Every finding on record at The Haven of Tuscola

Based on observation, interview and record review, the facility failed to ensure pain medication supply was available for administration for two residents (R1 and R2), failed to clarify a physician order for a pain medication dose for one resident (R2), and failed to initiate a care plan for pain triggered on a Care Area Assessment (CAA) for one resident (R2). These failures affected two (R1 and R2) of three residents reviewed for pain on the sample list of three residents. This failure resulted in R1, going without needed Morphine narcotic pain medications, during end-of-life (Hospice) comfort focused care, for greater than 24 hours.This failure resulted in R2 going without Lidocaine (topical numbing agent, for nerve ending) patch for pain, continually for five days which prevented R2's ability to sleep comfortably. 1. R1's Electronic Health Record (EHR) contains a nursing note dated 7/9/26 that documents R1 arrived at the facility at 11:30 a.m. via ambulance. R1's Physician Order Sheet (POS) dated 7/9/26 documents an order for Morphine Sulfate (Concentrate) Oral Solution 20 milligrams (mg) per milliliter (ml), give 10 mg sublingually every one hour as needed for pain and/or air hunger. R1's July 2026 Medication Administration Record (MAR) documents no administration of Morphine Sulfate on 7/9/26. This MAR also included an order for pain monitoring every shift; however, no pain monitoring was documented on 7/9/26. During the day shift on 7/10/26, the MAR documented that R1 rated the pain as five out of ten. R1's MAR further documents that R1 received the first dose of Morphine Sulfate on 7/10/26 at 1:41 p.m., approximately 26 hours after admission to the facility. R1's EHR contains a Hospice admission Note dated 7/9/26 that documents R1 was admitted to hospice with a diagnosis of End Stage Heart Failure. R1's Care Plan dated 7/10/26 documents R1 has a terminal condition and is at risk for loss of dignity during the dying process and at risk for unavoidable significant decline with a goal that R1's comfort will be maintained through the review date. This Care Plan documents an intervention for staff to monitor R1 for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. R1's Hospice Care Plan, dated 7/9/26, identified pain/physical discomfort as a problem area for R1. The care plan established a goal that R1's pain/physical discomfort would be reduced or maintained at or below the level identified in the patient's stated goal throughout the hospice episode. The care plan also included a pain management intervention instructing the facility nurse, resident, and caregiver on the medications used for pain management and to contact hospice if pain relief was unsatisfactory. R1's EHR contains a nursing note dated 7/10/26 that documents R1's family requested as needed pain medication; for R1 however, nursing staff were unable to locate the medication. Follow-up with hospice and the pharmacy revealed the prescriptions had not been received and were pending clarification regarding the pharmacy to receive the orders. The note documented that R1's family reported R1 had not received Morphine for 24 hours and requested the medication be sent to another pharmacy due to concerns about delayed delivery. On 7/31/2026 at 10:01 a.m., V4 Pharmacy Technician stated that the pharmacy received orders on 7/9/26 for R1; however, there was no order for morphine. On 7/31/2026 at 10:07 a.m., V5 Order Entry Manager for the facility pharmacy stated that the pharmacy received physician orders for R1 on 7/9/2026; however, those orders did not include an order for morphine. On 7/31/2026 at 12:59 p.m., V13 a Certified Nursing Assistant (CNA) stated that while providing R1 a bath on the day of admission, R1 appeared uncomfortable during repositioning, as evidenced by grunting with movement. On 7/31/2026 at 12:45 p.m., V14 Regional Nurse Consultant stated that facility policy requires nursing staff to use the local backup pharmacy when medications are not immediately available and to exhaust all efforts to obtain ordered medications without delay. V14 stated that staff should have taken these actions to ensure timely administration of the ordered pain medication to R1. 2. R2's Current Diagnoses list documents the following: R2 Current Diagnoses Sheet includes the following: Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain, Functional Quadriplegia, and Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, and Abnormal Posture. R2's Minimum Data Set (MDS) dated [DATE] documents the following: R2's Brief Interview of Mental status score as 11 out of a possible 15, indicating moderate cognitive impairment at the time of the assessment. R2's same MDS documents R2 had occasional moderate- severe pain intensity as reflected by the score of six out of ten on the standard pain scale 00-10, 10 being the worst pain. R2's Minimum Data Set - CAA (Care Area Assessment) documents R2's Pain Problem triggered to be carried over to R2's Care plan. R2's Current Care Plan does not document a care area category to direct staff on how to provide relief for R2's pain. R2's July 1-31, 2026, Physician Order Sheet documents the following: Lidocaine External Patch (Lidocaine), apply to affected area topically, one time a day for Mild Pain. (There is no identified dose), Acetaminophen (Tylenol) Oral Tablet 500 MG (extra strength/ milligram), Give 1 (one) tablet by mouth, every 4 (four) hours, as needed for Pain; Fever/Elevated Temperature. R2's July 1-31, 2026, Medication Administration Order (MAR) documents the following medication doses were not administered: Lidocaine External Patch (Lidocaine) Apply to affected areas topically one time a day for Mild Pain -Start Date-07/14/2026 at 0600 am documents the number nine which direct reader to see the nurses' notes on 7/26/26, 7/27/26, (7/28/26 was signed off as given, was in error per DON interview), 7/29/26 and 7/30/26. Corresponding Nurse progress note each document Lidocaine medication patch was out of stock. R2's same Medication Administration Record documents R2 was administered Tylenol 500 mg by mouth on 7/31/26 at 1:20 am for a pain level of five (different than R2's interview below of seven or eight) out of ten (moderate pain). On interview with R2 documented below R2's pain level was seven – eight (very strong) which resulted in poor sleep. On 7/31/26 at 10:20 am, R2 was seated bedside in a specialty wheelchair. R2 was restless, shifting R2's weight back and forth. R2 stated I have not had my Lidocaine Patch on (applied), for several days. I have never refused the nurses when they put one (Lidocaine patch) on me. I need them (Lidocaine patch), every day. I have asked a few different nurses (unidentified) to put one on me, and they all say they don't have any, but they have ordered more of them. I was real miserable last night. I could not get to sleep. My back pain was between seven (7) or eight (8), out of 10 ten. (standard pain scale is 1-10 range with 10 being the most severe). The night nurse (unidentified) gave me the real strong Arthritis Tylenol. That seven to eight-pain level is a lot more pain than I have had this week, without my patch (lidocaine). My pain was around five (5) out of ten after I got the emergency Tylenol from the night nurse. I could sleep (after Tylenol administration) but I would still wake up hurting. When I wear my patch my pain level is maintained at two out of ten. I can tolerate that. I will be asking for Tylenol again soon. You can see I am fidgety. My back is hurting now, at about five or six, again. On 7/31/26 at 11:03 am V6 (R2's) Family Member stated (R2) is almost 90, (R2) has pain all the time. The Lidocaine patches work to take the edge off. (R2) is not a complainer. (R2) is totally aware of when (R2) is hurting and will ask for Tylenol if (R2) has break through pain. (R2) has mentioned a few times that overnight (R2) has needed and been given (administered) Tylenol to sleep more comfortably. I was there (in the facility) for a visit on Monday (7/27/26) (R2) told me (R2) had problems sleeping the night before (7/26/26). I assumed (R2) was getting the Lidocaine patch and probably asked for Tylenol, too. On 7/31/26 at 12:05 pm, V2 Director of Nursing (DON) reviewed R2's medical record. V2 DON confirmed R2's Physician Order for the Lidocaine Patch did not include the dose, as is required for medications, to ensure the residents receive the appropriate amount of medication to treat their diagnosis. V2 also confirmed that R2 missed the application of Lidocaine medication patch on 7/26, 7/27, (DON confirmed 7/28/26 dose was likely signed in error as given, because there were no patches available), 7/29 and 7/30/26. V2 stated the missed doses were because the facility ran out of the Lidocaine medicated patches. V2 DON said that R2 received PRN (as needed) Extra Strength Tylenol for pain while waiting on the Lidocaine medicated patch. V2 DON confirmed the Lidocaine medicated patch was more specific to R2's back pain relief, where Tylenol is more for general pain. V2 DON confirmed that Lidocaine patches stock should have been available to maintain R2's comfort and prevent interruption of R2's sleep. On 7/31/26 at 1:25 pm, V14 Regional Nurse Consultant reviewed R2's medical records and confirmed R2's care plan does not include a category for pain to be addressed. V14 confirmed R2's Minimum Data Set - CAA (Care Area Assessment) documents R2's Pain Problem was to be carried over to R2's Care plan and interventions established, specific to R2's needs to relieve pain. V14 confirmed R2's pain medications would have been part of the intervention, and the care plan should include non-pharmacological intervention. V14 stated staff and pharmacy communication, and follow-up for obtaining medication must get better. V14 said V14's expectation is for the facility nursing staff to exhaust every effort to ensure the residents' medications are in the facility when due to be administered. The facility's Pain – Clinical Protocol policy, dated August 2008, documented that the physician is responsible for evaluating the resident's pain, including examining the resident, reviewing the resident's history, and discussing the resident's pain with the resident and staff. The policy further documented that the physician will establish pain management goals with input from the resident and/or advocate and order appropriate non-pharmacologic and pharmacologic interventions to address the resident's pain. The facility's Medication Administration policy, dated 10/25/2014, documents that medications are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized personnel. The policy further documents that the facility maintains sufficient staffing and a medication distribution system to ensure safe medication administration without unnecessary interruptions. If a medication with a current, active order cannot be located in the medication cart/drawer, medication room, or other areas of the facility, the pharmacy is contacted, or the medication is obtained from the night box/emergency kit after further investigation.

Based on observation, interview and record review the facility failed to obtain physician ordered medications in a timely manner, which resulted in significant medication errors due to repeated, missed administration of medication. These failures affected two (R1 and R2) of three residents reviewed for medication on the sample list of three residents.This failure resulted in R1, going without needed Morphine narcotic pain medications, during end-of-life (Hospice) comfort focused care, for greater than 24 hours.This failure resulted in R2 going without Lidocaine (topical numbing agent, for nerve ending) patch, for pain, continually for five days which prevented R2's ability to sleep comfortably and going without Mirabegron Urinary Antispasmodic medication for seven days, which increased frequency of urgency to urinate. 1. R1's Electronic Health Record (EHR) contains a nursing note dated 7/9/26 that documents R1 arrived at the facility at 11:30 a.m. via ambulance. R1's EHR contains a Hospice admission Note dated 7/9/26 that documents R1 was admitted to hospice with a diagnosis of End Stage Heart Failure. R1's Physician Order Sheet (POS) dated 7/9/26 documents an order for Morphine Sulfate (Concentrate) Oral Solution 20 milligrams (mg) per milliliter (ml), give 10 mg sublingually (under the tongue) every one hour as needed for pain and/or air hunger. R1's July 2026 Medication Administration Record (MAR) documents no administration of Morphine Sulfate on 7/9/26. This MAR further documents that R1 received the first dose of Morphine Sulfate on 7/10/26 at 1:41 p.m., approximately 26 hours after admission to the facility. R1's Medication Administration Record (MAR) dated July 2026 documents 26 potential missed doses of Morphine based on the PRN (as needed) medication order. R1's Care Plan dated 7/10/26 documents that staff should monitor R1 for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. On 7/31/2026 at 9:10 a.m., V7 (R1's) family member, stated that R1 did not receive the prescribed pain medication for more than 24 hours following admission to the facility. V7 stated that during this time R1 rated the pain as an eight on a scale of 0 to 10 and that the facility failed to provide the pain medication ordered to manage R1's pain because it was not available. On 7/31/2026 at 12:28 p.m., V3 Licensed Practical Nurse (LPN) stated that R1 exhibited nonverbal signs of pain on the morning of 7/10/2026 and that Morphine was not available for administration. On 7/31/2026 at 12:45 p.m., V14 Regional Nurse Consultant stated that facility policy requires nursing staff to use the local backup pharmacy when medications are not immediately available and to exhaust all efforts to obtain ordered medications without delay. V14 stated that staff should have taken these actions to ensure timely administration of the ordered pain medication to R1. 2. R2's Current Diagnoses list documents the following: R2 Current Diagnoses Sheet includes the following: Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain, Functional Quadriplegia, and Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, and Abnormal Posture. R2's July 1-31, 2026, Physician Order Sheet documents the following: Lidocaine External Patch (Lidocaine), apply to affected area topically, one time a day for Mild Pain. (There is no identified dose), Acetaminophen (Tylenol) Oral Tablet 500 MG (extra strength/ milligram), Give 1 (one) tablet by mouth, every 4 (four) hours, as needed for Pain; Fever/Elevated Temperature, and Mirabegron ER Oral Tablet Extended Release (ER) 24 Hour, 25 MG (Milligrams), Give 1 (one) tablet by mouth, every day shift for Urinary Antispasmodic. Start Date-07/11/2026 at 0600 am. R2's July 1-31, 2026, Medication Administration Order (MAR) documents the following medication were not administered: Lidocaine External Patch (Lidocaine) Apply to affected areas topically one time a day for Mild Pain -Start Date-07/14/2026 at 6:00 am documents the number nine which direct readers to see the nurses' notes on 7/26/2, 7/27/26, (7/28/26 was signed off as given was in error per DON interview), 7/29/26 and 7/30/26. Corresponding Nurse progress note each document Lidocaine medication patch was out of stock. R2's same MAR documents: Mirabegron ER Oral Tablet Extended Release 24 Hour 25 MG (Milligrams), Give 1 (one) tablet by mouth, every day shift, for Urinary Antispasmodic. Start Date-07/11/2026 at 6:00 am. The same MAR documents 7/14/26, 7/15/26, 7/16/26, 7/17/26, (on 7/18/26 it is documented that medication was administered. V2 confirmed in the interview that the medication was out of stock and was not given), 7/19/26, and 7/20/26, documents the number nine which direct readers to see the nurses' notes. Corresponding Nurse progress notes document Mirabegron medication was on order from the pharmacy. On 7/31/26 at 10:20 am, R2 confirmed R2 had not received R2's Lidocaine patches for several days which resulted in R2's inability to sleep comfortably. R2 also confirmed R2 had not received R2's Mirabegron ER medication for several days which caused R2 to have frequent, urgency to urinate. On 7/31/26 at 11:03 am, V6 (R2's) Family Member stated R2 had gone to the local hospital from another nursing home. R2 was subsequently transferred from the local hospital to this facility. V6 (R2's) Family Member said I (V6) had gone to the previous nursing home and brought what was left of (R2's) medications, (at the other facility) and brought what was left of the medications to this nursing home. That was the day after (R2) was admitted to this facility (7/10/26). V6 also said V6 had been told the nursing homes pharmacy would supply R2's medication after the medication V6 brought in, was used up. V6 also stated (R2) is almost 90, (R2) has pain all the time. The Lidocaine patches work to take the edge off. (R2) is not a complainer. R2 is totally aware of when R2 is hurting and will ask for Tylenol if R2 has break through pain. (R2) has mentioned a few times that overnight (R2) has needed and been given Tylenol to sleep more comfortably. I was there for a visit on Monday (7/27/26) (R2) told me (R2) had problems sleeping the night before. I assumed (R2) was getting the Lidocaine patch and probably asked for Tylenol, too. On 7/31/26 at 12:05 pm, V2 Director of Nursing (DON) reviewed R2's medical record. V2 DON confirmed R2's Physician Order for the Lidocaine Patch did not include the dose, as is required for medications, to ensure the residents receive the appropriate amount of medication to treat their diagnosis. V2 also confirmed that R2 missed the application of Lidocaine medication patch on 7/26, 7/27, 7/28 was likely signed in error as given, because there were no patches available, 7/29 and 7/30/26. V2 stated the missed doses were because the facility ran out of the medicated patches. V2 DON said that R2 received PRN Extra Strength Tylenol for pain while waiting on the Lidocaine medicated patch. V2 DON confirmed the Lidocaine medicated patch was more specific to R2's back pain relief, where Tylenol is more for general pain. V2 DON confirmed that Lidocaine patches stock should have been available. V2 DON also confirmed that R2 missed Mirabegron medication on 7/14, 7/15, 7/16 though documented as administered in error, 7/17, 7/19, 7/20, and 7/21/26. Though it was ordered, the supply did not come from pharmacy, as it should have. V2 stated the facility uses (private company name) pharmacy which is (outside the state of Illinois). Generally, the medication comes in the next evening. The facility uses their convenience box backup medications or if a medication is ordered STAT (immediately), (local pharmacy) is used. V2 confirmed the convenience facility medication supply box does not contain Mirabegron, and the order was not sent to (local pharmacy). During the same review of R2's medical record, V2 Director of Nursing, said the quantity of R2's missed medication doses, and the unrelieved pain equate to 'significant' medication errors. The facility's Medication Administration policy, dated 10/25/2014, documented that medications are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized personnel. The policy further documented that the facility maintains sufficient staffing and a medication distribution system to ensure safe medication administration without unnecessary interruptions. If a medication with a current, active order cannot be located in the medication cart/drawer, medication room, or other areas of the facility, the pharmacy is contacted, or the medication is obtained from the night box/emergency kit after further investigation.

