here for acute [CONDITION(S)] exacerbation secondary to PNA. Secondary dx [CONDITION(S)] with bacteremia and [CONDITION(S)], CHF exacerbation along with rhabdomyolysis (breakdown of skeletal muscle and [CONDITION(S)] to BLE. Guest is Axo4 (alert and oriented to name, place, time and situation). Guest has a wet cough, occasional clear productive, says not new.Guest on antibiotic until 10/5 for [CONDITION(S)] bacteremia. Guest has weakness to all extremities.2+ pit (pitting) [CONDITION(S)] to BLE (bilateral lower legs).Guest can use little bit of side rails to turn and reposition but mod/extensive assist for transfers. 09/29/2022 at 08:20 AM entered by the Director of Nursing (DON): Husband returned call from message that was left. This writer spoke to husband and explained situation that occurred with the guest. Husband made aware that she (R2) had been sent to .ER. Husband said he was with guest when she first admitted and then went home. He stated that guest called him at 7:30pm to ask him what are you doing. He stated he was sleeping and she said ok and then they hung up from each other. He stated that the guest called again at 10 pm and stated I want to leave and told him I love you. He stated that she was crying. He stated that she didn't verbalize that she wanted to hurt herself and I thought she was talking out of her head. Husband stated that she had never commented prior that she wanted to harm herself. 09/29/2022 07:34 PM (late entry, but not documented as such): Few minutes after the shift report was over, CNA3 assigned to the client came to the nurse's station asking is the patient at room [ROOM NUMBER] on suicidal ideation precaution? After confirming the name, this writer replied that she is not identified on such precaution on records nor during shift report. When asked why, he further stated that he found the patient not moving while covered with bedsheet on initial interaction and when further checked was found to have call light wire and telephone handset wire coiled tightly around her neck which he immediately removed. Time checked at 23:20 (09/28/2022 at 11:20 PM). Immediately, this writer went to check on patient who was seen laying on bed distraught and crying, repeatedly stating Let me go, let me go. Immediately scanned the room and kept patient away from possible sources of physical harm then tried to console her, but failed. Physical assessment was done and noted red skin with marked indentation cord pattern antero-lateral neck area resembling stretched telephone handset coil cord.SPO2 87-88% (for patients with mild respiratory diseases, should be 90% or above) on RA (room air) Temp 101.9.She remained crying endlessly .Insistently replied, Let me go. NO matter what you do, I will find a way. Immediately instructed CNA3 to continue 1:1 monitoring and never leave the patient at all cost and to use call light in case he needed help as this writer had to proceed with event protocols.DON was informed via text message.Called husband but 1st telephone on file was not in service.was able to retrieve another phone number and left message requesting a return call to this writer.left the facility (via EMS) at 12:15 am. Reviewed CNA3's written witness statement dated 09/28/2022 at 11:15 PM, which stated: At 11:15 pm I was doing my rounds to checked guest's vital signs. I went to room [ROOM NUMBER] to checked her. I called her name 10 times with no response, then decide to roll down her blanket to checked her BP (blood pressure) but I found out that the telephone cord wrapped and tied around her neck. I suddenly untied and unwrapped the cord and rubbed her chest and she started to cry and kept telling me let me go. I called my nurse to checked [sic] on her V/S (vital signs) checked and put O2 on. On 10/12/2022 at 03:30 PM, conducted a telephone interviewed the Registered Nurse (RN)2 who did the initial assessment on R4 after being informed she attempted suicide. RN2 said she was the incoming nurse, and they were just finishing report with the previous shift when one of the CNA's (CNA3) came to the nursing station and began talking to the nurses that were finishing their shift, telling the group what was going on. She said CNA3 mentioned he took off the cord. RN2 said she went to go see R4 immediately. RN2 said R4 was crying. Inquired what staff should do if found someone unresponsive or in that situation, and she said they should use the emergency button and call out for help. RN2 said CNA3 shouldn't have left her alone. Reviewed RN2's documentation together. At that time she acknowledged her entry was done late and said the night of the incident, she forgot to document, but was called in the next day to document her shift and the event.

