Every finding on record at Valley View Care and Rehabilitation

Based on record review and interviews with residents, staff, Psychiatric Provider and the Medical Director the facility failed to implement effective systems to prevent an accidental overdose. On 7/02/26, staff found Resident #1 in his room pale, sweating, and incoherent and observed crushed pills and white powder on his television stand. Staff administered Narcan (a nasal spray that rapidly reverses opioid overdose), and within two minutes Resident #1 was able to answer questions and assist with transfer to the Emergency Medical Services (EMS) stretcher. EMS transported Resident #1 to the local hospital where medical records documented diagnoses of acute encephalopathy (a sudden and severe loss of normal brain function, marked by confusion, extreme sleepiness, and changes in behavior), acute respiratory failure with hypoxia (a condition where the lungs cannot properly move oxygen into the blood) and acute renal failure (sudden drop in kidney function). The local hospital did not have nephrology (branch of medicine that deals with diagnosis and treatment of kidney diseases) services so Resident #1 was transferred to a hospital with nephrology services for further evaluation and treatment. He was readmitted to the facility on [DATE]. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included radiculopathy (caused by pinched or compressed nerves in the spine), spinal stenosis (a narrowing of the spaces within your spine that puts pressure on your spinal cord and nerves), chronic kidney disease and opioid dependence. Resident #1 was his own responsible party.Resident #1's Annual Minimum Data Set assessment dated [DATE] revealed he was cognitively intact, had no behaviors or rejection of care during the assessment period, and was coded for opioid use. He received scheduled pain medication and was frequently in pain but the pain did not affect his sleep or daily activities. Resident #1's care plan dated 4/23/26 showed a focus dated 9/08/21 that read in part Resident #1 had a behavior of hoarding his medications and now received medications in liquid form/crushed, and watch all medications being taken initiated on 9/08/21. The intervention was to watch all medications being taken.Review of Resident #1's medical record revealed a physician's order dated 4/06/21 that read watch pills being swallowed, staff to observe patient taking all meds and swallow (patient hoards otherwise) every day shift and every night shift for safety. The medical record showed two active orders for opioids: 3/16/26 Morphine Sulfate Oral Tablet 15 milligrams (MG) Give 1 tablet by mouth two times a day for Chronic Pain, and 4/16/26 Morphine Sulfate Extended Release (ER) Oral Tablet ER 30 MG (Give 1 tablet by mouth two times a day for chronic pain give with 15mg tab. During an interview on 7/15/26 at 1:20 PM Nurse Aide (NA) #2 revealed she entered Resident #1's room on 7/02/26 to collect his breakfast tray and observed him sitting in his wheelchair slumped over. Nurse Aide #2 reported she initially thought Resident #1 was sleeping but then observed feces on him. She recalled she asked Resident #1 if he was okay and he mumbled something and she was unable to understand. NA #2 stepped out of the room and asked NA #1 for help and the two of them assisted Resident #1 to the bathroom, but he remained slumped over and required additional assistance. Nurse Aide #2 stated the Director of Rehabilitation, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medication Aide #1 responded to assist with the situation. Nurse Aide #2 reported she observed pills on Resident #1's television stand and recalled there were three or four mushy looking pills, a small pile of white powder and a debit card. Nurse Aide #2 indicated she assisted staff with cleaning Resident #1 and transferring him to the stretcher for transport. Nurse Aide #2 revealed she had never observed pills in Resident #1's room before and had never seen him incoherent or disoriented. An interview on 7/15/26 at 12:13 PM with Nurse Aide #1 revealed NA #2 came to her around 9:00 AM on 7/02/26 and asked if Resident #1 had been having incontinence issues recently as he was in his room in his wheelchair and covered with feces. NA #1 indicated this was not normal for Resident #1 as he was able to get to the bathroom on his own, and she and NA #2 went into Resident #1's room. She reported Resident #1 was in his wheelchair by the window slumped over, and they took him to the bathroom and attempted to stand him up. NA #1 revealed Resident #1 was covered in sweat, mumbling and was unable to stand with their assistance. She left the room to get more staff assistance. The Director of Nursing, Assistant Director of Nursing (ADON) and the Director of Rehabilitation entered the room and NA #1 reported there were so many people assisting that she left and resumed resident care. While she was in the room, Nurse Aide #1 reported Nurse Aide #2 pointed out pills and an item resembling a debit card on the corner of Resident #1's television stand. Nurse Aide #1 observed approximately three pills that were chalky and mushy, and a smear of white powder approximately half the size of the debit card. Nurse Aide #1 stated Resident #1 had previously hoarded medications, but she had never seen Resident #1 in the condition he was in during this incident and had never observed loose pills in his room before.An interview on 7/15/26 at 1:43 PM with the Assistant Director of Nursing (ADON) revealed she was in a meeting when Nurse Aide #1 requested assistance with Resident #1. The ADON indicated she entered Resident #1's bathroom and he was slumped over in his wheelchair and was pale and sweaty. She reported Resident #1 responded to questions but his responses did not make sense. The ADON then observed three to four pills and white powder residue on Resident #1's television stand. She revealed the pills looked wet and mushy. She indicated she contacted the Medical Director and notified her of Resident #1's condition and the pills and powder she found in his room. The ADON reported the Medical Director instructed staff to send Resident #1 to the hospital for evaluation and treatment. The ADON explained she had previously administered medications to Resident #1 and monitored him to make sure he swallowed his pills. If she suspected he was attempting to pocket medication (retaining medications in the mouth) by moving his tongue, she reported she would ask him to open his mouth and he would sometimes become angry and refuse. On 7/15/26 at 4:31 PM a phone interview with Medication Aide #1 revealed she attempted to administer Resident #1's morning medications on 7/02/26 but Resident #1 was sitting in his wheelchair getting dressed. She reported Resident #1 told her to come back later, and she explained she did not return to administer the medications because staff responded to Resident #1's medical emergency before she had the opportunity to do so. Medication Aide #1 indicated she crushed and administered Resident #1's medication per physician's orders and that she had never observed Resident #1 pocket medications.A phone interview on 7/16/26 at 10:39 AM with Nurse #2 revealed she recalled Resident #1 getting angry about having staff watch him swallow his medications. She reported he had a history of attempting to pocket his medication so she would ask him to open his mouth which he would not do consistently for her. Nurse #2 indicated when he would open his mouth for her, she did not see any medications remaining in his mouth. She could not recall if she had reported this behavior to the provider. An interview on 7/16/26 at 2:08PM with Nurse #1 revealed she was aware of the order to observe Resident #1 taking his medication. She reported that she had never observed him attempt to pocket medication and that he opened his mouth whenever she asked, allowing her to confirm that he had swallowed his medication. Nurse #1 reported Resident #1's extended-release morphine tablet could not be crushed. An interview on 7/16/26 at 2:21 PM with Nurse #4 revealed she would watch Resident #1 swallow his medications and never observed signs of him trying to pocket his medication, such as coughing or gagging. She indicated she never suspected him of pocketing his medications. On 7/16/26 at 2:54 PM an interview with Nurse # 5 revealed she would stand and watch Resident #1 take his medication. She indicated he never moved his face around like he was trying to hide medications and she did not ask him to open his mouth to confirm he had swallowed his medication. Nurse #5 reported she had never suspected him of pocketing medication.During an interview on 7/15/26 at 11:27 AM Resident #1 revealed he had recently been hospitalized but did not wish to discuss the circumstances. He reported he had spoken with the Interim Administrator the previous day and stated any questions regarding the incident could be directed to the Interim Administrator. Resident #1 declined to discuss the incident or where he obtained the medications. He stated he was feeling much better and reported that chronic back pain related to a degenerative spine condition led to all this. Review of Resident #1's hospital records dated 7/02/26 showed he was diagnosed with acute encephalopathy, acute respiratory failure with hypoxia, and acute kidney injury. A urine screen was positive for opiates. He was intubated (a medical procedure in which a tube is placed into the windpipe to assist with breathing) on 7/02/26 to protect his airway and was maintained on minimal ventilator support before the tube was removed on 7/04/26. Resident #1 was monitored for renal function due to acute renal failure. His condition continued to improve, and he was stable for discharge on [DATE].An interview on 7/15/26 at 3:45 PM with the Medical Director revealed she had known Resident #1 for about three years and had never known him to attempt to pocket pills. She indicated Resident #1 had been very focused on his pain medications and would often ask for more to be prescribed. The Medical Director recalled receiving a call on 7/02/26 from the DON regarding Resident #1's altered mental status. She indicated she instructed the DON to observe Resident #1's pupils and if they were pinpoint to administer a dose of Narcan, which occurred. The Medical Director reported that Resident #1's pain management regimen underwent multiple adjustments, including crushed medications before transitioning him to extended-release morphine in an effort to manage his chronic pain. She stated she had referred Resident #1 to a pain management clinic, and that he initially agreed to the referral but later declined to attend.A follow-up interview on 7/16/26 at 10:29 AM with the Medical Director revealed that she was aware of a possible remote history of Resident #1 pocketing medications but she indicated that this had not been an ongoing concern since she had been seeing him. She reported that she had not been made aware any issues with Resident #1 attempting to pocket medication. On 7/16/26 at 1:15 PM an interview with the Psychiatric Provider revealed she followed Resident #1 for management of his psychiatric medications and saw him monthly. She indicated she discussed depression with Resident #1 and that he denied suicidal ideation. She reported Resident #1 expressed remorse for his actions, understood the seriousness of the event, and was thankful to have returned to the facility. She indicated she discussed opioid use, pain management, and medication tolerance with Resident #1 but did not manage his pain medications. On 7/15/26 at 4:07 PM an interview with the Director of Nursing (DON) revealed she was asked to assist in Resident #1's room the morning of 7/02/26. She called the Medical Director and was instructed to check Resident #1's pupils and administer Narcan if his pupils were pinpoint. The DON indicated Resident #1's pupils were pinpoint, she administered a dose of Narcan and within two minutes he was alert and able to answer questions coherently. She reported Resident #1 told her he wasn't trying to do anything to harm himself and that it works better this way. The DON revealed staff had been crushing his medication per physician order and mixing them in applesauce to administer.An follow-up interview conducted on 7/17/26 at 1:40 PM with the Director of Nursing (DON) revealed staff were expected to monitor residents to ensure medications were swallowed if there was a physician order to do so. She indicated staff had received education regarding identifying potential drug-seeking behaviors and were aware of signs to watch for and residents with orders for opioids had been identified as having a potential risk and had been care planned accordingly. An interview conducted on 7/17/26 at 1:52 PM with the Interim Administrator revealed that his first day at the facility was 7/06/26 and that he became aware of the incident involving Resident #1 that same day. He indicated he reviewed the documentation related to the incident and continued implementing the facility's plan of correction that was already in progress. The Interim Administrator reported he spoke with Resident #1 regarding the incident and Resident #1 relayed that he apologized for the incident and assured them he didn't mean to harm himself and he would not do anything like that again. The Interim Administrator revealed that he expected nurses and medication aides to follow physician orders, follow the facility's medication administration policies and procedures, and ensure residents swallowed their medications. He indicated staff were expected to remain with a resident until they verified the medication had been swallowed and to follow any additional physician orders related to medication administration. The Interim Administrator further reported that nursing staff were responsible for communicating any concerns regarding medication administration to the DON and/or Medical Director as appropriate.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to provide care in a safe manner when staff assisted a resident with muscle weakness, dementia, and was bedbound with incontinence care. The resident fell off the side of the bed onto the floor, was bleeding from her head, and immediately transferred to the hospital for treatment. A hospital x-ray (imaging test for body's internal structures) revealed Resident #3 had suffered a laceration to the left side of the scalp and neck fractures during the fall. Resident #3 received treatment at the hospital on 5/30/26 and was discharged back to the facility on 5/31/26. The deficient practice occurred for 1 of 3 residents for the prevention of accidents (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus, muscle weakness, bedbound, atrial fibrillation (irregular heart rhythm), osteoarthritis (deterioration of protective cartilage that cushions the end of bones), and dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was moderately cognitively impaired, had been assessed as being dependent on staff for all activities of daily living (ADL), transfers, mobility, and was always incontinent of bladder and bowel. Review of revised care plan dated 3/16/26 revealed Resident #3 required assistance with all activities of daily living related to history of right hip fracture on admission. Interventions included required maximum assistance from staff to complete tasks safely and encouraged Resident #3 to participate to the fullest extent possible with each interaction. Review of nursing progress note dated 5/30/25 written by Nurse #1 revealed she and Nurse Aide (NA) #1 were in Resident #3's room for incontinence care. Resident #3 was assisted with rolling onto her right side with NA #1 on one side and Nurse #1 on the other. Resident #3 suddenly rolled off the bed and into the floor face down. Nurse #1 immediately noted that there was blood coming from what appeared to be the side of Resident #3's head. Nurse #1 informed staff not to move resident, Emergency Medical Services (EMS) were called immediately, and Resident #3 was transported to the hospital. Resident #3 was at baseline when EMS arrived and remained conscious the entire time. Responsible person and physician were notified, and report was called in to the hospital nurse. An interview with Nurse #1 on 6/04/26 at 11:34 AM revealed she worked at the facility on 1st shift (7:00 AM to 7:00 PM), was scheduled to work on 5/30/26, and had been assigned to Resident #3. She stated earlier in her shift on 5/30/26, NA #1 had asked her if she would assist her with Resident #3's next incontinence care round so that she could assess a possible red area on Resident #3's bottom and see if it required any treatment or cream. Nurse #1 revealed around 6:40 PM was when NA #1 asked if she would assist her with Resident #3's incontinence care and assess the possible red area on her bottom. She stated NA #1 had gotten Resident #3's incontinent care supplies together prior to them entering the room and she had brought with her a medicated cream to apply if needed. She revealed Resident #3's bed was located by the window, and upon entering the room NA #1 positioned herself on the right side of the bed with her back towards the door and facing the window and Nurse #1 positioned herself on the left side of the bed with her back to the window and facing door. She stated that she informed Resident #3 about completing her incontinence care and assessing her bottom for any red areas and would apply some medicated cream if needed and Resident #3 agreed. Nurse #1 revealed NA #1 assisted with raising Resident #3's bed to waist level and while Resident #3 was lying on her back, NA #1 began cleaning Resident #3's front area. She stated after NA #1 was finished cleaning Resident #3's front area, they tucked her brief between the legs and rolled Resident #3 onto her right-side facing NA #1 so she could assess Resident #3's bottom. She revealed as she reached to pull Resident #3's brief down in the back she observed that Resident #3 was using the bathroom, so she pulled the back of her brief up to allow her time to finish. Nurse #1 stated that during this time Resident #3 remained rolled onto her right side and she and NA #1 remained standing on each side of her bed. She revealed about 2 minutes later she went to pull Resident #3's brief down in the back to see if she had finished and Resident #3 moved her left leg over her right and started to roll towards NA #1 and off the bed. She stated the incident happened so fast that she was trying to grab her from the other side of the bed, and she believed NA #1 also tried to catch her on her side of the bed, but she just fell so quickly neither of them were able to stop from her falling. Nurse #1 revealed she ran to the other side of the bed and saw that Resident #3 appeared to be bleeding from her head, so she instructed NA #1 not to touch her, ran to the door and yelled for help, and immediately called 911. She stated the Nurse Supervisor came into the room and she informed her not to touch or move Resident #3 that EMS was on their way, she stated Resident #3 remained conscious and at baseline during the incident and only complained of her head hurting. Nurse #1 revealed EMS responded quickly, assessed Resident #3, and transported her to the hospital. She stated she also contacted Resident #3's Responsible Party (RP) and the physician. She revealed Resident #3 returned to the facility the following day on 5/31/26 with scalp laceration that required 4 staples, neck fractures that required her to wear a C-collar for the next 12 weeks, and scheduled pain medications. A telephone interview with NA #1 on 6/04/26 at 2:13 PM revealed she had worked 1st shift (7:00 AM to 7:00 PM) at the facility for the past year and had been assigned to work with Resident #3 on 5/30/26. She stated earlier that day she had asked Nurse #1 if she would assist her with changing Resident #3 so that she could assess a possible red area that she had seen earlier on Resident #3's bottom. She revealed around 6:40 PM she had informed Nurse #1 that she was ready for Resident #3's incontinence care, collected all the incontinent care supplies they would need, and she and Nurse #1 entered into Resident #3's room to complete her incontinence care. NA #1 stated she was on the right side of the bed with her back towards the door and facing the window and Nurse #1 was on the left side of the bed facing the door with her back to the window. She revealed they spoke with Resident #3 and told her what they were about to do, raised her bed to waist level, and while Resident #3 was still lying on her back she pulled her brief down and cleaned her front area. She stated she and Nurse #1 rolled Resident #3 onto her right side facing her so Nurse #1 could clean her and assess her bottom but when Nurse #1 went to pull down Resident #3's brief down in the back she observed her using the bathroom so Nurse #1 pulled the brief back up and they waited for Resident #3 to finish. She revealed while they were waiting Resident #3 remained on her right side with her left leg on top of or behind her right leg and as Nurse #1 was going to pull down the back of Resident #3's brief to check if she was finished, Resident #3 moved her left leg over right leg and just started rolling towards her off the bed. NA #1 stated that it was an accident, she tried to stop her from falling but everything happened so fast and she just could not stop her from rolling onto the floor. She revealed Nurse #1 came around the bed and they both noticed that Resident #3 was bleeding from what appeared to be her head, but she was still talking. She stated Nurse #1 immediately yelled for help and instructed no one to touch or move Resident #3, called 911, and EMS came and transported her to the hospital. Review of hospital admission summary dated [DATE] revealed Resident #3 presented for evaluation after a fall out of bed. Resident #3 experienced a fall, laceration to left frontal scalp that was not actively bleeding on arrival, currently at mental status baseline, normal range of motion and neck supple, and had no other complaints. X-ray ordered for head, chest, abdomen, and pelvis to assess for any further injuries. Review of hospital Discharge summary dated [DATE] revealed Resident #3 was treated following a fall from her bed at her skilled nursing facility that resulted in trauma. On presentation, she was noted to have a 4-centimeter (cm) scalp laceration that had been repaired with staples. Initial evaluation included advanced imaging, which revealed nondisplaced fractures (broken or cracked bone that remain aligned in normal position) of the anterior (front ring of cervical vertebrae) and posterior arch (back portion of top vertebrae of spine) of C1 (topmost bone of neck) and a nondisplaced type III odontoid fracture (stable break at the base of the C2 vertebrae); x-ray of brain, chest, abdomen, and pelvis showed no acute injuries. Neurosurgery was consulted and recommended nonoperative management with a cervical collar (C-collar) to be worn 24 hours a day for 12 weeks, with outpatient follow-up. Resident #3 was deemed appropriate for return to her skilled nursing facility from a neurosurgical standpoint. Therapeutic interventions included maintenance of cervical spine precautions and pain management. Occupational therapy (OT) assessed her as total assist for ADL and functional mobility, consistent with her baseline, and signed off with no acute OT needs at discharge; her rehabilitation potential was poor, and she was bedbound at baseline. Review of nursing progress note dated 5/31/26 revealed Resident #3 would be returning to the facility with staples to laceration to left side of head, C1 anterior and posterior fracture, and Type III odontoid non-displaced fracture. Resident #3 must wear C-collar 24 hours a day for the next 12 weeks and follow up with neurologist in 3 to 4 weeks. Resident #3 returned from hospital via EMS with family at her side. C- collar was in place and Resident #3 was safely transferred to bed and positioned for comfort. Pain medication was administered, bed was in lowest position, and call- light within reach. A telephone interview with the Medical Director on 6/04/26 at 2:49 PM revealed she was familiar with Resident #3 and was made aware of her fall on 5/30/26. She stated she could not recall the exact details on Resident #3's fall just that she had rolled out of bed during incontinence care with 2 people, was sent out to the hospital immediately, and suffered a scalp laceration that required 4 staples and C1 and C2 fracture that required C-collar to be worn for 12 weeks. She revealed Resident #3 would follow-up with neurology in 3 weeks to assess her healing, 4 staples would be removed in-house, scheduled and as needed pain medications were prescribed, and they would continue to monitor her pain and adjust her medications as needed. The Medical Director stated that she had no concerns or issues regarding Resident #3's care or her fall, she believed the fall was truly an accident and that staff responded appropriately by immediately calling 911 and not moving or touching Resident #3 until EMS arrived. An interview with the Administrator on 6/04/36 at 4:19 PM revealed she was familiar with Resident #3 and her fall. She stated that she believed she received a message about the fall and Resident #3 being sent out either the evening of Saturday 5/30/26 or the following morning and then spoke with staff and Resident #3's family about it that Monday morning. She revealed to her knowledge the fall was an accident and occurred while staff were changing Resident #3 and she moved her legs and rolled off the bed before staff could stop her. The Administrator revealed staff immediately responded by calling 911 and not touching or moving Resident #3 until EMS arrived and transported her to the hospital. She stated she did feel this incident was an accident but that staff do need to make sure they are following all procedures when providing incontinence care to include making sure the correct number of staff are present, position of staff at bedside, making sure they have care supplies gathered prior to beginning care, and knowing how much assistance was required with each resident.

