Every finding on record at Transcendent Healthcare of Boonville - North

Based on interview and record review, the facility failed to establish a facility-wide system to prevent, identify, report, investigate, and control infections for 4 of 5 residents reviewed for hospitalizations (Resident 27, Resident 19, Resident 1, and Resident 48). Residents who experienced upper respiratory symptoms were not tested or treated for influenza. The facility did not investigate the cause of or track residents' signs and symptoms. This deficient practice resulted in Resident 27, Resident 1, and Resident 48 being hospitalized . Residents tested positive for influenza A upon arriving at the hospital. Resident 19 was ordered to be sent to the hospital, but expired before she could get there. Resident 27 and Resident 1 expired while in the hospital from complications from influenza A.This Immediate Jeopardy began on [DATE], when residents complained of upper respiratory symptoms. The facility failed to test residents for influenza A and track signs and symptoms in order to prevent the spread of contagion. The Administrator was notified of the Immediate Jeopardy on February 13, 2026, at 3:34 P.M. The Immediate Jeopardy was removed on February 16, 2026, but noncompliance remained at the lower scope and severity level of pattern, no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On [DATE] at 12:33 P.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, acute kidney failure, and influenza A. The most current full admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident 27 had severe cognitive impairment and did not have a respiratory diagnosis or infection. The most current Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident 27 had severe cognitive impairment and did not have a respiratory diagnosis or infection. An Informed Consent and Authorization for Immunizations document, dated [DATE], indicated Resident 27 declined to receive the influenza vaccine. Physician orders included, but were not limited to:kidneys, ureter, and bladder x-ray (KUB) and chest x-ray (CXR) STAT (immediately) for monitoring, dated [DATE] guaifenesin liquid (cough suppressant) 100 milligrams (mg) per 5 milliliters (mL) – Give 20 mL by mouth every four hours as needed (PRN) for cough, dated [DATE] benzonatate (cough suppressant) 100 mg capsule - Give one capsule by mouth three times a day for excessive mucus for six administrations, dated [DATE] May apply oxygen 2 to 4 liters (L) via nasal cannula to maintain oxygen saturation greater than 90%, dated [DATE] azithromycin (an antibiotic) 250 mg tablet – Give two tablets by mouth at bedtime for upper respiratory infection and give one tablet by mouth at bedtime for upper respiratory infection until [DATE], dated [DATE] The clinical record lacked a care plan to indicate Resident 27 experienced, or was being treated for, an upper respiratory illness or signs and symptoms of flu-like illness. A nursing alert note, dated [DATE] at 9:10 P.M., indicated that a chest x-ray was obtained. A radiology results report, dated [DATE] at 10:52 P.M., indicated that there was no acute focal consolidation (solid/fluid material inside the lungs) or effusion (solid/fluid material outside the lungs in the pleural space). A provider progress note, dated [DATE] at 11:59 P.M., indicated that Resident 27 was seen by the Nurse Practitioner (NP). The NP documented that Resident 27 was not feeling well, as evidenced by groaning and agitation. She had a frequent, dry cough on assessment, and lungs were diminished. Staff reported that the resident had a cough for the past three days, and she did not eat breakfast that morning. A complete blood count (CBC), complete metabolic panel (CMP), and stat (immediate) (CXR were ordered. On [DATE] at 10:00 A.M., PRN guaifenesin was administered. A communication with family note, dated [DATE] at 12:06 P.M., indicated There have been positive cases of flu within our building. At this time, appropriate infection control precautions have been implemented to help prevent further spread and to protect the health and safety of our residents and staff. Visitors are encouraged to perform frequent hand hygiene before, during, and after visits and to utilize available hand sanitizer stations throughout the facility. Mask use is recommended to prevent any further spread. We will continue to monitor closely and provide updates as necessary. Please contact the facility with any questions or concerns. Thank you for your understanding and continued support. A nursing alert note, dated [DATE] at 2:25 P.M., indicated that Resident 27 complained of generalized body pain and had a persistent cough. The nurse on duty was notified, and guaifenesin was administered. On [DATE] at 2:17 P.M., PRN guaifenesin was administered. On [DATE] at 7:18 A.M., PRN guaifenesin was administered. A communication with a physician note, dated [DATE] at 8:07 A.M., indicated Resident 27 was seen by the Nurse Practitioner (NP). New orders were received for benzonatate (non-narcotic medication used to relieve cough) 100 mg and DuoNeb via nebulizer every four hours for wheezing (a high-pitched whistling sound caused by narrowed or inflamed airways). The clinical record lacked documentation to indicate that the order for DuoNeb was placed in the clinical record or was administered to the resident. An order note, dated [DATE] at 11:35 A.M., indicated that Resident 27 was seen by the NP. New orders were received for azithromycin (antibiotic) for an upper respiratory infection and oxygen via nasal cannula to maintain oxygen saturation levels above 90%. It was noted that a chest x-ray had been completed five days prior and was negative; however, there was still copious amounts of mucus drainage. A nursing alert note, dated [DATE] at 1:30 A.M., indicated that Resident 27 would not keep her oxygen on. Resident 27's power of attorney (POA) was notified and did not wish to send Resident 27 to the hospital at that time. Resident 27 told the nurse, I'm sick. A provider note, dated [DATE] at 11:11 A.M., indicated that Resident 27 was seen by the Medical Director (MD). Resident 27 was assessed with rhonchi (low-pitched, rattling, or snoring-like lung sounds caused by airway obstruction from mucus or secretions in the large airways) present bilaterally in the lungs, and hoarseness and acute bronchitis were present. An order was given to send Resident 27 to the emergency room (ER) for further evaluation. A transfer/discharge note, dated [DATE] at 12:47 P.M., indicated Resident 27 was sent to the hospital room for respiratory distress and increased shortness of breath. The clinical record lacked documentation to indicate that Resident 27 was tested for influenza following identification of upper respiratory signs and symptoms on [DATE] at 9:10 A.M. and before leaving for the hospital on [DATE] at 12:47 P.M. The clinical record lacked documentation to indicate that the Infection Preventionist (IP) was notified that Resident 27 experienced signs and symptoms of upper respiratory and flu-like illness or that those signs and symptoms were tracked following identification of upper respiratory signs and symptoms on [DATE] at 9:10 A.M. and before leaving for the hospital on [DATE] at 12:47 P.M. An Emergency Department note, dated [DATE] at 1:13 P.M., indicated Resident 27 arrived at the ER with a wet cough and shortness of breath. A chest x-ray was concerning for developing pneumonia in the right midlung and right lower lobe. A respiratory panel was positive for influenza A. A urinalysis was positive for a urinary tract infection. The resident was admitted to the hospital for treatment of influenza A, acute renal failure secondary to dehydration, and a urinary tract infection. Hospitalist notes, dated [DATE] at 11:27 A.M., indicated Resident 27's blood culture grew MSSA (methicillin-susceptible Staphylococcus aureus) and her intravenous (IV) antibiotics were changed. A hospital Discharge summary, dated [DATE], indicated that Resident 27 expired in the hospital with influenza A as the presumptive cause of death. A nursing alert noted, dated [DATE] at 7:20 P.M., indicated the facility received a phone call from the hospital informing them that Resident 27 died at 4:06 P.M. while a patient in the Intensive Care Unit (ICU). During an interview on [DATE] at 11:50 A.M., the [NAME] County Health Department Clerk indicated that Influenza A was listed as a cause of death on Resident 27's death certificate. 2. On [DATE] at 9:26 A.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dementia, and acute respiratory failure with hypoxia. The most recent full Annual Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident 19 was cognitively intact, had diagnoses of COPD and respiratory failure, and did not have a respiratory infection. The most recent Quarterly MDS Assessment, dated [DATE], indicated that Resident 19 was cognitively intact, had diagnoses of COPD and respiratory failure, and did not have a respiratory infection. Physician orders included, but were not limited to:budesonide-formoterol fumarate (an inhalant used to help control the symptoms of asthma and improve lung function) 80-4.5 micrograms per actuation (mcg/act) - Two puffs inhale orally two times a day related to COPD and acute respiratory failure with hypoxia, dated [DATE] Continuous oxygen: Apply four Liters (L) via nasal cannula every shift related to COPD and acute respiratory failure with hypoxia, dated [DATE] Chest x-ray (CXR) immediately (STAT) for monitoring, dated [DATE] Guaifenesin (cough suppressant) liquid 100 milligrams (mg) per 5 milliliters (mL) - Give ten mL by mouth every four hours as needed (PRN) for cough, dated [DATE] Levaquin (an antibiotic) 750 mg tablet - Give 750 mg by mouth one time a day for pneumonia until [DATE], dated [DATE] Albuterol sulfate (a bronchodilator) nebulization solution (2.5 mg/3mL) 0.083% one vial - Inhale orally via nebulizer every four hours as needed for shortness of breath and wheezing, dated [DATE] Comprehensive Metabolic Panel (CMP) one time only for monitoring, dated [DATE] Complete Blood Count (CBC) and CMP one time only for monitoring, dated [DATE] Resident 19 received the influenza vaccination on [DATE]. A nursing alert note, dated [DATE] at 1:57 P.M., indicated that Resident 19 had an increased productive cough. The resident's vital signs were within normal limits. A COVID swab was ordered. The clinical record lacked documentation to indicate details of the completion of the COVID swab and the results. A nursing alert note, dated [DATE] at 9:10 P.M., indicated a chest x-ray was obtained. A Radiology Results Report, dated [DATE], indicated increased interstitial markings that may represent interstitial edema, a viral pneumonitis, or atypical pneumonia. A provider note, dated [DATE] at 11:59 P.M., indicated that Resident 19 was seen by the Nurse Practitioner (NP) for a cough. The resident complained of a frequent cough since yesterday. She was coughing up phlegm at that time. A stat chest x-ray and guaifenesin ten mL every four hours as needed was ordered. Staff were instructed to monitor for increased shortness of breath. The clinical record lacked documentation to indicate that PRN guaifenesin was administered for cough. A provider note, dated [DATE] at 11:59 P.M., indicated the NP saw Resident 19 for a follow-up to the chest x-ray. The resident indicated she was feeling better and was receiving oxygen at 3 L via nasal cannula. Levaquin (antibiotic) 750 mg daily for seven days was ordered. A respiratory infection care plan was initiated on [DATE]. A communication with family note, dated [DATE] at 12:06 P.M., indicated There have been positive cases of flu within our building. At this time, appropriate infection control precautions have been implemented to help prevent further spread and to protect the health and safety of our residents and staff. Visitors are encouraged to perform frequent hand hygiene before, during, and after visits and to utilize available hand sanitizer stations throughout the facility. Mask use is recommended to prevent any further spread. We will continue to monitor closely and provide updates as necessary. Please contact the facility with any questions or concerns. Thank you for your understanding and continued support. An infection noted, dated [DATE] at 6:18 P.M., indicated that wheezing (a high-pitched whistling sound caused by narrowed or inflamed airways) was noted upon exhalation in bilateral lung fields. Resident 19 complained of generalized achiness. The NP was notified, and a new order was received to start albuterol nebulizer treatment every four hours as needed for shortness of breath and wheezing. An infection note, dated [DATE] at 10:56 A.M., indicated that wheezing was noted upon exhalation in bilateral lung fields. An albuterol nebulizer treatment was administered. Resident 19 complained of generalized achiness. An infection note, dated [DATE] at 2:09 A.M., indicated that Resident 19 was on Levaquin for an upper respiratory infection and viral pneumonia. Lung sounds were diminished, and coarseness was noted upon auscultation. An infection note, dated [DATE] at 2:51 A.M., indicated that Resident 19 continued to have a productive cough. The clinical record lacked documentation to indicate that PRN guaifenesin was administered for cough. A doctor visit note, dated [DATE] at 9:46 A.M., indicated Resident 19 was seen by the Medical Director (MD). The resident complained of feeling weak and having increased sweating. A new order was given for a CMP. An infection note, dated [DATE] at 3:03 A.M., indicated that Resident 19 completed the course of antibiotics. The resident had a runny nose with clear, thin drainage. A Lab