Based on observation, interview, and record review (RR), the facility failed to implement a physician order [REDACTED]. Because of this deficient practice R91 developed a Stage 3 pressure ulcer on the medial aspect of her right knee. This deficient practice has the potential to affect other residents who are at risk for developing pressure ulcers. Findings Include: Resident (R)91 is a [AGE] year-old female who had a right hip hemiarthroplasty (replacement of a joint) following a fall that resulted in a right [MEDICAL CONDITION]. She was admitted to the facility on [DATE] for skilled rehabilitation. On 09/25/2018 R91 was transferred to Kuakini after she had increased pain, and internal rotation of the right hip. R91 was diagnosed and treated for [REDACTED]. Review of the Care Plan Report revealed R91 was at risk for altered skin integrity and had poor skin turgor. Staff were directed to keep knee immobilizer in place at all times as identified to be at risk-(D/C'd 10/24/18), and pain-at risk for immobility/friction/sheer. Review of the Kardex directed staff to use a hip abductor (foam pillow designed for post-operative positioning) and leave the knee brace on at all times. During an interview with the Unit Nurse Manager on 10/31/2018, she stated, the immobilizer would be taken off for bathing and checking CSM (circulation, sensation, and motion). On 10/23/2018 R91 had an outside appointment to see MD1. RR of the Consultation Request form that came back to the facility with R91 revealed new written orders from MD1: Discontinue knee brace, continue hip precautions. MD2 signed that the Consultation Request form was reviewed on 10/23/1018. During an Interview on 11/02/2018 at 1:20 PM, the Unit Nurse Manager stated, When the Consultation Request comes back, we put it in the binder and then MD2 signs when he reviewed it. The RN who gets the form reviews it, implements the orders, changes the Care Plan, and Kardex. They also communicate changes in report. RR of Clinical Notes include the following entries: 10/24/2018 entered at 1:59 AM by RN1. Guest returned from appointment with ORTHO. Consultation request left in MD communication book for review. carried out physician orders. will continue P[NAME] (plan of care). Physician orders: Discontinue Knee Brace. Continue hip precautions. 10/24/2018 entered at 1:44 PM by RN2. Guest cont (sic) reposition in bed abductor pillow on as indicated. Guest immobilizer on as indicated. 10/25/2018 entered at 2:33 PM by RN3, Brace to (sic) applied. 10/27/2018 entered at 2:27 PM by RN4, Immobilizer to be worn at all times. 10/28/2018 entered at 1:11 PM by RN4, Immobilizer to be worn at all times. 10/28/2018 entered by 11:31 PM by RN5, Guest found to have area of non blanchable redness measured 6x3.5 cm and open area measured 2x1cm. 10/29/2018 entered at 7:05 AM by RN5, Family member notified of new pressure ulcer wound found to right knee MD2 updated. RR of MD2 Progress note dated 10/29/2018 documented: Patient seen today for concerns about [MEDICAL CONDITION] on the right medial knee. Skin: Right medial knee with open [MEDICAL CONDITION] with central eschar. Review of Kardex revealed it was updated 10/31/2018 to reflect R91 no longer using knee immobilizer. At 11/02/2018 at 1:07 PM conducted a record review and interview with the Chief Nursing Officer (CNO), Director of Nursing (DON) and the Unit Nurse Manager. The CNO explained when the Care Plan is updated to reflect new orders or changes, this computer system does not time stamp or automatically date the revisions to the care plan, so we can't tell who or when the revision to discontinue the knee brace was added to the Care Plan. The Unit Nurse Manager stated, When the new orders were received, the RN should update the Treatment Administration Record (TAR), change the Kardex, and Care plan. It was confirmed the TAR was updated 10/24/2018 at 2:00 AM, and the Kardex was updated 10/31/2018. The CNO, DON, and Unit Manager confirmed the order to discontinue the immobilizer was written on 10/23/2018, but the doctor's order was never carried out. The resident continued to have the immobilizer on until 10/28/2018. As a result, the resident developed a Stage 3 pressure ulcer.