Based on observation, interview, and record review the facility failed to follow physician's orders and develop/implement a care plan and interventions for treatment and monitoring of Congestive Heart Failure (CHF) for two of two residents (R7, R8) reviewed for hospitalizations in the sample list of 40. These failures resulted in R7 and R8 being hospitalized with CHF exacerbation. Findings include: 1.) R7's Hospital History and Physical dated 1/15/26 documents R7 was recently diagnosed with Respiratory Syncytial Virus and reported having nonproductive cough for about a week with wheezing and shortness of breath for the past two days. R7's chest x-ray showed cardiomegaly, pulmonary vascular congestion, and possible pulmonary edema. R8 was admitted with Chronic Obstructive Pulmonary Disease (COPD) exacerbation, respiratory failure and acute on chronic heart failure with diuresis (excess fluid removed through increased urination) with intravenous Lasix (diuretic). R7's hospital discharge instructions dated 1/20/26 included a 2 liter (L) daily fluid restriction. R7's Hospital Cardiology Consult Note dated 3/9/26 documents R7 presented to the emergency room with shortness of breath and R8's chest x-ray showed suspected mild fluid overload with interstitial edema and streaky atelectasis. R7's B-type Natriuretic Peptide (BNP) was elevated, 338, and R7's liver enzymes were elevated. R7 was admitted to the intensive care unit and cardiology was consulted for suspected CHF exacerbation. R7's Hospital Discharge Instructions dated 3/24/26 documents Discharge Diagnoses included: Transaminitis (elevated liver enzymes), COPD exacerbation, Acute Kidney Injury, Hyperkalemia, Hypotension, Chronic Kidney Disease Stage Three, Type 2 Diabetes Mellitus, Acute and Chronic Heart Failure with preserved Ejection Fraction, and Respiratory Failure. R7's SOAP (Subjective, Objective, Assessment, Plan) Note dated 3/30/26, recorded by V13 Nurse Practitioner (NP), documents hospital follow up visit R7 was hospitalized with CHF and COPD exacerbations. R7's care plan dated 5/19/26 does not include problem, goals, and interventions to address CHF. R7's Physician Order dated 3/7/26 documents to obtain Complete Blood Count, Comprehensive Metabolic Panel, and BNP. There is no documentation a BNP was completed as ordered. R7's January-May 2026 Medication/Treatment Administration Records (MARs/TARs) documents 2 L daily fluid restriction 1/20/26-3/9/26 and daily weight monitoring initiated on 3/26/26. These MARs/TARs do not document any weights for March, 22 missing entries for April, and 15 missing entries May 1-19. R7's ongoing weight log documents: 139.6 lbs. on 12/3/25, 143.2 lbs. on 1/20/26, 143 lbs. on 2/19/26, 146.5 lbs. on 2/20/26, 147.5 lbs. on 2/21/26, 151 lbs. on 2/26/26, 151 lbs. on 37/26, 152 lbs. on 3/8/26, 141 lbs. on 3/25/26, 138 lbs. on 5/5/26, and 140 lbs. on 5/12/26. This weight log does not document R7's weight was obtained daily. There is no documentation in R7's EMR that R7's weight gain 2/20/26-2/26/26 was reported to a provider. R7's Nursing Note dated 3/6/26 at 3:50 AM documents: R7 complained of tightness, pain, and swelling to legs and R7 had 2 + pitting edema to left lower leg. R7 had a wet, productive cough with bilateral expiratory wheezing. V13 NP notified awaiting response. There is no documentation in R7's electronic medical record (EMR) why R7's fluid restriction was not resumed after returning from the hospital on 3/24/26 or that this order was clarified. R7's EMR does not contain cardiology progress notes January 2026-May 2026. On 5/18/2026 at 10:04 AM R7 stated R7 lost weight recently and was in the hospital a few months ago but was unable to provide additional information related to this. On 5/18/26 at 12:48 PM R7's noon meal included a glass of lemonade and water. R7's meal ticket did not indicate a fluid restriction. On 5/20/26 at 9:53 AM R7 was in her room and there was a full water pitcher next to her. R7 stated R7 is allowed to drink as much as she wants but R7 used to have to limit her fluid intake and felt like R7 was cooperative with that. R7 was unsure why the fluid restriction was changed. R7 stated R7 thought she is weighed daily and is cooperative with that. On 5/18/26 at 12:50 PM V4 Licensed Practical Nurse (LPN) stated R7 is weighed daily, documented in EMR, and no paper forms are used for documenting weights. On 5/20/2026 at 9:11 AM V18 Certified Nursing Assistant (CNA) stated R7 is cooperative for weights but R7 is not always on the weight list and depends on if the night nurse adds R7's name to the daily list. V5 LPN confirmed R7 should have daily weights. At 10:00 AM V18 stated R7 used to be on a fluid restriction prior to being hospitalized in March. V18 stated V18 was unsure why it was stopped and asked the dietitian about it a few days ago who was going to look into it and get back to her. On 5/20/26 at 9:28 AM V2 Director of Nursing (DON) stated daily weights are either documented on the MAR/TAR or in the vitals section of EMR. At 10:53 AM V2 stated R7 had cardiology appointments on 1/28/26 and 4/3/26 and V2 is attempting to obtain those notes from the physician's office. V2 stated BNP was not completed 3/7/26. V2 confirmed R7 had CMP and CBC drawn 3/7/26.On 5/20/26 at 9:34 AM V3 Assistant DON (ADON) stated R7 was very noncompliant with the fluid restriction and would drink out of the sink faucets and the fluid restriction was discontinued after R7 returned from the hospital on 3/24/26 without an order to continue the fluid restriction. On 5/20/26 at 10:45 AM V17 Minimum Data Set (MDS)/Care Plan Coordinator confirmed R7's care plan did not contain a problem, goals, and interventions for CHF. On 5/20/26 at 10:15 AM V13 NP stated residents with CHF should have respiratory/cardiac assessments, checking for lung sounds and edema, Oxygen saturation and vital signs at least daily if the resident is stable or increased to every shift for exacerbations. V13 stated these residents should be weighed daily and have recurrent CBC and CMP every three months unless ordered more frequently on hospital discharge orders. V13 stated V13 will have to check to see if R7 is supposed to be on a fluid restriction, a fluid restriction would be helpful and may have been ordered by cardiology. V13 stated R7 should be weighed daily with reporting of gains of 3 lbs. or more in 24 hours or 5 lbs. or more in a week. V13 stated V13 was not notified of weight gain 2/26/26 and would have increased R7's diuretic if R7 was having symptoms. V13 stated stress from CHF can increase liver enzymes. V13 confirmed R7 was hospitalized with CHF exacerbations in January and March. V13 stated R7 continued to smoke at that time which was not helping. On 5/20/26 at 1:40 PM V22 Cardiology Registered Nurse confirmed R7 was seen in the cardiology office on 1/28/26 and 4/3/26. V22 stated R7 was last seen by V22 Cardiology Physician's Assistant on 4/3/26. V22 stated R7's orders included a 2 L daily fluid restriction and daily weight monitoring with reporting of gains of 3 lbs. or more in 24 hours and 5 lbs. or more in one week. V22 stated the facility requested copies of R7's cardiology progress notes today and V22 is working on sending them to the facility. 2.) R8's Hospital discharge date d 12/26/25 documents R8 has heart failure and discharge instructions included daily weight monitoring and report gain of 3 lbs. or more in 24 hours and 5 lbs. or more in one week. R8 weighed 207 lbs. on hospital admission. This discharge documents to have Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) in three days. R8's active care plan dated 5/19/26 does not include a problem, goals, and interventions for CHF. There is no documentation in R8's electronic medical record (EMR) that CBC and BMP were completed as ordered, and there is no documentation that R8 had any laboratory results after returning from the hospital on [DATE] prior to being hospitalized on [DATE]. R8's EMR does not document daily weights were completed as ordered after 12/26/25. R8's December 2025 TAR documents an order for daily weights with start date 5/22/25 and end date 12/24/25. R8's weight log documents: 201 lbs. on 2/24/26, 201 lbs. on 3/1/26, 200 lbs. on 4/2/26, and last recorded weight of 194 lbs. on 5/2/26 until 5/19/26 with weight of 190.5 lbs.R8's Nursing Note dated 5/15/2026 at 5:38 AM documents R8 complained of chest pain and has chronic CHF and Chronic Obstructive Pulmonary Disease. R8 had dry cough upon deep inhalation and heart rate was irregular rhythm.R8's Hospital discharge date d 5/17/26 documents to weigh daily and report gains of 3 lbs. or more in 24 hours and 5 lbs. or more in one week. R8's SOAP Note dated 5/18/26, recorded by V13 Nurse Practitioner (NP), documents R8 was seen for hospital follow up and R8 has new onset Atrial Fibrillation (AFib) and CHF exacerbation. This note documents R8 was diuresed in the hospital for acute on chronic systolic HF and R8 continues on Lasix. On 5/18/26 at 12:50 PM V4 LPN stated R8 is weighed monthly. On 5/20/2026 at 9:11 AM V5 LPN stated R8 should be weighed daily. V18 CNA stated R8 was on V18's list to weigh today but R8 is not usually on the list for daily weights. V18 stated the nurses document the resident's weight in the EMR. V5 confirmed daily weights are documented on the TAR. On 5/20/26 at 9:28 AM V2 DON stated daily weights are either documented on the MAR/TAR or in the vitals section of the resident's EMR. V2 reviewed R8's 5/17/26 hospital discharge orders and confirmed instructions for daily weight monitoring and reporting. At 12:12 PM V2 confirmed all of R8's laboratory results for the last six months were provided. On 5/20/26 at 9:34 AM V3 ADON stated R8's daily weight orders may have dropped off when R8 returned from the hospital or R8 was noncompliant, and V3 will look for documentation of this. V3 reviewed R8's December 2025 MAR/TAR and confirmed daily weights were not resumed after R8 returned from the hospital on [DATE]. On 5/20/26 at 10:15 AM V13 NP stated R8 has been pretty stable and doesn't generally present with weight gain and therefore would be appropriate to have weekly weight monitoring. V13 stated R8 should have daily weight monitoring for two weeks post hospitalization. V13 confirmed R8 was hospitalized for CHF and new onset AFib on 5/15/26. At 1:22 PM V13 stated R8 should have had CBC and CMP done between hospitalizations. V13 stated R8's low ejection fraction due to CHF was the cause of AFib but would not be considered abnormal due to R8's age and length of having CHF. V13 stated R8 may have had AFib that went undetected due to no signs. On 5/20/26 at 10:45 AM V17 MDS/Care Plan Coordinator confirmed R8's care plan did not include problem, goals, and interventions for CHF. On 5/20/26 at 1:40 PM V2 stated the facility did not have a policy related to CHF but has a batch order entry for standard orders related to CHF, which V2 will provide. At 1:46 PM V2 provided a copy of the batch orders for CHF which includes: 2 liter fluid restriction, follow up appointments, dietary consult, monitoring/reporting heart rate and blood pressure, reporting BNP as ordered or default of 500, weight weekly/daily/every other day, and reporting weight gains.