Results Report, collected and reported on [DATE], indicated the following lab results contained abnormal values:BUN (blood urea nitrogen) (nitrogen in the blood that comes from the waste product urea) – 45 mg/deciliter (dL) (normal 8-23) Creatinine (a waste product from normal muscle metabolism) – 2.8 mg/dL (normal 0.4 – 1.1) Potassium (used to diagnose, monitor, or manage kidney disease, as damaged kidneys cannot properly remove excess potassium from the blood) – 5.5 millimole (mmol)/L (normal 3.5 – 5.4) Alkaline Phosphatase (ALK PHOS) (measures the level of the ALP enzyme in the blood, primarily used to detect liver disease or bone disorders) – 172 units (u)/L (normal 25-130) Alanine aminotransferase (ALT) (measures the level of the ALT enzyme in the blood to detect liver damage or disease) – 6 u/L (normal 7-35) Estimated Glomerular Filtration Rate (EST GFR) (measures how well kidneys filter blood) – 15 mL/minute (min)/1.73 meters squared (sq.m) (normal >90) The clinical record lacked documentation to indicate why the CMP lab ordered on [DATE] was not collected until [DATE]. On [DATE] at 3:44 P.M., an albuterol nebulizer treatment was administered. An order note, dated [DATE] at 3:22 P.M., indicated that the NP assessed Resident 19 due to increased weakness, fatigue, decreased appetite, and complaints of moderate pain. Pain medication was adjusted at that time, and fluids were encouraged. A communication with family note, dated [DATE] at 8:32 A.M., indicated Resident 19 felt lethargic and weak and was unable to get out of bed and into her wheelchair. A nursing alert note, dated [DATE] at 11:43 A.M., indicated that results from the chest x-ray were received. Findings indicated increased interstitial markings that may represent interstitial edema (abnormal accumulation of fluid within the tissue spaces surrounding cells), a viral pneumonitis (common, often contagious lung infection caused by viruses like influenza, RSV, or COVID-19, leading to air sac inflammation, fluid buildup, fever, and coughing), or atypical pneumonia (a mild infection of the lungs). The NP was notified. No new orders were received. The clinical record lacked an order for the chest x-ray that was performed on [DATE]. The clinical record lacked documentation to indicate why a chest X-ray was ordered on [DATE]. On [DATE] at 2:27 P.M., Resident 19's oxygen saturation was 86% (normal for a person with a COPD diagnosis 90% - 92%) and blood pressure was 96/60 (normal 120/80). A nursing alert note, dated [DATE] at 6:25 P.M., indicated Resident 19 had increased sleepiness and decreased appetite. The resident was seen by the NP. The resident refused to be sent out for further evaluation. Lab results were pending. Blood pressure and oxygen saturations were trending downwards (blood pressure 88/40 and oxygen saturation 84%). The resident's Power of Attorney (POA) was notified and requested that the resident to be sent to the emergency room (ER) to be evaluated. The NP was notified, and an order was received to send the resident to the ER. A Death Packet progress note draft, dated [DATE] at 10:48 P.M., indicated Resident 19 died at 7:20 P.M in the facility. Paramedics were present and confirmed the death. The physician and family were notified. A Lab Results Report, collected and reported on [DATE], indicated the following lab results contained abnormal results:White Blood Count (WBC) (measures the total number of leukocytes in your blood, acting as a crucial indicator of your immune system's response to infections, inflammation, or diseases) – 28.0 thousand/uL (thousands of cells per microliter of blood) (normal 4.0 – 10.4) Mean Corpuscular Volume (MCV) (measures the average size of your red blood cells) - 102.2 femtoliters (fL) (normal 81.0 - 98.0) Mean Corpuscular Hemoglobin Concentration (MCHC) (measures the average concentration of hemoglobin (the oxygen-carrying protein) inside a specific volume of red blood cells) - 29.3 grams (g)/dL (normal 33.0 - 37.0) Red Cell Distribution Width – Coefficient of Variation) RDWCV (measures the variation in size and volume of red blood cells) - 15.3% (normal 11.5 - 14.5) Red Cell Distribution Width – Standard Deviation) RDW-SD (measures the variation in volume and size of red blood cells) - 57.7 fL (normal 35.0 - 42.0) Platelet (PLT) (measures the number, size, and function of platelets, tiny blood cells in bone marrow that help blood clot) - 450 thousand/uL (normal 130 – 400) Neutrophils (NEUT) (measures the body's immediate immune response to infection, inflammation, and injury) - 88.6% (normal 42.2 - 75.2) Lymphocytes (LYMPH) (measures the number of specialized white blood cells in the blood to assess immune system function, typically indicating how the body is fighting infections) - 7.0% (normal 20.5 - 51.1) Eosinophil (EO) (measures the number of specialized white blood cells in the blood to assess immune system function) - 0.0% (normal 1.0 - 3.0) Immature Granulocytes (IMMATURE GRAN) (measures the presence of young while blood cells and used to diagnose and monitor severe infections) - 0.8% (normal 0.0 - 0.4) Absolute Neutrophil Count (ABS NEUT) (measures the exact number of neutrophils, the primary infection-fighting white blood cells) - 24.8 thousand/uL (normal 1.7 - 8.3) Absolute Immature Granulocytes (ABS IMM GRAN) (measures the concentration of precursor white blood cells circulating in the peripheral blood, indicating early bone marrow release and often signaling severe infection) - 0.21 thousand/uL (normal 0.00 - 0.04) Glucose (measures the concentration of sugar in the blood to evaluate how well the body manages energy usage) - 282 mg/dL (normal 70 – 99) BUN - 67 mg/dL (normal 8 – 23) Creatinine - 2.7 mg/dL (normal 0.4 - 1.1) Potassium - 5.6 mmol/L (normal 3.5 - 5.4) Total Bilirubin (a waste product from the breakdown of red blood cells) - 0.2 mg/dL (normal 0.3 - 1.2) EST GFR - 16 mL/min/1.73 m² (normal >90) An Interdisciplinary Team (IDT) note, dated [DATE] at 9:45 A.M., indicated that on [DATE], Resident 19 was noted to be lethargic. Vitals were trending down. Labs were pending. The resident did not want to go to the hospital. The NP was aware. At 6:25 P.M. that day, the resident's vitals continued to trend downwards, and the resident was unable to make any decisions. The POA was notified and requested to have the resident sent to the ER for evaluation. Emergency Medical Services (EMS) was called and arrived at the facility. The resident expired at the facility. A late charted nursing alert note, dated [DATE] at 9:51 A.M., indicated that on [DATE] at 5:00 P.M., Resident 19 was alert and oriented, and at 6:25 P.M., Resident 19 was noncoherent. The clinical record lacked documentation to indicate that Resident 19 was tested for influenza following identification of upper respiratory signs and symptoms on [DATE] at 1:57 P.M. and prior to expiring on [DATE] at 7:20 P.M. The clinical record lacked documentation to indicate that the Infection Preventionist (IP) was notified that Resident 19 experienced signs and symptoms of upper respiratory and flu-like illness or that those signs and symptoms were tracked following identification of upper respiratory signs and symptoms on [DATE] at 1:57 P.M. and prior to expiring on [DATE] at 7:20 P.M. 3. On [DATE] at 9:47 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic cough, and influenza A. The most recent full Annual Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident 1 had moderate cognitive impairment, had a diagnosis of COPD, and had pneumonia. The most recent Quarterly MDS Assessment, dated [DATE], indicated Resident 1 had severe cognitive impairment, had a diagnosis of COPD, and did not have any respiratory infections. Physician orders included, but were not limited to:Robafen DM (Dextromethorphan-Guaifenesin) Cough (a cough reduction medication) oral liquid 10-100 milligrams (mg)/5 milliliters (mL) - Give ten mL by mouth every six hours as needed (PRN) for cough related to chronic cough and give ten mL by mouth at bedtime for chronic cough related to chronic cough and give ten mL by mouth one time a day for cough for five days, dated [DATE] Benzonatate (a cough suppressant medication) Capsule 200 mg - Give one capsule by mouth as needed for cough related to chronic cough twice a day, dated [DATE] Ipratropium-albuterol (a bronchodilator) solution 0.5- 2.5 (3) mg/3mL - inhale every four hours for upper respiratory symptoms for seven days while awake, dated [DATE] Levaquin (an antibiotic) oral tablet 750 mg - Give 750 mg by mouth one time a day for upper respiratory symptoms, dated [DATE] Resident 1 received the influenza vaccination on [DATE]. On [DATE] at 8:28 A.M., PRN benzonatate was administered. The clinical record lacked documentation to indicate why the benzonatate was administered. On [DATE] at 8:30 A.M., PRN Robafen was administered. The clinical record lacked documentation to indicate why the Robafen was administered. On [DATE] at 3:36 P.M., Resident 1 had a temperature 99.5 Fahrenheit (F). A warning of high of 99.0 was exceeded was indicated. A communication with family note, dated [DATE] at 3:56 P.M., indicated Resident 1 was dealing with upper respiratory symptoms. The Nurse Practitioner (NP) was notified. New orders for Levaquin750 mg daily and ipratropium-albuterol every four hours were received. The clinical record lacked documentation to indicate what upper respiratory symptoms the resident experienced and if Resident 1 was seen by the NP. A respiratory infection care plan was initiated on [DATE]. On [DATE] at 6:44 P.M., PRN benzonatate was administered. An infection note, dated [DATE] at 2:08 A.M., indicated Resident 1 took Levaquin 750 mg as ordered for an upper respiratory infection. It was tolerated well without adverse reaction. Oxygen saturations were within normal limits. A coarse and congested cough was noted, but no sputum was noted, and the resident was afebrile. The [DATE] electronic Medication Administration Record (eMAR) indicated Resident 1 did not receive Levaquin 750 mg due to being hospitalized . A nurse's note, dated [DATE] at 4:12 A.M., indicated the Registered Nurse (RN) entered the resident's room to give him the scheduled nebulizer treatment, and the resident was warm to the touch. The RN assessed the resident and noted an elevated temperature of 100.4 Fahrenheit (F). Resident 1 responded to painful stimuli but otherwise was not responsive and had diaphragmatic breathing. The RN auscultated the resident's lungs and found them to be wet with a coarse rub noted and an occasional cough. The RN applied the nebulizer treatment and again assessed overall status and vital signs (all vital signs except for temperature were within normal limits). Resident 1 never became very arousable. The NP was notified, and orders were received to send the resident to the emergency room (ER) for evaluation. The clinical record lacked documentation to indicate that Resident 1 was tested for influenza following identification of upper respiratory signs and symptoms on [DATE] at 8:28 A.M. and prior to leaving for the ER on [DATE] at 4:12 A.M.The clinical record lacked documentation to indicate that the Infection Preventionist (IP) was notified that Resident 1 experienced signs and symptoms of upper respiratory and flu-like illness or that those signs and symptoms were tracked following identification of upper respiratory signs and symptoms on [DATE] at 8:28 A.M. and prior to leaving for the ER on [DATE] at 4:12 A.M. A hospital history and physical note, dated [DATE] at 6:42 A.M., indicated that upon arrival in the ER, the resident was still unresponsive and had a Glasgow Coma Scale score (GCS) of 5 (a severe brain injury or deep comatose state) and was intubated upon arrival. Resident 1 had a temperature of 102 F, a respiratory rate of 26 (elevated), and he was tachycardic (increased heart rate) with heart rates between 108 and 117. ABG (arterial blood gas) showed a pH of 7.3, pCO2 was 32, and pO2 was 428 (indicating respiratory acidosis). Resident 1 had an elevated lactic of 2.6 (indicative of sepsis). A respiratory panel indicated Resident 1 was positive for influenza A. A computed tomography scan (CT scan) (a noninvasive imaging test used to diagnose injuries, tumors, infections, and internal bleeding) of the head was concerning for severe sinusitis. A chest x-ray showed patchy bilateral lung opacities suspicious for pneumonia. Resident 1's admitting diagnoses included, but was not limited to, severe sepsis (sepsis with associated acute organ dysfunction) secondary to influenza A, possible bilateral pneumonia, metabolic encephalopathy (a broad term for brain dysfunction caused by non-structural issues like metabolic, toxic, or organ-related imbalances), acute hypoxic respiratory failure with mechanical ventilation, and severe sinusitis (inflammation of the sinus lining). A nursing alert note, dated [DATE] at 1:03 A.M., indicated the facility received a call from the hospital that Resident 1 expired at the hospital on [DATE] at 10:00 P.M. During an interview on [DATE] at 11:50 A.M., the [NAME] County Health Department Clerk indicated that influenza A, acute hypoxia due to respiratory failure requiring intubation, and sepsis secondary to bilateral pneumonia was listed as causes of death on Resident 1's death certificate. 4. On [DATE] at 12:13 P.