Based on record reviews and interviews with staff and Nurse Practitioner, the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for significant medication error (Resident #1). Medication Aide #1 administered Lyrica (a medication that treats nerve pain by calming overactive nerves in your body and can also treat epilepsy by preventing and managing seizures) to Resident #1 that was prescribed for Resident #2, and that Resident # 1 had a documented allergy to. Resident #1 had no significant adverse reaction related to being administered the Lyrica.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular disease and unspecified convulsions.Review of Resident #1's medical record revealed an allergy to Lyrica.Review of Resident #1's admission Minimum Data Set assessment dated [DATE] indicated the Resident was cognitively intact.Review of Resident #1's physician orders revealed orders for:- acetaminophen 500 milligrams (mg) by mouth at bedtime dated [DATE],- levetiracetam (anticonvulsant) 1000 mg by mouth twice a day dated [DATE],- atorvastatin (statin) 40 mg by mouth at bedtime dated [DATE],- melatonin (sedative) 3 mg by mouth for sleep dated [DATE],- metoprolol (antihypertensive) 25 mg by mouth every 12 hours dated [DATE],- cetirizine (antihistamine) 10 mg by mouth one time only for rash/swelling dated [DATE].Review of Resident #1's Medication Administration Record (MAR) for [DATE] revealed the Resident was administered acetaminophen, atorvastatin, melatonin and levetiracetam on [DATE] at 7:00 PM. The MAR indicated that metoprolol was held and the cetirizine was administered on [DATE] at 11:27 PM.Resident #2 was admitted to the facility on [DATE] with diagnoses that included polymyalgia rheumatica (an inflammatory disorder causing severe muscle pain and stiffness, predominantly in the shoulders, neck, and hips).Review of Resident #2's physician orders revealed an order for Lyrica 300 mg by mouth three times a day for pain dated [DATE].Review of Resident #2's Medication Administration Record for [DATE] revealed the Lyrica was documented as administered on [DATE] at 7:00 PM.Review of a Medication Variance Report dated [DATE] at 8:35 PM written by the Assistant Director of Nursing (ADON) indicated in part that Medication Aide (MA) #1 administered medications to Resident #1 who was in bed A that belonged to Resident #2 in bed B. Bed A was not labeled (on the door) and the room change had not yet been updated in the computer system. The MA stated she greeted Resident #1 by saying Resident #2's name and Resident #1 looked at her and responded appropriately. The medication was administered before the error was realized. Upon discovery, the medications that were administered to Resident #1 were reviewed thus noting that Resident #1 had an allergy to one of the medications (Lyrica). Resident #1's vital signs were taken every 15 minutes. The ADON notified the family and asked about prior reactions to Lyrica. The family stated that the Lyrica caused a rash and some swelling but had no difficulty breathing. The on-call physician service was notified about the medication error and the side effects reported by the family (for the Lyrica allergy). The physician gave instructions to administer cetirizine 10 mg one time and to monitor for any rash, swelling or other symptoms. The physician also gave orders to obtain vital signs every one hour for four hours and then every four hours for eight hours. The family was notified of the orders.Review of Resident #1's medical record revealed the vital signs documented on [DATE] and [DATE] were obtained as ordered and were within normal limits.An interview was conducted with Resident #1 on [DATE] at 9:10 AM who explained that she remembered being given her roommate's medication (could not name the medication) when she was moved to a different room. She stated she had taken the medication in the past and developed a rash and itching on her face. She stated she was sent to the emergency room but came back the same day and was not given any treatment to counteract the reaction. Resident #1 continued to explain that she did not develop a rash or itch, nor did she have a negative reaction from the medication.An interview was conducted with Medication Aide #1 on [DATE] at 12:20 PM. The MA explained that she reported to work on the evening shift on [DATE] and had started the medication pass. She stated the nurse instructed her to start with Resident #2 because the Resident stated she felt like she was going to have a seizure. When she got to Resident #2's room, there was only one name on the door, so she thought Resident #2 was the only resident in that room. The MA prepared Resident #2's medications that were due to be given at 7:00 PM and opened the door and saw Resident #1 in bed A. The curtain was pulled so she could not see bed B. She called Resident #2's name and Resident #1 looked at the MA and answered yes, so the MA gave Resident #2's medications to Resident #1. The MA continued to explain that Resident #1 asked her to raise the head of her bed and when she went to the foot of the bed and cranked the bed, she noticed that someone was lying in bed B (Resident #2). The MA stated she immediately went to the computer to see who was in bed B and discovered that it was Resident #2 by looking at the Resident's picture on the computer. The MA reported that she went to find the nurse and saw the ADON at the nursing desk and she reported that she made a medication error to the ADON, but she did not know who the resident was because the name was not on the door. The ADON happened to be on the phone with the Director of Nursing at the time who informed the ADON that they had moved Resident #1 temporarily into Resident #2's room because Resident #1's roommate had expired and it was going to be a while before the funeral home could pick her up. The MA stated that she and the ADON looked at Resident #1's medical record to see if she was allergic to any of the medications that were given to her and found that she was allergic to the narcotic (Lyrica). The ADON then called the on-call physician and the family to see what kind of reaction Resident #1 had to the medication and the family told her the Resident developed a rash. The ADON called the on-call physician back and informed them of what the family told her. The MA stated she did not know what other orders if any the on-call physician gave the ADON after that. The MA stated they watched Resident #1 closely throughout the night and obtained her vital signs numerous times and her vital signs were within normal limits. She reported that Resident #1 was sleepy but was easily aroused when they went into render care. The MA explained that she gave Resident #1 her due medications except her blood pressure medication (metoprolol). When asked why the MA made the medication error she stated she was in a hurry to give Resident #2 her medication to prevent a seizure and she felt that if Resident #1's name had been put on the door she would have recognized there were two residents in the room and made sure she identified the correct resident before she made the medication error. During an interview with the Assistant Director of Nursing on [DATE] at 11:00 AM, the ADON explained that she was working the evening shift on [DATE] when MA #1 came to the nursing desk and reported that she had just made a medication error. The MA explained that she had given Resident #2's medications to her roommate (Resident #1). There was only one name on the door which was Resident #2 and she prepared Resident #2's medication and gave it to Resident #1 who was in bed A. The ADON stated she was on the phone with the DON at the time and the DON informed her that they moved Resident #1 to Resident #2's room for a while because her roommate had died and it was going to be a while before the funeral home picked the resident up and Resident #1 did not want to stay in the room with the deceased resident. The ADON continued to explain that she went to see if Resident #1 was allergic to any of the medications that were given to her by mistake and discovered that she was allergic to Lyrica. She stated she assessed Resident #1 and took her vital signs which were in normal limits. She called the on-call physician and while she waited for the physician to return her call, she called the Resident's family to see what kind of reaction Resident #1 had to Lyrica. The family reported that she developed a facial rash. The ADON stated that by the time the physician called her back, Resident #1 reported she was having itching on her neck, but she did not have a rash. When the physician called back the ADON reported the medication error of giving Resident #1 the Lyrica for which she had an allergy to, and the physician gave her an order to administer a one-time dose of cetirizine 10 mg and to monitor her vital signs every hour for four hours and then every four hours for eight hours. She stated she had obtained vital signs more often than what she was told and monitored her throughout the night and she slept most of the night. The ADON also reported that she went over each medication with the physician that was given to Resident #1 in error and what the Resident's vital signs were, and the physician instructed her to give Resident #1 her due nighttime medications except for the antihypertensive (metoprolol) because the other medications could lower her blood pressure. The ADON stated she counseled the MA on the five rights of a safe medication administration and observed her administer more medications that night that included Resident #1's medications.An interview was conducted with Nurse #1 on [DATE] at 11:00 AM. The Nurse explained that she came on duty on [DATE] at 7:00 AM and received in report that Resident #1 had been given her roommate's medication which included Lyrica that she had a known allergy to. The Nurse stated she monitored Resident #1 throughout the shift and she was sleepy but easily aroused when she was spoken to. She stated the family was at the facility and wanted her to send her to the emergency room to evaluate her for the drowsiness, so she sent her to the emergency room.An interview was conducted with Nurse #2 on [DATE] at 2:45 PM who explained that she was on duty [DATE] at 12:10 AM and received a verbal report from the emergency room that Resident #1 would be coming back to the facility. The report included that they obtained labs and an electrocardiogram (EKG) and they were all within normal limits for Resident #1. There were no new orders for the Resident. The Nurse reported that Resident #1 slept throughout the night and had no rash or complaints of itching.An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 3:30 PM who explained that on [DATE] she was asked to visit Resident #1 because on [DATE] she had been given another resident's medications that included Lyrica and it was documented that she had an allergy to Lyrica which caused her have facial swelling and a rash. The staff called the on-call physician who gave orders to administer cetirizine and to hold Resident #1's blood pressure medication that night. The NP continued to explain that she was notified the next day that Resident #1 seemed lethargic, which did not surprise her. The family insisted on the Resident being sent to the emergency room. The NP reported she saw Resident #1 on [DATE] and reviewed the emergency room notes which showed normal complete blood counts, normal complete metabolic panel, normal urinalysis and no acute changes on the EKG and she was sent back to the facility. The NP stated when she saw Resident #1 on [DATE] she was awake and smiling and back to her usual self. She stated she would have held the melatonin which could attribute her lethargy but other than that she would have given the same orders as the on-call physician gave. The NP added that she considered the medication error to be significant but was grateful that the facility acted quickly to counteract the reaction of the Lyrica.The Director of Nursing was not available for interview.An interview was conducted with the Administrator on [DATE] at 4:00 PM who explained she was notified of the medication error the next morning on [DATE]. Resident #1 was closely monitored by the staff, but her family wanted her sent to the hospital, so the Director of Nursing called the physician and got an order to send her to the emergency room on [DATE]. The Administrator continued to explain that the decision to move Resident #1 temporarily was her decision because she did not want to be in the room with the deceased roommate. The Administrator stated she expected the MA to honor the five rights for safe medication administration and if she had, there would not have been a medication error made. The Administrator added that she did not discount that the medication error was not serious because it was.

Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.5% for 1 of 2 residents observed during the medication administration (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease with heart failure.Review of Resident #4's physician orders were orders for:- metolazone (diuretic used to treat fluid retention associated with heart failure) 2.5 milligrams (mg) by mouth one time a day for edema. Give 30 minutes before bumetanide, dated 03/13/26.- bumetanide 2 mg by mouth in the morning for edema. Give 30 minutes after metolazone is administered, dated 04/08/26.- fluticasone propionate suspension (corticosteroid used to treat seasonal allergies) one spray in each nostril twice a day for sinus congestion dated 04/13/26.Review of Resident #4's Medication Administration Record (MAR) for June 2026 revealed- metolazone (diuretic used to treat fluid retention associated with heart failure) 2.5 milligrams (mg) by mouth one time a day for edema. Give 30 minutes before bumetanide, dated 03/13/26.- bumetanide 2 mg by mouth in the morning for edema. Give 30 minutes after metolazone is administered, dated 04/08/26.- fluticasone propionate suspension (corticosteroid used to treat seasonal allergies) one spray in each nostril twice a day for sinus congestion dated 04/13/26.On 06/04/26 at 8:35 AM an observation was made of medication administration made by Medication Aide (MA) #2. The MA prepared Resident #4's medications which included fluticasone nasal spray, metolazone and bumetanide and took the medications into the Resident's room. The MA handed the cup of pills to Resident #4, and the Resident took the cup of pills. The MA handed the nasal spray to Resident #4 in which the Resident proceeded to spray two sprays into each nostril then handed the nasal spray back to the MA. The MA did not instruct the Resident on how many sprays to instill in each nostril.An interview was conducted with the Medication Aide on 06/04/26 at 2:30 PM. The MA was asked to review the medication cards for the metolazone and bumetanide and read the instructions of each medication then stated she did not pay close attention to the directions for the fluticasone nasal spray, metolazone and bumetanide and did not administer the fluticasone nasal spray, metolazone and bumetanide as ordered. The MA was asked how many nasal sprays were supposed to be administered to Resident #4 and she looked at the directions on the computer and stated, one spray. When the MA was asked how many sprays Resident #4 gave herself, she stated she did not know. The MA explained that she did not instruct the Resident on how many sprays to administer because the Resident was independent and administered the nasal sprays herself. She confirmed that she did not give the bumetanide and metolazone 30 minutes apart because she did not see the instructions on the medication card or physician order to administer the medications 30 minutes apart. During an interview with the Nurse Practitioner (NP) at 3:30 PM on 06/04/26. The NP explained that Resident #4 was prescribed both the metolazone and bumetanide because of her heart failure and when given 30 minutes apart the metolazone accentuates the bumetanide which enables the diuretics to be more effective to prevent edema when given as they were prescribed. If they were not administered as prescribed, then they will not work as well. The NP stated she expected the medications to be administered as ordered including the fluticasone nasal spray.The Director of Nursing was unavailable for interview.An interview was conducted with the Administrator on 06/04/26 at 5:00 PM who explained that she was surprised that MA #1 made the medication errors because she had been audited by the Assistant Director of Nursing and the pharmacist on past audits and always did well on her medication administration audits. Nevertheless, she expected the MA to honor the five rights of safe medication administration.

Based on record reviews, and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure medications were administered as prescribed by the physician when Medication Aide #1 administered medications to Resident #1 that were prescribed for Resident #2. The medications included doxepin (antidepressant), lamotrigine (anticonvulsant), folic acid (vitamin B9) and acetaminophen (analgesic). The deficient practice affected 1 of 3 residents reviewed for medication errors.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular disease, hypertension, hyperlipidemia and unspecified convulsions.Review of Resident #1's admission Minimum Data Set assessment dated [DATE] indicated the Resident was cognitively intact.Review of Resident #1's physician orders revealed orders for:- acetaminophen 500 milligrams (mg) by mouth at bedtime dated [DATE],- levetiracetam (anticonvulsant) 1000 mg by mouth twice a day dated [DATE],- atorvastatin (statin) 40 mg by mouth at bedtime dated [DATE],- melatonin (sedative) 3 mg by mouth for sleep dated [DATE],- metoprolol (antihypertensive) 25 mg by mouth every 12 hours dated [DATE],- cetirizine (antihistamine) 10 mg by mouth one time only for rash/swelling dated [DATE].Review of Resident #1's Medication Administration Record (MAR) for [DATE] revealed the Resident was administered acetaminophen, atorvastatin, melatonin and levetiracetam. The MAR indicated that metoprolol was held and the cetirizine was administered on [DATE] at 11:27 PM.Resident #2 was admitted to the facility on [DATE] with diagnoses that included epilepsy, insomnia, vitamin B deficiency and polymyalgia rheumatica.Review of Resident #2's physician orders revealed the following medications were to be administered at 7:00 PM- doxepin 25 mg by mouth at bedtime for sleep dated [DATE],- lamotrigine 300 mg by mouth twice a day for epilepsy dated [DATE],- folic acid 400 micrograms by mouth twice a day for vit B deficiency dated [DATE] and- acetaminophen 1000 mg by mouth four times a day for pain dated [DATE].Review of a Medication Variance Report dated [DATE] at 8:35 PM written by the Assistant Director of Nursing (ADON) indicated in part that Medication Aide (MA) #1 administered medications to Resident #1 who was in bed A that belonged to Resident #2 bed B. Bed A was not labeled (on the door) and the room change had not yet been updated in the computer system. The MA stated she greeted Resident #1 by saying Resident #2's name and Resident #1 looked at her and responded appropriately. The medications were administered before the error was realized. Resident #1's vital signs were taken every 15 minutes. The ADON notified the family, and the on-call physician service gave instructions to obtain vital signs every one hour for four hours and then every four hours for eight hours. The family was notified of the orders.Review of Resident #1's medical record revealed the vital signs documented on [DATE] and [DATE] were obtained as ordered and were within normal limits.An interview was conducted with Resident #1 on [DATE] at 9:10 AM who explained that she remembered being given her roommate's medications (could not name the medications) when she was moved to a different room. She stated she was sent to the emergency room but came back the same day and was not given any treatment. Resident #1 continued to explain that she did not have a negative reaction from the medications.An interview was conducted with Medication Aide #1 on [DATE] at 12:20 PM. The MA explained that she reported to work on the evening shift on [DATE] and had started the medication pass. She stated the nurse instructed her to start with Resident #2 because the Resident stated she felt like she was going to have a seizure. When she got to Resident #2's room, there was only one name on the door, so she thought Resident #2 was the only resident in that room. The MA prepared Resident #2's medications that were due to be given at 7:00 PM and opened the door and saw Resident #1 in bed A. The curtain was pulled so she could not see bed B. She called Resident #2's name in which Resident #1 looked at the MA and answered yes, so the MA gave Resident #2's medications to Resident #1. The MA continued to explain that Resident #1 asked her to raise the head of her bed and when she went to the foot of the bed and cranked the bed, she noticed that someone was lying in bed B (Resident #2). The MA stated she immediately went to the computer to see who was in bed B and discovered that it was Resident #2 by looking at the Resident's picture on the computer. The MA reported that she went to find the nurse and saw the ADON at the nursing desk and she reported that she made a medication error to the ADON, but she did not know who the resident was because the name was not on the door. The ADON happened to be on the phone with the Director of Nursing at the time who informed the ADON that they had moved Resident #1 temporarily into Resident #2's room because Resident #1's roommate had expired and it was going to be a while before the funeral home could pick her up. The MA stated that she and the ADON looked at Resident #2's medical record to identify which wrong medications had been given to Resident #1. The ADON then called the family and the on-call physician service to report the medication error, but she did not know what new orders were given to the ADON. The MA stated they watched Resident #1 closely throughout the night and obtained her vital signs numerous times and her vital signs were within normal limits. She reported that Resident #1 was sleepy but was easily aroused when they went into render care. The MA explained that she gave Resident #1 her due medications except her blood pressure medication (metoprolol). When asked why the MA made the medication error she stated she was in a hurry to give Resident #2 her medication to prevent a seizure and she felt that if Resident #1's name had been put on the door she would have recognized there were two residents in the room and made sure she identified the correct resident before she made the medication error.During an interview with the Assistant Director of Nursing on [DATE] at 11:00 AM, the ADON explained that she was working the evening shift on [DATE] when MA #1 came to the nursing desk and reported that she had just made a medication error. The MA explained that she had given Resident #2's medications to her roommate (Resident #1). There was only one name on the door which was Resident #2 and she prepared Resident #2's medications and gave them to Resident #1 who was in bed A. The ADON stated she was on the phone with the DON at the time and the DON informed her that they moved Resident #1 to Resident #2's room for a while because her roommate had died and it was going to be a while before the funeral home picked the resident up and Resident #1 did not want to stay in the room with the deceased resident. The ADON continued to explain that she assessed Resident #1 and called the on-call physician and while she waited for the physician to return her call, she called the Resident's family and reported the medication error. The ADON stated that when the physician called back, she reported the medication error of giving Resident #1 the doxepin, folic, acetaminophen and lamotrigine and the physician gave her an order to administer a one-time dose of cetirizine 10 mg and to monitor her vital signs every hour for four hours and then every four hours for eight hours. She stated she had obtained vital signs more often than what she was told and monitored her throughout the night and Resident #1 slept most of the night. The ADON also reported that she went over each medication with the physician that was given to Resident #1 in error and what the Resident's vital signs were, and the physician instructed her to give Resident #1 her due nighttime medications except for the antihypertensive (metoprolol) because the other medications could lower her blood pressure. The ADON stated she counseled the MA on the five rights of a safe medication administration and observed her administer more medications that night that included Resident #1's medications.An interview was conducted with Nurse #1 on [DATE] at 11:00 AM. The Nurse explained that she came on duty on [DATE] at 7:00 AM and received in report that Resident #1 had been given her roommate's medications. The Nurse stated she monitored Resident #1 throughout the shift and she was sleepy but easily aroused when she was spoken to. She stated the family was at the facility and wanted her to send her to the emergency room to evaluate her for the drowsiness, so she sent her to the emergency room.An interview was conducted with Nurse #2 on [DATE] at 2:45 PM who explained that she was on duty [DATE] at 12:10 AM and received a verbal report from the emergency room that Resident #1 would be coming back to the facility. The report included that they obtained labs and an electrocardiogram (EKG) and they were all within normal limits for Resident #1. There were no new orders for the Resident. The Nurse reported that Resident #1 slept throughout the night and had no complaints.An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 3:30 PM who explained that on [DATE] she was asked to visit Resident #1 because on [DATE] she had been given another resident's medications including lamotrigine, acetaminophen and doxepin. The staff called the on-call physician who gave orders to administer cetirizine and to hold Resident #1's blood pressure medication that night. The NP continued to explain that she was notified the next day that Resident #1 seemed lethargic which did not surprise her because the doxepin could be given for insomnia but her vital signs were stable. The family insisted on the Resident being sent to the emergency room. The NP reported she saw Resident #1 on [DATE] and reviewed the emergency room notes which showed normal complete blood counts, normal complete metabolic panel, normal urinalysis and no acute changes on the EKG and she was sent back to the facility. The NP stated when she saw Resident #1 on [DATE] she was awake and smiling and back to her usual self. She stated she would have held the melatonin which could attribute her lethargy but other than that she would have given the same orders as the on-call physician gave. The NP indicated the medication errors were not considered to be significant but unfortunate and was grateful that the facility acted quickly to counteract the reactions Resident #1 might could have had related being given the wrong medications.The Director of Nursing was not available for interview.An interview was conducted with the Administrator on [DATE] at 4:00 PM who explained she was notified of the medication error the next morning on [DATE]. Resident #1 was closely monitored by the staff, but her family wanted her sent to the hospital, so the Director of Nursing called the physician and got an order to send her to the emergency room on [DATE]. The Administrator continued to explain that the decision to move Resident #1 temporarily was her decision because she did not want to be in the room with the deceased roommate. She stated she expected the MA to honor the five rights for safe medication administration and if she had, there would not have been a medication error made. The Administrator added that she did not discount that the medication error was not serious because it was.

Based on observations and interviews, the facility failed to clean the circulatory fan covers in the walk-in refrigerator and failed to dispose of food stored for use with signs of spoilage in the facility's walk-in refrigerator. This was for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect food served to residents. Findings Included:a. On 4/27/26 at 10:51 AM an observation in the walk-in refrigerator found the two circulatory fan covers with a buildup of greyish, clumpy and crumbly to touch substance. The substance was covering the 2 fan covers and would move when the fans were running.b. On 4/27/26 at 10:54 AM an observation in the walk-in refrigerator found a box of whole cucumbers located on the top shelf of a food storage rack. The cucumbers in the box were observed with a thick layer of white and fuzzy in appearance substance that covered about 50 percent of the cucumbers. The outside of the box had a received date of 3/23 written on it. On 4/27/26 at 11:00 AM the Dietary Manager observed the walk-in refrigerator with the surveyor. The Dietary Manager observed the circulatory fan covers and the box of cucumbers. On 4/27/26 at 11:02 AM the Dietary Manager was interviewed and stated she was not aware the fan covers had a substance on them. She said the fans were not on a routine cleaning list, and she did not know the last time they had been cleaned. The Dietary Manager further stated the box of cucumbers had been overlooked, and she had not yet checked the walk-in refrigerator for expired food. She stated the refrigerators were checked daily by her, and by the cook on the weekends. The Administrator was interviewed on 4/30/26 at 3:10 PM. She stated the food storage areas should be cleaned on a routine basis and expired or spoiled food should be disposed of.