Based on interview and record review the facility failed to have a Registered Nurse for eight consecutive hours per day and a full time Director of Nursing. These failures affect all 47 residents in the facility. Findings include: The schedule for 05/03/26 documented RN (Registered Nurse) coverage for six and one-half hours. The timecard report showed that V16, RN, clocked in at 3:06 PM and clocked out at 9:25 PM, with no lunch break recorded.The schedule for 05/16/26 documented zero hours of RN coverage.V3, ADON (Assistant Director of Nursing), verified that the RN coverage information was accurate. V3 stated that the facility has three part-time RNs on staff. V3 further stated, V17, the Minimum Data Set Coordinator, assists with RN coverage Monday through Friday from 8:00 AM to 5:00 PM and that staff know to go to V17 with any issues.V3 also stated that V2, Interim DON (Director of Nursing), is from the regional office and is not present in the facility 40 hours per week.The Long-Term Care Facility Application for Medicare and Medicaid, dated 05/18/26, documents that the facility has a census of 47 residents.

Failures at this level required more than one Deficient Practice Statement.A. Based on observation, interview, and record review, the facility failed to implement Legionella control measures. This failure affects all 47 residents in the facility. B. Based on observation, interview, and record review, the facility failed to perform hand hygiene prior to putting on and taking off gloves and between residents during medication administration for nine of 15 (R6, R7, R13, R20, R24, R26, R29, R31) residents reviewed for infection control, in a sample of 40.Findings include: a.1. The facility's Legionella Policy and Procedure dated 2/7/25 documents Legionella is a bacterium commonly found in water systems and can grow in artificial water systems such as hot and cold water systems, hot water tanks, pipes, taps and showers. This policy documents Legionella can survive relatively low temperatures 68-113 degrees Fahrenheit (F.) and high temperatures above 140 F. kills Legionella bacteria. Legionnaires Disease is a potentially fatal form of pneumonia that is caused by inhaling the legionella bacteria in contaminated water droplets. This policy lists control measures including run through taps and showers no longer used or used infrequently for at least a minute once per week, take shower heads apart and clean/disinfect every three months, ensure water stored in the hot water tanks is above 140 F. The facility's Water Management Plan - Legionella Bacteria Risk Management dated 11/17/24 documents the facility has four hot water heater tanks, 78 resident room sinks, and four showers. This plan documents the hot and cold water in sink and shower outputs creates an optimal temperature for bacterial growth, showers have been a known source for Legionella bacteria, and showers aerosolize water which creates an ideal environment for water vapor inhalation. This plan documents hot water heaters heat the supply water and store the heated water in storage tanks, and due to the risk of scalding many storage tanks are set to a temperature below the minimum needed to kill bacteria. This plan documents a log sheet guide for implemented control measures including hot water storage tanks not less than 140 degrees Fahrenheit (F) and use of mixing valve to prevent scalding and deliver water to rooms between 100 F and 110 F; check hot water tank temperatures daily and record on the log. On 5/20/26 at 11:42 AM V8 Maintenance Director provided the facility's legionella policy, water management plan and control measures, which were reviewed with V8. V8 stated V8 flushes sinks and shower that are not in use on a weekly basis, but V8 does not have documentation of this. V8 confirmed shower head cleaning as part of the facility's policy. V8 stated he started working for the facility in late January 2026 and has not cleaned any shower heads but will look for documentation to see when this was last completed. V8 stated the facility has four hot water heater tanks which should have temperature of 120 F., this is checked monthly but V8 did not have any documentation of this. At 12:11 PM V8 stated he was unable to locate documentation that shower heads have been cleaned. On 5/20/26 at 11:50 AM V8 stated the facility has two hot water heater tanks that deliver hot water to the resident rooms. The North hall hot water heater tank in the maintenance office temperature was 115 F, verified with V8. The South hall hot water heater tank in the housekeeping closet temperature was 102 F., verified with V8. The facility's The Long-Term Care Facility Application for Medicare and Medicaid dated 05/18/26 documents the facility has a census of 47 residents. b1.On 05/18/2026 at 11:41 AM V19, Certified Nurse Assistant (CNA), donned gloves without benefit of hand hygiene. She then, with gloved hand, touched the back of R22 while talking with her. With the same glove hands, she served R20 his meal and opened his ice cream. Then she donned a hair net with same gloved hands and severed tray to R6. V19 then doffed her gloves and removed a resident out of the dining room. V19 returned to the dining room, reached into her pocket and donned gloves without benefit of hand hygiene. V19 served lunch trays to R24 and R13. On 05/20/2026 at 10:15 AM V19, CNA stated that when passing lunch trays, she would wash her hands prior to donning and after taking off her gloves. She stated that if she touched an object that was not food like a resident's arm or rub their back, she would remove her gloves and wash her hands prior to putting another pair on. On 05/20/2026 at 10:20 AM, V18, CNA, stated that she would wash her hands prior to putting on and after taking off her gloves. The facility's policy, Personal Protective Equipment-Using Gloves, dated 6/2025, documented, 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) b.2.) On 5/19/26 at 7:54 a.m., V5, Licensed Practical Nurse (LPN), administered oral medications to R7 while R7 was seated in the hallway. V5 handed R7 a cup containing medications followed by a cup of water. After R7 consumed the medications, R7 returned the used medication cup and water cup to V5. V5 did not perform hand hygiene before, during, or after the medication administration process. On 5/19/26 at 8:04 a.m., V5, LPN, administered oral medications to R29 while R29 was seated in the front lobby. V5 handed R29 a cup containing medications followed by a cup of water. R29 removed the medications from the cup and placed them on a blanket covering his lap. R29 then returned the used medication cup and water cup to V5. V5 did not perform hand hygiene before, during, or after the medication administration process. On 5/19/26 at 8:35 a.m., V5, LPN, removed a cell phone from his scrub pocket, checked the phone, and returned it to his pocket without performing hand hygiene. On 5/19/26 at 8:36 a.m., V5, LPN administered medication to R26 while R26 was seated at the dining room table. V5 handed R26 a cup containing medications followed by a cup of water. R26 then sat the two cups on the table and returned the used medication cup and water cup to V5. V5 did not perform hand hygiene before, during, or after the medication administration process. On 5/19/26 at 9:35 a.m., V5, LPN, administered eye drops to R31 while R31 was seated in a recliner in her room. V5 put on gloves and administered eye drops to both eyes; however, V5 failed to perform hand hygiene before putting on gloves, during the procedure, or after removing the gloves. On 5/19/2026 at 9:39 a.m., V5, LPN stated he should have performed hand hygiene between each resident. On 5/20/26 at 10:15 a.m., V3, Assistant Director of Nursing (ADON) stated that the expectation for nurses during medication administration is to perform hand hygiene between each resident encounter. The facility's Handwashing/Hand Hygiene Policy, dated March 2020, stated it is the facility's policy to ensure staff practice recognized handwashing/hand hygiene procedures as a primary means to prevent the spread of infection among residents, staff, and visitors. The policy stated alcohol-based hand rubs (ABHR) may be used when hands are not visibly soiled or contaminated with blood or bodily fluids. The policy documented that all employees shall be educated on recognized handwashing/hand hygiene procedures and follow those procedures. The policy documented that employees will perform hand hygiene: before direct contact with residents; before putting on gloves; before preparing or handling medications; after direct resident contact; after contact with a resident's intact skin; after contact with potentially contaminated equipment or objects in the resident's environment, and after glove removal, after removing gloves; during resident meal service: in between tray pass if contact with resident is made hand hygiene should be used, when removing trays hand hygiene should be used before contact with fresh tray or with a resident; The policy also documented that the use of gloves does not replace compliance with handwashing/hand hygiene procedures.

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of resident's personal and medical information for five residents (R7, R8, R26, R29, R60) of six residents reviewed for privacy out of a total sample of 40 residents. Findings:On 5/19/26 at 7:46 a.m., V5, Licensed Practical Nurse (LPN) walked away from his computer leaving the screen unattended which displayed R8's physician orders visible to the public.On 5/19/26 at 7:49 a.m., V5, LPN walked away from his computer leaving the screen unattended which displayed R60's physician orders visible to the public.On 5/19/26 at 7:54 a.m., V5, LPN walked away from his computer leaving the screen unattended which displayed R7's physician orders visible to the public.On 5/19/26 at 8:04 a.m., V5, LPN walked away from his computer leaving the screen unattended which displayed R29's physician orders visible to the public.On 5/19/26 at 8:33 a.m., V5, LPN walked away from his computer leaving the screen unattended which displayed R26's physician orders visible to the public.On 5/19/26 at 9:39 a.m., V5, LPN, stated management had instructed him to lock his computer screen whenever stepping away during medication administration to protect resident privacy and confidentiality.On 5/20/26 at 10:15 a.m., V3, Assistant Director of Nursing (ADON), stated facility expectation requires nurses to lock their computer screens whenever stepping away from the computer to protect resident privacy and confidentiality. V3 acknowledged V5, LPN, failed to lock his computer screen, leaving resident information visible while the medication cart was unattended.The facility's Confidentiality of Information policy, dated December 2006, stated the facility shall treat all resident information confidentially and safeguard all resident records, including medical, financial, and social information, to protect confidentiality. The policy documented that access to resident medical records would be limited to staff and consultants providing services to the residents.

Failures at this level required more than one Deficient Practice Statement.A. Based on interview, observation and record review, the facility failed to keep resident rooms at comfortable temperatures for seven of nine (R19, R22, R25, R27, R28, R31, R57) residents reviewed for safe, clean, comfortable homelike environment, in a sample of 40.B. Based upon observation, interview, and record review, the facility failed to provide a clean and sanitary environment for one of nine residents (R16) reviewed for safe, clean, comfortable homelike environment, in a sample of 40.Findings include:a.1. The facility's policy, Accommodation of Needs and Homelike Environment Guideline, dated 10/2023, documented, Comfortable and safe temperature levels, means that the ambient temperature shall be maintained to provide comfortable temperatures in all areas. Air temperature shall be maintained in a temperature range of 71 (degrees Fahrenheit) to 81 (degrees Fahrenheit). On 05/19/2026 at 12:54 PM, R27 had a thermometer with a humidity reading of 86% and the temperature was 82 degrees Fahrenheit. R27 was wearing his oxygen. R27 stated that it was uncomfortable and very humid in their room. R27 Minimum Data Set (MDS), dated [DATE], documented that his cognition was intact. R27's Physician's order sheet, dated 5/2026, documented diagnoses of Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. It also documented an order to titrate (oxygen) to maintain sats greater than 90%. Do not exceed 3(Liters/min) without notifying physician. a.2. On 05/19/2026 at 12:54 PM, R28 had a thermometer in her room with a humidity reading of 86% and the temperature was 82 degrees Fahrenheit. R28 was wearing her oxygen. R28 stated that it was uncomfortable and very humid in their room. R28's MDS, dated [DATE] documented that her cognition was intact. R28's Physician's Order sheet, dated 5/2026, documented a diagnosis of Chronic Obstructive Pulmonary Disease and an order to titrate O2 to maintain sats greater than 90%. Oxygen (O2) at 2.5 Liters/Minute at (night) and (as needed) for (shortness of breath). a.3. On 5/18/2026 at 10:55 AM, R22 stated that her room has been hot and uncomfortable and that there was no air conditioning put in yet. R22's MDS dated [DATE] documented her cognition was intact. R22's Physicians order sheet, dated 5/2026, documented diagnoses of Asthma and Congestive Heart Failure. a.4. On 5/19/2026 at 10:55 AM, R25 stated that her room has been hot and uncomfortable and that there was no air conditioning put in yet. R25 was sitting in her wheelchair with her oxygen on. R25's MDS, dated [DATE], documented that her cognition was intact. R25's Physician's Order Sheet, dated 5/2026, It also documented a diagnosis of Chronic Obstructive Pulmonary Disease and an order Continuous Positive Air Pressure at night with settings 15-20 centimeters (water) with 1 (liter). On 05/19/2026 at 12:00 PM V8, Maintenance Director, stated that he puts the air conditioners in for the residents who are on constant oxygen first and then the common areas like the dining room and activity room are put in. He stated that he has not been checking air temperatures but there is a small thermometer in the hallway that he looks at, but he does not document room air temperatures. On 05/20/2026 at 9:55 AM V2, Interim Director of Nurses, stated that they do not have a policy regarding which residents get their window air conditioning unit in first. a.5.) On 5/19/26 between 9:15 AM and 2:30 PM the air in the facility's hallways and conference room felt sticky/humid. On 5/18/2026 at 11:02 AM R31 stated it would be nice to have our air conditioner (AC) units installed, R31's roommate R19, has difficulty breathing so we can't open the windows due to the humidity and pollen. R31 stated we have been asking staff for the window AC units for about a month. There was no fan or AC in R31's/R19's room. The room air felt humid and sticky. At 1:05 PM R19 was in her room and was using oxygen. R19 stated it would be nice to have the AC installed. On 5/18/26 at 1:10 PM V8 Maintenance Director stated V8 is working on installing the window AC units in resident rooms and R31's/R19's room is on his list. On 5/19/2026 at 11:00 AM V6 Certified Nursing Assistant stated R31 and R19 complained of not having AC about 2-3 weeks ago, and R19 wanted the AC for her breathing and R19 uses oxygen. V6 stated V8 was notified the same day, and we had been opening the windows in the meantime. On 5/19/26 at 3:10 PM V11 LPN stated about two weeks ago R19 and R31 had complained to dayshift nurse V4 LPN about needing AC and this was reported to V8. V11 stated this past Saturday it was pretty warm in the building. On 5/19/26 at 3:13 PM V5 LPN stated about 2-3 weeks ago R19 complained of it being warm in her room and needing AC. V5 stated R19 reported that when the temperature gets above 75 F R19 has difficulty breathing since R19 uses oxygen and nebulizer treatments. V5 stated V5 reported this and was told that R19 would be one of the first residents to get AC units, but that didn't happen. V5 stated V5 reported this to V3 Assistant Director of Nursing and V8. R19's active diagnoses list includes asthma, congestive heart failure, and respiratory failure. R19's physician order dated 10/24/25 documents continuous oxygen at 2 liters per minute. R19's Minimum Data Set, dated [DATE] documents R19 as cognitively intact. a.6.) On 5/19/2026 at 11:22 AM R57 and V12 (R57's Family) were in R57's room. There was an oscillating fan in R57's room. R57 stated it is hotter than h*** in here and she talked to staff on Saturday about getting AC for her room. V12 and R57 stated the fan was one they brought from home. R57 stated V8 came in this morning to measure R57's window. The air temperature in R57's room was 77.8 degrees Fahrenheit (F.). On 5/19/2026 at 10:54 AM V5 Licensed Practical Nurse (LPN) stated V4 received complaints from R57 and family requesting AC on Friday, and a note was left for maintenance. V4 stated the air was stuffy in the facility on Saturday. The Weather Underground Weather History Reports for April and May 2026 documents the following maximum daily temperatures and % humidity: 4/9/26- 78 F. 66% 4/12/26- 81 F. 87% 4/13/26- 84 F. 84% 4/14/26- 83 F. 90% 4/15/26- 77 F. 93% 4/16/26- 77 F. 97% 4/17/26- 83 F. 100% 4/22/26- 80 F. 84% 4/23/26- 83 F. 97% 5/4/26- 75 F. 89% 5/12/26- 83 F. 72% 5/17/26- 84 F. 100% 5/18/26- 77 F. 97% 5/19/26- 78 F. 93% b.1.) R16's Care Plan, undated documents R16 admitted to the facility on [DATE] with medical diagnosis that include Type 2 Diabetes Mellitus, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Vascular Dementia, and muscle weakness. Also documents R6 is always incontinent at night and tends to put soiled linens under her bed. On 5/18/26 at 12:00PM and 2:50PM, R16's room had overwhelming odor of urine and bed linens had large dry urine stains covering 50 percent of bed. Soiled clothing on floor in corner of the room and garbage can was overflowing with soiled adult briefs. On 5/19/26 at 11:15AM, R16's room continued to have overwhelming odor of urine and bed linens had 2 pads covering large urine stains covering 50 percent of bed. Soiled clothing on floor in corner of the room and garbage can was overflowing with soiled adult briefs. On 5/19/26 at 11:20AM, V2 Interim Director of Nursing alerted the condition of R16's and confirmed through observation that room needed cleaned and sanitized immediately. On 5/19/26 at 2:35PM, R16 stated that no one cleans her room and she has to request clean linens to change bed. R16 stated that she has to make her bed however even with clean sheets on, the mattress is still wet so when she sits on the bed, the clean linens just soak into the sheets. Housekeeping Services Policy, undated, documents the facility is to maintain a clean, odor free, comfortable and orderly environment in all areas which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable home-like environment.