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, dysphagia and influenza A. The most current full admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated that Resident 48 had moderate cognitive impairment and did not have a respiratory diagnosis or infection. The most current Quarterly MDS Assessment, dated [DATE], indicated that Resident 48 had moderate cognitive impairment and did not have a respiratory diagnosis or infection. Physician orders included, but were not limited to:May have immunizations as required, including, but not limited to, influenza, pneumonia, and TB (1st and second step) and annual TB, dated [DATE] acetaminophen (a fever reducer) 325 milligrams (mg) tablet – Give two tablets via percutaneous endoscopic gastrostomy (PEG) tube (a medical device inserted directly into the stomach through the abdominal wall to provide long-term nutrition, fluids, and medication for individuals unable to meet their needs orally) every four hours as needed for temperature of 100 Fahrenheit (F) or above, dated [DATE] Send to the emergency room (ER) for peg tube replacement. One time only for evaluation and treatment, dated [DATE] An Informed Consent and Authorization for Immunizations document, dated [DATE], indicated Resident 48 gave consent to receive the influenza vaccine. The clinical record lacked documentation to indicate the influenza vaccination was given to Resident 48. A nursing alert note, dated [DATE] at 2:04 P.M., indicated Resident 48 complained of not feeling well and a low-grade temperature of 100.2 Fahrenheit (F) was noted. The Nurse Practitioner (NP) was notified, and a COVID swab was ordered. Acetaminophen was administered. The clinical record lacked documentation to indicate details of the completion of the COVID swab and the results. A skilled nursing evaluation, dated [DATE] at 2:04 P.M., indicated Resident 48 had a cough. On [DATE] at 8:12 A.M., Resident 48 had a temperature of 101.9 F. A warning of high of 99.0 was exceeded was indicated. Acetaminophen was administered. The clinical record lacked documentation to indicate the provider was notified of the elevated temperature. A communication with family note, dated [DATE] at 12:06 P.M., indicated There have been positive cases of flu within our building. At this time, appropriate infection control precautions have been implemented to help prevent further spread and to protect the health and safety of our residents and staff. Visitors are encouraged to perform frequent hand hygiene before, during, and after visits and to utilize available hand sanitizer stations throughout the facility. Mask use is recommended to prevent any further spread. We will continue to monitor closely and provide updates as necessary. Please contact the facility with any questions or concerns. Thank you for your understanding and continued support. On [DATE] at 11:37 A.M., Resident 48 had a temperature of 100.0 F. A warning of high of 99.0 was exceeded was indicated. Acetaminophen was administered. The clinical record lacked documentation to indicate that the provider was notified of the elevated temperature. On [DATE] at 8:13 A.M., Resident 48 had a temperature of 100.1 F. A warning of high of 99.0 was exceeded was indicated. Acetaminophen was administered. A doctor visit note, dated [DATE] at 10:52 A.M., indicated the Medical Director (MD) assessed the resident with no acute or abnormal findings. On [DATE] at 8:47 A.M., Resident 48 had a temperature of 99.1 F. A warning of high of 99.0 was exceeded was indicated. The clinical record lacked documentation to indicate that the provider was notified of the elevated temperature. The clinical record lacked documentation between [DATE] at 8:47 A.M. and [DATE] at 2:30 P.M. to indicate that Resident 48 was assessed for signs and symptoms of infection or the resident's condition was monitored. On [DATE] at 2:30 P.M., Resident 48's vital signs were taken and were within normal limits. A nursing alert note, dated [DATE] at 7:50 A.M., indicated that Resident 48's PEG tube was not functioning properly. The NP was notified and an order was given to send

Based on interview, observation, and record review, the facility failed to ensure fall prevention measures were in place for 1 of 2 residents reviewed for falls resulting in major injury. This deficient practice resulted in a fall with a brain bleed. (Resident 5)Finding includes: On 2/11/26 at 9:19 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, dementia.A care plan dated 7/23/24 indicated the resident was at risk for falls related to confusion, unaware of safety needs, vision/hearing problems with diagnosis of dementia. Interventions included, but were not limited to:Non-skid strips to shower floor dated 4/28/25Apply Fluorescent tape to armrest for visual guidance dated 8/6/25Dycem (non-slip material to provide grip and stability) in recliner dated 9/2/25Provide spill proof cup for hydration to prevent spills that may cause slipping and falls in room dated 11/21/25Adding non-slip furniture pads under recliner dated 12/18/25.Quarterly Minimum Data Set (MDS) Assessment, dated 10/9/25, indicated Resident 5 was severely cognitively impaired, required supervision for eating, partial assistance (staff do half of the work) for toileting, bathing, upper and lower body dressing and putting on/taking off footwear, and transfers.The record indicated the resident had 44 falls between January 2025 and January 2026.Fall #26, dated 10/24/25 at 8:48 A.M., indicated the care plan intervention was provide the resident with non-slide socks at HS (bedtime).Fall #27, dated 11/2/25 at 3:30 A.M., indicated the care plan intervention was non-skid socks to be in place and remind the resident to use call light and ask for assistance.Fall #44, a fall incident report, dated 1/5/26 at 1:31 A.M., indicated Resident 5 had an unwitnessed fall that resulted in two lacerations to right forehead temple with skull exposed, skin tear to right hand and knuckle, and abrasions to bilateral knees and toes. Resident was found in the bedroom, face down in a puddle of blood. The resident became less responsive while waiting for the ambulance. Staff had assisted Resident 5 to the bathroom [ROOM NUMBER] minutes prior and was checked on by staff five minutes prior. The resident was bare foot and did not have any non-slip socks on at the time of the fall.Resident 5 was sent to the ER. A hospital history and physical note, dated 1/5/26 at 3:07 A.M., indicated Resident 5 had hemorrhaging (bleeding) of the right frontal lobe, and laceration to the right forehead closed by sutures. The resident returned to the facility and the following interventions were implemented.Bed in lowest position, every shift for fall prevention; Start date 1/7/26Full size mattress with fall mat next to bed with sensor pressure to mat will turn call light on, check function every shift for fall prevention; Start date 1/30/2615 minutes safety checks-initiated due to fall risk, every shift for fall prevention; Start date 2/9/26A care plan dated 1/6/26 indicated the resident had a floor alarm with a full-size mattress that will sound and turn on my call light due to my poor safety awareness, history of frequent falls, and occasional difficulty with communication. POA (power of attorney) and hospice both would like this in place as a safety intervention.The most recent Significant Change MDS Assessment, dated 1/9/26, indicated Resident 5 was severely cognitively impaired, required supervision for eating, required partial assistance (staff do more than half of the work) for toileting and transfers, required maximal assistance for bathing, upper and lower body dressing, putting on/taking off footwear, and had one fall with injury since the last MDS assessment.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/26/26, indicated Resident 5 was severely cognitively impaired, required maximal assistance (staff do more than half of the work) for eating, toileting, bathing, upper and lower body dressing, putting on/taking off footwear, and transfers, and had one fall with major injury since the last MDS assessment. During an observation on 2/12/26 at 1:19 P.M., Resident 5's room did not have a recliner, did not have a drink cup, did not have non-slip pads under any furniture, there was no fluorescent tape to the arm rest of a chair.During an interview on 2/12/26 at 2:49 P.M., the MDS Coordinator indicated she leaves care plan interventions in place even if it is not working or is no longer in use, as reference what has been used as intervention previously, and indicated she did not update the care plan with interventions provided by hospice.During an interview on 2/12/26 at 3:07 P.M., the Administrator indicated Resident 5's recliner was removed after last fall, and care plan interventions should be updated when interventions are no longer in place. During an observation on 2/12/26 at 3:45 P.M., the Director of Nursing reviewed fall interventions in Resident 5's care plan. The DON confirmed Resident 5 did not have a recliner in the room, there were no nonslip pads under furniture, stated she was unsure what fluorescent tape was supposed to be on. Resident 5 does not have shower in his room; the DON reviewed the shower room and confirmed there were no non-slip strips in the shower room.During an interview on 2/13/26 at 8:49 A.M., The DON indicated if a fall care plan intervention says a resident should be wearing non-slip socks, resident should have them on.On 2/17/26 at 12:47 P.M., the Administrator provided an undated policy titled Fall Protocol that indicated Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions.On 2/17/26 at 12:47 P.M., the Administrator provided an undated policy titled Falls and Fall Risk Managing that indicated If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. (Food Services Director) Findings include:During an interview on 2/9/26 at 9:30 A.M., the Dietary Manager indicated that she was currently enrolled in the course for dietary manager. She indicated that she missed passing the test by 1 point in 2024 and had to wait to re-enroll and take the course. On 2/9/26 at 2:00 P.M., the manager produced an invoice where she had just registered for the class on [DATE] at 12:00 P.M.On 2/12/26 at 11:00 A.M., the employee record for the Food Service Manager indicated she started her role on 1/2/26.During an interview on 2/13/26 at 8:55 P.M., the Administrator indicated that the dietary manager should be certified and during the survey 2/9/26-2/13/26.On 2/17/26 at 1:55 P.M., the Administrator provided a current, non-dated copy of the [Facility Name] Job Description for the Director of Food Services. The FDS job description . indicated the Food Service Director must be registered as a Food Service Director in this state .Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association .the director was to provide leadership training that includes the administrative and supervisory principles essential of the Food Services Department 3.1-20(g)(2)

Based on record review and interview, the facility failed to ensure the required staff were present at the monthly Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings related to the Infection Preventionist and Medical Director, or designee, and Director of Nursing not being present. This had the potential to affect all residents in the facility.Finding includes:During an interview on 2/17/26 at 11:31 A.M., the Administrator indicated the QAA/QAPI committee met monthly. Monthly attendance records of meetings were requested. On 2/17/26 at 2:27 P.M., the Administrator provided QAPI committee meeting attendance sheets for the following dates: 2/20/25 (Infection Preventionist and Director of Nursing not present) 3/19/25 (Infection Preventionist and Director of Nursing not present) 4/22/25 (Infection Preventionist and Director of Nursing not present) 7/28/25 (Infection Preventionist and Medical Director not present) 10/16/25 (Infection Preventionist and Medical Director not present) 1/12/26 (Infection Preventionist not present) 1/16/26 (Infection Preventionist not present) During an interview on 2/13/26 at 9:38 A.M., the Infection Preventionist indicated she worked from another building and came to the facility monthly for QAPI meetings and staff in-services related to infection control. During an interview on 2/17/26 at 2:07 P.M., the Administrator indicated there was a QAPI meeting held on 2/6/26 but no attendance was signed during the meeting. On 2/10/26 at 3:36 P.M., the Administrator provided a 2026 QAPI Plan that indicated The Executive Leadership team will assure that time and resources are provided to the designated persons that participate on the QAPI Steering Committee or any other associated work groups. Minutes of meetings will reflect membership and attendance of those participating and will be reported quarterly in the monthly QAPI summary report 3.1-52

Based on observation, interview, and record review, the facility failed to ensure a designated infection preventionist was onsite to implement programs and activities to prevent and control infections. Finding includes: During the entrance conference on 2/9/26 at 10:27 A.M., the Administrator indicated the facility's Infection Preventionist (IP) worked from another building. On 2/12/26 at 1:59 P.M., the IP's employee file was reviewed. The Infection Control Nurse job description included duties such as: Make rounds to nursing units for the purpose of case findings, review of environmental sanitation procedures, and supervision of isolation precautions/practices. Visit isolated residents as necessary to ensure that established isolation precautions and aseptic technique are followed. Works in office area(s) as well as throughout the facility. During an interview on 2/13/26 at 9:38 A.M., the IP indicated she worked from another building and came to the facility monthly for QAPI meetings and staff in-services related to infection control. On 2/17/26 at 12:47 P.M., the Administrator provided an undated policy titled Infection Preventionist that indicated The infection preventionist is employed on site and at least part time.