Based on observations, record review, and resident and staff interviews, the facility failed to repair a privacy curtain track which prevented the privacy curtain from extending around a resident's bed to provide total visual privacy. This deficient practice occurred for 1 of 19 residents reviewed for privacy (Resident #29). Findings included:Resident #29 was admitted on [DATE]. A review of Resident #29's quarterly Minimum Data Set (MDS) dated [DATE] coded her with moderate cognitive impairment.On 4/28/26 at 9:30 AM an observation of Resident #29's room found the privacy curtain on the track was unable to fully close.On 4/28/26 at 9:40 AM Resident #29 was interviewed. She stated she had not paid any attention to the privacy curtain and did not know how long it had not fully closed. On 4/29/26 at 3:20 PM an observation of Resident #29's privacy curtain track remained unchanged. On 4/29/26 at 3:32 PM Nursing Aide (NA) #1 stated Resident #29's privacy curtain had not been closing all the way for a couple weeks. She stated she did not know if a work order had been put in to repair the curtain track and she had not put in a work order for the curtain track. She stated multiple NAs and Nurses had provided care to the resident and she assumed one of them had put in a work order to repair the track. On 4/29/26 at 3:34 PM the Maintenance Manager stated he was new to the facility and was unaware Resident #29's privacy curtain track needed repair. He stated he was in the process of looking through work orders and did not know if a work order had been submitted. On 4/29/26 at 3:37 PM Nurse #1 stated she was unaware Resident #29's privacy curtain track could not fully close. She stated she would put in a work order. On 4/30/26 at 3:10 PM the Administrator stated in February 2026 a water line had burst in the ceiling that caused damage to some rooms. She stated Resident #29's privacy curtain track may have been damaged at that time. The Administrator indicated the facility had been using paper work orders at that time and had switched to electronic work orders since then. She did not know the privacy curtain track needed repair and was unaware if a work order had been submitted. The Administrator said the privacy curtain track should have been reported on a work order when it was discovered to be not working properly.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #18 and Resident #4) and alarms (Resident #9) for 3 of 9 residents whose MDS were reviewed.The findings included: 1.Resident #18 was admitted to the facility on [DATE]. A review of the physician's orders in Resident #18's medical record indicated no order for an anticoagulant. The quarterly MDS dated [DATE] indicated Resident #18 was taking an anticoagulant. An anticoagulant, also known as a blood thinner, is a medication that helps prevent blood clots from forming or growing larger. A review of the Medication Administration Record for Resident #18 for January 2026 indicated he did not receive an anticoagulant. An interview with the MDS Coordinator on 4/29/26 at 3:27 PM revealed she made an error with coding Resident #18 as receiving an anticoagulant on the quarterly MDS. The MDS Coordinator stated she made the error because Resident #18 received an antiplatelet medication which she confused with a similar sounding generic name for an anticoagulant. An interview with the Director of Nursing and the Administrator on 4/30/26 at 3:08 PM revealed the MDS Coordinator should have coded Resident #18's quarterly MDS accurately. 2. Resident #4 was admitted to the facility on [DATE]. A review of the physician's orders in Resident #4's medical record indicated no order for an anticoagulant. The annual MDS dated [DATE] indicated Resident #4 was taking an anticoagulant. An anticoagulant, also known as a blood thinner, is a medication that helps prevent blood clots from forming or growing larger. A review of the Medication Administration Record for Resident #4 for February 2026 indicated he did not receive an anticoagulant. An interview with the MDS Coordinator on 4/29/26 at 2:49 PM revealed she made an error with coding Resident #4 as receiving an anticoagulant on the annual MDS. The MDS Coordinator stated that Resident #4 received an antiplatelet medication which she confused as an anticoagulant. An interview with the Director of Nursing and the Administrator on 4/30/26 at 3:08 PM revealed the MDS Coordinator should have coded Resident #4's admission MDS accurately. 3. Resident #9 was admitted on [DATE] with diagnoses which included vascular dementia. Physician orders dated 1/4/26 included a wander alarm (a wearable electronic device that trigger door locks or alarms when a resident approaches an exit, allowing for freedom of movement within safe, monitored boundaries) to be placed on Resident #9's left lower leg and to monitor the wander alarm placement on the left lower leg every shift. Resident #9's care plans included one dated 1/4/26 for elopement risk and wanderer related to dementia with attempts to leave the facility unattended. Interventions included the use of an electronic monitoring device. The care plan was written by the Activities Director. Resident #9's significant change in status MDS assessment dated [DATE] did not indicate the use of a wander/elopement alarm. Resident #9's quarterly MDS dated [DATE] did not indicate the use of a wander/elopement alarm. On 4/29/26 at 2:48 PM the MDS Coordinator stated she was unaware Resident #9 had an order for a wander alarm and she had not correctly coded the MDS. She confirmed she had completed Resident #9's MDS assessments dated 1/22/26 and 2/3/26. The MDS Coordinator added that she began working as the MDS Coordinator on 12/25/25 and had missed the order for the wander alarm dated 1/4/26. On 4/30/26 at 3:10 PM the Administrator stated the wander alarm should have been captured on Resident #9's MDS assessments.

Based on record review and staff interviews, the facility failed to complete a comprehensive Care Area Assessment (CAA) to address the underlying causes and contributing factors of the triggered areas for 3 of 3 residents reviewed for comprehensive assessments (Resident #4, Resident #65 and Resident #9).The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included myocardial infarction (heart attack), peripheral vascular disease, generalized anxiety disorder and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact. A review of the Care Area Assessment summary of the admission MDS assessment dated [DATE] indicated a total of 6 care areas were triggered for Resident #4. The assessment did not include any information in the analysis of findings for 6 of the 6 triggered areas to describe the nature of Resident #4's problems, possible causes, contributing factions, risk factors related to the care area and reasons to proceed with care planning for the following triggered care areas: functional abilities, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury and psychotropic drug use. An interview with the MDS Coordinator on 4/29/26 at 2:49 PM revealed that when she completed Resident #4's admission MDS, she did not know how to fill out and complete the CAA. The MDS Coordinator stated that after going through an online training on MDS a couple of weeks ago, she now had a better understanding about the CAA, and she learned that she had to explain the rationale behind care planning for the triggered care areas and if there were other issues that needed to be addressed. An interview with the Director of Nursing and the Administrator on 4/30/26 at 3:08 PM revealed both of them received an education about the CAA today and understood that the CAA should have been completely filled out by the MDS Coordinator. 2. Resident #65 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, diabetes, schizoaffective disorder and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #65 was cognitively intact. A review of the Care Area Assessment summary of the admission MDS assessment dated [DATE] indicated a total of 7 care areas were triggered for Resident #65. The assessment did not include any information in the analysis of findings for 7 of the 7 triggered areas to describe the nature of Resident #65's problems, possible causes, contributing factions, risk factors related to the care area and reasons to proceed with care planning for the following triggered care areas: cognitive loss/dementia, functional abilities, urinary incontinence and indwelling catheter, behavioral symptoms, nutritional status, pressure ulcer/injury and psychotropic drug use. An interview with the MDS Coordinator on 4/29/26 at 2:49 PM revealed that when she completed Resident #65's admission MDS, she did not know how to fill out and complete the CAA. The MDS Coordinator stated that after going through an online training on MDS a couple of weeks ago, she now had a better understanding about the CAA, and she learned that she had to explain the rationale behind care planning for the triggered care areas and if there were other issues that needed to be addressed. An interview with the Director of Nursing and the Administrator on 4/30/26 at 3:08 PM revealed both of them received an education about the CAA today and understood that the CAA should have been completely filled out by the MDS Coordinator. 3. Resident #9 was admitted on [DATE] with diagnoses which included vascular dementia, psychotic disturbance and mood disturbance. Resident #9's physician orders included one dated 1/14/26 for quetiapine fumarate (an antipsychotic medication) 25 milligrams (mg) give 2 tablets at bedtime for paranoid delusion. Resident #9's Care Area Assessment (CAA) summary for the significant change in status Minimum Data Set (MDS) assessment dated [DATE] was reviewed. For the triggered area of Psychotropic Drug Use the CAA summary was checked for Care Planning Decision but was blank and without documentation supporting the reason for care planning. On 4/29/2026 at 2:48 PM the MDS Coordinator stated she began working as the MDS Coordinator on 12/25/25 and didn't know how to complete CAAs. She stated she completed Resident #9's MDS assessment dated [DATE] and did not complete Resident #9's CAA on the comprehensive assessment. The MDS Coordinator added, she had received education recently and now knows she should have completed it. During an interview on 4/30/26 at 3:10 PM the Administrator stated the MDS Coordinator had not received enough education on how to complete the CAAs and recently had been educated on completing them.

Based on observations, record reviews, and resident and staff interviews, the facility failed to maintain an intact headboard without rough edges (Resident #14) and maintain chair rail molding in good repair (Resident #14 and Resident #53). This deficiency occurred for 2 of 4 residents reviewed for safe, clean and homelike environment (Resident #14 and Resident #53) on 1 of 5 facility halls.The findings included:On 4/28/26 at 3:36 PM an observation was made of Resident #14's headboard. The upper right side of the headboard (as viewed from the foot of the bed) was visible eight inches above the mattress with the top edge angled downward. Observation looking down from the head of the bed revealed the left third of the headboard was missing. The remaining piece was connected to the right side of the bed frame, and the left side had a rough edge from top to bottom, resting on a screw sticking out of the left side of the bed frame. Close observation of the mounts on the headboard frame revealed a layer of wood-like splinters present on top of the metal mounts. An observation of the wall behind Resident #14's bed revealed a horizontal chair rail molding was mounted the length of the wall 18 inches above Resident #14's mattress, protruding 2 inches from the wall. The chair rail molding had six chipped areas with paint missing across the bottom edge with scattered wood-like splinters. Starting midway from the width of the bed, the chair rail molding was pulled away from the wall a quarter inch to where the privacy curtain met the wall where it was pulled away one inch from the wall. Review of Resident #14's quarterly Minimum Data Set (MDS) on 1/23/26 indicated she was cognitively intact and dependent for bed mobility. In an interview with Resident #14 on 4/28/26 at 3:37 PM she stated she wondered if the headboard got damaged when they changed out her air mattress a few weeks ago. Resident #14 explained she could not see the headboard because she had been unable to reposition herself to look at it. Resident #14 revealed one of the nurse aides told her it had a crack but could not recall exactly who it was or when she knew about the crack but that it was after getting her new mattress. The interview further revealed Resident #14 was able to see the end of the piece of chair rail molding pulled from the wall near the privacy curtain but could not see what it looked like behind the bed. Resident #14 stated this probably happened when the tall nurse aides put her bed up higher and her headboard pushed on the chair rail molding because the bed was too close to the wall but could not recall when this was. Nurse Aide (NA) #4 was interviewed on 4/30/26 at 9:06 AM and stated she had been caring for Resident #14 early in the morning on 4/27/26 when she noticed her headboard had a crack running down the middle. NA #4 stated it was the first time she had seen the crack but thought she heard another nurse aide say it had been cracked for a while but did not recall who. NA #4 explained she touched the headboard where the crack was to check it out and a broken piece fell to the ground. NA #4 explained when she looked more closely at the broken headboard she also noticed the chair rail molding above the bed had pulled away from the wall and thought it had been broken by the headboard. NA #4 revealed she put a sticky note with the room number on the broken piece and put it in a box outside the maintenance office door. She explained the process for reporting broken equipment was to fill out an electronic work order and she did an electronic work order to report the broken headboard when she noticed it but didn't specifically mention the chair rail molding being pulled from the wall. On 4/30/36 at 9:21 AM an interview was conducted with NA #2 who explained she had noticed a crack in Resident #14's headboard maybe a month ago. NA #2 stated she had told the hall nurse the day she noticed the crack but did not remember the exact day or which nurse it had been. She further explained she did not fill out a work order because she could not find any work order papers at the nurses' station or in the shelf cubbies in the lobby where they used to be. NA #2 revealed another coworker showed her the electronic workorder system, but she did not put in a work order for the cracked headboard because she got busy and forgot. On 4/30/26 at 10:59 AM an interview was conducted with NA #3 who stated she knew Resident #14's headboard had been broken, probably for several weeks. NA #3 stated she had forgotten there was an electronic work order system and thought she had left a note in a black work order folder at the nurses' station but could not remember for sure. At 4/30/26 at 9:57 AM the Maintenance Director was interviewed when he was observed walking down the hall with a headboard and stopped in front of Resident #14's room. The Maintenance Director explained he had started at the facility on 4/27/26 and staff had told him this morning that Resident #14's headboard was broken and he was there to replace it. He further explained no one had mentioned broken chair rail molding to him nor had he seen any work orders for Resident #14. During the interview the Maintenance Director stated the chair rail molding was there to stop damage on the wall from the headboards. He observed the damaged chair rail molding and headboard in Resident #14's room and stated it looked like the chair rail damage was caused by the bed. The Maintenance Director indicated because wood chip pieces were stuck to the headboard frame it looked like when the bed was raised the headboard got caught on the chair rail and probably pulled it from the wall. The Maintenance Director stated that when the Interim Maintenance Director had done training with him on 4/27/26 he received a paper list of needed repairs, but the broken headboard was not on the list. When asked if he had seen an electronic workorder for the broken headboard the Maintenance Director revealed he had received basic education on the workorder system but was still learning how to use it and had not seen all the electronic work orders yet. An interview was conducted with the Business Office manager on 4/30/26 at 10:00 AM with the Maintenance Director present. She explained she was assisting the new Maintenance Director with training on the electronic system used by the maintenance department, which included work orders as well as other facility processes. The Business Office Manager also stated she had been helping staff to put work orders into the system during the time the Interim Maintenance Director had been coming in the afternoons to help him keep up with things since he was at the facility part time. The Business Office Manager revealed she had not seen any paper or electronic work orders about a cracked or broken headboard and no one had mentioned it to her before today. A telephone interview was conducted with the Interim Maintenance Director on 4/30/26 at 11:28 AM. The interim Maintenance Director stated he was the full time Maintenance Director at a sister facility and been coming to this facility since mid-March to help in the afternoons after their prior Maintenance Director had left. He explained the Interim Administrator had given him a list of priority projects to complete. The Interim Maintenance Director explained he remembered being aware of a broken headboard when a work order came across his phone at some point but did not remember the date and could not check because he didn't have current access to the system. He stated he had several large projects going on at the time and tried to knock out the smaller things when he could but did not remember looking at the headboard. The Interim Maintenance Director further explained he had seen the piece of broken headboard in the maintenance door box within the last week but there was no sticky note on it and he had not asked anyone about it. An interview was conducted on 04/30/26 at 11:36 AM with the Interim Administrator who stated she had filled in for the Administrator from 1/8/26 until 4/6/26. She explained having asked the Interim Maintenance Director from a sister facility to come help and had given him a list with some priority repair projects and from there he worked from the electronic workorder system. The Interim Administrator stated she had not been aware of any broken headboards during her time at the facility. The Interim Administrator further explained if equipment was broken that staff had been trained to put a workorder in the electronic work order system. She revealed during the time the Interim Maintenance Director was coming to help that she had asked staff to also do a paper work order so she would know what was needed even during times when there was no maintenance person immediately on-site. During an interview with the Administrator on 4/30/26 at 12:28 PM she explained the facility had been using a paper work order system but now the process was to put work orders in electronically and the staff had training on how to do this when they implemented the system a few months ago. The Administrator revealed she had been unaware of any resident headboards being broken since her return from leave a few weeks ago. She further explained Resident #14's broken headboard could have potentially caused injury and that residents needed a headboard for positioning and safety. The Administrator stated she was sorry that Resident #14's headboard had not been replaced sooner. The interview further revealed she had been unaware of any broken pieces of chair rail molding in resident rooms until today. She revealed a broken piece of molding could potentially cause a skin tear or bruising and they would look at replacing or removing the chair rail molding in rooms with problems. 2. An observation was made on 4/28/26 at 9:40 AM of the wall next to Resident #53's bed. The left side of the bed was directly against the wall. There was horizontal chair rail molding 18 inches above the mattress, protruding 2 inches from the wall which ran from the back wall to mid-way in the room at the privacy curtain. The chair rail molding had 12 gouges in the wood without paint and ended in a 45-degree point partly visible behind the privacy curtain where it was pulled away from the wall half an inch. From the privacy curtain to the rest of the distance to the front wall, a strip the width of the chair rail molding painted a different color was visible and had six half inch holes evenly spaced in the wall. Review of Resident #53's quarterly MDS on 3/2/26 revealed he was cognitively intact. In an interview with Resident #53 on 4/28/26 at 3:12 PM he stated the chair rail molding on the wall had been like that as long as he could remember and he had not spoken with anyone about it. An interview was completed with NA #1 on 4/30/26 at 10:29 AM who stated she had noticed a piece of chair rail molding was missing in Resident #53's room a few weeks ago and told the nurse but could not recall which nurse, who thought there had been a workorder in for that. NA #1 stated she had not known the piece of chair rail molding over Resident #53's bed was broken off to a point. In an interview with NA #4 on 4/30/26 at 10:30 AM room she explained she took care of Resident #53 but did not know the chair rail molding over Resident #53's bed had a sharp point sticking out from the wall. In an interview and observation with the Maintenance Director on 4/30/26 at 9:57 AM he stated he started at the facility on 4/27/26 and had not yet been in Resident #53's rooms and had not been aware of the broken chair rail moldings. He further explained no one had mentioned broken chair rail molding to him nor had he seen any work orders for Resident #53's room. During the interview the Maintenance Director stated the chair rail molding was there to stop damage on the wall from the headboards. In a follow-up interview and observation with the Maintenance Director on 4/30/26 at 10:46 AM in Resident #53's room, he observed the chair rail molding on the wall over Resident #53's bed and explained it had at least 12 gouges in the wood with no paint and the end was at a 45 angle to a point at the height of the headboard where the privacy curtain met the wall and was pulled out from the wall half an inch. He explained the point was from where a now missing piece of molding had joined with this piece and could be a hazard if someone were to bump into it. The Maintenance Director stated he did not know why there was a missing piece of chair rail molding, but it may have been damaged from a headboard or just came loose over time and the holes in the wall were from where screws had been. During an interview with the Director of Nursing (DON) on 4/30/26 at 11:16 AM she stated during orientation that staff had training from maintenance that included how to put in electronic work orders. She explained that training had been done with current staff but maybe some staff had forgotten how. The DON revealed it was important for staff to put in work orders for broken equipment or furnishings to prevent injury. In an interview with the Administrator on 4/30/26 at 12:28 PM she stated she had been unaware of any broken pieces of chair rail molding in resident rooms until today. She revealed a broken piece of molding could potentially cause a skin tear or bruising and they would look at replacing or removing the chair rail molding in rooms with problems.