Based on observation, interview, and record review the facility failed to appropriately label insulin vials with the date opened for three residents (R7, R12, R52) of six residents reviewed for medication administration from a sample list of 40.Findings:On 5/20/2026 at 9:47 a.m., a review of the North Hall medication cart was conducted in the presence of V5, Licensed Practical Nurse (LPN). During the inspection, an open vial of insulin glargine for R7 and open vials of lispro insulin for R12 and R52 were found without documented dates of opening.Review of R7's Medication Administration Record (MAR) dated May 2026 documents that R7 has an active physician's order and is currently receiving insulin glargine two times a day.Review of R12's MAR dated May 2026 documents that R12 has an active physician's order and is currently receiving insulin lispro three times a day.Review of R52's MAR dated May 2026 documents that R52 has an active physician's order and is currently receiving insulin lispro everyday with meals.On 5/20/26 at 10:05 a.m., V5, LPN stated insulin vials and pens are required to be labeled with the date opened. V5 stated he normally labels them when opening a new vial and was unsure why some vials were not dated but acknowledged they should have been labeled.On 5/20/26 at 10:15 a.m., V3, Assistant Director of Nursing (ADON) stated the facility policy is for nurses to document the date immediately upon opening an insulin vial. V3 stated the vials observed should have been labeled with the date opened to ensure they are disposed of within the appropriate timeframe after opening.

Based on interview, observation and record review, the facility failed to provide palatable and appetizing food for 5 of 8 (R3, R22, R23, R25, R28) residents, reviewed for nutritive value, appearance, palatable and preferred food temperatures, in a sample of 40.Findings include:1.On 5/18/2026 at 11:15 AM, R3 stated that the food has no seasoning and just isn't good.R3's Minimum data set (MDS), dated [DATE], documented that her cognition was intact.2. On 5/18/2026 at 11:15 AM, R22 stated that the portions are too small, and the food has no flavor.R22's MDS, dated [DATE], documented her cognition was intact.3.On 5/18/2026 at 10:00 AM, R23 stated that the food is terrible and always cold. She also stated that there are too many starches.R23's MDS, dated [DATE], documented that her cognition was intact.4.On 5/18/2026 at 11:15 AM, R25 stated that she can't have pork and when they have pork on the menu, the substitute was a ham sandwich.R25's MDS, dated [DATE], documented that her cognition was intact.R25's Physician's Order Sheet, dated 5/2026, documented a diet order that recommended to not eat pork, tomato products or fried foods.5. On 5/18/2026 at 11:15 AM, R28 stated that the food does not taste good, and the substitutes are always sandwiches. R28 stated that they used to serve chef salads as a substitute, and they took those away.R28's MDS, dated [DATE], documented that her cognition was intact.On 05/20/2026 at 12:45 PM, a lunch meal was tested. On the tray was a bowl of chicken stew, white rice, a dinner roll and a bowl of pineapple. All food was temped, and all was within normal limits. The white rice was sticky and bland. The chicken stew was bland.On 05/20/2026 at 9:50 AM, V18, Certified Nurses Assistants (CNA), stated that if a resident does not like the meal, they offer a substitution. She would go to the kitchen and see what was available. She also stated that the residents' diets are on their cards. On 05/20/2026 at 9:55 AM, V19, CNA, stated she would ask dietary for a substitute if a resident wanted something different and to find out what the residents' diet is.On 5/20/2026 at 1:00 PM, V9, Dietary Manager, stated that they follow the recipes when cooking.Resident council meeting minutes, dated 2/16/2026, documented Substitutions: more options and wants.Resident Council Meeting minutes, dated 3/16/2026, documented, Compliments or Concerns It continues, Food needs improvement. It continues, Jelly, butter served with rolls without having to be asked, more fresh vegetables with salad, more fresh bananas, pickles, yogurt, more fresh fruit.Resident Council Meeting minutes, dated 4/15/2026, documented, Salads not being offered every day, getting meals before drinks.The facility's policy, Service of Food, dated 6/2023, documented, The purpose of this policy is to create and exceptional culinary experience for our residents.

Based on interview and record review, the facility failed to honor a resident's request to postpone a shower for one resident (R4) of two residents reviewed for choices on a total sample of 40 residents.Findings: On 5/20/26 at 8:04 a.m., R4 stated that on the day she was admitted to the facility staff immediately placed her in the shower despite her stating she was in pain and did not want one. R4 stated the experience was terrible and felt like torture and that staff had to wrestle her into the shower, and that it took five staff members to assist. R4 stated she was told showering upon arrival is facility protocol.R4's Electronic Health Record (EHR) documents that R4 was admitted to the facility on [DATE] after hospitalization for a broken left broken hip. R4's Minimum Data Set (MDS) dated [DATE] documented that R4 was cognitively intact. This MDS also documented that R4 required substantial to maximal assistance from staff for bathing and dependent on staff for transfers to get in and out of a tub/shower.R4's Care Plan dated 4/29/26 documents that R4 required substantial/maximum hands-on assistance or weight bearing assistance from one staff related to limited mobility and range of motion.A nurse's progress note dated 4/11/26 written by V14, Licensed Practical Nurse (LPN) documented that R4 received a shower upon arrival to the facility and was anxious, frequently screaming during the process.A document titled Shower/Abnormal Skin Report dated 4/11/26 documents that staff assisted R4 with a shower.On 5/20/26 at 8:41 a.m., V14, LPN stated R4 didn't want to get out of bed for a shower on the day R4 was admitted . V14 stated it took three staff members to get her out of bed for shower that day because R4 wasn't helping at all and was screaming off and on. On 5/20/26 at 11:52 a.m., V2, Director of Nursing (DON) stated facility protocol is for residents to be showered upon admission for completion of a skin assessment; however, if a resident refuses, staff are to reapproach at a later time. At 12:09 p.m., V2, DON stated residents have the right to refuse care and staff should have documented the refusal and respected R4's wishes. The facility's Resident Rights Guideline dated October 2023 documented that residents are provided an environment in which they may exercise their rights daily and are afforded rights and protections under federal law. The policy documented that the facility ensures these rights through care and related services at all times. It further states residents have the right to be treated with respect and dignity and to choose schedules, including sleeping and waking times.

Based on interview and record review, the facility failed to submit a request for a new Level I Preadmission Screening and Resident Review (PASRR) for a resident with a new diagnosis of mental illness and failed to ensure an individual admitted with a mental illness diagnosis was accurately screened for Level I PASRR for two of three residents (R7, R20) reviewed for PASRR in the sample list of 40.Findings include: 1.The facility's Assessment Pro Skilled Nursing Facility policy dated 7/28/23 documents to follow up with the Care Coordination Unit for the Determination of Needs screening. R20's Care Plan, undated, documents R20 admitted to the facility on [DATE] with medical diagnosis that include Hypertension, Kidney Failure, Major Depressive Disorder, Insomnia, and generalized Anxiety. R20's Medication Administration Record dated December 2025 documents medications that include Mirtazapine Oral Tablet 7.5 milligrams (mg) daily for depression and Melatonin 5mg at bedtime for insomnia. R20's Medication Administration Record dated January 2026 documents medications that include Mirtazapine Oral Tablet 7.5 milligrams (mg) daily for depression, Melatonin 5mg at bedtime for insomnia and Seroquel 25mg twice daily for mania and anxiety. R20's Psychiatric Practitioner Routine Visit note dated 12/31/25 documents R20 is currently prescribed mirtazapine 7.5mg for depression, and melatonin 5mg for sleep, both of which appear effective without any reported or observable side effects. R20's Psychiatric Practitioner Acute Visit note dated 1/16/26 documents R20 has new documented psychiatric diagnoses include depression general anxiety, and collateral report of lifelong mood disorder and obsessive compulsive disorder; staff describe a new or worsening manic/confused presentation since the recent hospitalization. During this encounter the clinician initiated a low dose quetiapine (Seroquel) oral regimen to be administered twice daily for mood stabilization, agitation, and confusion. R20's Electronic Medical Record does not document a new Level I PASARR. On 5/20/26 at 3:30PM V7 Business Office Manager (BOM) denied submitting a new Level I PASARR screening for R20 after new diagnosis was documented. V7 denied knowledge of need to submit new level 1 screens for residents with new psychiatric diagnosis or medications. 2.) R7's Census documents R7 admitted to the facility on [DATE]. R7's Diagnosis List includes Schizophrenia dated 9/5/24 added to this list on 12/26/24. R7's Hospital Discharge Instructions dated 9/5/24 does not list Schizophrenia as a diagnosis and R7's medication orders included Aripiprazole (antipsychotic) 7 milligrams (mg) by mouth daily, Sertraline (antidepressant) 50 mg by mouth daily, Trazodone (antidepressant) 150 mg 1/2 tablet by mouth daily. R7's Physician Progress Note dated 10/28/24 documents R7's diagnoses included Schizophrenia. May 2026 Medication Administration Record documents orders for Aripiprazole 5 mg daily, Trazodone 150 mg 1/2 tablet daily increased to one tablet daily on 5/20/26, and Sertraline 25 mg daily. R7's Level I PASRR dated 9/9/24 documents no suspected or confirmed PASRR conditions, no mental health diagnosis or behaviors/symptoms or mental health medications; no Level II required. There are no other PASRRs in R7's electronic medical record (EMR). On 5/19/26 at 11:55 AM V7 Business Office Manager reviewed R7's Level I PASRR and confirmed only a level I was completed and does not include any mental health diagnoses or medications. V7 confirmed R7's diagnoses list includes Schizophrenia added 12/26/24. V7 confirmed this was the only PASRR completed for R7. On 5/20/26 at 3:30PM V7 stated V7 was unaware of the need to verify for accuracy or follow up for level II PASRR.

Based upon observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one of one (R16) resident reviewed for incontinence on a sample list of 40.R16's Care Plan, undated documents R16 admitted to the facility on [DATE] with medical diagnosis that include Type 2 Diabetes Mellitus, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Vascular Dementia, and muscle weakness. Care Plan also documents that R16 has bladder incontinence with physical limitations initiated on 7/23/25. Interventions include to check R16 every 2 hours for incontinence, change brief, wash, rinse and dry perineum and change clothes as needed and after every incontinent episode.On 5/18/26 at 12:00PM and 2:50PM, and on 5/19/26, R16's room had overwhelming odor of urine and bed linens had large dry urine stains covering 50 percent of bed. Soiled clothing on floor in corner of the room and garbage can was overflowing with soiled adult briefs.On 5/19/26 at 2:35PM, R16 denied staff helping her with toileting. R16 stated that no one cleans her room and she has to request clean linens to change bed. R16 stated that she has to make her bed however even with clean sheets on, the mattress is still wet so when she sits on the bed, the clean linens just soak into the sheets and that's why she keeps getting infections.R16's progress notes dated 5/5/26 document a urine sample was sent to lab for R16's complaints of burning with urination.R16's lab results dated 5/10/26 documents urine sample positive for Escherichia coli (E.coli) bacteria.Facility's Urinary Incontinence Clinical Protocol dated August 2008 documents staff with identify and implement interventions that help facilitate toileting and monitor for signs and symptoms of infection.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary toilet for one resident (R9) out of ten residents reviewed for environment from a total sample of 40 residents. Findings:On 5/18/26 at 9:52 a.m., observations of the toilet in R9's bathroom revealed that the lid covering the toilet tank was missing, leaving the interior of the tank exposed. The tank contained standing water, and a rusty brown substance was visibly settled along the bottom interior surface of the tank. On 5/18/26 at 1:17 p.m., R9 stated the lid to the toilet tank in the bathroom attached to his room had been missing for a couple of weeks and that he had to jiggle the handle in order for the toilet to function properly. R9 also stated he had reported the issue to the Maintenance Director several times, but the toilet had not been fixed yet.R9's Minimum Data Set (MDS) dated [DATE] documents that R9 is cognitively intact. This MDS also documents that R9 is always continent of bowel and bladder and required set-up or clean up assistance from staff.On 5/19/26 at 11:22 a.m., V6, Certified Nurse Assistant (CNA) stated the toilet tank in R9's bathroom had been missing its lid for approximately eight months, since she began working at the facility, and confirmed that R9 is independent with toileting and R9 uses the toilet with the missing tank lid.On 5/19/26 at 12:48 p.m., V8, Maintenance Director observed the toilet in R9's bathroom and confirmed it was missing the tank lid. V8 stated he was not aware the lid was missing and that no work order had been submitted. V8 further stated the toilet would need to be replaced and acknowledged that all toilets should have a tank lid.The facility's Accommodation of Needs and Homelike Environment Guideline dated October 2023 documents that it is the practice of the facility to identify and provide reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This policy refers to Environment as any environment in the facility that is frequented by residents, including (but not limited to ) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.This policy defines homelike environment as one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment.