Based on observation, interview and record review, the facility failed to ensure medications were properly secured, failed to keep insulin refrigerated until opened, and to label and date vials of tuberculin solution with open and expiration dates for 2 of 2 medication carts and the [Pharmacy Name] Medication room refrigerator. (West Medication Cart, East Medication Cart, [Pharmacy Name] Medication Room) FIndings include: 1, On 2/9/26 at 2:19 P.M., during random observation of the [NAME] Medication Cart the following was observed:1 unopened Lantus pen for Resident 26 with no open date or expiration date1 open Lispro insulin pen for Resident 4 with no open date or expiration date 2. On 2/9/26 at 2:27 P.M., during a random observation of the East Medication Cart the following was observed:1 large round white pill number N32 During an interview on 2/9/26 at 2:21 P.M., Qualified Medicine Aide (QMA) 4 indicated insulin should be refrigerated if unopened. During an interview on 2/9/26 at 2:45 P.M., QMA 5 indicated there should be no loose pills in the medication carts if there were a loose pills it was to be placed in a drug buster solution and reported to the nurse. 3. On 2/10/26 at 2:19 P.M., during a random observation of the [Pharmacy Name] Room, the following was observed in the medication refrigerator. 2 open bottle of tuberculin testing solution with no open date or expiration date. On 2/10/26 at 2:25 P.M., Licensed Practical Nurse(LPN) 6 indicated the vials should be dated when opened. During an interview on 2/13/26 at 8:45 A.M., the Director of Nursing (DON) indicated that insulin needs to go straight to the refrigerator if not used immediately and needs to be dated with the open date.On 2/17/26 at 1:46 P.M., the Administrator provided a current, undated policy Medication Labelling and Storage The policy indicated .mediations and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly .multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .3.1-25(k)3.1-25(o)

Based on observation, record review, and interview, the facility failed to ensure that a sink in a therapy restroom was safely secured to the wall and personel belongings in shared restrooms were labeled with resident names in 4 of 4 shared restrooms reviewed.( Sink in therapy area restroom, Shared restrooms between rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], rooms [ROOM NUMBERS])Findings include:1. On 2/12/23 at 9:15 A.M, during random observations of restrooms, the following were observed:In the restroom between rooms [ROOM NUMBERS]:1 bottle of shampoo with no name1 tube of toothpaste with no name2 bottles of lotion with no namesIn the restroom between rooms [ROOM NUMBERS]:1 toothbrush with no name1 tube of toothpaste with no name3 bottles of lotionIn the restroom between rooms [ROOM NUMBERS]:1 bottle of mouthwash with no name1 tube of toothpaste with no name 1 can of shaving cream with no nameIn the restroom between rooms [ROOM NUMBERS]:1 tooth cup with no name1 tube of toothpaste with no name1 toothbrush with no name2 combs with no name2 bottles of lotion with no name2. On 2/12/26 at 2:30 P.M., during a random observation in the therapy restroom the sink was observed to have pulled away from the wall and loose in movement.During an interview on 2/11/26 at 9:45 A.M., Certified Nursing Assistant (CNA) 11 indicated that she knew what most residents were capable of doing for hygiene, but all of resident's personal items needed to be labeled with their names and if the items were not labeled, she would usually through the items away. During an interview on 2/13/26 at 8:40 A.M., the Administrator indicated that the sink should be against the wall and all residents' personal belongings should be labeled with their names.On 2/17/26 at 11:55 A.M., the Administrator provided a current, non-dated policy Homelike Environment. The policy indicated . the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment .On 2/17/26 at 11:55., the Administrator provided a current non-dated policy Personal Property. The policy indicated Resident belongings are treated with respect by facility staff, regardless of perceived value. Personal care items will be properly stored to prevent the spread of infection, such as toothbrushes and hairbrushes/combs will be stored in individual containers, etc . 3.1-19(f)

Based on interview and record review, the facility failed to develop care plans for 1 of 1 residents reviewed for Urinary Tract Infection (UTI) and 1 of 1 residents reviewed for Respiratory Care. A care plan was not developed for residents for use of antibiotics and oxygen use. (Resident 3, Resident 34) Findings include: 1. On 2/12/2026 at 1:43 P.M., Resident 3's clinical record was reviewed. Diagnoses included but were not limited to Parkinson's Disease without Dyskinesia, unspecified dementia, and Alzheimer's Disease. The current Quarterly Minimum Data Set (MDS) Assessment, dated 12/15/25, indicated Resident 3 was mildly cognitively intact. She needed supervision to eat, but required partial to moderate assistance for toileting, dressing, hygiene, and transferring. Current physician orders included but were limited to:Cipro 500 mg (Milligrams) BID for 7 d for UTI. Dated 2/7/26. A care conference was conducted on 11/5/2025 at 3:15 P.M., with the resident and Power of Attorney present. The care plan was reviewed at that time. The current clinical documentation lacked a care plan for antibiotic use during the time the resident use of one 2/7-2/13/26 During an interview on 2/17/26 at 10:55 A.M., the Minimum Data Set (MDS) Coordinator indicated care plans were initiated with MDS reviews and quarterly. Care plans needed to be updated with new intervention with changes and needed. 2. On 2/11/26 at 11:53 A.M., Resident 34's clinical record was reviewed. Resident 34 was admitted on [DATE]. Diagnoses included, but were not limited to, congestive heart failure. The most recent annual Minimum Data Set (MDS) Assessment, dated 1/3/26, indicated Resident 34 was cognitively intact, required maximal assistance (staff do more than half of the work) for toileting, bathing, and transfers, and was using oxygen therapy. Physician orders included, but were not limited to: Oxygen via nasal cannula at two liters two times a day, Start date 2/8/26 Change all oxygen supplies every Sunday every night shift, Start date 2/1/26 The clinical record lacked a care plan related to oxygen use. On 2/17/26 at 12:47 P.M., the Administrator provided an undated policy titled Care Plans, Comprehensive Person-Centered that indicated The comprehensive, person-centered care plan includes: measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change 3.1-35(b)(1)

Based on observation, record review, and interview, the facility failed to ensure interventions were in place for 1 of 2 resident reviewed for falls. An intervention for falls was not implemeted.(Resident 21) Finding includes:During a random observation on 2/12/26 at 9:30 A.M., there were no non-skid stripes observed on the floor of Resident 21's During a random observation on 2/13/26 at 8:37 A.M., Resident 21 was observed lying in bed, and no non-skid strips were observed on the left or right floor of the resident's bed. On 2/11/26 at 1:35 P.M., the clinical record for Resident 21 was reviewed. Diagnoses included, but were not limited to Alzheimer's disease, personality disorder, and fracture of the nasal bones, subsequent encounter for fracture for routine healing. The current Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 21 was cognitively intact. Resident 21 needed supervision with eating, but required partial to moderate assistance with dressing, mobility, and hygiene also had a history of falls. Physician orders included, but were not limited to the following:Send to ER for evaluation and treatment. No directions specified dated 11/22/25.The current care plan had potential for fall-related injury r/t related/to decreased mobility d/t Due/to falls. Psychotropic medication use was revised on 7/24/23. Included interventions related to but not including:Send to the emergency room (ER) for evaluation and treatment dated 11/22/25.Review medications to r/o medications that may be potential ADR's Adverse Drug Reaction (ADR's) causing falls with possible reduction or discontinue (D/C) dated 11/23/25.Non-skid strips on the exit side of the bed on the floor dated 11/25/25. An initial reported fall date 11/22/25 at 9:58 A.M., indicated this was the first unwitnessed fall for the resident. The note indicated that the resident was noted to be ambulating down hallway with blood running down his face. Resident stated, I fell out of bed. Upon assessment, the resident was observed with multiple facial injuries including a laceration to distal mid-forehead, nasal bridge visibly misaligned with swelling, redness and sm abrasion.A post hospital return summary dated 11/22/25 at 6:10 P.M., indicated that resident had an unwitnessed fall that resulted in the resident having a nasal fracture, a maxillary fracture of the left side and facial laceration measuring 1 centimeter x 0.3 centimeters in length sealed with wound glue. Care plan intervention was to be sent to the emergency room (ER). An initial fall report dated 11/23/25 at 4:53 P.M. indicated this was a second unwitnessed fall for this resident. The report indicated the resident was noted sitting on floor with knees bent, blood running down face from laceration on forehead and nares. Hematoma noted above L orbital area. Resident stated, I fell out of bed. The Nurse Practioner was notified and was ordered to send to the ER. An Interdisciplinary (IDT) note dated 11/24/25 at 9:23 A.M., indicated that the team agreed with the intervention for sending to ER and adding an intervention to review the resident's medication to rule out medications that may add risk of falls.An additional IDT note dated 11/24/2025 at 10:05 A.M., add non-skid strips to the floor by bed on the side the resident exits on.A third fall's initial incident report dated 11/25/25 at 3:45 A.M., indicated that the resident had witnessed a fall sliding to floor while getting up from a couch. There were no new injuries. The intervention was to add non-skid strips to the floor was on the care plan dated 11/25/25. During an interview on 2/17/26 at 11:15 A.M. Certified Nursing Assistant 10 indicated that the resident should have non-skid strips on the sides of his bed and he did not. On 2/17 at 1:47 P.M., the Administrator provided a current, non-dated policy Care Plans, Comprehensive Patient Centered. The policy indicated .Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change . 3.1-35(b)(1)

Based on record review and interview, the facility failed to ensure the physician documented a clinical contraindication when a gradual dose reduction (GDR) was declined for 3 of 5 residents reviewed for unnecessary medications (Resident 2, Resident 4, and Resident 33).Findings include:1. On 2/12/26 at 8:53 A.M., Resident 2's clinical record was reviewed. Resident 2 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/16/25, indicated Resident 2 was moderately cognitively impaired, required partial assistance (staff do half of the work) for toileting, bathing, and transfers, and received antipsychotic, antianxiety, antidepressant, and anticonvulsant medication during the seven day lookback period. Physician orders included, but were not limited to: Duloxetine HCl Capsule (Drizalma) Delayed Release Particles 30 MG (milligrams) Give one capsule by mouth two times a day related to depression, Start date 8/31/25 Clonazepam Tablet 0.5 MG Give one tablet by mouth two times a day related to anxiety disorder, Start date 11/6/24 The current care plan included, but was not limited to: I do take antidepressant as ordered. Date Initiated: 3/3/23 I take antianxiety as ordered, and an anticonvulsant for off label use. Date Initiated: 5/28/25 A Pharmacy Physician Recommendations form, dated 9/2/25, indicated the Pharmacy made a recommendation to reduce the Duloxetine 30 MG and Clonazepam 0.5 MG. The Nurse Practitioner indicated no change in doses made, but did not provided a rational for declining the pharmacy recommendations. 2. On 2/11/2026 at 8:35 A.M., Resident 4 clinical record was reviewed. Diagnoses included, but were limited to, major depressive disorder, anxiety disorder, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side. The current Quarterly MDS dated [DATE] indicated Resident 4 was cognitively intact. Resident 4 needs substantial to maximum assistance eating, dressing, and transferring, but partial to moderate assistance with hygiene. She also takes antidepressant medications. Physician orders included, but were not limited to: Trazodone (antidepressant) HCl Oral Tablet 50 MG. Give 1 tablet by mouth at bedtime dated 12/5/25. Desvenlafaxine (antidepressant) ER Oral Tablet Extended Release 24 Hour 100 MG. Give 1 tablet by mouth one time a day dated 6/10/25. Consultant Pharmacist Recommendation to prescriber for Resident 4 dated 12/18/25 for Divalproex DR (antiseizure medication) 250 Milligrams (mg) 1 po bid initiated on 7/25/25 was reviewed and Nurse Practitioner did not provide rationale for disagreement of the drug dose reduction. Consultant Pharmacist Recommendation to prescriber for Resident 4's dated 1/21/26 for Trazodone (antidepressant) HCl Oral Tablet 50 MG. Give 1 tablet by mouth at bedtime dated 12/5/25 was reviewed and Nurse Practitioner did not provide rationale for disagreement of the drug dose reduction. 3. On 2/11/2026 at 10:15 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were limited to, brief psychotic disorder, anxiety disorder, and unspecified dementia. The current Quarterly MDS assessment dated [DATE] indicated Resident 33 was severely cognitively impaired. Resident 33 needed substantial to maximum assistance eating, dressing toileting, and transferring and taking antianxiety and anticonvulsant medications. Current physician orders included, but were not limited to: Divalproex DR (antiseizure medication) 250 Milligrams (mg) 1 po (by mouth) bid (twice a day) initiated on 7/25/25. Buspirone (anti-anxiety) 7.5 mg 1 po bid initiated on 7/11/25. Consultant Pharmacist Recommendation to prescriber for Resident 33 dated 12/18/25 for Buspirone (anti-anxiety) 7.5 mg 1 po bid initiated on 7/11/25 was reviewed and Nurse Practitioner did not provide rationale for disagreement of the drug dose reduction. Consultant Pharmacist Recommendation to prescriber for Resident 33 dated 1/21/26 for Divalproex DR (antiseizure medication) 250 Milligrams (mg) 1 po bid initiated on 7/25/25 was reviewed and Nurse Practitioner did not provide rationale for disagreement of the drug dose reduction. During an interview on 2/12/26 at 9:15 A.M., the Nurse Practitioner indicated if there is a disagreement on the Gradual Dose Agreement (GDR) there needs to be a reason why there is disagreement. On 2/17/26 at 12:00 P.M., the Administrator provided a current, non-dated policy Psychotropic Medication Use. The policy indicated . If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued, and document the rationale for this decision . 3.1-25(i)