Based on record review and staff interviews, the facility failed to review and update the Facility Assessment annually. This had the potential to affect all residents residing in the facility.The findings included:Review of the Facility Assessment revealed it was dated 3/20/25 and there was no documentation to show the assessment had been reviewed and updated since that time or annually.On 4/30/26 at 11:48 AM an interview was held with the Administrator. She stated that she had been on medical leave from some time in November 2025 until April of this year. The Administrator stated that there was an Interim Administrator that covered her position for her when she was on medical leave. The interview further revealed the Administrator knew the facility assessment was due but did not pass this information on to the Interim Administrator. Her plan was to go over the Facility Assessment at next week's Quality Assurance & Performance Improvement (QAPI) meeting.On 4/30/26 at 12:02 PM an interview was conducted with the Interim Administrator. She stated that she was the Interim Administrator for the month of March 2026 and she had not been made aware that the Facility Assessment needed to be updated by 3/20/26.

Based on record reviews and staff interviews the facility failed to provide dental services for 1 of 1 (Resident #17) residents reviewed for providing emergency dental services. The findings included: Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus and heart failure. Resident #17 was care planned for oral and dental health problems on 06/25/24 with interventions that included monitor document and report any signs or symptoms of oral problems needing attention and provide mouth care. Resident #17 had a physician order dated 7/23/24 for dental consultation as needed. A provider progress note dated 11/25/24 read in part the resident had a lesion in the left lower buccal (cheek) fold along the edge of the left lower denture. The resident is agreeable to an alteration to the lower denture area. The provider wrote that a dental consult would be beneficial to make some alterations along the lower edge of the left lower denture. Resident #17 had a physician order dated 11/25/24 that read; dental referral to evaluate lower full denture which is causing recurrent buccal trauma. Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded her as severely cognitively impaired. She was coded for loose or broken dentures and yes for difficulty, pain with swallowing chewing. She required a therapeutic and mechanically altered diet and needed set-up assistance with eating. A Provider Progress Note dated 2/3/25 read in part, Resident #17 was seen for sore area on the left side of her mouth and jaw. The resident had issues with her denture causing recurrent trauma to her inner left mouth area in the last few months. The denture needed to be modified, and the dental consultation was not completed. Resident #17 had an approximately .5 to 1 centimeter laceration and the left lower buccal fold that was adjacent to the sharp edge of her lower denture. The provider note wrote Resident #17 had an appointment in-house for a dental consultation on 2/5/25. A nursing progress note dated 2/8/25 written by Nurse #1 read Resident #17 had a sore area on her left inner cheek. The resident stated it was very sore, and magic mouthwash did not help much. The resident's bottom denture was very loose, and the resident's family was concerned. A note was left for the Physician to evaluate and advise. Attempts to interview Nurse #1 were unsuccessful. A progress note written by a provider dated 2/11/25 read in part the resident was seen at the request of Resident #17's family for a follow-up concern regarding a mouth lesion. The resident had been seen for this concern numerous times starting in the fall of 2024 when a dental consult was placed. The progress note wrote, it was determined the lesion was caused by the lower denture defect and required an alteration. The family did not want to take the resident out for dental care and the request was put in for residency care by the traveling dentist. She was scheduled to see the dentist at this location and was postponed until later in the week of 2/10/25 -2/14/25. The provider wrote the resident did not wear her bottom dentures that caused difficulty when eating. The progress note went on to say the provider had confirmed the dentist was coming to the facility later in the week of 2/10/25-2/14/25. The provider requested special attention that the resident was seen and if for some reason the resident was not seen by the dentist, the resident needed to be seen as soon as possible. A note written on 3/6/25 by the Transportation Driver read Resident #17 will be seen by the dentist on 5/29/25 at 11:00 AM. Resident #17 had a physician order dated 03/09/25 that read; lidocaine viscous (used to numb red, swollen, and painful sores in mouth) mouth and throat solution 2% with direction to place and dissolve 15 milliliters buccally before meals for left lower buccal lesion for 14 days and discontinue if lesion is healed. A review of Resident #17's March 2025 Medication Administration Record (MAR) found the resident received the lidocaine viscous as ordered. A review of the in-house dentist and dental hygienist visits and notes dated 10/30/24 through 3/10/25 was completed. Resident #17 was not seen by the hygienist or the dentist. The business office manager (BOM) was interviewed on 3/13/25 at 3:28 PM. The BOM stated Resident #17's family initially did not want to enroll the resident into the dental program because they thought the resident was going to be a short-term resident. The family later decided the Resident #17 was going to be a long-term resident, and she was enrolled in the dental program on 1/27/25 by the resident's family. The residents' information along with physician order was sent to the in-house dental provider on 2/10/25. The BOM said the facility was unaware the resident was not seen on 3/10/25 and would be seen on the next visit to the facility on [DATE] and was unsure if the dental provider did emergent visits. A follow-up interview with the BOM on 3/13/25 at 3:56 PM was conducted. The BOM stated the dental provider was called and asked if Resident #17 could be seen emergently. The dental provider told the BOM a triage form could be filled out and sent to the dental provider and a regional dentist would review and develop a plan of care for the resident. The BOM stated the facility was unaware of the triage form and the form would be completed on 3/13/25 and sent to the dental provider for Resident #17. Furthermore, the BOM said the dental provider told her the dentist needed to see Resident #17 for an evaluation prior to the dental hygienist providing any oral care. On 3/10/25 the dental hygienist was at the facility and Resident #17 had not been evaluated by a dentist and was not included on the list to be seen. The Administrator was interviewed on 3/14/25 at 4:53 PM. She stated the facility did attempt to schedule Resident #17 a dentist appointment when the referral was written but was unable to find a dentist to accept the residents insurance. The Administrator said if the facility was aware of the triage option for the resident, it should have been completed and submitted soon after the resident was signed up with the in-house dentist. The resident was not included on the dental provider list to be seen on 3/10/25 because the dentist had not evaluated Resident #17. The Administrator said Resident #17 should have been seen on 3/10/25.

2.Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, depression, and anxiety. Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] coded her as severely cognitively impaired. She was coded for taking an antidepressant Resident #17 had a physician's order dated 7/23/24 for trazadone Hcl oral tablet 50 milligrams give one tablet by mouth as needed (PRN) for insomnia at bedtime. The physician's order was discontinued on 11/25/24. Pharmacy recommendations from July 2024 - February 2025 for Resident #17 were reviewed. A recommendation dated 7/26/24 read in part Resident #17 had a PRN antidepressant trazadone without a stop date. The physician's response was to add a 14-day stop date and was signed dated 8/14/24. A recommendation dated 11/13/24 read in part Resident #17's prescriber accepted a pharmacy recommendation to add a stop date to PRN trazadone on 8/15/24, but the order has not been processed. The pharmacy recommendation was signed by the Director of Nursing on 11/25/24 and noted the order for trazadone PRN was discontinued 11/25/24. The DON stated on 3/14/25 at 10:25 AM the pharmacy recommendation to place a stop date on the PRN trazadone was overlooked by her in the August 2024 pharmacy review and she did not discontinue the medication until 11/24/24 pharmacy recommendation found it. The DON stated until recently, she was not retaining or scanning the pharmacy recommendations into the electronic charting when she received them from the consulting pharmacist. The DON said she was faxing the physician responses to the pharmacy recommendations to the pharmacy, and she thought the pharmacy was changing the orders. The consultant pharmacist was interviewed on 3/14/25 at 11:15 AM and stated PRN psychoactive medications should have a 14-day stop date. He said he had made recommendations for a 14-day stop date for any PRN psychoactive medications a resident received that did not include a stop date and they were sent to the DON monthly. The Medical Director was interviewed on 3/14/25 at 1:37 PM. She stated her orders should be followed to add a 14-day stop date to the antipsychotic medication. The Administrator stated on 3/14/25 at 4:53 PM the DON was faxing signed physician pharmacy recommendations to the pharmacy. The DON did not know she needed to make the changes in Resident #17's orders. Based on record review, staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for a resident who received an antipsychotic medication (Resident #46). In addition, the facility failed to ensure a physician order for an as needed (prn) psychotropic medication was limited to 14 days (Resident #17). This deficient practice occurred for 2 of 5 residents reviewed for unnecessary psychotropic medications (Resident #46 and Resident #17). The findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, anxiety disorder, and major depressive disorder. A review of the electronic medical record revealed Resident #46's last AIMs was completed on 10/5/23. (Abnormal Involuntary Movement Scale is a scale to measure abnormal involuntary movements in patients taking antipsychotic medications). A review of Resident #46's active physician's orders revealed the following orders: -An order dated 7/10/24 that read, olanzapine (antipsychotic medication) 2.5 milligrams (mg) give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for schizophrenia. -An order dated 12/24/24 that read, olanzapine 5 mg by mouth daily for schizophrenia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. He was not documented for behaviors or rejection of care. The MDS documented that he received antipsychotic medication. An interview was conducted on 3/14/25 at 11:15 AM with the Consultant Pharmacist. He explained what he was looking for when he did the pharmacy medical record review for Resident #46 was a documented AIMS assessment with a date on it and he had not seen that completed. An interview was conducted with the Director of Nursing on 3/14/25 at 10:14 AM. She explained the MDS nurse was historically responsible for completing the AIMS assessments. The DON reported the facility had changed MDS nurses several times in the last couple of years. She stated the current MDS nurse was new in the position and was not aware it was something she needed to do. The DON said she was not entirely sure on how often AIMS assessments needed to be completed until she looked up the policy today (3/14/25), she reported she kind of new but was not entirely sure. The DON stated after checking the policy, AIMS assessments should be completed on admission, when there were changes in the antipsychotic medication, and quarterly. An interview was conducted with the MDS Nurse on 3/14/25 at 4:11 PM. The MDS Nurse reported she had worked at the facility since August 2024. She explained she had not been told she was supposed to do the AIMS assessments or was supposed to look and make sure they were done. She further explained she had not been told AIMS were part of her role, she said if it was, she was unaware. The MDS Nurse stated she did not know who was supposed to do the AIMS assessments or was responsible for them. An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director stated the facility should complete AIMS assessments to monitor residents for side effects of antipsychotic medications. An interview was conducted with the Administrator on 3/14/25 at 4:44 PM. The Administrator said AIMS assessments should be completed for residents who received antipsychotic medication. The Administrator said AIMS assessments should be done every three months, when a new medication was added, or if requested by pharmacy or a provider.

Based on record review, and staff, Medical Director, and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendations to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (Resident #46) who received an antipsychotic medication. In addition, the facility failed to follow pharmacy recommendations that had been signed by the physician to add a 14-day stop date for a prn (as needed) psychotropic medication for a Resident #17. This deficient practice occurred for 2 of 5 residents reviewed for pharmacy recommendations (Resident #46 and Resident #17). The findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, anxiety disorder, and major depressive disorder. A review of Resident #46's active physician's orders revealed the following orders: -An order dated 7/10/24 that read, olanzapine (antipsychotic medication) 2.5 milligrams (mg) give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for schizophrenia. -An order dated 12/24/24 that read, olanzapine 5 mg by mouth daily for schizophrenia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. He was not documented for behaviors or rejection of care. The MDS documented that he received antipsychotic medication. Review of the Consultant Pharmacist's pharmacy consultation reports revealed an AIMS assessment was recommended on 10/12/24, 12/7/24, and on 2/9/25. (Abnormal Involuntary Movement Scale is a scale to measure abnormal involuntary movements in patients taking antipsychotic medications). The pharmacy recommendations dated 10/12/24, 12/7/24, and 2/9/25 read, please monitor for involuntary movements now and at least every 6 months or per facility protocol. It is recommended that monitoring frequency increase following does adjustments. The comments read, [Resident #46] receives olanzapine which may cause involuntary movements, including tardive dyskinesia (abnormal involuntary movements caused by medications), but an abnormal involuntary movement scale (AIMS), or other appropriate assessment was not documented in the medical record within the previous 6 months. -The pharmacy recommendation dated 10/12/24 was signed by the Director of Nursing (DON) on 10/24/24. Under DON comments it read, recommendations added to orders. -The pharmacy recommendation dated 12/7/24 was signed by the Director of Nursing on 12/23/24. Under DON comments it read, order updated with recommendation. -The pharmacy recommendation dated 2/9/25 was signed by the Director of Nursing on 2/19/25. Under DON comments it read, followed recommendation. An interview was conducted on 3/14/25 at 11:15 AM with the Consultant Pharmacist. The consultation report recommendations for Resident #46 from 10/24/24, 12/23/24, and 2/19/24 were for an AIMS assessment to be completed due to Resident #46 receiving an antipsychotic medication. The Consultant Pharmacist stated he kept sending the recommendation because he did not see an AIMS assessment that had been done. An interview was conducted with the Director of Nursing on 3/14/25 at 10:14 AM. She reported she was responsible for reviewing and ensuring pharmacy recommendations were completed. The DON explained she had misunderstood what the pharmacy recommendations for Resident #46 were asking for. The DON explained she had added to monitor for involuntary movements now and at least every 6 months as an order and added it to the olanzapine medication order for Resident #46. The DON reported she had not realized the pharmacy recommendations indicated an AIMS assessment needed to be completed for Resident #46. An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director stated the facility should follow pharmacy recommendations. An interview was conducted with the Administrator on 3/14/25 at 4:44 PM. The Administrator said Resident #46 should have had an AIMS completed and the pharmacy recommendations should have been followed. The Administrator stated she was not sure why the DON missed the recommendation to do an AIMS. 45272 2. Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, depression, and anxiety. Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] coded her as severely cognitively impaired. She was coded for taking an antidepressant. Resident #17 had a physician's order dated 7/23/24 for trazadone Hcl oral tablet 50 milligrams give one tablet by mouth as needed (PRN) for insomnia at bedtime. The physician's order was discontinued on 11/25/24. Pharmacy recommendations from July 2024 through February 2025 for Resident #17 were reviewed: A recommendation dated 7/26/24 read in part Resident #17 had a PRN antidepressant trazadone without a stop date. The physician's response was to add a 14-day stop date and was signed dated 8/14/24. The pharmacy recommendation dated 9/9/24 repeated the recommendation, with the same physician response. A pharmacy recommendation dated 11/13/24 read in part Resident #17's prescriber accepted a pharmacy recommendation to add a stop date to PRN trazadone on 8/15/24, but the order has not been processed. The pharmacy recommendation was signed by the Director of Nursing on 11/25/24 and noted the order for trazadone PRN was discontinued 11/25/24. The DON stated on 3/14/25 at 10:25 AM the pharmacy recommendation to place a stop date on the PRN trazadone was overlooked by her in the August 2024 pharmacy review and she did not discontinue the medication until 11/24/24 pharmacy recommendation found it. The DON stated until recently, she was not retaining or scanning the pharmacy recommendations into the electronic charting when she received them from the consulting pharmacist. The DON said she was faxing the physician responses to the pharmacy recommendations to the pharmacy, and she thought the pharmacy was changing the orders. The Consultant Pharmacist was interviewed on 3/14/25 at 11:15 AM and stated PRN psychoactive medications should have a 14-day stop date. He said he had made recommendations for a 14-day stop date for any PRN psychoactive medications a resident received that did not include a stop date and they were sent to the DON monthly. The Medical Director was interviewed on 3/14/25 at 1:37 PM. She stated her orders should be followed to add a 14-day stop date to the antipsychotic medication. The Administrator stated on 3/14/25 at 4:53 PM the DON was faxing signed physician pharmacy recommendations to the pharmacy. The DON did not know she needed to make the changes in Resident #17's orders.