Based upon interview and record review, the facility failed to document the emergent transfer of one of two (R49) residents reviewed for discharge on a sample list of 40.R49's Clinical Census dated 5/20/26 documents an admission date of 3/13/26 and a discharge date of 3/18/26.R49's Progress Notes dated 3/18/26 at 4:41 AM R49 had no c/o pain or discomfort. R49 was experiencing intermittent confusion that was R49's normal baseline and R49 slept well throughout night. R49's Progress Notes dated 3/18/26 at 11:34PM documents R49 was admitted to the Intensive Care Unit at the hospital for sepsis and hypothermia. R49's Electronic Medical Record does not document events surrounding transfer out of facility. On 5/20/26 at 10:15 AM, V3 Assistant Director of Nursing verified that R49's record does not contain any information regarding R49's emergent transfer to hospital.Facility Transfer and Discharge Policy dated 11/2016 documents when any transfer or discharge occurs, facility must document the reason for transfer, location of transfer, and notification of transfer to provider and responsible party.

Based on observation, interview, and record review the facility failed to utilize footrests when transporting a dependent resident in a wheelchair resulting in entrapment of lower extremities in front wheels and the staff member transporting the resident failed to report the incident resulting in a two day delay of care for one (R1) of three residents reviewed for accidents in a sample of three residents. This failure caused R1 to suffer a fractured left tibia. Findings Include:R1's Care Plan, updated on 12/17/25, lists the following diagnoses: Congestive Heart Failure, Chronic Kidney Disease Stage III, Paroxysmal Atrial Fibrillation, Lymphedema and Chronic Venous Insufficiency of the lower extremities, unsteady gait, muscle wasting, and difficulty walking.R1's Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively intact and totally dependent on staff to propel her 150 feet in the corridor using a manual wheelchair.R1's Progress Note dated 12/27/25 at 5:21 a.m. documents: Message sent to (V8), Nurse Practitioner (NP), regarding left knee swelling and bruising. (R1) states it has been present for three days. Pedal pulse palpable, skin warm, able to push down and pull back with foot. States there is pain, not severe.R1's Progress Note dated 12/28/25 at 3:41 p.m. documents: At approximately 3:00 p.m., CNA came and notified nurse that (R1's) leg appeared more swollen and (R1) was having difficulty rolling. Nurse went to (R1's) room to assess her leg and noted it was worse than earlier that morning. (R1) stated she was agreeable to being sent to the hospital. Nurse completed paperwork, notified (V8), NP, called the ambulance at approximately 3:13 p.m., and notified the Power of Attorney. The ambulance arrived at 3:30 p.m., and the nurse called report to the hospital at 3:40 p.m.R1's Progress Note dated 12/29/25 at 1:30 p.m. documents: Nurse writer called to obtain an update after rounds. Hospital nurse stated the resident would need surgery; however, they were waiting for the surgeon to discuss the surgery and risks with the resident and her daughter prior to scheduling. Nurse stated the CT scan showed a mildly displaced oblique fracture of the proximal left tibia.On 2/4/26 at 9:00 a.m., R1 was observed lying in her bed wearing an orthopedic boot on her left lower extremity. R1 stated, I think it was the day before Christmas I decided to have them get me up in my chair. (V6) and (V10), Certified Nurse Aides (CNAs), came in with the sling-type mechanical lift and moved me to my chair. Since I was up, (V6) pushed me down to the scale to weigh me. She didn't put on the foot pedals. There is a little bump when you wheel onto the scale, and I slipped down in the chair a little. When she pushed me off the scale, my left foot got caught on the front wheel under the chair. I said, 'Ouch, I'm tangled,' and (V6) got me loose. It hurt, but I have swelling and bad circulation in my feet and legs, so sometimes I don't feel pain as much. After a while, the pain and swelling got so bad I couldn't stand for my leg to be moved. They sent me to the hospital, and my leg was broken. They talked about surgery, but with my heart problems, my weight, and not being able to stand anyway, we decided to use the boot and let it heal.On 2/5/26 at 10:18 a.m., V6 stated, I took (R1) in her wheelchair down to the scale to weigh her. I think it was the day after Christmas. I was hurrying and did not put on the foot pedals. When I pushed (R1) off the scale, her left foot got caught in the left front wheel under the wheelchair. I immediately got it loose. I think (R1) said something like, 'Ouch, I'm caught,' but I thought she was okay. I took her back to her room. I 100% should have used the foot pedals. If I had thought she was hurt, I would have gotten the nurse right away. I didn't tell anyone else, and I know I should have.On 2/5/26 at 10:24 a.m., V8, Nurse Practitioner (NP), stated, It is likely the incident when (R1's) foot was twisted under the wheelchair caused her leg fracture. When I was contacted, I was not made aware that there had been trauma. I assumed it was related to (R1's) history of cellulitis, lymphedema, and vascular insufficiency, so I ordered an antibiotic. If I had known trauma had occurred, I would have ordered an X-ray.On 2/5/26 at 12:30 p.m., V2, Director of Nursing (DON), confirmed the facility was not aware of the wheelchair incident until after the fracture was diagnosed on [DATE]. An investigation was immediately initiated, and V6 then reported the wheelchair incident.The facility's Accident/Incident and Unusual Occurrence Policy, effective February 2014, states the purpose is to record all accidents and incidents in writing, ensure thorough investigation to prevent future occurrences when possible, and identify hazards to the health and safety of residents, employees, and visitors, including notification to external review agencies and/or authorities as required. The policy further states all employees are responsible for reporting to their immediate supervisor any accident or incident that has or could have resulted in injury to residents, staff, visitors, or others, including completion and submission of the required report for review and signature.

Based on interview and record review the facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every twenty-four hours. This failure has the potential to affect all 47 residents who reside in the facility.Findings:The facility's Midnight Census Report dated 12/27/25 documents that there are 47 residents that reside at the facility.V2 Director of Nursing (DON) provided the nursing schedules for October through December 2025. Review of these schedules showed multiple days without an RN scheduled for eight consecutive hours. Those days are as follows: October 2025: 4, 5, 6, 7, 11, 12, 15, 16, 17, 20, 21, 22, 23, 28, and 31, November 2025: 3, 4, 7, 8, 9, 10, 11, 12, 13, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, and 30, December 2025: 1, 2, 3, 4, 6, 7, 8, 11, 12, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 29, 30, and 31.On 12/28/25 at 10:14 AM, V2 DON stated the facility was not meeting the requirement to have a registered nurse on duty for eight consecutive hours each day, seven days a week every twenty-four hours.

Based on observation, interview, and record review, the facility failed to provide and ensure the use of the correct size incontinence brief for three of three residents (R3, R4, R5) reviewed for insufficient supplies on a sample list of five residents. This failure placed the residents at risk for skin breakdown.Findings:R3's Minimum Data Set (MDS) dated [DATE] documents that R3's cognition is intact. This MDS also documents that R3 is frequently incontinent of bowel and bladder. R4's MDS dated [DATE] documents that R4's cognition is intact. This MDS also documents that R4 is always incontinent of bowel and bladder.R5's MDS dated [DATE] documents that R5's cognition is intact. This MDS also documents that R5 is always incontinent of urine and frequently incontinent of bowel.On 12/27/25 at 9:19 AM, V9 Certified Nurse Assistant (CNA) stated the facility had a recent shortage of size 3X incontinence briefs due to a shipment error that sent supplies to another state. V9 (CNA) stated that during the shortage, CNAs were instructed to use size 2X pull-up type briefs, which are harder to manage and less absorbent for residents with large urine output. V9 CNA stated that several residents have expressed concerns about the facility frequently running out of supplies.On 12/27/25 at 1:21 PM, V14 CNA stated supplies occasionally run low, mostly at the end of the week, including disposable washcloths and bariatric incontinence briefs. V14 stated the CNAs improvise by using smaller briefs, which residents dislike.On 12/27/25 at 1:45 PM, V12 CNA stated CNAs are using XL incontinence briefs instead of 3X for a few residents with increased body size and excessive urine output, making it difficult to keep them dry. V12 CNA reported that this issue has been ongoing for two weeks and has been brought to the attention of the person responsible for ordering (Director of Nursing (DON)) and the (Assistant Director of Nursing (ADON)) multiple times. V12 CNA stated at one point, staff were told they would have to make do with what was available.On 12/27/25 at 2:51 PM, R4 stated the facility occasionally runs out of large incontinence briefs (3X), requiring R4 to wear smaller ones (2X) that rub her skin and cause discomfort. R4 stated this occurred for two days a couple of weeks ago until a shipment arrived and noted this issue has persisted since R4's admission to the facility.On 12/28/25 at 9:20 AM, R3 stated the facility has had a recent shortage of large (3X) incontinence briefs lasting a couple of days, during which R3 had to wear smaller briefs (2X pull-ups type). R3 stated the 2X incontinence briefs are uncomfortable, less absorbent, and require more frequent changes due to R3's large urine output.On 12/28/25 at 9:30 AM, R5 stated the facility has a frequent shortage of 3X incontinence briefs since R5's admission in September. R5 stated the facility has run out of 3X briefs five times and R5 was told to use size 2X pull-up type incontinence briefs until the 3X shipment arrived. R5 stated the 2X pull-up type incontinence briefs are difficult for R5 to manage and cause skin irritation. R5 expressed concern about sores returning.On 12/28/2025 at 10:14 AM, V2 DON acknowledged awareness of the shortage of 3X incontinence briefs and stated that some residents who use that size were unhappy about having to wear smaller briefs. V2 DON agreed that smaller briefs can be uncomfortable and may cause skin irritation.On 12/28/25 at 10:26 AM, V3 ADON stated the facility has experienced supplier issues resulting in a shortage of 3X incontinence briefs. During the shortage, only 2X pull-ups were available, which did not meet the needs of residents requiring 3XL briefs. V3 agreed residents who feel more comfortable in larger briefs should have them provided but stated the facility cannot always meet preferences.The facility's undated Incontinence Care Educational Training Guidelines document that CNAs must ensure briefs fit appropriately. These guidelines document that the purpose of proper incontinence care is to monitor skin condition, maintain cleanliness and comfort, and prevent infection, skin irritation, and skin breakdown.

Based on observation, interview, and record review the facility failed to ensure that each resident's nutritional and hydration status was maintained for two (R1, R3) of three residents reviewed for weight loss. Findings include:The facility's Passing Meal Trays undated policy provided by the facility documents that nursing will be responsible for delivering all trays to residents whether the resident is eating in the dining room or in the resident room. Nursing will advise Food Service of residents not eating in their usual location. The facility's Meal Schedule undated policy provided by the facility documents that three meals will be served daily at similar times as served in the community. This policy documents the following: there will be no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. And an evening snack will be served. Nourishing snacks will be offered if the span is more than 14 hours between the ending of the evening meal and the serving of at least one or in combination from the basic food groups. Example: milk, grain product, meat/cheese or other protein rich item, fruit or 100% fruit juice.R1 was admitted to the facility on [DATE] for rehabilitation following left total hip replacement. R1 was discharged from the facility on 8/12/25. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of fifteen indicating that R1 has normal cognitive function.R3's MDS dated [DATE] documents a BIMS score of fifteen indicating that R1 has normal cognitive function.R3's Care Plan dated 8/05/25 documents that the resident has potential for pressure ulcer development related to alteration in circulation. This Care Plan lists an intervention for staff to monitor nutritional status and serve diet as ordered, monitor intake and record intake.On 8/25/25 at 11:14 AM, R1 stated the facility didn't bring her breakfast or lunch on the day after her admission on [DATE]. R1 also stated that she was not offered any snacks while residing at the facility and she lost ten pounds.On 8/25/25 at 11:49 AM, R3 stated the facility failed to bring her breakfast on several days within the past 2 weeks and that she had to call to have it delivered.R1's Electronic Medical Record (EMR) documents an admission weight of 181 pounds. On 8/25/25 at 3:15 PM, V16 Registered Nurse (RN) working with V17 Physician Assistant (PA) confirmed that R1 was seen by V17 for a surgical follow-up on 8/12/25. V16 stated that R1 was weighed at this visit and was 78 kilograms (171.9 pounds). V16 stated that R1 was wearing baggy pants and R1 told V16 that the facility was feeding her.On 8/26/25 at 8:12 AM, R3 was sitting up in her bed with the head of the bed elevated and she was wearing a clothing protector. R3 stated that breakfast hadn't arrived yet and that R3's last meal was delivered around 5:30 PM the previous evening. On 8/26/25 at 8:30 AM, R3's breakfast observed being delivered to R3's room. On 8/26/25 at 9:30 AM, V17 PA stated that he saw R1 for a surgical follow-up visit on 8/12/25. V17 stated that he had known R1 as a patient for 14 years and had never seen her so distraught. V17 said that R1 was very upset and crying. V17 stated R1 told him that the facility was not feeding her. V17 stated that R1 did appear to be thinner and that if she would have continued to remain at the facility, he feared for R1's health and her recovery.On 8/26/25 at 11:36 AM, V2 Director of Nursing stated that obviously if R1 missed meals it could have led to her weight loss.On 8/26/25 at 1:06 PM, V14 Dietary Manager stated that they use an electronic system to enter resident information regarding their dietary needs and then create daily meal tickets. V14 stated that she could not provide me with any documentation showing that R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to R1. R1's admission weight dated 8/6/25 documents that R1 weighed 181 pounds. R1's weight on 8/12/25 was 171.9 pounds which is equivalent to 5 % weight loss in 6 days.