Based on interview and record review, the facility failed to ensure vaccinations were provided according to residents' informed consent for 2 of 6 residents reviewed for immunizations. A resident who consented to receive the influenza vaccine did not receive it. A resident who declined to receive the influenza vaccine did receive it. (Resident 48 and Resident 33)Findings include:1. On 2/12/26 at 10:44 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The resident was admitted to the facility on [DATE].The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/13/25, indicated Resident 33 had severe cognitive impairment and received the influenza vaccination on 10/27/25.Physician orders included, but were not limited to:May have immunizations as required including, but not limited to: influenza, pneumonia, and tuberculosis (TB) (first and second step) and annual TB., dated 6/18/25Monitor resident for low grade fever, aches, redness, soreness, itching and swelling at the flu vaccine injection site every shift x 72 hours. Left Deltoid every shift for flu vaccine monitoring for three days. If symptoms arise, notify physician, dated 10/27/25Current care plans included, but were not limited to:Would like to exercise my right to refuse being vaccinated for Flu, Pneumococcal, COVID, or RSV. I and/or my power of attorney (POA) have been educated on benefits and risk and decline the option to receive the vaccine at this time, initiated 2/6/26An Informed Consent and Authorization for Immunizations, dated 6/18/25, indicated the influenza vaccination was declined and was signed by the POA.An Informed Consent and Authorization for Immunizations, dated 1/15/26, indicated the influenza vaccination was declined and was signed by the POA.A nursing alert note, dated 10/27/25 at 3:14 P.M., indicated that Resident 33 received the influenza vaccine in her left deltoid per consent. The clinical record lacked documentation to indicate who gave the consent.On 2/12/26 at 3:16 P.M., the Regional Consultant provided an Informed Consent and Authorization for Immunizations form, dated 10/27/25. The form indicated verbal consent was acquired from the POA on 10/27/25.During an interview on 2/13/26 at 9:13 A.M., the POA indicated she did not give consent for Resident 33 to have the influenza vaccine. She saw it had been given to Resident 33 on the communication application the facility used to communicate to families what care had been given to residents. She indicated that staff called her after the fact and told her that Resident 33 wanted the influenza vaccine, but Resident 33 had severe dementia. She indicated if they would have called her before administering the vaccination, she would have declined it.2. On 2/13/26 at 12:13 P.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, dysphagia and influenza A. Resident 48 was admitted to the facility on [DATE].The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/1/25, indicated that Resident 48 had moderate cognitive impairment and did not receive the influenza vaccination because she declined it.An Informed Consent and Authorization for Immunizations, dated 8/27/25, indicated consent to receive the influenza vaccination was given and was signed by the resident's responsible party.The clinical record lacked documentation to indicate the influenza vaccination was given to Resident 48.On 2/14/26 at 12:43 P.M., the MDS Regional Coordinator provided a list of all residents who received the influenza vaccination and the date it was received. Resident 48 received the influenza vaccination on 2/13/26.During an interview on 2/13/26 at 9:38 A.M., the Infection Preventionist (IP) indicated that influenza vaccine consents were obtained on admission and annually thereafter. If a resident had cognitive impairment, the POA or guardian gave consent or declined the vaccination on behalf of the resident. On 12/13/26 at 12:31 P.M., the Administrator provided a current undated Influenza Vaccine policy that indicated All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associate with vaccinations against influenza . Prior to the vaccination, the resident (or resident's legal representative) .will be provided information and education regarding the benefits and potential side effects of the influenza vaccine . A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.3.1-13(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a resident with a history of exit-seeking/elopement behavior from exiting the facility and leaving the property for 1 of 3 residents reviewed for elopement. This deficient practice resulted in an elopement that occurred during the morning hours of September 1, 2025. The resident was located with the assistance of the local police department, approximately 1.2 miles from the nursing facility, near a previous residence. This Immediate Jeopardy began on September 1, 2025, when the facility failed to ensure Resident C did not exit the facility property through a doorway on the [NAME] Hall at approximately 5:30 A.M. Resident C was not realized to be missing until 7:15 A.M. after staff noticed she was not in her room. A search in and around the facility lasted approximately 30 minutes before local law enforcement was notified and arrived to the facility at approximately 7:50 P.M. Resident C was located by local law enforcement and returned to the facility at approximately 8:30 A.M. The Facility Administrator was notified of the Immediate Jeopardy on 9/15/25 at 3:45 P.M. (Resident C)Finding includes: During record review on 9/15/25 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, early onset Alzheimer's disease, unspecified convulsions, anxiety, depression, and chronic obstructive pulmonary disease (COPD). Resident C's most recent admission date was 8/24/25. Resident C had previously been discharged from the facility on 11/30/24. A risk for elopement assessment, dated 8/24/25 indicated Resident C had a history of or attempted elopement at home, had verbally expressed a desire to go home, packed belongings to go home, or stayed near an exit door, and was recently admitted to the facility and was not accepting of the situation. The elopement assessment indicated a score of 3 or at risk for elopement. ,The most recent admission MDS (Minimum Data Set) assessment, dated 8/31/25 indicated the resident had no cognitive impairment and the resident required supervision for mobility and transfers. Resident C's care plan included, but was not limited to, Resident has sleep issues and takes medication to help sleep with an intervention that included, monitor for abnormal sleep patterns (initiated 8/25/25). Resident C's nurse's progress notes included, but were not limited to:8/24/25 at 7:30 A.M. - Resident arrived at facility at 6:30 A.M. from home.8/26/25 at 9:10 A.M. - Resident ambulated to smoke, staff spoke to her, and she looked at staff in silence then looked away. Staff to monitor for mood. Resident exited building to smoke with the smoking group.8/30/25 at 5:22 A.M. - Resident up and pacing hallways and asking for a light and wants to smoke. Resident is agitated and upset, short in demeanor. Resident reports that someone has wrecked her room but when nursing observed her room, her bed was made and her belongings were all in place, as were the roommate's belongings. Resident went back to her room. 9/1/25 at 8:55 A.M. - Registered Nurse (RN) entered resident's room at approximately 3:30 A.M. to administer medication to the resident's roommate. Resident C was awake and watching television. RN observed Resident C's Hall (West Hall) at approximately 5:20 A.M. and observed Resident C in her room. During shift change at 7:15 A.M, the oncoming RN indicated being unable to locate Resident C in her room or bathroom. A search in and around building was initiated. The Facility Administrator was notified of an elopement. Law enforcement was notified at 7:45 A.M. after 30 minutes of searching and they arrived at the facility at 7:50 A.M. Camera footage showed Resident C walked into the [NAME] hallway, looked up and down hall, and then walked to the exit doors at the end of the hall where she entered the passcode on the keypad and exited the building around 5:30 A.M. Officers were informed of a previous home address and they located Resident C two houses from that address and brought resident back to facility at 8:30 A.M. Resident was placed on elopement precautions. During an interview on 9/15/25 at 10:30 A.M., the Facility Administrator indicated Resident C was able to open the [NAME] Hall exit doors without staff being made aware and without a door alarm sounding by pushing the correct code into the keypad to unlock the door. The keypad had a label that indicated the keycode was month/year (star). An observation on 9/15/25 at 11:10 A.M., included Resident C's room was near the far end of the [NAME] Hall, two doors down from a locked exterior exit door that the resident used to exit the facility on 9/1/25. A keypad controlled the locking mechanism for the exterior doors and no label that indicated the code was observed. During an interview on 9/15/25 at 11:15 A.M., Resident C's Power of Attorney (POA) indicated Resident C had trouble with her memory and occasionally thought she needed to go home, not realizing that she no longer lived there. Resident C had a residence near where she was found on the morning of 9/1/25 around 20 years prior. Resident C had not had any wandering or exit seeking behavior prior to the elopement on 9/1/25 since admission 8/24/25 that the POA was aware of. Resident C had lived at the facility prior to the most recent admission, but the resident did not recall the previous stay. The POA indicated the resident knew the code for the keypad to unlock the door at the end of the [NAME] Hall. Resident C had lived with the POA for 9 months prior to the admission on [DATE]. During the last month while living with the POA, Resident C became increasingly agitated, was having increased thoughts that she needed to go home and would forget that she was living with her POA. Resident C had not eloped or attempted to elope from the home, but that was a concern and part of the reason for the admission to the facility. During an interview on 9/15/25 at 1:30 P.M., the Facility Administrator indicated the resident could be seen on camera leaving the facility wearing a T-shirt, shorts, and tennis shoes. Area weather during the time of elopement on the morning of 9/1/25 was recorded as fair with no precipitation and a temperature range between 55 and 60 degrees Fahrenheit. During an interview on 9/15/25 at 1:40 P.M., the Social Service Director (SSD) indicated any new assessment that indicated a resident was at risk were discussed during daily morning meeting. If a resident is assessed to be at risk for elopement, or other safety concerns, the resident's plan of care should be updated as soon as possible. During an interview on 9/15/25 at 2:55 P.M., the SSD indicated newly admitted residents initially have a baseline care plan that starts off being somewhat generic based on what information the facility knows about the resident and should be updated as new behaviors or as new information is observed. During an interview and observation on 9/16/25 at 11:55 A.M., Resident C was sitting in her room in her recliner dressed in a T-shirt, shorts, and tennis shoes. Resident C indicated she was able to ambulate by herself. Resident C recalled taking a walk from the facility the morning of 9/1/25. Resident C could not recall the route she took but indicated she thought she was walking home at the time and just wanted to get home and that she missed her cat. Resident C made it to a previous address and realized she didn't live there anymore. She recalled having to sit down on porch steps along the way as she was tired and short of breath. Resident C also recalled hiding in bushes because she figured someone was looking for her. She described the incident as just taking a walk and getting her exercise for the day. Resident C then teared up, but did not give a specific reason, just that she cried at times. On 9/15/25 at 3:11 P.M., the Facility Administrator supplied a facility policy titled, Care Plans - Baseline, dated 1/2/19. The policy included, .1. Within 48 hours of admission the facility will develop and implement a baseline care plan for each resident. 2. The content of the baseline care plan will include: .Instructions needed to provide effective and person-centered care that meets professional standards of quality of care. The resident's immediate health and safety needs. On 9/16/25 at 12:00 P.M., the facility administrator supplied undated facility policies titled, Wandering and Elopements, and Routine Resident Checks. The Wandering and Elopements policy included, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . The Routine Resident Checks policy included, Staff shall make routine resident checks to help maintain resident safety and well-being. 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least every two hours during each shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see fi the resident is sleeping, needs toileting assistance, etc.Immediate Jeopardy was removed on 9/16/2025 at 2:50 P.M. The deficient practice remained at isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented a systemic plan that included the following actions: the facility completed audits of clinical records for all residents for all residents at risk for exit-seeking behavior or elopement. Labels that indicated keycodes were removed from keypads, and in-service training was provided to all staff on the elopement exit seeking policy and establishing interventions for residents who have been assessed to be at risk for wandering/elopement. This citation relates to intake 2606761. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to implement the plan of care for 1 of 1 residents observed for catheter care. Catheter care orders and treatments were not completed per the physician orders and the plan of care. (Resident C) Finding includes: During an observation on 3/24/25 at 12:30 P.M., Resident C was observed in the dining room in a wheelchair. Catheter tubing connected to a catheter drainage bag was clipped to the side of the wheelchair. During record review on 3/24/25 at 1:45 P.M., Resident C's diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, prostatic hyperplasia with lower urinary tract symptoms, and dementia. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/4/25, indicated the resident had moderate cognitive impairment and had an indwelling catheter. Resident C's physician orders included, but were not limited to, monitor Foley catheter output each shift, (ordered 11/18/24), acetic acid irrigation solution 60 milliliters (ml) via irrigation on time a day every Friday for catheter maintenance (ordered 2/25/25), Foley catheter with 60 ml normal saline flush for blockage every shift (ordered 11/20/24), and change catheter 20 Fr (French) coude (curved tip) one time a day starting on the 20th (day of the month) (ordered 3/11/25). Resident C's care plan included, but was not limited to, resident has indwelling Foley catheter in place for urinary retention (initiated 11/7/24). Interventions included, catheter care as ordered, intake and output as ordered, empty catheter bag at least three times daily (initiated 11/7/24). Resident C's Treatment Administration Record (TAR) for the month of March 2025 indicated the following regarding the completion and documentation of catheter care orders: Change catheter 20 Fr coude one time a day starting on the 20th (ordered 3/11/25) not completed 3/20/25. Foley catheter with 60 ml normal saline flush for blockage every shift (ordered 11/20/24) not completed on day shift of 3/11/25, 3/13/25, 3/14/25, 3/18/25, 3/19/25, and 3/20/25. Monitor Foley catheter output each shift (ordered 11/18/24) not completed on day shift 3/11/25, 3/15/25, day and night shift 3/17/25 & 3/18/25, day shift 3/20/25, and 3/22/25. During an interview on 3/25/25 at 8:40 A.M., LPN 4 indicated being unsure if Resident C had catheter care orders every shift. During an interview on 3/25/25 at 9:55 A.M., CNA 6 indicated Resident C's catheter care should be completed every shift and documented. On 3/25/25 at 10:40 A.M., RN 8 supplied a facility policy titled, Catheter Care, Urinary. The policy included, .Input/Output 1. Observe the resident's urine level for noticeable increases or decreases . 2. Follow the facility procedure for measuring and documenting input and output . 5. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction . This citation relates to complaint IN00455471. 3.1-35(a) 3.1-35(g)(2)