Based on record review, staff, resident and Medical Director interviews, the facility failed to follow physician orders for checking a diabetic resident's blood glucose levels twice daily for 2 of 2 residents with physician orders for blood sugar monitoring (Resident #23 and Resident #17). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. His medical diagnoses included: Diabetes Mellitus Type-2. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Resident #23 had a care plan for Diabetes Mellitus type-2 dated 2/28/25. The care plan interventions read, fasting serum blood sugar as ordered by doctor. Review of Resident #23's active physician orders for March 2025 revealed the following orders: - An order dated 2/17/25 that read, Lantus (long-acting insulin)100 unit/ milliliter (ml), inject 20 units subcutaneously at bedtime. - An order dated 2/21/25 entered by the Medical Director that read, blood glucose (BG) twice daily. Review of the electronic medical record revealed the following blood glucose results: - A result of 125 obtained on 2/20/25 - A result of 193 obtained on 2/25/25 There were no other blood glucose results documented in the electronic medical record An interview was conducted with Resident #23 on 3/12/25 at 2:04 PM. He said it had been a while since his blood glucose had been checked at the facility. Resident #23 said he felt like he had not experienced any symptoms of high or low blood sugar. An interview was conducted with Nurse #1 on 3/12/25 at 2:20 PM. Nurse #1 stated Resident #23 did not get blood glucose checks and he did not have an order to check them. After she reviewed his active physician order, Nurse #1 verbalized Resident #23 did have an active order for blood glucose checks twice a day. She opened the blood glucose order entry details and reviewed the order. After reviewing the order entry details, Nurse #1 explained the order had been entered in by the Medical Director. She further explained the order did not show up on Resident #23's Medication Administration Record (MAR) because the order had been entered incorrectly. Nurse #1 stated she did not know to check Resident #23's blood glucose because the order did not pull to the MAR to let her know to check it. Nurse #1 reported there was not a process she was aware of for checking orders entered by providers to ensure they were entered correctly. An interview was conducted with the Medical Director on 3/13/25 at 1:37 PM. The Medical Director reported she had been notified about Resident #23's blood glucose order being entered She said the staff did not know to check Resident #23's blood glucose because she had not entered the order correctly to pull to the MAR. An interview was conducted with the Director of Nursing (DON) 3/14/25 at 4:44 PM. The DON explained the order for Resident #23's blood glucose checks had been entered by the Medical Director incorrectly and did not pull to the MAR to for the nurses to see. The DON stated the nurses did not know to check his blood glucose because it was not on the MAR. The DON explained orders were reviewed during the morning clinical meeting. She reported an orders report from the prior day was pulled and the orders were reviewed from the printed report. The DON stated order entry was not checked for the orders when they were reviewed during the morning meeting. The DON said there was not a current process for a second check of orders entered by providers to ensure they had been entered correctly. An interview was conducted with the Administrator on 3/14/25 at 4:50 PM. The Administrator said staff had not known to check Resident #23's blood glucose because the order had been entered incorrectly by the Medical Director. The Administrator said there should be a process for checking orders entered by providers to ensure they were entered correctly. 45272 2. Resident #17 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus. Resident #17 had a care plan dated 6/25/24 for type 2 diabetes dated 6/25/24 with interventions that included to monitor blood glucose checks as ordered. Resident #17 had a physician's order dated 12/14/24 for dulaglutide pen-injector 1.5 milligrams to inject 3 milligrams subcutaneously weekly every Saturday. (Dulaglutide is a once-a-week injection drug prescribed to treat type 2 diabetes mellitus.) Resident #17 had a physician order dated with a start date 1/10/25 and end date 1/20/25 for fingerstick glucose (blood sugar check) two times daily (BID) before meals. A review of Resident #17's Medication Administration Record (MAR) for January 2025 found blood glucose checks were not initialed as completed on 1/10/25 through 1/18/25 at 6:00 AM and 4:30PM. On 1/19/25 Nurse #2 had initialed blood glucose check was completed at 4:30 PM and the blood sugar level was not documented on the MAR. Nurse #2 was interviewed on 4/14/25 at 12:53 PM. She stated she was assigned to Resident #17 on some of the days the blood glucose checks were not completed. Nurse #2 said she was not aware Resident #17 had an order blood glucose checks two times daily before meals from 1/10/25 through 1/18/25. Nurse #2 confirmed that Resident #17 did have an order for blood glucose checks beginning on 1/10/25 and was not able to explain why the blood sugar checks were not completed, and confirmed Resident #17 had a current order to check blood sugars. Nurse #2 stated she always followed physician orders and completed all blood sugar checks. The Medical Director was interviewed on 3/14/25 at 1:38 PM. She stated the order for Resident #17 to receive blood sugar checks was written on 1/10/25 by the Nurse Practitioner. The Medical Director stated the Nurse Practitioner did not correctly enter the order into the electronic chart and it was not visible for the nurses to see. The Medical Director stated the NP and herself had not received much training for entering orders in the electronic medical chart and did not enter the orders correctly. An interview was conducted with the Director of Nursing (DON) 3/14/25 at 4:44 PM. The DON explained the order for Resident #17's blood glucose checks had been entered by the Nurse Practitioner incorrectly and did not pull to the MAR to for the nurses to see. The DON stated the nurses did not know to check his blood glucose because it was not on the MAR. The DON explained orders were reviewed during the morning clinical meeting. She reported an orders report from the prior day was pulled and the orders were reviewed from the printed report. The DON stated order entries were not reviewed to ensure they had been made visible for nurses to see on the MAR. The DON said there was not a current process for a second check of orders entered by providers to ensure they had been entered correctly. An interview was conducted with the Administrator on 3/14/25 at 4:53 PM. The Administrator said staff had not known to check Resident #17's blood glucose because the order had been entered incorrectly by the Nurse Practitioner. The Administrator said there should be a process for checking orders entered by providers to ensure they were entered correctly.

Based on observations and interviews with residents and staff, the facility failed to maintain repair or replace damaged bed power cord for 2 of 12 ( Room#101 and Room#103) resident rooms on 1 of 4 resident halls reviewed for maintaining a safe, clean, and homelike environment. The findings included: a.On 3/11/25 at 11:16 AM an observation of room [ROOM NUMBER] b bed revealed the bed remote and power cord lying on top of the bed. Electrical tape was wrapped around multiple areas of the bed's power cord. Further observation revealed the outer protective wire coating was broken, torn, or missing exposing 3 inner color-coded wires spanning the length of the visible portion of the power cord as it attached under the bed. The resident in room [ROOM NUMBER] was interviewed on 3/11/25 at 3:30 PM. She stated the bed power cord wire had been damaged and wrapped with electrical tape for as long as she had been in the room. A follow-up observation of room [ROOM NUMBER] b bed on 3/14/25 at 11:30 AM found the bed cord unchanged. b.On 3/11/25 at 3:42 PM an observation of room [ROOM NUMBER] b bed revealed the bed remote and the power cord laying on top of the bed. Black electrical tape was wrapped around the cord in 5 locations. Upon closer observation, the power cord's outer wire covering was missing sections of the protective covering. The inner color-coded wires were exposed and visible without electrical tape covering the inner wires. The resident stated during the observation that the bed remote power cord had been damaged for 2 years without repair. On 3/14/25 at 11:30 AM an observation of room [ROOM NUMBER] b bed and 103 b bed with the Maintenance Director revealed the bed cords to be unchanged. The Maintenance Director stated the bed power cords were damaged and replacement power cords had been ordered 2-3 weeks prior. A follow-up interview with the Maintenance Director was conducted on 3/14/25 at 11:51 AM. He stated a replacement cord for a bed was ordered 2-3 weeks prior when he was made aware of the damaged cord by an administrative staff who was conducting a round in room [ROOM NUMBER] room. The Maintenance Director presented an invoice dated 2/17/25 for one replacement bed power cord. The ordered cord was delivered to the facility earlier in the week and the replacement cord did not fit the bed in room [ROOM NUMBER] and another power cord needed to be ordered. He stated the cord had not been reordered, and he would place an order on the current day (3/14/25). The Maintenance Director said he would replace room [ROOM NUMBER] b bed with a manually operated bed until the correct cord had arrived. The Maintenance Director went on to state he was unaware how many of the bed power cords needed to be replaced in the facility, and he would conduct an audit, he was not aware of room [ROOM NUMBER] b bed's damaged bed cord. The Maintenance Director stated room [ROOM NUMBER] b bed and 103 b bed's damaged power cords did not have frayed or exposed inner wires, the outside coating of the power cords was cracked and missing in some places and he felt the damaged cords did not pose an electric shock hazard. He reported he had placed electrical tape around the damaged cords at some point and could not recall how long it had been. Additionally, the Maintenance Director reported he did not have a specific routine audit of the bed cords but did monthly checks of the mattresses that would include looking at the bed power cords. The Administrator was interviewed on 3/14/25 at 12:17 PM and stated the damaged bed cords should have been repaired or replaced when they were identified.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) for a resident (Resident #23) with a feeding tube and a resident with a wound (Resident #32) when Nurse #1 failed to wear a gown while administering a tube feeding for Resident #23 and the Wound Care Nurse failed to wear a gown while performing wound care for Resident #32. This deficiency occurred for 2 of 2 staff members reviewed for infection control practices (Nurse #1 and the Wound Care Nurse). The findings included: Review of the facility's policy and procedure dated August 2022 entitled Enhanced Barrier Precautions read in part: Enhanced Barrier Precautions (EBP) are used as an infection control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. EBP's employ targeted gown, and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact care activities requiring the use of gown and glove for EBP include: Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ ventilator; wound care (any skin opening requiring a dressing). EBPs are indicated for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization. 1. An observation was completed on 3/12/25 at 2:20 PM of Nurse #1 accessing Resident #23's gastrostomy feeding tube and administering his tube feeding. The nurse performed hand hygiene using hand sanitizer and donned clean gloves. She did not don a gown. Nurse #1 checked placement of the feeding tube, flushed the tube with water, administered a bolus tube feeding through the tube, flushed the tube with water, and replaced the stopper at the end of the tube. She disposed of the trash, removed her gloves, and performed hand hygiene using hand sanitizer. An interview was conducted with Nurse #1 on 3/12/25 at 2:30 PM. Nurse #1 said the EBP sign on the outside of Resident #23's room door was for Resident #23's roommate. She explained the EBP sign was hung above or below the name on the door to identify who in the room the EBP were for. She reported she had received education on EBP and that residents with indwelling devices and wounds should have EBP. She said she should have known Resident #23 needed EBP since he had a feeding tube, but said she did not think about it. Nurse #1 reported she should have worn a gown and gloves when she did Resident #23's tube feeding. An interview was conducted with the Infection Preventionist (IP) on 3/14/25 at 9:39 AM. She explained residents with indwelling devices and chronic wounds should have EBP in place. She said Nurse #1 should have worn a gown and gloves when administering Resident #23's tube feeding. The IP said she thought Nurse #1 may have been nervous and just forgot. She said Nurse #1 had received education on EBP and should have known Resident #23 needed EBP since he had a feeding tube. An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director reported she was familiar with EBP. She stated the facility should use and follow EBP for residents with feeding tubes. An interview was conducted with the Director of Nursing (DON) and Administrator on 3/14/25 at 4:44 PM. The DON said residents with wounds and indwelling devices should have EBP in place. She explained nurses should follow EBP and should wear a gown and gloves for residents who require EBP. The DON reported Nurse #1 should have worn a gown when administering Resident #23's tube feeding. The Administrator added the facility has plenty of personal protective equipment (PPE) and that it was just human error. 2. An observation and interview was completed on 3/13/25 at 12:37 PM with the Wound Care Nurse. The Wound Care Nurse was observed performing wound care to Resident #32's right foot wound. The Wound Care Nurse said the wound was classified as a vascular wound and betadine was being applied to the wound because of maceration around the wound. She performed hand hygiene using hand sanitizer, donned gloves, and removed the dressing from the bottom of Resident #32's right foot and placed the dressing in the trash. She removed her gloves, performed hand hygiene using hand sanitizer, and donned new gloves. She cleaned the wound with normal saline, she removed her gloves and performed hand hygiene using hand sanitizer. She donned new gloves, applied betadine to the wound, and covered the wound with a foam dressing. She removed her gloves and performed hand hygiene using hand sanitizer. An additional interview was conducted with the Wound Care Nurse on 3/14/25 at 8:52 AM. She reported she had not worn a gown when performing Resident #32's wound care because she was not on EBP. The Wound Care Nurse reported EBP were used if a resident grew out an organism on a wound culture, but that EBP was not used for other wounds. The Wound Care Nurse stated she was not sure if residents with wounds should have EBP. She said she thought chronic wounds may need EBP but that she would check and let the surveyor know. The Wound Care Nurse returned after a few minutes and said she checked with the Infection Preventionist (IP) and was told anyone with chronic wounds needed EBP. She reported she was not aware Resident #32 needed EBP and that was why she did not use EBP and wear a gown when she did her wound care. The Wound Care Nurse said she had received education on EBP. An interview was conducted with the IP on 3/14/25 at 9:39 AM. She explained residents with indwelling devices and chronic wounds should have EBP in place. The IP reported gown and gloves should be worn when performing wound care. The IP said Resident #32 had not had EBP in place because the IP was not aware of her wound. She reported there should be better communication between herself and the Wound Care Nurse about wounds. The IP said the Wound Care Nurse had received education on EBP, she said she was not sure why the Wound Care Nurse did not remember Residents with wounds needed EBP. An interview was conducted with the Medical Director on 3/14/25 at 1:37 PM. The Medical Director reported she was familiar with EBP. She stated the facility should use and follow EBP for residents with wounds. An interview was conducted with the Director of Nursing (DON) and Administrator on 3/14/25 at 4:44 PM. The DON said residents with wounds and indwelling devices should have EBP in place. She said there was miscommunication between the IP and Wound Care Nurse and that was why Resident #32 did not have EBP in place. She explained nurses should follow EBP and wear gown and gloves for resident who required EBP. The Administrator added the facility has plenty of personal protective equipment (PPE) and that it was just human error.