Based on observation, interview, and record review the facility failed to provide a bedtime snack and breakfast for two (R1, R3) of three residents reviewed for food services on a sample list of six. Findings include:The facility's undated Passing Meal Trays policy provided by the facility documents that nursing will be responsible for delivering all trays to residents whether the resident is eating in the dining room or in the resident room. Nursing will advise Food Service of residents not eating in their usual location. The facility's Meal Schedule undated policy provided by the facility documents that three meals will be served daily at similar times as served in the community. This policy documents that there will be no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. And an evening snack will be served. R1 was admitted to the facility on [DATE] for rehabilitation following left total hip replacement. R1 was discharged from the facility on 8/12/25. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of fifteen indicating that R1 has normal cognitive function.R3's MDS dated [DATE] documents a BIMS score of fifteen indicating that R1 has normal cognitive function.R3's Care Plan dated 8/05/25 documents The resident has potential for pressure ulcer development related to alteration in circulation. This Care Plan lists an intervention for staff to monitor nutritional status and serve diet as ordered, monitor intake and record.On 8/25/25 at 11:14 AM, R1 stated the facility failed to bring her breakfast or lunch on the day after her admission to the facility on 8/05/25. R1 stated she lost ten pounds while residing in the facility. On 8/25/25 at 11:49 AM, R3 stated the facility failed to bring her breakfast on several days within the past two weeks and that she had to call to have it delivered.R1's Electronic Medical Record (EMR) documents an admission weight of 181 pounds. On 8/26/25 at 8:12 AM, R3 was sitting up in her bed with the head of the bed elevated and R3 was wearing a clothing protector. R3 stated that breakfast hadn't arrived yet and that R3's last meal was delivered around 5:30 PM the previous evening. On 8/26/25 at 8:30 AM, R3's breakfast was observed being delivered to R3's room. On 8/26/25 at 9:30 AM, V17 PA stated that he saw R1 for a surgical follow-up visit on 8/12/25. V17 stated that he had known R1 as a patient for 14 years and had never seen her so distraught. V17 said that R1 was very upset and crying. V17 stated R1 told him that the facility was not feeding her. V17 stated that R1 did appear to be thinner and that if she would have continued to remain at the facility, he feared for R1's health and her recovery. On 8/26/25 at 11:36 AM, V2 Director of Nursing stated that obviously if R1 missed meals it caused her to lose weight.On 8/26/25 at 1:06 PM, V14 Dietary Manager stated that they use an electronic system to enter resident information regarding their dietary needs and then it creates daily meal tickets. V14 stated that she could not provide me with any documentation showing that R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to R1. On 8/25/25 at 3:15 PM, V16 Registered Nurse (RN) working with V17 Physician Assistant (PA) confirmed that R1 was seen by V17 for a surgical follow-up on 8/12/25. V16 stated that R1's weight at this visit was 78 kilograms (171.9 pounds). V16 stated that R1 was wearing baggy pants and R1 told V16 that the facility was not feeding her.

Based on interview and record review, the facility failed to effectively supervise R1 to prevent a traumatic fall and thoroughly investigate a fall. This failure resulted in R1 striking R1's head on a closet door during a fall to the floor and sustaining a brain bleed requiring emergency medical evaluation and treatment at two hospitals. R1 is one of three residents reviewed for accidents in the sample list of three. Findings include: The facility Fall Prevention Policy (revised 11/10/18) documents the following: All staff must observe residents for safety. If residents with a high risk code are observed getting up, help must be summoned or assistance must be provided to the resident. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. The unit nurse will place documentation of the circumstances of the fall in the nurses notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. R1's Face Sheet dated 3/4/25 documents R1's diagnoses include: Cerebral Infarction, Mild Cognitive Impairment of Uncertain/Unknown Etiology, Muscle Wasting and Atrophy, Unsteadiness on Feet, Lack of Coordination, and Abnormalities of Gait and Mobility. R1's January 2025 Physician Orders documents an order for Xarelto (anticoagulant) 2.5 milligrams by mouth twice a day. R1's Comprehensive assessment dated [DATE] documents R1 is cognitively intact with no upper or lower limb impairments, uses a wheelchair and/or walker for mobility, and requires partial/moderate assistance with toileting and transfers. R1's Care Plan (January 2025) documents R1 is high risk for falls related to gait/balance problems and requires assistance to transfer. This same record documents R1 had a fall on 1/5/25 due to unsteady gait with root cause of R1 having increased confusion, trying to reach for tray and slipped out of R1's recliner. Further documents R1 had a fall on 1/21/25 with root cause of R1 confused, tried to stand up unassisted, lost balance and fell . Intervention: Educate resident on the importance of calling for help when transferring from recliner. R1's Nursing Progress Note dated 1/22/25 at 3:30pm, documents R1 complained of being tired and documents R1 has been more lethargic today. Further documents V4 R1's Representative at facility to visit R1 and R1 reporting to V4 that R1 did hit head [during fall on 1/21/25]. Further documents Emergency Medical Services (EMS) notified and R1 sent to local emergency department for evaluation and treatment. R1's Emergency Department Report dated 1/22/25 documents the following: Chief Complaint: EMS reports patient [R1] fell last night hitting back of head on cubbie. Complains of 7/10 head and neck pain. Patient had stroke one month ago and still taking thinners for AFIB. ED Course: Patient is presenting for an unwitnessed fall last night that occurred around 10:30pm. Patient is complaining of headache and reports hitting the back of head. No palpable hematoma or signs of significant head trauma. Patient is slow to respond and somnolent. Mild dysarthria (a speech disorder characterized by difficulty in speaking clearly due to damage or dysfunction in the muscles or nerves that control speech. Dysarthria can be caused by strokes.) Stroke about one month ago. On Xarelto for A-fib and the prior stroke. Disposition: Transfer to (higher level of care) trauma facility. Assessment: 1. Subdural hematoma, acute 2. Unwitnessed fall 3. Chronic anticoagulation. R1's Computed Tomography of Brain/Head dated 1/22/25 documents the following: Reason for exam: Fall, slurring. Impression: New mild hyperdensity along the falx concerning for minimal acute subdural hemorrhage. R1's Incident Investigation Form completed by V3 Agency Licensed Practical Nurse (LPN) on 1/23/25 documents R1 had an unwitnessed fall on 1/21/25 at 10:30pm and R1 was found on the floor in R1's room lying on R1's left side. This same record documents R1 denied hitting head. R1's Fall Investigation dated 1/23/25 documents R1 had an unwitnessed fall on 1/21/25 with increased confusion noted on 1/22/25. Further documents R1 sent to local emergency department on 1/22/25 and diagnosed with a subdural hematoma. V5 Certified Nursing Assistant (CNA) statement dated 1/25/25 documents the following: R1 had an unwitnessed fall on 1/21/25 at 10:30pm and R1 was on the floor at the end of R1's bed and appeared to have hit R1's head on the closet door. Further documents V3 Agency LPN asking R1 if R1 hurt anywhere and R1 stating bottom and head. V5's statement documents R1 receiving a phone call on R1's cell phone from the local police department regarding a call R1 had placed claiming someone was breaking into R1's apartment. Further documents R1 being confused during this incident. R1's Quality Care Reporting Form, Investigative Report for Falls, AIM for Wellness (all part of the facility fall packet), and Nursing Progress Note related to R1's 1/21/25 fall was not completed by V3 until 1/23/25. On 2/28/25 at 11:46am, V4 R1's Representative stated R1 had a stroke on 12/21/24. V4 stated R1 uses walker to ambulate and was trying to get out of bed thinking someone was breaking into R1's apartment. V4 stated R1 called the local police and the police went to R1's apartment then came to facility after calling R1's cell phone. V4 stated V4 came to facility around 3:00pm on 1/22/25 and R1 was slurring R1's speech. V4 stated R1 was sent out at this time for evaluation and treatment at local emergency department. V4 stated R1 was transferred from the local emergency department on 1/22/25 to a higher level of care hospital. On 3/4/25 at 10:18am, V7 LPN stated V7 worked during the day on 1/22/25 and took report from V3. V7 stated V3 advised R1 had fallen. V7 stated V3 advised V7 that R1 landed on R1's bottom and had no injuries. V7 stated V7 was unable to locate the fall packet for R1. V7 stated R1 on 1/22/25, appeared per norm, talking, took medications without issue and R1 stated, 'tired, kept up all night.' V7 stated the procedure for after a resident fall is to assess the resident, fill out the fall packet, and if on blood thinners (anticoagulant) or the resident hit their head, automatically send resident out [for evaluation and treatment]. V7 stated neurological checks are initiated and the resident is also monitored throughout the day. On 3/4/25 at 1:17pm, V5 CNA stated V5 didn't usually work over on R1's side of the facility but was familiar with R1. V5 stated R1 was not usually confused. V5 stated R1 is usually with it and talks to a lot of people. V5 stated V3 and V5 were at the nurses desk on 1/21/25 and heard a loud noise down the 100 hallway. V5 stated V3 was in front of V5 when they arrived at R1's room and R1 was on the ground with R1's head near closet door and R1's wheelchair was right beside R1. V5 stated R1 had one sock on and one sock off. V5 stated R1 stated, 'I'm letting the cops in' (from the closet door). V5 stated V3 assessed R1. V5 stated during this time R1 received a phone call from an unknown number on R1's cell phone and R1 answered the call and it was the local police department. V5 stated V3 asked R1 if R1 hit R1's head or if anything hurt and R1 stated R1 hit R1's head. V5 stated they assisted R1 back into R1's wheelchair and then bed. V5 confirmed R1 was not sent out for evaluation and treatment at that time. V5 stated after the fall, R1 was very confused and unaware of who staff were and was frightened. V5 stated R1 was one assist with supervision and needed help with toileting and transfers. V5 stated any residents with unwitnessed falls and/or hit their head were usually sent out for evaluation and treatment. On 3/4/25 at 2:24pm, V10 CNA stated stated R1 was one assist but known to get up per self and R1 would transfer from recliner to R1's bed without notifying anyone. On 3/4/25 at 2:30pm, V2 Regional Director of Nursing stated V3 Agency LPN should have completed the fall packet and reported R1's 1/21/25 fall on 1/21/25. V2 confirmed the fall packet was not completed until 1/23/25.

Based on interview and record review the facility failed to timely obtain a urinalysis and follow up with the physician to treat a urinary tract infection for one (R1) of three residents reviewed for change in condition in the sample list of ten. This failure resulted in R1 being hospitalized with Acute Encephalopathy secondary to Urinary Tract Infection and Sepsis. Findings include: R1's September 2023 Physicians Order Summary (POS) documents an order dated 9/19/23, signed by V4 Nurse Practitioner, to obtain urinalysis with culture and sensitivity. There is no documentation in R1's medical record that attempts were made to obtain R1's urine sample until 9/24/23 (5 days later). R1's Urine Culture and Sensitivity (C&S) collected on 9/24/23 at 9:30 PM and reported on 9/28/23 2:09 PM, documents R1's urine contained 70-99,000 Colony Forming Units per milliliter (ml) of Escherichia (E.) Coli (bacteria) ESBL (Extended Beta-Lactamase) (multidrug resistant organism). R1's urinalysis dated as reported 9/28/23 at 2:09 PM documents a handwritten notation that the results were reported to V4 via (electronic communication software). There is no documentation in R1's medical record of communication with V4 or V6 Physician regarding R1's urine C&S results and whether or not orders were given, or if R1 had Urinary Tract Infection (UTI) symptoms. There is no documentation in R1's medical record that R1 received antibiotic treatment between 9/28/23 and 10/14/23. R1's Nursing Note dated 10/14/23 at 6:00 PM documents R1 had increased confusion. R1's Nursing Note dated 10/15/23 at 10:00 PM documents R1's Power of Attorney (V5) voiced concerns that R1 was semi-lethargic (sluggish) and feeling bad. V5 requested R1 be tested for UTI and explained that R1 had been on an antibiotic approximately 2-3 weeks ago. V5 asked what antibiotic R1 had been given and after review of R1's Medication/Treatment Administration Records and POS there were no antibiotic orders written. V5 then requested for R1 to be transferred to the hospital. R1's Hospital Discharge Summary documents R1 admitted on [DATE] and discharged on [DATE]. This Summary documents R1's admission diagnoses as Acute Encephalopathy (brain damage/disease) sec (secondary) to Complicated UTI and includes a diagnosis of Sepsis (a life threatening complication of an infection that can damage multiple organ systems). This summary documents R1 presented to the hospital with confusion and lethargy, and R1's urine culture showed E. Coli ESBL. On 10/30/23 at 9:17 AM V5 (R1's Power of Attorney) stated V5 had requested R1 be tested for a Urinary Tract Infection (UTI) in September 2023 and R1's results came back on 9/28/23 as positive for a UTI. V5 stated the staff told me there was no medication ordered to treat R1's UTI, but when I viewed the unidentified nurse's computer screen (electronic communication software) it showed an order for Bactrim (antibiotic) Double Strength twice daily for five days. V5 stated the unidentified floor nurse told V5 that the nurse located the order, but V3 Assistant Director of Nursing forgot to implement the order. V5 stated on 10/14/23 R1 had slurred speech and was sleepy and on 10/15/23 R1 would not eat and was transferred to the hospital. V5 stated a resistive strain of E. Coli was found in R1's urine, R1 was admitted to the hospital for 9 days, and R1 was given intravenous antibiotics. On 10/30/23 at 12:11 PM V3 Assistant Director of Nursing (ADON) stated V3 uploaded R1's Urine C&S on 9/28/23 into (electronic communication software) and did not receive any response back from the nurse practitioner. On 10/30/23 at 2:27 PM V7 Licensed Practical Nurse (LPN) stated V5 came to visit R1 on 10/15/23 in the afternoon and R1 was sent to the hospital and diagnosed with a UTI. V7 stated V5 told V7 that V5 had previously requested that R1 be checked for UTI and R1 was supposed to have been given antibiotics. V7 stated V7 did not know what V5 was talking about, because V7 could not locate any orders for an antibiotic for R1. V7 stated V3 ADON had uploaded R1's urine C&S results into the (electronic communication software) and the following response message from V4 was unable to be viewed, it showed deleted. On 10/30/23 at 3:16 PM V8 LPN stated V8 sent R1 to the hospital on 10/15/23, R1 was not R1's self, and R1 was more confused and slower to respond. On 10/30/23 at 12:13 PM V2 Director of Nursing stated all of the facility's nurses have access to (electronic communication software) and the nurses obtain orders through this system or by contacting the physician/Nurse Practitioner directly. V2 stated physician notification with new orders, is documented in a nursing note and on the POS; if there are no new orders the communication should be documented in a nursing note. The (electronic communication software) was viewed with V2, R1's Urine C&S dated 9/28/23 was uploaded, and the following message from V4 Nurse Practitioner showed up as deleted. There was no further communication between facility staff and V4 Nurse Practitioner regarding R1's urine culture. V2 stated the laboratory company comes to the facility on Mondays, Wednesdays, and Fridays to obtain/pick up laboratory samples. At 4:00 PM V2 confirmed there is no documentation in R1's medical record that R1's 9/28/23 Urine C&S was reviewed with V4 or V6 (R1's Physician). On 10/30/23 at 2:00 PM V4 stated urine samples should be obtained as soon as possible, and within 24 hours of the order. V4 stated V4 did not specify to wait until 9/24/23 to obtain R1's urine culture. V4 stated V4 recalls being notified on 9/28/23 of R1's urine C&S and referred to (electronic communication software). V4 confirmed V4's response message was deleted. V4 stated V4 ordered an antibiotic to treat R1's UTI. V4 stated if a UTI is not treated it can lead to Sepsis and Encephalopathy. The facility's Notification for Change in Resident Condition or Status policy dated as revised 12/7/17 documents the nurse will notify the resident's physician of changes in a resident's condition including when there is a need to alter treatment significantly, symptoms of an infectious process, and abnormal laboratory results. This policy documents to record information regarding the change in the condition in the resident's medical record. The facility's Conformance with Physician Medication Orders policy dated as reviewed on 9/27/17 documents physician's orders may be obtained by telephone or electronic facsimile, telephone orders must be signed by the nurse and the physician, and the resident's Physician Order Sheet will include a complete and accurate list of medications.