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage of at least 8 hours daily. Weekend RN coverage did not include at least eight (8) hours on two occasions. Finding includes: On 3/25/25 at 10:00 A.M., during a review of the facility's nursing schedule from 3/10/25 through 3/24/25, eight (8) hours of RN coverage was not indicated by the schedule on 3/22/25 or 3/23/25. An RN was scheduled to be in the facility on 3/22/25 from 12:00 A.M. to 7:00 A.M. and on 3/23/25 from 6:30 P.M. to 12:00 A.M. During an interview on 3/25/25 at 10:20 A.M., LPN 15 indicated she worked the weekend of 3/22/25 and 3/23/25 and did not recall that the DON was in the building. LPN 15 indicated the DON was on call during the weekends but did not typically come to the facility to work a full shift. On 3/25/25 at 10:40 A.M , RN 8 provided an undated facility policy titled, Staffing, Sufficient and Competent Nursing. The policy included, .A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week . This citation relates to complaint IN00455471. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident without pressure-related skin impairment did not develop a pressure injury for 1 of 2 residents reviewed for pressure injuries. Following the development of a pressure ulcer, no initial assessment was documented, and no documented treatment was given for 4 days and interventions were not routinely documented as completed by the plan of care. This deficient practice resulted in Resident 12 developing a facility acquired stage III pressure ulcer (Full-thickness skin loss with damage to subcutaneous tissue. The ulcer may extend into the subcutaneous tissue layer. Granulation tissue and epibole [rolled wound edges] are often present. No exposure of bone, tendon, or muscle. The sore looks like a crater and may be foul-smelling on the coccyx that led to a colonization of MRSA (Methicillin-resistant Staphylococcus aureus) in the wound. (Resident 12) Finding includes: During an observation and interview on 11/7/24 at 12:20 P.M., Resident 12 was lying in bed on a pressure reducing air mattress. The resident indicated she had a wound on her coccyx that developed in the facility. During record review on 11/8/24 at 1:40 P.M., Resident 12's diagnoses included, but were not limited to, chronic kidney disease, vitamin deficiency, atrial fibrillation, and chronic obstructive pulmonary disease. A Braden scale, completed on 3/18/23, indicated Resident 12 was at risk for pressure. Resident 12's most recent Quarterly Minimum Data Set (MDS) assessment, dated 9/7/24, indicated the resident had moderate cognitive impairment, used a wheelchair for mobility, required partial to moderate assistance with rolling side to side, moving from lying to sitting position, and moving from sitting to standing position. The resident was occasionally incontinent of bladder and frequently incontinent of bowel, was at risk for the development of pressure injuries, had no unhealed pressure injuries, and was on a turning and repositioning program. Resident 12's current physician orders included, but were not limited to, Candida Auris swab of wound on buttocks. One time only for testing (11/8/24), dressing change to coccyx: cleanse with wound cleanser, pat dry. Pack with 1/4 packing strip moistened with NaCl (sodium chloride), cover with bordered gauze dressing. Initial and date, every day shift for wound care, and as needed for soiled or dislodged dressing (started 11/1/24), and barrier cream, apply to buttock/coccyx topically as needed for wound prevention, incontinent episodes, and Incontinent care every shift per protocol (started 11/23/28). An Activity Participation Note, dated 9/9/24 at 4:20 P.M., indicated the resident had a recent decline in group activity participation. Resident 12 bases active participation in activities on mental mindset and physical ability each day. Resident 12 still wishes to participate in activities but struggles to attend some days due to increasing physical limitations. Resident 12's care plan included, but was not limited to, resident has potential for skin breakdown such as pressure ulcers due to decreased mobility, variable need for assistance with Activities of Daily Living (ADLs), occasional incontinence of bladder (revised 9/10/24). Interventions included, but were not limited to, offer/assist with toileting as needed, observe for decline in continence status and notify the physician as needed. Resident is occasionally incontinent of bladder due to variable need for assistance with ADLs, diagnoses of stress incontinence (revised 9/10/24). Interventions included, check routinely for incontinence, and provide incontinent care as needed, observe skin condition during toileting and incontinent care. Notify the nurse of any abnormal findings. A Nurse's Note, dated 9/16/24 at 8:25 A.M., indicated staff reported Resident 12 was needing assistance with meals and experienced increased incontinence. The resident had an area on her coccyx. Staff will attempt to get the resident to the dining room for meals. The resident's decline was reported to the physician and Nurse Practitioner (NP). The note did not include an assessment or further information regarding the area on the coccyx. No documentation of the area on the coccyx was found in the resident's record prior to 9/16/24. Resident 12's care plan was updated to include: resident has Stage III pressure ulcer to coccyx due to immobility (initiated 9/17/24). Interventions included but were not limited to, the resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. A Physician's Visit Note, dated 9/18/24 at 1:05 P.M., indicated the physician was in to see Resident 12 and the resident had experienced a noted decline. Resident 12 voiced no complaints. An increase in incontinence and generalized weakness as well as a decline of ADL's was reported to the physician. No new orders were given by the physician. A Weekly Skin Assessment Note, dated 9/18/24 at 3:49 P.M., indicated a recent wound to coccyx was evaluated by RN 11 and treatment orders were received. A review of Resident 12's Medication Administration Record/ Treatment Administration Record (MAR/TAR) for the month of September 2024 included a wound treatment order of, dressing change to coccyx: Lift dressing daily to assess and apply Medihoney (wound dressing containing Leptospermum honey). If the dressing comes dislodged prior to dressing change, use triad paste (wound dressing) until next scheduled dressing application, every day shift for wound care (started 9/18/24). No other wound treatments were ordered or documented as completed prior to 9/18/24. An as needed (PRN) order for barrier cream to buttocks/coccyx topically as needed for wound prevention/ incontinent episodes was not documented as administered during the month of September 2024. A Weekly Wound Assessment, dated 9/17/24 at 11:38 A.M., indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 4 cm (centimeters) L (length) x 5.5 cm W (width) x 0.1 cm D (depth) and was acquired on 9/14/24. The assessment indicated the wound bed contained 25% epithelial tissue, 25% granulation tissue, 25% slough, and 25% necrotic tissue with minimal serous drainage and that an odor was present. This was documented as the first observation from the wound nurse, and included a new treatment order, a request for an air mattress, and indicated the resident was on a turning and repositioning routine. A Wound Assessment, dated 9/24/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 4 cm L x 4 cm W x 0.1 cm D. The assessment indicated the wound bed contained 25% epithelial tissue, 25% granulation tissue, 25% slough, and 25% necrotic tissue with moderate serous drainage, and an odor was present. A Wound Assessment, dated 10/1/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 1cm L x 2 cm W x 0.2 cm D and described tunneling or undermining of 0.8 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 10% granulation tissue, 65% slough with moderate serous drainage and that an odor was present. A Wound Assessment, dated 10/8/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 0.8 cm L x 1.5 cm W x 0.3 cm D and described tunneling or undermining of 0.4 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 10% granulation tissue, 65% slough with moderate serous drainage and that an odor was present. A Wound Assessment, dated 10/15/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 1 cm L x 1.8 cm W x 0.1 cm D and described tunneling or undermining of 0.8 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 25% granulation tissue, 50% slough with minimal drainage and that an odor was present. No changes to the plan of treatment. A Wound Assessment, dated 10/22/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 2 cm L x 1.5 cm W x 0.8 cm D and described tunneling or undermining of 1.2 cm at 12 o'clock and that the wound was worsening. The assessment indicated the wound bed contained 25% epithelial tissue, 50% granulation tissue, 25% slough with minimal drainage. A Wound Assessment, dated 11/5/24, indicated a facility-acquired stage III pressure ulcer on Resident 12's coccyx measured 1 cm L x 1.2 cm W x 0.1 cm D and described tunneling or undermining of 0.4 cm at 12 o'clock. The assessment indicated the wound bed contained 25% epithelial tissue, 75% granulation tissue with minimal drainage. A review of Resident 12's documented tasks for Turn and Reposition Every 2 Hours & PRN from 10/10/24 to 11/7/24 included that no documentation of turning and repositing had occurred on 10/11/24, 10/14/24,10/17/24, and 10/26/24. A Lab Results Report, dated 11/12/24 at 8:18 A.M., included results for Resident 12's wound culture that indicated the wound was positive for MRSA. During an observation and interview on 11/12/24 at 11:40 A.M., RN 11 provided Resident 12's wound treatment and completed a weekly wound assessment. A sign indicated that the resident was on enhanced barrier precautions and a bin of personal protective equipment was located outside the resident's room. RN 11 indicated that Resident 12's wound has recently been cultured and tested positive for MRSA. RN 11 indicated that the wound was healing well and was going to complete the treatment order as it was ordered at the time by packing the wound, however felt wound packing was no longer needed due to healing and nearly no depth to the wound. The wound measured 1.2 cm L x 1 cm W x 0.1 cm D and with 0.2 cm tunneling at 12 o'clock. RN 11 indicated at the time the wound developed, Resident 12 was experiencing a decline in abilities and was having significant loose stools with an increase in incontinence. Resident 12 had a history of bouts of loose stools due to a prior diagnosis. During an interview on 11/13/24 at 1:00 P.M., LPN 9 indicated Resident 12 had a decline in September but had bounced back well. During that time, she required more assistance and did not want to get out of bed. During an interview on 11/13/24 at 1:40 P.M., the ADON (Assistant Director of Nursing) indicated that the resident was having increased incontinence of bowels due to loose stools and developed a small area on coccyx on 9/14/24. The ADON indicated the wound developed during the weekend and could not explain why no documentation of the wound was made from 9/14/24 through 9/16/24 or why no documented treatment was completed before 9/18/24. The ADON indicated that if a new area is observed by staff, the charge nurse on duty should be notified and administer a temporary treatment until new orders are received by either the physician or wound nurse. According to the National Library of Medicine (ncbi.nlm.nih.gov), clinical signs that a pressure ulcer may be infected include, malodorous, purulent exudate, excessive draining, bleeding in the ulcer, and pain. On 11/14/24 at 10:46 A.M., the MDS nurse provided an undated facility policy, titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol. The policy indicated, Assessments and Recognition .the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue . Treatment/Management 1. The physician will order pertinent wound treatments . 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored under proper temperature controls for 1 of 1 medication storage rooms reviewed. Finding includes: On 11/13/24 at 10:40 A.M., the refrigerator in the storage room was observed. The log indicated the last temperature was taken on 5/28/24. The freezer area was covered in ice. Medications in the refrigerator included, but was not limited to, insulin pens. During an interview on 11/13/24 at 10:48 A.M., the Director of Nursing (DON) indicated the nursing staff should be reading the temperature of the refrigerator at least once a day and documenting it in the log. She was unaware of any reason that it wasn't being done. At that time, the refrigerator temperature was observed to be 46 degrees Fahrenheit. The range on the log sheet indicated a temperature of 33-41 degrees Fahrenheit was acceptable. On 11/14/24 at 10:44 A.M., a current non dated Medication Labeling and Storage Policy was provided by the MDS (Minimum Data Set) Coordinator and indicated The facility stores all medications and biologicals in locked compartments under proper temperature . The nursing staff is responsible for maintaining medication storage . Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station . 3.1-25(m)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents observed during medication pass and 4 of 4 residents reviewed for use of Enhanced Barrier Precautions (EBP). A pill was dropped on the medication cart, touched with a bare hand, and administered to the resident. Residents with indwelling catheters and open wounds were not placed on precautions as indicated. (Resident 12, Resident 44, Resident 54, Resident 205, Resident 2) Findings include: 1. During an observation and interview on 11/7/24 at 12:20 P.M., Resident 12 was lying in bed on a pressure reducing air mattress. The resident indicated they had a wound on her coccyx that developed in the facility. No signage was present indicating the resident was on EBP and no personal protective equipment (PPE) was observed inside or outside the resident's room. Resident 12's physician orders included but were not limited to, dressing change to coccyx: cleanse with wound cleanser, pat dry. Pack with 1/4 packing strip moistened with NaCl (sodium chloride), cover with bordered gauze dressing. Initial and date, every day shift for wound care, and as needed for soiled or dislodged dressing (started 11/1/24). No orders for EBP were found in the resident's record. A lab results report dated 11/12/24 at 8:18 A.M. included results for Resident 12's wound culture that indicated the wound was positive for MRSA (Methicillin-resistant Staphylcoccus aureus bacteria). During an observation and interview 11/12/24 at 11:40 A.M., RN 11 was providing Resident 12's wound treatment and completing a weekly wound assessment. A sign indicated that the resident was on enhanced barrier precautions and a bin of PPE was located outside the resident's room. RN 11 indicated that Resident 12's wound has recently been cultured and tested positive for MRSA. 2. During an observation on 11/7/24 at 9:21 A.M., Resident 44 was lying in bed. The resident had a trapeze bar hanging over the bed for positioning and the resident appeared to be a bilateral lower leg amputee. The resident had no signage that indicated the resident was on EBP and no PPE was located inside or outside the resident's room. Resident 44's physician orders included, but were not limited to, dressing change - Right above knee amputation site: Leave steri-strips in place, allow to fall off naturally. Cleanse with wound cleanser, pat dry. Cover with 4x10 bordered gauze dressing. Initial and date every day shift every other day for surgical incision AND as needed for soiled or dislodged dressing (started 11/12/24), change tunneling dual lumen PICC (peripherally inserted central catheter dressing on right chest weekly (started 11/10/24), Vancomycin HCl (hydrochloric acid) Intravenous Solution 1000 MG (milligrams)/10 ML (milliliters) (Vancomycin HCl). Use 1 gram intravenously one time a day for infection with the incision (started 11/4/24). A nurse's progress note dated 11/11/24 at 2:41 A.M., indicated, Infection Note - Resident continues on Vancomycin and Cefepime for infection. Tolerates well without adverse reactions. Resident is afebrile and taking probiotic as ordered. No signs or symptoms of infection to incisions and no drainage or issues with right hip at this time. Right Subclavian continue to flush in both ports without resistance and remains patent. Dressing change to Subclavian site done as ordered and per protocol and resident tolerated well. No redness or drainage or issues. 46416 3. On 11/13/24 7:48 A.M., Qualified Medication Aide (QMA) 10 was observed preparing medications for Resident 54. When she was dumping the pills into the medication cup from the packet containing multiple medications, the Ezetimebe 10 mg (Milligram) tablet fell on to the medication cart. QMA 10 picked up the pill with her bare hand and placed it into the medication cup with the other pills and then administered them to the resident. 