Based on record review, observations, and staff interviews, the facility failed to provide sufficient nursing staff to assist residents with incontinence care, showers, bed baths and hair care, wound care, and to provide pneumococcal vaccines to eligible residents for 5 of 12 residents (Residents #259, #51, #13, #25, and #7) reviewed for sufficient staffing. The findings included: This tag was cross-referenced to: F550 - Based on record review and resident and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance when requested by a resident (Resident #259) with a wet brief for 1 of 2 residents reviewed for dignity. Resident #259 stated this made her feel not too good, aggravated and worried that staff had forgotten her. F561 - Based on record review, observation, and resident and staff interviews, the facility failed to honor a resident request to have two showers per week for 1 of 1 resident (Resident #51) reviewed for choices. F677 - Based on record review, observations, resident and staff interviews, the facility failed to provide a complete bed bath and hair care to a dependent resident for 1 of 3 residents (Resident #13) reviewed for activities of daily living. F684 - Based on observations, record review, resident, staff and Medical Director interviews, the facility failed to assess, obtain a physician's order and perform dressing changes for a weeping area on a resident's lower extremity for 1 of 1 resident reviewed for skin condition (Resident #25). F883 - Based on record review, and staff interviews, the facility failed to administer the pneumococcal vaccine to eligible residents for 2 of 5 residents (Resident #259 and Resident #7) reviewed for immunizations. An interview with Nurse Aide (NA) #7 on 10/31/23 at 5:13 PM revealed they used to have two shower aides at the facility but a few months ago, one of the shower aides got injured so she had to go back to working on a hall. The shower aide 2 list got assigned to the hall nurse aides which was too much for them because there were usually only two to three nurse aides to care for at least 50 residents on both the day and evening shifts. NA #7 stated that they didn't have enough time to get everything done. An interview with Nurse #1 on 10/31/23 at 3:41 PM revealed she was supposed to be the wound care nurse, but she did not get to do this full-time because she got pulled to work on the hall most of the days she was scheduled to work. An interview with the Scheduler on 11/2/23 at 8:47 AM revealed the staffing goal was to have at least 6-8 nurse aides, 2 hall nurses and a wound nurse for day shift but they had been down to 5-6 nurse aides depending on what day of the week it was. The Scheduler stated she still had been working around vacation requests since August. They normally had 2-3 hall nurse aides and 1-2 shower aides for day shift. For the evening shift from 7:00 PM to 7:00 AM, they had 2 nurses and 2 nurse aides but sometimes a nurse aide came in at 4:00 PM and helped until 11:00 PM. The Scheduler stated they needed at least 3 nurse aides for the evening shift. She shared that the current open positions at the facility were for 2 day shift nurses, 1 night shift nurse and 2 night shift nurse aides. The Scheduler stated they had been trying to recruit staff online and had patient care aides who were getting ready to take their certification test. She also revealed that the facility did not currently use agency staff and it had been over a year since they had last used them due to a corporate decision. A phone interview with the Director of Nursing (DON) on 11/2/23 at 2:02 PM revealed the facility had a staffing problem and she herself had been pulled to work on a hall at least 4-5 times since August. She shared that in the past two weeks, they had hired more nurses and nurse aides to cover some of the current open positions the facility had. An interview with the Administrator on 11/2/23 at 2:55 PM revealed they did have some openings but the staffing number each day had been going up as far as how many people were employed by the facility. The Administrator stated some of the staffing challenges the facility faced was due to some staff being out due to health issues and a few of the nurse aides were terminated even before the Administrator started working at the facility. She shared that they had increased their wages, offered sign-on bonuses and referral bonuses, advertised on all the social media platforms, and ordered some signs to post around town that they were hiring. The Administrator acknowledged that staffing had been worse this week than it had been in a while.

Based on record review and resident and staff interviews, the facility failed to maintain a resident's dignity by not providing assistance when requested by a resident (Resident #259) with a wet brief for 1 of 2 residents reviewed for dignity. Resident #259 stated this made her feel not too good, aggravated and worried that staff had forgotten her. The findings included: Resident #259 was admitted to the facility on [DATE] for Repair of Displaced Spiral Fracture of Right Tibia (a broken lower leg bone in a twisted motion) and Spondylosis (breakdown and separation of the lower spinal vertebra and disks). The 5-Day Admission Minimum Data Set Assessment on 10/25/23 indicated Resident #259 was cognitively intact. She was frequently continent of bladder and continent of bowel function. She had an impairment on her right lower extremity. She required partial/moderate assistance with toileting. Her vision was impaired and used glasses for reading small prints. During an interview on 10/30/23 at 2:52 PM, Resident # 259 said she had periods of urinary incontinence since half of her perineal area was numb. She said she pressed her call light button because she had wet herself on 10/25/23 at 6:20 PM. Resident # 259 said there was a staff member who came after a while to check and ask what she needed and left. She said Nurse #4 came in next after an hour and gave her medications. She said the nurse told her she would leave her call light on and would ask staff to attend to her. She said nobody came to assist her until 9:50 PM. She said she laid in bed wet the whole time. She told the Social Worker and another nurse about the incident 3 to 4 days ago. Resident # 259 said she thought it was the Director of Nursing (DON) and Assistant Director of Nursing (ADON) who went to talk to her that next day, and they had a staff meeting. During a follow-up interview on 11/1/23 at 10:45 AM, Resident # 259 clarified how she kept track of the time she had to wait for staff to assist her in changing her brief. She pointed to the clock in her room above the bathroom door and said that was how she knew how long she waited to be changed on 10/25/23. She said she used to be a nurse and worked in health care and knew she may have to wait a little bit. She stated it was a lady with long black hair that finally helped her at 9:50 PM. She stated she did not feel good about it mentally but physically, the urine started to burn on her back side. Resident # 259 stated what aggravated her the most was that they left her call light on, and she could not press it again when she got worried that the staff had forgotten her. Resident # 259 said she called her family member on her cell phone that night on 10/25/23 and her family member got mad and offered to go to the facility, but she told him not to. She said she had her call light on for twenty minutes the morning of 11/1/23. She said the medication nurse came in to give her medications around 9:00 AM. The nurse told her the staff were passing out ice in the other hallway and left her call light on. Resident # 259 said she got worried and thought here we go again. She said Nurse Aide (NA) #7 finally came after about 20 minutes and assisted her with changing her brief. She stated residents' needs should take precedence over passing out ice. During another follow-up interview on 11/2/23 at 8:55 AM, Resident # 259 said it was Receptionist #1 who came to check on her first the night of 10/25/23. She said she told Receptionist #1 she needed to be dried. Resident # 259 said she could not remember the exact time and said it was between 7:00 to 8:00 PM. She said she was not changed after dinner that night because staff said they could not change anybody until trays were out. She said the staff usually served dinner at 5:30 PM. Resident # 259 said nobody ever turned her call light off when she turned it on, not even the nurse who gave her medication. During an interview on 11/1/23 at 4:05 PM, NA #11 said she worked from 4:00 PM to 7:00 PM on 10/25/23 on D Hall where Resident #259 resided. She said NA #10 took over D Hall at 7:00 PM. She said she did remember Resident # 259's call light was on at dinner time. NA #11 said she went in and asked what the resident needed. She said Resident #259 needed her brief changed. NA #11 said she told Resident # 259 that they were passing out dinner trays and were not allowed to change residents until all trays were passed out. She said she left the call light on and went to help pass out trays. NA #11 said she got re-assigned to work on the A, E and F halls and started doing her rounds. NA #11 stated she did not provide incontinence care to Resident #259 after dinner. Nobody made her aware that Resident # 259's call light was still on after she did her rounds. NA #11 stated she was told by nurses that the resident was pretty much continent but did not want to go to the bathroom. NA #11 said Resident # 259 could go to the bathroom by herself but said she had always changed Resident # 259's briefs when she was assigned to D hall and that the resident never asked for a bed pan. During an interview on 10/31/23 6:05 PM, NA #10 said she worked from 7:00 PM to 7:00 AM on 10/25/23 on B, C and D hall where Resident #259 resided. NA #10 said she did not remember Resident #259's call light being on for a long time. She said that she might have been with another resident in another hall and was doing her rounds with another nurse aide. She said no one told her about Resident #259 needing to be changed and did not notice her call light being on for a long time. NA #10 said there were 2 nurses and 2 nurse aides working on the night of 10/25/23 and that was the normal staffing numbers. She said Resident #259's call light was on when she responded to her, and that the resident did not complain about her call light being on for a long time. NA #10 said the resident needed her brief changed. She said she could not remember exactly what time she responded to the resident's call light but said that was after her rounds at around 9:30 PM. During a follow up telephone interview on 11/1/23 3:20 PM, NA #10 said Resident #259's brief was not fully soaked when she went to change her on 10/25/23. She said the resident's brief was a little wet but not soaking wet. NA #10 reported Resident #259 was able use the bedside commode some. NA #10 said when she went to answer the resident's call light, she just asked to be changed. She said Resident #259 did not say anything about being upset or having to wait for a long time. During a telephone interview on 11/2/23 at 11:55 AM, Receptionist #1 said she answered Resident # 259's call light at around 7:45 pm on 10/25/23. She asked the resident what she needed, and Resident # 259 stated she needed her brief changed. Receptionist #1 said she told Resident # 259 that she would let the staff know. Receptionist #1 stated she saw NA #11 in another hall passing out ice/snack and told her at around 7:50 PM that Resident #259 needed to be changed. Receptionist #1 also found NA #10 near the nurse's station at around 8:03 PM and told her about Resident # 259's brief needing to be changed. Receptionist #1 said she did not see NA #11 go in Resident #259's room and did not see NA #10 go in the resident's room since she clocked out and left after telling NA #10. Receptionist #1 said Resident # 259's call light had been on since after dinner at around 5:30 PM and nobody cut it off, so she went to see what she needed. During a telephone interview on 11/1/23 at 6:50 PM, Nurse #4 said she remembered answering Resident #259's call light last week at around 8:20 PM and asked what the resident needed. She said she could not remember the exact days but Resident #259 told her she needed changed. Nurse #4 said she told Resident #259 that she would tell NA #10 and told the resident she would leave her light on. Nurse #4 said NA #10 was passing out ice and snacks at that time. Nurse #4 said she told NA #10 that Resident #259 would like to be changed if she could. Nurse #4 said NA #10 went to Resident #259's room within 5 minutes. Nurse #4 said she went to pass out medications on the other hall and did not know if Resident #259's brief was changed at that time. Nurse #4 said the nurse aides do what they could. There were not enough of them at night. Nurse #4 said Resident #259's turned her call light on again the next night, and she might have had to wait longer that next night because NA #10 was checking other residents' vital signs and was changing other residents' briefs also. Resident #259 had to wait longer for maybe an hour. Nurse #4 said Resident #259 was concerned her call light was not working that night, but Nurse #4 said it was working because she turned it off while in resident's room and turned it back on when she left Resident #259's room. During a telephone interview on 11/1/23 8:30 AM, the Assistant Director of Nursing (ADON) said the Staff Development Manager told her about Resident #259's complaint on 10/26/23. She said Resident #259 was upset about having to wait for a long time the night before to be changed. The ADON said she and the Social Worker (SW) went in to talk to Resident #259 on 10/26/23. ADON said Resident #259 reported that she turned her light on at around shift change and the nurse came in to give her medication. She said Resident #259's medication nurse told the resident that she would get somebody to help her and that she would leave her call light on so she would not be forgotten. The ADON said Resident #259 told her from 8:00 PM to 8:30 PM, the receptionist went to check on Resident #259 and told resident she would go find someone. The ADON said Resident #259 told her that it was close to 10:00 PM when staff came in to change her. The ADON said Resident #259 did have a clock in her room and had her personal cell phone. The ADON stated it was her expectation for anybody nearby to answer call lights immediately and for the nurses to supervise their nurse aides. She said she was not done with her investigation because NA #10 was not back to work until the evening of 11/1/23. During a telephone interview on 11/2/23 at 3:10 PM, the Director of Nursing (DON) said they have had a staffing problem since she took the DON job 3 months ago. She also stated there was an existing culture problem with regards to not answering call lights immediately in the building. She said it was the Administrator's and her goal to continue improving the building to ensure residents were taken care of. The DON said the nurses were also expected to help check on the call lights and not just the nurse aides. She said she was not aware of a written protocol for nurse aides not to assist in changing resident's briefs if the nurse aides were passing out ice, snacks, or meal trays. She said she recently asked the nurse aides to do their rounds 30 minutes before meals to ensure the residents were dry. She said she asked them to do hourly rounding and was still trying to educate them. The DON said if the rounding was performed correctly, it would help everything including maintaining residents' dignity.

Based on observations and staff interviews, the facility failed to maintain a clean kitchen floor, discard expired food items available for resident use in 1 of 1 walk-in cooler, label and date food in 1 of 1 reach-in refrigerator, maintain a clean refrigerator in 1 of 1 nourishment room on E Hall and maintain air vents free from dust buildup in the kitchen. These practices had the potential to affect food and beverages served to the residents. The findings included: a. An initial observation of the kitchen on [DATE] at 9:10 AM was made with the Dietary Manager (DM). During the observation, the kitchen floor had drops of liquid spilled and when walked across, shoes stuck to the floor. A follow up observation of the kitchen on [DATE] at 11:20 AM revealed a clean, dry floor but shoes still stuck to the floor when walking. A follow up observation on [DATE] at 10:30 AM, revealed a sticky dry floor with several drops of liquids under the tea dispenser. The DM stated that those were spilled tea and would be mopped after serving breakfast. b. An initial observation of the walk-in cooler on [DATE] at 9:12 AM revealed two brown bowls with ,d+[DATE] written on lids and a red gelatin in a small brown cup with ,d+[DATE] written on the lid. The two brown bowls contained light yellow fruit chunks. The Dietary Manager (DM) stated the two brown bowls were pineapple and should have been discarded when they were not served to the residents on [DATE]. She stated the red gelatin should also have been discarded on [DATE]. c. An initial observation of the reach in cooler on [DATE] at 9:20 AM revealed a pack of sliced cheese inside an unlabeled plastic bag. The DM said the kitchen staff used it to make sandwiches the night before. DM took it out and stated the kitchen staff should have put a date and time on it. d. An initial observation of the nourishment refrigerator on E hall on [DATE] at 9:30 AM revealed an unlabeled frozen chocolate milk shake with a straw inside the freezer compartment. The DM stated it belonged to a staff member and stated it should not have been in there. The DM took the milkshake out of the refrigerator and threw it in the trash can. There was also a plastic bag containing a disposable container which was on a glass shelf inside the refrigerator. The plastic bag was labeled with a name and was dated [DATE]. There was a large, dried puddle of a sticky yellowish substance underneath the plastic bag. The shelves on the refrigerator door were dusty and had food crumbs on them. The DM stated the plastic bag was for a resident. The DM wet a bunch of paper towels and wiped down the refrigerator's shelves. During an interview with the Dietary Manager (DM) on [DATE] at 9:35 AM, she stated the kitchen staff was supposed to clean the nourishment refrigerator every day. The DM was not aware when the refrigerator was last cleaned. The DM stated staff were not supposed to store their food in the nourishment refrigerator. She stated she checked the kitchen coolers and freezers three times a week for expired and unlabeled food items and her staff were supposed to check them every day. She stated she did not get to check this morning because a kitchen staff had to leave early, and she had to help with serving breakfast trays. DM stated there were only 2 of them serving breakfast this morning. The kitchen staff should have discarded the expired food items and should have labeled food items before storing them. e. A follow up observation of the kitchen on [DATE] at 11:20 AM revealed an aluminum drying rack containing washed lids and plastic cups was parked close to the kitchen sink. Beside it was an old door with a rectangular vent above the door. The rectangular vent had grates full of thick, black, fibrous, oily looking material. Another aluminum rack containing washed plates was parked across the dishwasher. Above this rack was a square vent on the ceiling. The grates were covered with gray, dusty material. During a follow up observation of the kitchen on [DATE] at 10:30 AM, there was a short aluminum drying rack containing wet blue lids beside the door with a rectangular vent full of thick, black, fibrous, oily looking materials. Another taller aluminum rack containing red cups, blue lids and white dishes was under the square ceiling vent that still had gray dust on its vents. During another follow up kitchen observation on [DATE] at 10:10 AM, the short aluminum drying rack containing white dishes and cups was beside the door with the dirty rectangular vent above it. Another tall aluminum drying rack with lids and dishes was under the dusty square ceiling vent. During an interview with the Dietary Manager (DM) and the Administrator on [DATE] at 10:15 AM, the DM stated the maintenance staff were responsible for cleaning the vents. She stated the maintenance staff cleaned the vents sometime in September of this year. The Administrator pointed out another clean vent over the sink and stated that vent was cleaned but not those two vents. The Administrator stated the kitchen staff were responsible for cleaning the kitchen and food storage and preparation, and maintenance was responsible for cleaning the vents and the ice machine. During an interview on [DATE] at 2:45 PM, the Maintenance Director stated they cleaned the vents today. He said his staff cleaned the vents in September and was not aware where the dirt on the vents came from. The Maintenance Director said there was not a definite schedule, but they tried to clean the vents at least twice a year. He said he did not realize those vents got that dirty. During a follow up interview on [DATE] at 2:58 PM, the Administrator stated the maintenance crew were responsible for cleaning those vents and cleaned them in September. She said maintenance cleaned the vents twice a year and said she would have to look at a definite cleaning schedule.