Based on interview and record review the facility failed to follow physician's orders, assess, monitor, and complete follow-up for a Urinary tract Infection with indwelling urinary catheter for one resident (R1) of three residents reviewed for catheters in a sample list of three residents. This failure caused R1 to develop a Catheter Associated Urinary Tract Infection resulting in hospitalization for Sepsis. Findings Include: R1's Post Hospital Evaluation dated 5/1/23 by V10, Advanced Practice Nurse documents the following diagnoses: Congestive Heart Failure, Syncope, Fall with Fractured Ankle, and Urinary Retention with a Urinary Tract Infection. This evaluation also documents Indwelling Catheter would like it out as soon as possible. This evaluation also documents Perioperative urine retention, noted to be associated with Urinary Tract Infection of E. coli (Escherichia coli). Continue Keflex (sensitive) through 5/5/23. R1's Discharge Physician's Orders from the hospital dated 4/28/23 document a physician's order for Keflex 500 (MG) Milligrams four times daily for seven days. This would be 28 500 MG doses in 7 days. R1's Medication Administration Record for April and May 2023 documents the facility gave a total of 22 doses of Keflex from 4/29/23 until 5/10/23 (10 days). Six of the 28 doses were omitted completely. There is no documentation the physician was notified of these errors. R1's Post-Acute Note dated 5/8/23 by V5, Medical Director documents please plan to follow-up with our Urology Clinic outpatient for further care of your urinary retention. This evaluation also documents follow up on your urine cultures. R1's Physician's Order Sheet documents an order dated 5/8/23 (R1) has a Foley Catheter in place. Please keep it in place one more week. There is no documentation to support a Urology consult was ever obtained. There is no documentation to support follow-up cultures were ever obtained. On 6/5/23 at 8:45AM V9, R1's family member stated R1 called us 5/17/23 at 5:33PM and complained to be shivering, not feeling well, and call light not being answered. We called the facility and asked them to check on R1. On 5/18/23 at 1:24 PM two family members visited R1 and saw that R1 looked terrible and was under eight blankets and still chilling. We were also told by staff R1 had diarrhea since 5/17/23. We called V2 the Director of Nursing and she kept kind of brushing us off saying R1 did not have a fever and was being taken care of. At the hospital R1's temperature was 102.2. R1's hospital record from 5/19/23 documents R1's temperature was 102.2 On 5/19/23 R1's 8:40AM R1's AIMS (Assess, Intercommunicate, and Manage) note by V2, Director of Nursing documents R1 sent to emergency room for evaluation and treatment. The symptoms included in this assessment are malaise, fever, low back pain, decreased mobility, and weakness. R1's Nurse's Note dated 5/19/23 documents R1 complained of diarrhea times three days R1's hospital note dated 5/20/23 at 3:24PM by V11 Medical Hospitalist documents: R1 sent to emergency room with patient having fever, chills, as well as not eating and drinking much and on arrival at emergency department patient diagnoses Sepsis secondary to complicated Urinary Tract Infection due to chronic foley catheterization. R1's blood culture is positive for E. coli (Escherichia coli). On 6/5/23 at 4:05PM V2 Director of Nursing confirmed the facility failed to correctly administer the ordered antibiotic, did not follow-up with the recommendations to seek Urology consult or re-culture the urine and did not remove the catheter as ordered. V2 stated my expectation would be that a skilled assessment and baseline care plan should be done on admission and a skilled nursing assessment should be completed every shift and the Urinary Tract infection and catheter should be addressed in all of this documentation. When asked if V2 could provide the documentation V2 expected for R1 V2 stated I cannot. On 5/6/23 at 10:30AM V5, Medical Director stated If the antibiotic was not completed as ordered it actually could decrease its effectiveness against the infection. R1 had some urinary retention after her surgery and a Urinary Tract Infection. V5 stated it should have been re-cultured as we recommended, and we would expect the facility to follow-up on the recommendation to see Urology. It would be safe to say the E. coli did not clear up from the UTI we treated a few weeks ago and that was seen in the blood cultures, but in any case, the infection got worse again and R1 became septic and was hospitalized .

Based on observation, interview, and record review the facility failed to assess and implement interventions to manage Congestive Heart Failure (CHF) by failing to administer diuretic medications, obtain daily weights, daily vital signs and implement physician orders to monitor swelling and shortness of breath for one resident (R3) out of four residents reviewed for following physician orders in a sample list of four residents. This failure resulted in R3 being hospitalized for exacerbation of CHF. Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 requires total assistance of two staff for transferring and toileting. R3's Care Plan does not include a focus area, goal nor interventions for Congestive Heart Failure (CHF). R3's Physician Order Sheet (POS) dated May 1-31, 2023, documents a physician order dated 11/17/22 for Lasix 20 milligrams (mg) twice daily. R3's Physician Order Sheet dated April 1-30, 2023, documents an order to increase R3's Lasix to 60 milligrams in the morning and 20 mg in evening for four days (4/13/23-4/16/23). This same POS documents physician orders dated 1/21/22 to obtain blood pressure and pulse daily. This same POS documents a physician order dated 1/24/23 to obtain weights daily. R3's Medication Administration Record (MAR) dated April 1-30, 2023, does not document Lasix 20 milligrams as being administered the evenings of 4/13/23-4/16/23 or that R3's Lasix 20 mg twice daily was restarted on 4/17/23 after the four day increase prior to R3's hospitalization for exacerbation of Congestive Heart Failure (CHF) on 4/21/23. This same MAR documents physician orders to obtain blood pressure, pulse, and weight daily. This same MAR's does not document R3's blood pressure, pulse, and weight from 4/1/23-4/21/23 and 4/28-4/30/23. R3's Treatment Administration Record (TAR) April 1-30, 2023, does not document R3's weight, blood pressure nor pulse was obtained for 4/1/23-4/21/23 and 4/28/23-4/30/23. R3's medical record documents a physician order dated 4/18/23 to monitor swelling and shortness of breath. This same medical record does not document monitoring of shortness of breath or swelling for R3 from 4/18/23-4/21/23. R3's Hospital Record documents R3 was admitted to hospital on 4/21/23 with a diagnosis of Exacerbation of CHF due to 'having worsening shortness of breath and weight gain over the past few weeks. (R3) lower legs also showed significant swelling indicative of an acute exacerbation of Chronic Heart Failure (CHF) likely due to not receiving (R3's) proper diuretic regimen at facility'. On 5/23/23 at 1:00 PM V2 Director of Nurses (DON) stated The missed medications mostly came from two agency nurses that are no longer here. They (V11, V12) just signed off medications and did not give the medications to the residents. (R3) did not receive her Lasix like it had been ordered. (R3) has been on Lasix for a long time. The physician increased the dose for four days and it should have been clarified as to what dose (R3) should have received after those four days were up but again those agency nurses failed to do their jobs. Unfortunately (R3) ended up in the hospital because of it. V2 stated (R3's) Medical Record had daily vital signs and daily weights listed as orders for months that have not been completed. (R3's) weekly weights have been documented but I don't have any documentation of daily weights or vital signs. V2 stated R3 had a physician order to monitor R3's edema and shortness of breath. V2 stated R3's monitoring of shortness of breath and edema should be on the Treatment Administration Record (TAR) or in the nurse progress notes or in the skilled nursing notes but are not. V2 stated I know there is a problem and we (facility) have been trying to go through each chart in morning meeting, but I haven't got to (R3's) chart yet. Part of the problem is we (facility) do not have a CHF protocol, so it is just left up to the nurses to decide what to do. I have been working the floor so much I haven't had time to do the chart reviews. I will call the Physician and ask what should be done. V2 DON stated We (facility) should obtain daily weights on every resident who has Congestive Heart Failure (CHF). The physician should be notified of a weight gain of three pounds in a day or five pounds in a week. This was not done for (R3). I don't know why (R3) did not get Lasix on the evenings of 4/13-4/16/23 or from 4/17-4/21. This was a time when we (facility) had two agency nurses (V11, V12) working and they (V11, V12) just simply didn't do their jobs. On 5/23/23 at 3:45 PM V19 Nurse Practitioner (NP) stated R3 should not have been taken off of her Lasix. V19 NP stated (R3) has chronic Congestive Heart Failure (CHF). Whoever took the order to increase (R3's) Lasix order from 4/13-4/16 should have asked about whether the Lasix should be continued. (R3) should not have gone any amount of days without her Lasix or some sort of diuretic. V19 stated There is a general expectation for any CHF resident. Daily weights should have been done, monitoring of (R3's) swelling should have been done. The nurses should notify the Physician or Nurse Practitioner when there is an increase of three pounds in a day or five pounds in a week.