4. On 11/12/24 at 10:35 A.M., the completed Facility Matrix was reviewed and indicated Resident 205 had a gastrostomy tube (gtube-a small, flexible tube surgically inserted through the abdomen and into the stomach used to provide nutrition). On 11/13/24 at 10:46 A.M., Licensed Practical Nurse (LPN) 9 was observed changing the dressing of Resident 205's gtube wearing gloves but not a gown. There was no signage for EBP in Resident 205's room. On 11/12/24 at 3:14 P.M. , Resident 205's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and gastrostomy placement. Resident 205 was admitted (with the gtube) to the facility on [DATE]. The Admission MDS (Minimum Data Set) assessment was still in progress. Resident 205's clinical record lacked a Physician's Order and Care Plan for the resident to be on EBP. 5. On 11/12/24 at 10:35 A.M., the completed Facility Matrix was reviewed and indicated Resident 2 had an indwelling urinary catheter and an unstageable pressure ulcer. On 11/08/24 at 1:20 P.M., Resident 2 was observed sitting up in a wheelchair in his room eating lunch, Foley covered hanging on wheelchair. There was no signage for EBP in Resident 2's room. On 11/8/24 at 2:19 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur and neuromuscular dysfunction of bladder. Resident 2 was readmitted from the hospital on 10/31/24 after fracturing his left femur and returned with the Foley. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 10/10/24 indicated Resident 2 had moderate cognitive impairment, was independent in bed mobility, partial/moderate assistance for toilet use and supervision for transfers, had no skin issues and no Foley catheter. Resident 2's clinical record lacked a Physician's Order and Care Plan for the resident to be on EBP. During an interview on 11/13/24 at 11:18 A.M., LPN 9 indicated she was not aware of EBP and nursing staff would only wear gloves while changing dressings or providing care for urinary catheters. At that time, she indicated she was the nurse for all residents and she did not have any residents on EBP currently. During an interview on 11/14/24 at 8:55 A.M., the Infection Preventionist (IP) indicated the facility was not aware of EBP needed to be in place for providing high contact care to residents with open wounds and indwelling devices. At that time, she indicated staff was not in serviced on EBP prior to the survey. If staff passing medications would drop a medication on the medication cart,. she would expect the medication to be discarded and replaced. Staff should not touch medications with bare hands. On 11/14/24 at 10:44 A.M., a current non dated Administering Medications Policy was provided by the MDS Coordinator and indicated . Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications . On 11/14/25 at 10:44 A.M., a current non dated Enhanced Barrier Precautions Policy was provided by the MDS Coordinator and indicated Enhanced barrier precautions are utilized to prevent the spread of multi-drug resistant organisms to residents . EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply . examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc) and wound care (any skin opening requiring a dressing) . 3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 1 resident admitted on hospice. One resident failed to have orders for hospice and oxygen. (Resident 204) Finding includes: On 11/12/24 at 9:41 A.M., Resident 204 was observed lying on a mattress on floor with a brief on and covered with sheet with O2 (oxygen) on at 2 lpm (liters per minute) per nasal cannula. On 11/12/24 at 10:26 A.M., Resident 204's clinical records were reviewed. Resident 204 was admitted on [DATE]. Diagnosis included, but were not limited to liver cell carcinoma, abdominal pain, chronic obstructive pulmonary disease, and hypertension. The Admission MDS (Minimum Data Set) assessment was still in progress. Physician orders included, but were not limited to, the following: haloperidol lactate Concentrate 2 MG/ML (milligram/milliliter) (anxiety medication) Give 2 mg by mouth every 4 hours for Restlessness, dated 11/10/2024 lorazepam Oral Tablet (anxiety medication) 1 MG Give 1 tablet by mouth every 2 hours as needed for Anxiety/Restlessness, dated 11/06/2024 lorazepam Oral Tablet 1 MG Give 1 tablet by mouth three times a day for Anxiety/Restlessness, dated 11/06/2024 Morphine Sulfate (Concentrate) Oral Solution (pain medication) 100 MG (milligram)/5ML (milliliter) Give 0.5 ml by mouth every 30 minutes as needed for pain or SOB (shortness of breath), dated 11/03/2024 oxycodone HCl (hydrochloride) (pain medication) Oral Tablet 30 MG Give 1 tablet by mouth every 6 hours for end of life comfort related to liver cell carcinoma, dated 11/05/2024 Physician orders lacked an order for hospice and oxygen. Current Care Plans include, but not limited to, the following: Resident is currently on hospice care and exhibits restlessness, agitation, and chronic confusion, alongside short-term memory loss and disorientation. Due to cognitive and physical limitations, resident requires 1:1 supervision and frequent cues at this time. Resident is experiencing ongoing pain, which exacerbates agitation and restlessness. Staff will focus on providing calming sensory activities, supportive interactions, and gentle reorientation to create a safe, low-stimulation environment that reduces agitation and promotes comfort, dated 11/6/2024. Admission Progress Note from 10/30/24 indicated O2 98.0 % - 10/30/2024 8:58 A.M. Method: Oxygen via Nasal Cannula .Respiratory: No signs of difficulty breathing. Shortness of breath noted. Resident reported Shortness of breath (upon exertion). Nurse observed Shortness of breath (upon exertion). Lung issue #001: New Location: Right: Anterior Upper Lobe Rhonchi on auscultation. Lung sounds present on exhalation. Lung sounds present on inhalation.#002: New Location: Left: Anterior Upper Lobe Wheezes on auscultation. Diminished on auscultation. Lung sounds present on exhalation.#003: New Location: Left: Posterior Upper Lobe Wheezes on auscultation. Diminished on auscultation. Lung sounds present on exhalation.#004: New Location: Right: Posterior Upper Lobe Rhonchi on auscultation. Lung sounds present on exhalation. Lung sounds present on inhalation.#005: New Location: Right: Anterior Middle Lobe Wheezes on auscultation. Diminished on auscultation. Lung sounds present on exhalation. Lung sounds present on inhalation.#006: New Location: Left: Anterior Lower Lobe Diminished on auscultation. Lung sounds present on inhalation. Lung sounds present on exhalation.#007: New Location: Left: Posterior Lower Lobe Diminished on auscultation.#008: New Location: Right: Posterior Middle Lobe Diminished on auscultation.#009: New Location: Right: Anterior Lower Lobe Diminished on auscultation.#010: New Location: Right: Posterior Lower Lobe Diminished on auscultation. Humidification: Yes. Oxygen via nasal cannula. Cough present. Moist/loose non-productive cough noted. Cough with effective airway: Yes.Cough with retained secretions: Yes. Pain related to coughing: No .Comfort concerns - note: on hospice pain management not controlled yet . During an interview on 11/13/24 at 10:29 A.M., the MDS (Minimum Data Set) Coordinator indicated Resident 204 should have physician orders for hospice and oxygen. On 11/14/24 at 10:43 A.M., the MDS Coordinator provided an undated Physician Services policy which indicated .2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician . 3.1-30(a)

Based on record review and interview, the facility failed to ensure the comprehensive assessment was completed within 14 days after admission for 1 of 5 residents reviewed that were admitted in the last 30 days. A resident admitted on [DATE] did not have a comprehensive assessment completed within 14 days of admission. (Resident 205) Finding includes: On 11/12/24 at 3:14 P.M., Resident 205's clinical records were reviewed. Resident 205 was admitted on [DATE]. Diagnosis included, but were not limited to, unspecified dementia, aphasia, depression, and gastrostomy status. The admission MDS (Minimum Data Set) assessment, dated 10/24/24, was still in progress. The admission MDS assessment should have been completed on 11/7/24. During an interview on 11/13/24 at 10:29 A.M., the MDS Coordinator indicated she had two weeks to complete the admission MDS assessment. On 11/14/24 at 10:44 A.M., the MDS Coordinator provided an undated MDS Completion and Submission Timeframes Policy, which indicated 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' (Centers for Medicare and Medicaid Services) QIES (Quality Improvement and Evaluation System) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . 3.1-31(d)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident specific plan of care was developed for 2 of 14 resident care plans reviewed. A dependent resident was not care planned for ADL's (Activities of Daily Living) and a resident at nutritional risk was not care planned timely following an unplanned significant weight loss. (Resident 25, Resident 44) Findings include: 1. During record review on 11/8/24 at 2:00 P.M., Resident 25 diagnoses included, but was not limited to, bi-polar disorder, anxiety, and major depression. Resident 25's most recent Quarterly MDS (Minimum Data Set) assessment, dated 10/12/24, indicated that the resident had a weight loss while not on a prescribed weight loss regimen. A nutritional assessment dated [DATE] indicated the resident was high risk. Resident 25's documented monthly weights indicated the resident experienced a significant weight loss of greater than 10 % from 3/7/24 weighing 170.9 pounds (lbs) to 146.2 lbs on 3/27/24. Resident 25's care plan included, but was not limited to, resident has potential for nutritional problem, initiated 8/30/24. No other nutritional care plans were created following the nutritional assessment on 10/19/23 or following the significant weight loss on 3/27/24. 2. During an observation on 11/7/24 at 9:21 A.M., Resident 44 was lying in bed. The resident had a trapeze bar hanging over the bed for positioning and the resident appeared to be a bilateral lower leg amputee. During record review on 11/12/24 at 11:39 A.M., Resident 44's diagnoses included but were not limited to, muscle wasting and atrophy, acquired absence of left leg above knee, pain in right shoulder, impingement syndrome in right shoulder, and obesity. Resident 44's most recent Quarterly MDS assessment, dated 9/13/24, indicated the resident had 1 sided lower extremity impairment, used a wheelchair for mobility, required substantial assistance from staff for toileting and rolling side to side, and was totally dependent on staff for toileting, bathing, changing position from lying to sitting, and for all transfers. Resident 44's care plan included, but was not limited to, resident has an amputation of left above the knee and right below the knee due to diabetes. Interventions included, change position frequently and physical therapy and occupational therapy to evaluate and treat as ordered. No other care plans addressed the resident's need for assistance to complete ADL's. During an interview on 11/13/24 at 2:20 P.M., the MDS nurse indicated that a resident with significant weight loss should have a care plan developed addressing the weight loss, and that a resident who is dependent on staff for completing ADL's should have a care plan addressing the need for assistance for those ADL's. On 11/14/24 at 10:44 A.M., the MDS nurse provided an undated facility policy titled, Care Plans, Comprehensive Person-Centered. The policy indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change . 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to revise care plans and follow interventions to reduce the risk of falls for 2 of 4 residents reviewed for accidents. This deficient practice resulted in a fall with fractures requiring hospitalization and a fall with a closed head injury requiring hospitalization . (Resident M, Resident P). Findings include: 1. On 9/19/23 at 1:13 P.M., Resident M's clinical record was reviewed. Resident was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease, Major Depressive Disorder, and Diabetes Mellitus. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 5/14/23, indicated Resident M had severe cognitive impairment, required extensive assistance of 2 or more staff for bed mobility and transfers and a total assistance of 2 or more staff for toileting and bathing, and had no falls since the prior MDS assessment on 4/5/23. Current physician orders included, but was not limited to: Low bed at all times while in bed and not receiving care, dated 8/31/23. Toe touch weight bearing on the left side, dated 8/25/23. Maintain Post total hip precautions for L (left) hip arthroplasty, dated 5/25/23. A current falls care plan, revised 7/17/23, indicated Resident M was at risk for falls due to a history of a wedge compression fracture and included the interventions: Staff to ensure resident using walker at all times while ambulating, dated 11/11/22. Relocate closer to Nurse's station when out of isolation, dated 4/4/23. Assistive device front wheeled rolling walker, dated 11/21/22. Encourage and educate resident on using the call light when needing assistance. Clip call light to shirt for visual reminder when in chair or bed in room, dated 11/21/22. Low bed, dated 8/30/23. Non skid footwear at all times, dated 11/21/22. Non skid strips left side of bed, dated 7/18/23. Therapy as ordered, dated 11/21/22. Transfer assist with 1 staff assist, gait belt and walker at all times, dated 11/21/22. The clinical record indicated Resident M had fallen 5 times since admission. On 11/10/22 at 4:15 A.M., Resident M sustained an unwitnessed fall while attempting to ambulate to the bathroom. The intervention staff to ensure resident using walker at all times while ambulating was added to the care plan. On 11/21/22 the following interventions were added: assistive device front wheeled rolling walker, Encourage and educate resident on using the call light when needing assistance. Clip call light to shirt for visual reminder when in chair or bed in room, non-skid footwear at all times, Therapy as ordered, and transfer assist with one staff member, gait belt and walker at all times. On 4/3/23 at 1:00 P.M., Resident M sustained an unwitnessed fall. At that time, the resident was in isolation for COVID-19. The resident was unable to recall what happened and was sent to the ER (emergency room ) for treatment and evaluation. The intervention relocate closer to nurse's station when out of isolation was added to the care plan on 4/4/23. A progress note, dated 5/16/23, indicated that Resident M had been complaining of left hip pain especially when in therapy and was ordered to get a left hip x-ray. A progress note, dated 5/17/23, indicated the x-ray showed an old femoral neck fracture with moderate displacement and bone resorption without callus formation. The resident was sent to the hospital. A progress note, dated 5/18/23, indicated the resident was scheduled for hip surgery. Resident M was readmitted to the facility on [DATE]. On 6/28/23 at 4:15 P.M., Resident M sustained a witnessed fall while attempting to stand up unassisted from the bed. The fall was witnessed by maintenance staff. The resident hit his head on his bedside table and complained of left hip pain. The resident was sent to the ER. The intervention non skid strips left side of bed was added to the care plan on 7/18/23. A progress note, dated 6/28/23 at 6:04 P.M., indicated the resident would be admitted to the hospital with a fracture to his left femur and would require surgery. Resident M was readmitted to the facility on [DATE]. On 8/22/23 at 8:30 P.M., Resident M sustained a witnessed fall. Staff observed the resident sliding from the bed onto the floor landing on his buttocks, but was unable to reach the resident in time to stop the fall. The care plan was not updated with an intervention. The clinical record lacked documentation of an IDT (interdisciplinary team) meeting. Fall Documentation, dated 8/23/23, indicated the resident needed a low to the floor bed. On 8/25/23 at 2:45 A.M., Resident M sustained an unwitnessed fall while attempting to get out of bed. Resident was observed sitting on the floor with both legs out in front of him. At that time, he complained of left hip pain, the left leg appeared to be longer than the right leg and was rotated inward, and resident was unable to move his left leg. The resident was sent to the ER. The intervention low bed was added to the care plan. The clinical record lacked documentation of an IDT meeting. The low bed was added to the care plan on 8/30/23. A progress note, dated 8/25/23, indicated Resident M had a left hip fracture that would be repaired nonsurgically. Orders were given to get repeat films in 2 weeks, monitor pain relief at the facility, and to be toe touch weight bearing on the left side. On 9/18/23 at 10:05 A.M., Resident M was observed lying in bed. The bed was raised. There was a sign next to the bed that indicated Put my bed back in lowest position before you leave! Thank you!. There were no skid strips next to the bed. On 9/20/23 at 8:35 A.M., the resident was observed sitting in his recliner in his room. There were no skid strips next to the bed, no walker in the room, and the call light was wrapped around the bed side rail. On 9/20/23 at 10:52 A.M., OT (occupational therapist) 27 and PT (physical therapist) 19 indicated that Resident M came off of toe touch weight bearing orders last week and was now full weight bearing for transfers. They indicated that the resident used a walker previously, but had not used a walker for a while now. On 9/20/23 at 3:22 P.M., Resident M was observed lying in bed. The bed was raised. At that time, the DON (Director of Nursing) indicated the bed was not in its lowest position and it should be. On 9/21/23 at 9:18 A.M., QMA (Qualified Medication Aide) 2 indicated fall interventions for Resident M were a low bed, assistance of 2 staff for transfers using a gait belt, and skid strips next to the bed. At that time, QMA 2 indicated the skid strips were not there. On 9/21/23 at 9:23 A.M., CNA (Certified Nurses Aide) 7 indicated she was not sure what fall interventions were in place for Resident M. On 9/21/23 at 2:52 P.M., Resident M was observed lying in bed. The bed was raised. At that time, the DON indicated the bed was not in the lowest position and should be. She indicated that all staff were gathered earlier that morning and inserviced about Resident M's bed being in the lowest position. 