Based on staff and physician interviews, and medical record review, the facility failed to assess a resident regarding bowel movement frequency and consistency for 1 of 11 residents reviewed for bowel movements (Resident #39). The findings included: Resident #39 was admitted to the facility 09/02/12 with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] indicated impaired cognition and dependence on extensive staff assistance for all care including eating. The MDS specified the resident was incontinent of bladder frequently and bowel always and no problems with constipation were identified. The MDS pain assessment noted Resident #39 received pain medications as needed and no signs of experienced pain were observed in the past 5 days. A quarterly MDS dated [DATE] was unchanged. A care plan dated 09/11/12 documented Resident #39 was incontinent of bowel and bladder. The care plan goal was to keep the resident clean and dry and decrease the number of incontinent episodes over next 3 months. Interventions included nurses would monitor bowel patterns. A care plan related to alteration in comfort and dated 09/11/12 specified Resident #39 experienced acute pain episodes. The care plan goal was for the resident not to experience unrelieved pain. Interventions included administer pain medication per physician's orders [REDACTED]. A review of a physician's progress note dated 12/07/12 revealed Resident #39 was receiving 2 laxatives daily. The laxatives were listed as Senna-S one tablet twice a day and [MEDICATION NAME] 17 grams (g) daily. Pain medication was listed as [MEDICATION NAME] 10/325 milligrams (mg) 1 tablet 4 times daily and every 6 hours as needed (PRN) for pain. The physician's assessment documented the resident's constipation status had improved. A review of the December 2012 Medication Administration Record (MAR) revealed Resident #39 was on a pureed [MEDICATION NAME] diet with regular liquids. The MAR indicated the resident received the Senna-S twice a day and [MEDICATION NAME] daily as ordered by the physician. The [MEDICATION NAME] was administered 4 times a day as scheduled except for 12/03/12, 12/16/13, and 12/17/13. Nursing notes indicated the resident was sleeping for the 12:00 AM dose and was not awakened. No PRN pain medication was administered during the month. A physician's progress note dated 01/04/13 indicated the resident was seen by the physician related to constipation issues. The note specified Resident #39 had received enemas but was still not totally cleaned out. The physician's physical examination revealed the resident's abdomen was soft and non tender. The physician further documented the pain medication contributed to the constipation problems. His plan included decreasing pain medication dosage by one half, increasing dosages Senna-S to 2 tablets twice a day and [MEDICATION NAME] 17 g to twice a day, and the addition of [MEDICATION NAME] 30 mililiters (ml) at bedtime. The physician also ordered 3 [MEDICATION NAME] suppositories to be administered on this date. A review of physician orders [REDACTED]. A review of the 01/01/13 through 01/10/13 MAR revealed the laxative suppositories were added to the MAR but were not initialed as administered. The MAR indicated the additional doses of Senna-S and [MEDICATION NAME] were added and initialed as administered twice everyday. The [MEDICATION NAME] was added and initialed as administered daily. An interview was conducted via phone with Nurse #2 on 03/27/13 at 6:15 PM. Nurse #2 confirmed she worked nights at the facility. Nurse #2 stated she administered the 3 laxative suppositories ordered by the physician on 01/04/13 and did not initial the MAR. Nurse #2 added the results were documented by the NA on the bowel and bladder detailed entry report. A review of a bowel and bladder detailed entry report reveled documentation by nurse aides regarding frequency and consistency of bowel movements. On 12/31/12 through 01/03/12 no bowel movements were documented. A medium formed and was documented on 01/03/13. On 01/04/13 a medium formed stool was documented at 2:16 PM by Nurse Aide (NA) # 1 and a large loose stool by NA #2 at 10:16 PM. An interview with Nurse #1 was conducted on 03/28/13 at 8:29 AM. Nurse #1 stated she worked 01/03/13 and 01/04/13 and had administered a total of 3 enemas to Resident #39. She described the results as a small to medium amount of formed to loose stools. Nurse #4 stated when the physician made rounds around 3:00 PM on 01/04/13, she reported the results of the enemas to him. Nurse #1 explained she did not document the enemas, results of the enemas, or notification of the physician. She added she should have documented her assessments and all she did regarding Resident #39's bowel status. Continued review of the bowel and bladder detailed entry report revealed on 01/05/13 a large loose stool was documented at 3:04 AM by NA #3 and 4:56 AM by NA #4, a small loose stool at 2:40 PM by NA #5, and a large loose stool at 5:35 PM by NA #6. On 01/06/13 a large loose stool was documented at 5:25 AM by NA # 4 and at 2:32 PM by NA #5. There were no stools documented on 01/07/12 or 01/08/12. On 01/09/12 an extra-large loose stool was documented at 2:35 AM by NA #3 and a large loose stool documented at 5:01 AM by NA #4. An interview was conducted via phone with NA #3 on 03/27/13 at 2:55 PM. She described Resident #39's bowel movements on 01/05/13 and 01/09/13 as loose and runny and not dark in color. NA #3 stated the stools were so large, complete bed changes were required. She stated she reported the loose stools to the hall nurse. An interview was conducted via phone with NA #4 on 03/27/13 at 2:59 PM. NA #4 reported there was a stomach virus going around the facility during the first of January 2013. She described Resident #39's stools as runny and watery and not hard. She stated she reported the loose stools to the hall nurse. An interview was conducted with NA #5 on 03/27/13 at 2:11 PM. NA #5 stated she worked 01/05/13 and 01/06/13. She stated she did report the stool on 01/06/13 because it was so large. NA #5 described Resident #39 without demonstrating signs of discomfort. NA #5 added at the time the resident was having loose stools, other residents in the facility were doing the same. She stated there was [MEDICAL CONDITION] going around involving residents and staff. An interview was conducted via phone with NA #6 on 03/27/13 at 3:30 PM. NA #6 stated she recalled Resident #39 had large stools that required a complete bed change. She described the stools as grainy and not formed. NA #6 stated it was her normal practice to report diarrheal stools to the nurse but was unable to recall if she reported the loose stool on 01/06/13 to the hall nurse. An interview was conducted via phone with Nurse #3 on 03/27/13 at 3:05 PM. She stated she worked 01/05/13 and 01/06/13 at the facility. Nurse #3 did not recall any reports of loose stools regarding Resident #39. She stated during the first week in January several residents developed a stomach virus and had loose stools. A review of Resident #39's nursing notes from 12/31/12 through 01/10/13 revealed no documentation of enemas received or results of these enemas. No assessments related to frequency or consistency of bowel movements or abdominal status were documented. Continued review of nursing notes revealed no documentation of administration of laxative suppositories or results produced by the suppositories. Review of a nursing note dated 01/10/13 at 9:00 AM revealed documentation of a phone call from Resident #39's attending physician. The note specified the physician notified the facility that the resident had been admitted to an acute care facility from the wound clinic. A review of a History and Physical (H&P) dated 01/10/13 and written by the acute care facility physician was conducted. The H&P specified Resident #39 was sent to the wound clinic for treatment of [REDACTED]. Nursing assessments in the wound clinic revealed the resident exhibited an increased in pulse and a decrease in blood pressure. The resident was sent to the emergency department (ED) for evaluation. In the ED Resident #39 was assessed with [REDACTED]. A digital rectal examination by the ED physician resulted in palpation of hard impacted stool. An abdominal x-ray showed a fecal impaction with dilatation of the lower colon. The H&P specified the pain medication more than likely contributed to the constipation. A review of a Discharge Summary (DS) dated 01/18/13 revealed Resident #39 was sent back to the long term care facility in stable condition. The DS described the resident's hospital course involved resolution of a fecal impaction that included a variety of treatments. Discharge [DIAGNOSES REDACTED]. A review of Resident #39's medical record revealed when the resident returned to the long term care facility, the care plan was not updated to address constipation monitoring or treatment. An interview was conducted via phone on 03/27/13 at 5:49 PM with the Medical Director (MD) that was the attending physician for Resident #39. The MD stated when he visited the facility on 01/04/13 he was verbally informed by the nurses regarding administration of enemas and the constipation problems exhibited by the resident. He stated he examined Resident #39 and described his findings in the physician's progress notes of 01/04/13. The MD stated he changed the resident's medications as was also documented in the progress notes. He stated he does not recall being notified regarding consistency of bowel movements after his orders on 01/04/13. He added he remembered verbal reports that the resident was having bowel movements. The MD stated he wanted the stools to be loose, but not watery. If he had known the consistency and frequency of the bowel movements, he would have adjusted the resident's medications, ordered an abdominal x-ray, and asked the nurses to perform a digital rectal examination. The MD explained loose bowel movements could mean stool was moving around an impaction. An interview was conducted with the Director of Nursing (DON) on 03/27/13 at 6:21 PM. She stated she reviewed a bowel movement report in January and noted Resident #39 was having bowel movements. This report did not specify consistency and she stated she was unaware of the consistency of the stools. The DON explained if she had noted the stools were loose, she would have thought the resident had the stomach virus diagnosed in many other residents and staff at that time. An additional interview with the Director of Nursing (DON) was conducted on 03/28/13 at 10:47 AM. The DON stated she reviewed the bowel reports for Resident #39 from 10/01/12 through 01/10/13. She reported the documentation revealed 38% of the resident's bowel movements were loose and 62% were formed. The DON added no stools were documented as hard. The DON stated she expected nurses to assess residents with bowel concerns and to document assessments performed and medications administered.

Based on staff and physician interviews and medical record review, the facility failed to notify the physician regarding resident response to treatments of constipation to prevent a fecal impaction for 1 of 3 residents reviewed for notification of change. (Resident #39) The findings included: Resident #39 was admitted to the facility 09/02/12 with [DIAGNOSES REDACTED]. A care plan dated 09/11/12 documented Resident #39 was incontinent of bowel and bladder. The care plan goal was to keep the resident clean and dry and decrease the number of incontinent episodes over next review period. Interventions included nurses would monitor bowel pattern. A physician's progress note dated 01/04/13 indicated the resident was seen by the physician related to constipation issues. The note specified Resident #39 had received enemas but was still not totally cleaned out. The physician's physical examination revealed the resident's abdomen was soft and non tender. His plan included decrease of pain medication dosage, increasing dosages of current laxatives with the addition of another daily laxative and 3 laxative suppositories to be administered on this date. A review of physician orders [REDACTED]. A review of a bowel and bladder detailed entry report from 01/05/13 through 01/10/13 revealed documentation by nurse aides regarding frequency and consistency of bowel movements. On 01/05/13 a large loose stool was documented at 3:04 AM by NA #3 and 4:56 AM by NA #4, a small loose stool at 2:40 PM by NA #5, and a large loose stool at 5:35 PM by NA #6. On 01/06/13 a large loose stool was documented at 5:25 AM by NA # 4 and at 2:32 PM by NA #5. There were no stools documented on 01/07/12 or 01/08/12. On 01/09/12 an extra-large loose stool was documented at 2:35 AM by NA #3 and a large loose stool documented at 5:01 AM by NA #4. No stools were documented on 01/10/13. An interview was conducted via phone with NA #3 on 03/27/13 at 2:55 PM. She described Resident #39's bowel movements on 01/05/13 and 01/09/13 as loose and runny and not dark in color. NA #3 stated the stools were so large, complete bed changes were required. She stated she reported the loose stools to the hall nurse. An interview was conducted via phone with NA #4 on 03/27/13 at 2:59 PM. NA #4 described Resident #39's stools on 01/05/13 and 01/06/13 as runny and watery and not hard. She stated she reported the loose stools to the hall nurse. An interview was conducted with NA #5 on 03/27/13 at 2:11 PM. NA #5 stated she worked 01/05/13 and 01/06/13. She stated she did report the stool to the hall nurse on 01/06/13 because it was so large. An interview was conducted via phone with NA #6 on 03/27/13 at 3:30 PM. NA #6 stated she recalled Resident #39 had large stools that required a complete bed change. She described the stools as grainy and not formed. NA #6 stated it was her normal practice to report diarrheal stools to the nurse but was unable to recall if she reported the loose stool on 01/06/13 to the hall nurse. An interview was conducted via phone with Nurse #3 on 03/27/13 at 3:05 PM. She stated she worked 01/05/13 and 01/06/13 at the facility. Nurse #3 did not recall any reports of loose stools regarding Resident #39. She stated during the first week in January several residents developed a stomach virus and had loose stools. A review of Resident #39's nursing notes from 01/05/13 through 01/10/13 revealed no documentation of reporting laxative results or stool consistency and frequency to the physician. Review of a nursing note dated 01/10/13 at 9:00 AM revealed documentation that Resident #39 had been sent to an acute care facility for evaluation of nausea and vomiting. A review of a History and Physical (H&P) dated 01/10/13 and written by the acute care facility physician was conducted. The H&P specified Resident #39 was sent to the wound clinic for treatment of [REDACTED]. Nursing assessments in the wound clinic revealed an increase in pulse and a decrease in blood pressure. The resident was sent to the emergency department (ED) for evaluation. In the ED Resident #39 was assessed with [REDACTED]. A digital rectal examination by the ED physician resulted in palpation of hard impacted stool. An abdominal x-ray showed a fecal impaction with dilatation of the lower colon. Review of a Discharge Summary dated 01/18/13 revealed Resident #39 was sent back to the long term care facility with [DIAGNOSES REDACTED]. An interview was conducted via phone on 03/27/13 at 5:49 PM with the Medical Director (MD) and attending physician for Resident #39. The MD stated when he visited the facility on 01/04/13 he was verbally informed by the nurses regarding administration of enemas and the constipation problems exhibited by the resident. He stated he examined Resident #39 and described his findings in the physician's progress notes of 01/04/13. The MD stated he changed the resident's medications as was also documented in the progress notes. He stated he does not recall being notified regarding consistency of bowel movements after his orders were written on 01/04/13. He added he remembered being told the resident was having bowel movements. The MD stated he wanted the stools to be loose, but not watery. If he had known the consistency and frequency of the bowel movements, he would have adjusted the resident's medications, ordered an abdominal x-ray, and asked the nurses to perform a digital rectal examination to check for impaction. The MD explained loose bowel movements could mean stool was moving around an impaction. An interview with the Director of Nursing on 03/28/13 at 2:25 PM revealed she expected nurses to notify the physician of changes in condition and unexpected results from laxatives.