Based on interview and record review the facility failed to ensure a resident received medications and monitoring for congestive heart failure management, and failed to obtain wound treatment orders, complete skin assessments, and provide wound care for one of one residents (R1) reviewed for Congestive Heart Failure and stasis ulcers on the sample list of six residents. These failures resulted in R1 being readmitted to the hospital with Congestive Heart Failure and worsening lower extremity wounds. Findings include: R1's Medical Record documents R1 admitted to facility on 4/15/23, was discharged to hospital on 4/21/23 and returned to facility on 4/22/23. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Baseline Care Plan dated 4/15/23 documents R1 as dependent on staff for all cares and has current wounds. R1's Hospital Record dated 4/15/23 documents medical diagnoses as Congestive Heart Failure (CHF) Acute on Chronic, Acute Kidney Injury (AKI), Neuropathy, Bilateral Knee Pain, Renal Failure, Cellulitis of Left Lower Extremity, Chronic Back Pain, Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disorder (COPD), Degenerative Joint Disease, Generalized Weakness, Coronary Artery Bypass Graft (CABG), Iron Malabsorption, Paroxysmal Atrial Fibrillation, Presence of Cardiac Pacemaker, Severe Mitral Insufficiency, Severe Tricuspid Regurgitation, Skin Ulcer of Pretibial Region of Right Lower Extremity, Traumatic open wound of Lower Leg with Delayed Healing, Venous Stasis Ulcers of both Lower extremities, Vitamin B12 Deficiency, Anemia due to Stage 4 Chronic Kidney Disease, Ischemic Cardiomyopathy and Coronary Artery Disease (CAD). R1's Hospital Discharge Transfer Record dated 4/15/23 documents physician orders to obtain daily weight, daily skin assessments and daily vital signs. These same discharge orders included physician orders to continue Torsemide (Diuretic) 40 milligrams daily, Amlodipine (Antihypertensive) 5 mg daily and Carvedilol (Antihypertensive and treatment of Heart failure) 6.25 mg twice daily. This same record documents to follow up with (V14) facility Physician for ongoing medical care at the facility. R1's Physician Order Sheet (POS) dated April 1-30, 2023, are not signed by a physician. This same POS does not include orders for obtaining daily weight, daily skin assessments and daily vital signs. This same POS does not include physician orders to continue Torsemide 40 milligrams daily, Amlodipine 5 mg daily and Carvedilol 6.25 mg twice daily. R1's Medication Administration Record (MAR) dated April 1-30, 2023, does not document physician orders to obtain daily weight, daily skin assessments and daily vital signs. This same MAR does not include physician orders to continue Torsemide 40 milligrams daily, Amlodipine 5 mg daily and Carvedilol 6.25 mg twice daily. R1's medical record does not include documentation of (V14) Physician being notified of R1's admission to facility, nor medication reconciliation from (V14) Physician. R1's Weekly Wound Tracking dated 4/15/23 documents R1's Right Lower Extremity Venous Ulcer as 15 centimeters (cm) long by width of entire circumference with minimal drainage, R1's Right Foot Venous Ulcer as 20 cm long by width of entire circumference with minimal drainage, R1's Left Lower Extremity Venous Ulcer as 14 cm long by width of entire circumference with minimal drainage and R1's Left Foot wound as 19 cm by 10 cm with no depth and minimal drainage. R1's Weekly Wound Tracking dated April 1-30, 2023, does not document R1's Left Foot, Left Lower Extremity, Right Foot and Right Lower Extremity Venous Stasis Ulcers were assessed on 4/22/23 nor 4/29/23. R1's Treatment Administration Record (TAR) dated 4/15/23 does not include any physician ordered daily skin assessments nor physician orders for treatments for R1's Left Foot, Left Lower Extremity, Right Foot and Right Lower Extremity Venous Stasis Ulcers from 4/15/23-4/25/23. This same TAR documents a physician order dated 4/26/23 to wash R1's bilateral lower extremities and feet with soap and water, apply Extra Protective Cream (EPC) cream, wrap with gauze and compression gauze daily. R1's TAR does not document R1's dressings were completed on 4/26/23, 4/27/23, 4/28/23 and 4/30/23. R1's Nurse Progress Note dated 4/21/23 at 10:49 AM documents (R1) feet purple and no pedal pulses were present. Provider recommended sending to emergency department for evaluation. R1's Hospital record dated 4/15/23 documents principal problem as 'End Stage Systolic Heart Failure, Acute on Chronic'. R1's Nurse Progress Note dated 4/24/23 documents (R1) is a [AGE] year-old female who is in Post-Acute Care following two hospitalization s as follows: 4/3/23-4/15/23 Congestive Heart Failure (CHF), acute and chronic, 4/21/23-4/22/23 CHF bilateral leg Cellulitis/Edema, Acute Kidney Injury (AKI). Skin exam: General redness of bilateral lower legs, a few open areas are shallow, small with no inflammation. Strict daily weight, record in Medication Administration Record (MAR), contact provider for weight gains. Venous Stasis Dermatitis of both lower extremities: with recent diagnosis for Cellulitis bilateral. On 4/29/23 at 2:25 PM V2 Director of Nurses (DON) stated the facility is unable to provide any documentation of any weights being obtained for R1. V2 DON stated all new residents should have admission weights. V2 DON stated any resident who has an order for daily weights should be weighed daily. V2 DON stated If we (facility) had weighed (R1) daily like the discharge orders clearly say to do, then maybe (R1) might not have ended up in the hospital. We (facility) clearly failed. On 4/29/23 at 3:30 PM V11 (R1's) husband stated (R1) has had Congestive Heart Failure (CHF) for years. (R1) has been in and out of the hospital many times for CHF. When (R1) came in here on 4/15/23 she could walk and now she can't. (R1's) lower legs and feet got really swollen and blistered up. Then the blisters opened and now (R1) has these open sores, and she can't walk anymore because her feet hurt so bad. (R1) had to go to the hospital because they (facility) were not taking care of her feet. They (facility) should have been weighing her every day from the day she got here but they didn't. That is why (R1's) CHF got so bad her feet swelled up. (V14) didn't even know about it because the facility never told her. (R1) can't be without her diuretic and the facility never gave it to her in the beginning. The Torsemide didn't get started again until (R1) had to go to the hospital again. On 4/30/23 at 2:00 PM V2 Director of Nurses (DON) stated the facility should have read the entire discharge orders, transcribed all physician orders to (R1's) Physician Order Sheet (POS), Medication Administration Record (MAR) and Treatment Administration Record (TAR). V2 DON stated the facility should have done a skin assessment and nursing assessment on admission. V2 DON stated, Since none of these things were done, several of (R1's) physician orders were never followed. V2 stated We (facility) should have clarified the Amlodipine, Carvedilol, (lab) and Torsemide orders with (V14) Physician. We (facility) never did those things so (R1) did get worse and had to be hospitalized for the CHF and her cellulitis in her bilateral feet. We (facility) never got any weights or did any skin checks. I know we (facility) really made a lot of mistakes with (R1). I should have reviewed (R1's) admission but I was too busy working the floor. On 5/1/23 at 8:00 AM V9 Nurse Practitioner (NP) stated This facility has had history of not notifying medical providers of new admission, discharges or changes in a resident's condition. (R1) has a long history of Congestive Heart Failure (CHF). (V14) Physician nor I were ever notified of (R1's) admission to this facility. We (V9, V14) did not review any of (R1's) hospital discharge orders since we did not know (R1) was at facility. (R1's) medications listed on the hospital discharge orders should have been reviewed with (V14) or me upon (R1's) admission to facility. I have seen this problem before with this facility. I provide an order to obtain daily weights and they don't get done. I don't get notified of daily weights for other residents there also. The first time we (V9, V14) were made aware of (R1's) admission to facility was on 4/21/23 when the facility called (V3) who was the on call Advanced Practice Registered Nurse (APRN) to notify of (R1's) blue and purple feet with no pulses. (V3) NP gave orders then to send (R1) to the hospital for evaluation. I saw (R1) for the first time on 4/24/23 and treated that visit as a new patient visit since there had been no reconciliation of (R1's) medications the first week she was at the facility. Basically (R1's) bilateral lower legs were edematous due to the CHF and very poor heart function which caused the blisters. (R1's) blisters then broke open which caused her to have open sores on both lower legs and feet. We (V9, V14) might have been able to help prevent that from happening but will never know since we did not even know (R1) was at facility.

Based on record review and interview the facility failed to transfer one (R2) resident safely by not using the appropriate sized sling for a mechanical lift. This resulted in R2 falling from the mechanical lift during a staff assisted transfer to the floor and R2 sustaining a fractured left ankle. R2 is one of three residents reviewed for falls in a sample list of 11 residents. Findings include: R2's undated Face Sheet documents diagnoses of: [CONDITION(S)] ([CONDITION(S)]), Impaired Mobility, [CONDITION(S)], Wheelchair Dependent, and Weakness of Left Arm. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 15 out of 15 possible points indicating intact cognition. This same MDS documents R2 requires total dependence of two staff for transfers. R2's Care Plan dated 5/7/20 documents Advise resident (R2) what is expected during the transfer. Reassure resident (R2) of safety as needed. Keep hand on resident (R2) to reassure safety as needed. Ensure lift sheet is intact and correct size for resident. R2's Physician Order Sheet (POS) dated July 1-31, 2021 documents a physician order to Obtain X-Ray of Left Ankle. Three views AP, oblique and lateral. Portable due to decreased mobility and health. Diagnosis: [CONDITION(S)] and complaint of pain. This same POS documents another Physician order to Send to emergency room for fracture of Left Ankle and Pain Control. R2's X-Ray report dated 7/14/21 documents Findings: A fracture is noted involving the Medial Malleolus. The fracture abuts the articular surface. Anterior medial displacement of the distal fracture fragment is noted. The ankle mortise is intact. [CONDITION(S)] changes are present. Osteopenia is noted. The surrounding soft tissues are normal. Impressions: Fracture involving the Medial Malleolus. Clinical Correlation and follow up are recommended. Chronic and [CONDITION(S)] changes. R2's Final Abuse Investigation Report dated 7/21/21 to the state agency documents R2 was being transferred with the mechanical lift when she (R2) slid out of the sling onto the floor. X-Ray of the Left ankle obtained showing fracture involving the medial malleolus, chronic and [CONDITION(S)] changes. R2's After Visit Summary dated 8/2/21 documents Use a fracture boot, adjusted to comfortably snug. Keep the boot on as tolerated for the next six weeks, except while bathing. On 8/3/21 at 2:20 PM V13 Certified Nurse Aide (CNA) stated V13 and V25 CNA's assisted R2 out of bed into wheelchair using a mechanical lift on 7/14/21. V13 CNA stated tried to get R2's mechanical lift sling to fit several times but it was too small. We (V13 and V25) raised and lowered (R2) over bed several times trying to adjust the sling. The sling we (V13, V25) used was a six-point sling, but it was too small to criss cross between her (R2) legs, so we (V13, V25) didn't criss cross the sling. It (sling) barely covered her (R2) buttocks. We (V13, V25) thought it would be ok to just go to the wheelchair, but it wasn't. She (R2) slid out of the sling and fell on the floor. She (R2) broke her ankle. If we (V13, V25) would have just got a bigger sling, she (R2) wouldn't have fallen and broken her (R2) ankle. On 8/3/21 at 3:30 PM V1 stated nursing staff should always use the correct size of sling for mechanical lift and (R2's) fall and fracture would have been prevented if correct size sling was used during 7/14 transfer. V26 Physician stated on 8/4/21 at 2:45 PM If the staff used the correct size of sling for the patient (R2), the fall and fracture would have been prevented. (R2's) Osteopenia and chronic changes would not have caused this fall due to the fall was related to the failure of the staff to use the appropriate size sling for this patient (R2). This fracture was not caused by the chronic [CONDITION(S)] changes. The fracture was caused by the fall. This fall will most likely cause the patient (R2) chronic discomfort due to probable ligament injury and documented fracture of medial malleolus of Left Ankle. The facility policy titled 'Mechanical Lift' revised 10/30/08 documents the following: The mechanical lift may be used to lift and move a resident with limited mobility during transfer while providing safety and security for residents and nursing personnel. Place sling straps under thighs and cross.

Based on observation , record review and interview the facility failed to follow Centers for Disease Control (CDC) Guidelines and their own Infection Control Policy by allowing two residents (R15, R16) to reside in the same room while one (R15) had an active case of MRSA (Methicillin Resistant Staphylococcus Aureus) and the other (R16), susceptible to infection. The roommate (R16) acquired a new infection, MRSA, approximately 3 weeks after being placed with (R15). R16's acquired infection required antibiotic therapy. The facility failed to disinfect a blood glucose meter following its use by 1 of 6 sampled residents ( R2) and 2 supplemental residents (R18, R20) receiving blood glucose monitoring. The facility failed to implement their Infection Control Program relating to the following elements: surveillance, investigation, monitoring and analysis of infections, monitoring employee illness and antibiotic review to prevent and control the spread of infection in the facility. This failure has the potential to affect all 55 residents residing in the facility. Findings include: 1. The Infection Control Log dated May 2010 lists R15 as being infected with MRSA with an onset date of 5/22/10 related to an open wound on the buttocks. The June 2010 Infection Control Log also lists R15 as being in isolation. The physician's orders [REDACTED]. The Infection Control Log dated February 2011 lists R16 as being infected with MRSA of the groin with an onset date of 2/14/11 and was placed in contact isolation. The Laboratory test dated 2/14/11 confirms that R16 had a culture collected on 2/11/14 and was positive for MRSA. On 2-14-11 R16's physician ordered that R16 receive Bactrim (antibiotic) for 10 days. R16 was removed from isolation on 2/25/11 due to receiving a negative culture. R16 had another Laboratory report on 3/18/11 which confirmed a positive result for MRSA and was placed back in contact isolation on 3/18/11. The Admission Face Sheets for R15 and R16 document that R15 and R16 resided in the same room together since the admitted for R16 March 29,2010. The facility policy titled "Contact Precautions" revised 12/09 states "Resident Placement : Place the resident in a private room. When a private room is not available, place the resident in a room with a resident(s) who has active infection with the same microorganism, but with no other infection (cohorting)...." The facility failed to follow the CDC "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007" Part III: "Precautions to Prevent Transmissions of Infectious Agents" section III.B.1. "Contact Precautions" reads "....A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate)....." E1, Administrator and E2, DON (Director of Nurses) confirmed on 3/30/11 at 3:45 PM that R16 was placed in contact isolation for a positive culture of MRSA on 3/18/11. E2 stated that R16's roommate, R15 had an active case of MRSA in May 2010 and was in contact isolation at that time and R16 was residing with R15 during this time and R16 did not have any type of infection. E1 and E2 both confirmed that R15 and R16 had been room mates since R16's admission to the facility (3/29/10) and were residing in the same room when R15 was placed in isolation for MRSA. Z1, Physician Assistant for R16 stated on 3/31/11 at 1:00 PM that she was not aware that R16 was in a room with a resident who was positive with MRSA. Z1 continued to state R16 did not have a [DIAGNOSES REDACTED]. 2. On 3/28/11 at 10:55 am E8, LPN(Licensed Practical Nurse) checked the blood glucose level on R20, checked the blood glucose level on R18 at 11:05am, and checked the blood glucose level on R2 at 11:20am using a blood glucose meter. E8 did not clean the glucose meter between uses. The same glucose meter was used to test blood specimens for all three residents R20, R18 and R2. No resident contact occurred with the blood glucose meter or specimens. The facility policy titled "Cleaning and Disinfecting of Glucometer" dated 6/9/10 states "The blood glucose meters will be cleaned between each resident test to avoid cross contamination issues." The section titled "Procedure" for #1 states "Cleaning and disinfecting with a Germicidal Disposable Wipe will be completed each time the blood glucose meter is used with a pre-moistened towelette...." The manufacturer recommendations for disinfecting the meter states " dilute 1 mL(milliliter) of house bleach (5%-6% sodium hypochlorite solution) in 9 mL of water. This is a 1 :10 dilution. ..." E8, LPN stated on 3/28/11 at 11:30 am that she should have wiped the glucose meter off with the bleach wipe/Sani wipe that they have to use between each use. E8 stated she forgot to do this. 3. The facility Infection Control Policy titled "Surveillance and Monitoring" addresses how the facility will be preventing and controlling infection through surveillance, investigation , monitoring/analysis of infections as well as how this will be documented. The policy also addresses monitoring of employees with communicable diseases or infected skin lesions. The Infection Control Log dated January 2010 to February 2011 does not include documented complete data in regards to the total numbers of infection per month. The infection control log does not summarize the data to reflect how many infections were Skin infections, Urinary Tract Infection, Upper Respiratory Infections, Eye infections or Other. The monitoring log was incomplete regarding employees also. Information was not collected from employees in regards to calling off from work (signs/symptoms of illness, communicability, etc.). E2 confirmed on 3/29/11 at 2:30 PM that she is not doing data analysis, surveillance or antibiotic review as part of the facility's infection control program. E2 stated that she just started doing the infection control log every month and was not aware that she needed to monitor employee illness or the reason staff are not coming to work.