38770 2. On 9/19/23 at 2:16 P.M., Resident P's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and non-traumatic brain dysfunction. admitted was 10/11/22. The most recent quarterly MDS Assessment, dated 7/13/23, indicated a severe cognitive impairment. Resident P required extensive assistance of two staff with bed mobility, transfers, eating, and toileting, and was totally dependent of two staff for bathing. Resident P had experienced one fall with injury since the previous assessment. A falls risk assessment, dated 10/12/22 indicated a moderate fall risk on admission. Current physician orders included, but were not limited to, the following: pommel cushion for positioning, dated 3/21/23. A current risk for falls care plan, dated 10/12/22, included, but were not limited to, the following interventions: Fall mat placed at bedside, dated 6/14/23. If resident is in a stationary chair, keep wheelchair out from resident reach/vision to prevent resident from attempting to transfer without assistance, dated 11/4/22. Non skid footwear at all times, dated 10/12/22. Fall incident reports since admission included the following falls: Fall 1 11/4/22 at 12:10 P.M. Fall was witnessed. Resident stood up from a chair, pushed her wheelchair over, and sat on the floor. She did not hit her head. The new intervention at that time was to move wheelchair out of reach, and the care plan was updated. Fall 2 12/4/22 at 12:15 P.M. Fall was not witnessed by staff. Resident stood from wheelchair attempting to get into bed and fell per roommate, resulting in a facial laceration. First aid applied, and resident was sent to the emergency room (ER). At the ER, a CT of cervical spine without contrast and CT of the head without contrast were both negative for injury. The following day, 12/5/22, the Interdisciplinary Team (IDT) reviewed the fall and agreed that an appropriate intervention following the fall was a pad alarm at all time. The falls care plan was not updated with a new intervention. Fall 3 12/29/22 at 7:30 A.M. Fall was not witnessed. Resident fell while ambulating in her room, and hit back of head. Resident was sent to the ER, where she fell again. Resident received three staples to a laceration on the back of head, and a CT was negative. Upon return from the ER, and alert note dated 12/29/23 indicated a new intervention for a self release alarm belt. The falls care plan was updated. Staples were removed 1/13/23. Fall 4 1/16/23 at 11:35 P.M. Fall was not witnessed. Resident was found with neck cocked to the left side against the wall with blood on the wall. The resident was pale and with loss of consciousness, as she was staring with eyes deviated up not blinking or moving. When assessed, pupils were slightly unequal. The roommate indicated the resident had gotten up to walk and tried to grab the wheelchair and fell . Resident regained consciousness after about a minute, and was sent to the ER, where she received three staples to the back of the head (in a different area than the previous fall). Prior to the fall, an alert note dated 1/15/23 indicated resident got up out of bed and ambulated in the hall, she is placed in her wheelchair, she is making repeated attempts to ambulate on her own, her gait is too unsteady for this, she is toileted given tylenol and put back to bed, no further attempts to ambulate on her own, bed alarm in place. The falls care plan was not updated with a new intervention. Staples were removed on 1/27/23. Fall 5 6/13/23 at 3:30 P.M. Fall was not witnessed. Resident was found on the floor with a large hematoma on the left side of the forehead and dilated pupils. Resident was alert to staff, and blood pressure was elevated at 206/93. Resident was sent to the ER and returned same day. An alert note dated 6/13/23 at 8:04 P.M. indicated Resident received back from hospital with a diagnosis of closed head injury and scalp hematoma, hematoma and bruising noted on the left forehead and a dressing noted on the left elbow . Prior to the fall, on 6/13/23 at 1:35 P.M., an alert note indicated resident noted to be trying to exit the foot of her bed, this resident returned to the correct position per 1, bed in low position and her mat in place. Care plan was updated on 6/14/23 for fall mat at bedside. Progress notes included, but were not limited to, the following: 10/22/22 at 12:39 P.M. Admission . While in ER(9/26)fell and hit head causing a hematoma on scalp . 1/17/23 at 2:39 P.M. Res [resident] is lethargic and unable to stand w/o [without] max assist of 2 . 1/30/23 at 1:26 P.M CNAs' reported concern to this RN about residents L [left] facial droop. Resident was laying asleep on her left side in recliner with pull tab alarm on, after receiving morning medication. When resident awoke CNAs took resident to dining room to eat. CNAs statedresident [sic] had L flaccid arm and not making eye contact. Upon RN assessment resident sitting in w/c [wheelchair] leaning to left, but this position not abnormal for resident, neither is residents L facial droop. RN walked behind residents left side, she turned andlooked [sic]. Walked to residents' right side, she turned and looked . RN does not see any indication to send resident to hospital at this time 1/30/23 at 3:37 P.M. Nurse Practioner visit indicated no new orders 2/13/23 at 6:46 A.M. this resident is sitting on the floor at this time. The clinical record lacked any other information related to the fall. 3/6/23 at 12:09 P.M. Resident has slid out of w/c twice in front of nurses. Did not hit head, no injuries. [psych services] called for recommendation. The clinical record lacked any other information related to the fall. 3/6/23 at 12:45 P.M. OK to increase Klonipin [sic] [an anti-anxiety medication] to 0.5mg TID [three times a day] 3/14/23 at 10:42 A.M. HOLD [medication orders] PER LPN/resident lethargic 3/18/23 at 1:48 P.M. HOLD this noon clonazepam [an anti-anxiety medication] per LPN d/t sleeping, lethargy 6/15/23 at 9:57 A.M. Therapy came to RN and expressed concern that resident is lethargic. Asleep in the chair with head lying R [right] side. Resps [respirations] 17 even/ unlabored. Resident arouses to stimuli, moves all extremities. Hematoma to L eye unchanged, scabbed over . Continue to monitor 6/30/23 at 12:21 P.M. resident was in bed lying on back and vomitted [sic] small amount. lungs sounded wet upper anterior and diminished throughout posteriorly. when turned to listen she coughed pretty forcefully clearing some. resident was gotten up in chair. reported that resident had vomited couple times past few days. went and listened to resident again and upper airway has cleared some. she is in no distress. abdomen is soft but bowel sounds are diminished. texted [Nurse Practitioner] all the above. awaiting further instructions 6/30/23 at 2:02 P.M. [Nurse Practitioner] here to see resident. resident looks better. lungs fairly clear diminished posteriorly. BS hypoactive. she is in no distress. no new orders at this time. resident in bed with head of bed elevated 7/5/23 at 2:52 P.M. follow stroke protocol and send to ER for CT scan of brain. Sedating meds held at lunch. Sent to ER . 7/6/23 at 6:02 P.M. Res admitted with Pneumonia. Will continue to follow up 7/8/23 at 5:00 P.M. resident returned from the hospital per transport and is in a wheelchair at this moment, resident transferred per 1 without difficulty, this resident has a fixed glaze at this time and her pupils do not react to light, facial features are not bilateral, adrooping [sic] noted on the left side of her mouth, an MRI in hospital showed negative for stroke [two days prior], bruising noted on her right wrist and left top of her hand, red sacrum covered with a mepilex at this time, 127/69,P80, T98, R16,02 sat is 93%, resident is in bed on her left side and the bed is in low position, call bell at bedside although resident never utilizes it, no attempts to get out of bed, she is trying to sleep 7/8/23 at 7:32 P.M. after 2 attempts made to feed this resident but still not waking up, will try snacks later if she wakes up, in bed in low position, no attempts made to get out on own 7/10/23 at 10:22 A.M. Res has been noted to pocket food at meals. Oral care after meals has Un swallowed food. Res is having difficulty swallowing since return from hospital. left side of face has droop and res tends to lean to left side. Will report to Speech therapist and have evaluated. Will monitor 7/14/23 at 5:48 P.M. I spoke with [POA] and stated that [resident] is declining and could benefit from a hospice evaluation, [POA] approved completely that we could implement hospice, hospice will be notified . 8/5/23 at 6:08 P.M. Resident has appeared restless throughout this shift more so after 12p, fidgeting around while in w/c causing chair alarm to sound, as well as while in bed, had to be assisted from fall mat in bdrm [bedroom] back into bed multiple x's [times] after 1200 On 9/20/23 at 8:38 A.M., Resident P was observed sitting in a high back wheelchair in the common area with an alarm box hanging from the back of it and clipped to the collar of her shirt. The back of the wheelchair was observed with the left anti-tipper facing down and engaged, and the right was facing up. Resident P was observed to rock back and forth in the wheelchair. On 9/21/23 at 1:33 P.M., Resident P was observed during the survey on the floor between the bed and a mat on buttocks wearing incontinence brief and no pants. The fall mat was observed 1-2 feet from the bed. Resident P was observed grimacing and moaning. The sock on the left foot was hanging halfway off. Staff was notified and assisted the resident back into the bed. Once back in the bed, Resident P was observed to move around a lot. On 9/21/23 at 2:19 P.M., the Director of Nursing (DON) indicated Resident P had been care planned to come off of the bed onto a mat, and because of that would not be considered a fall every time she rolled out of bed. At that time, Resident P's care plan were reviewed with the DON and she indicated that intervention had not been care planned as intended. On 9/22/23 at 9:25 A.M., Resident P was observed lying in bed. Resident P's wheelchair was observed beside the foot of the bed within sight of the resident. On 9/22/23 at 11:22 A.M., the DON indicated Resident P's wheelchair should be out of reach as well as out of sight while lying in the bed. On 9/25/23 at 9:26 A.M., Resident P was observed sitting in a high back wheelchair in the common area with no socks or shoes on. On 9/21/23 at 2:10 P.M., the DON indicated that, after a fall, the IDT meets and the care plan should be updated with a relevant intervention that is different than before. On 9/21/23 at 12:49 P.M., the Administrator provided a current non-dated Falls and Fall Risk policy that indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . a fall is defined as Unintentionally coming to rest on the ground, floor or other lower level . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . This Federal tag relates to complaint IN00417903. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident was free of unnecessary drugs, failed to ensure physician orders [REDACTED]. Resident A Findings include: On 9/2/16 at 9:25 A.M., the Administrator provided a list of residents, indicating those residents who were considered interviewable. Resident A was marked as interviewable. The clinical record of Resident A was reviewed on 9/2/16 at 10:55 A.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED].>170. A physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 7/11/16, indicated the resident scored a 14 out of 15 for cognition, with 15 indicating no memory impairment. Physician orders, dated 7/3/16, indicated, Discontinue [MEDICATION NAME]. A physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. The August MAR indicated [REDACTED]. The resident's blood pressure ranged from 128/70 to 141/70 on those dates. Nurses Notes included the following notations: 8/7/16 at 10:33 A.M.: Resident non-responsive. Unable to obtain Blood Pressure. Other vitals WNL (within normal limits) .On Call doctor paged, awaiting response. The resident was transferred to the hospital on [DATE] at 11:03 A.M., and was admitted to the hospital. A hospital history and physical, dated 8/7/16 at 6:03 P.M., indicated, The patient is a 87 y.o. female .who resides at the NH (nursing home). Was found this morning .minimally responsive with low blood pressure .Pt (patient) began to respond when legs were raised and initial BP (blood pressure) was documented 88/50 .Family thought patient was off all BP medications at the NH .Current Outpatient Prescriptions .[MEDICATION NAME] 0.2 mg .[MEDICATION NAME] 120 mg .Assessment/Plan: [MEDICAL CONDITIONS] - likely related to [MEDICAL CONDITION] (low blood pressure)/mild dehydration. Had similar episode few months ago. Will hold antihypertensives and hydrate On 9/2/16 at 11:45 A.M., during an interview with the Administrator, she indicated from what she understood, Resident A's daughter informed the previous DON that her mother was allergic to [MEDICATION NAME], and it was discontinued. She indicated she was unaware of a problem with the [MEDICATION NAME]. The Administrator indicated the previous DON or ADON incorrectly imported the discontinued medications into the August 2016 orders. On 9/6/16 at 10:40 A.M., Resident A was interviewed. Resident A indicated she was feeling okay now. She indicated she had been in the hospital approximately 1 month previous, because she got too much medicine. It knocked me out. On 9/6/16 at 1:45 P.M., the Administrator provided the current facility policy on Medication Administration, dated 1/27/16. The policy included, The facility will provide appropriate care and services to manage the resident's medication regimen to avoid unnecessary medications and minimize negative outcomes. The licensed nurse and/or QMA shall administer each resident's medications in accordance with the physician's orders [REDACTED]. This Federal tag relates to Complaint IN 286. 3.1-48(a)(1)