Every finding on record at Villa Manor Care Center

Based on record review and interviews, the facility failed to develop and implement policies and procedures related to immunizations for five (#4, #6, #12, #38 and #58) of five residents reviewed for immunizations out of 37 sample residents.Specifically, the facility failed to:-Ensure the residents medical records indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and,-Ensure the residents medical records documented if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Findings include:I. Professional referenceAccording to the Centers for Disease Control's (CDC) Staying Up to Date with COVID-19 Vaccines, updated 11/19/25, retrieved on3/30/26 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, read in pertinent part, Getting the 2025-2026 COVID-19 vaccine is important because:-Protection from the COVID-19 vaccine decreases with time;-Immunity after COVID-19 infection decreases with time; and,-COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. Getting the 2025-2026 COVID-19 vaccine is especially important if you:-Never received a COVID-19 vaccine;-Are ages 65 years and older;-Are at high risk for severe COVID-19; and,-Are living in a long-term care facility.II. Resident #4 A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the 1/7/26 minimum data set (MDS) assessment diagnoses included stroke, CAD (coronary artery disease), hypertension, hyponatremia, hyperlipidemia, dementia, hemiplegia or hemiparesis (weakness and paralysis) and malnutrition. The assessment documented the resident was cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not received.B. Record reviewA review of Resident #4's immunization record in the electronic medical record (EMR) failed to reveal documentation requesting or offering the SARS-COV-2 (COVID 19) vaccination. III. Resident #6 A. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the 12/31/25 MDS assessment diagnoses included stroke, anemia, hypertension, diabetes mellitus, hyperlipidemia, dementia, and hemiplegia or hemiparesis. The assessment documented the resident was cognitively impaired with a BIMS score of five out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not receivedB. Record reviewA review of Resident #6's immunization record in the EMR failed to reveal documentation requesting or offering the SARS-COV-2 (COVID 19) vaccination. IV. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on [DATE]. According to the 3/9/26 MDS assessment diagnoses included anemia, hypertension, hyponatremia, hyperlipidemia, aphasia, and hemiplegia or hemiparesis. The assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not received.B. Record reviewA review of Resident #12's immunization record in the EMR failed to reveal documentation requesting or offering the SARS-COV-2 (COVID 19) vaccination. The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not receivedV. Resident #38 A. Resident statusResident #38, age greater than 65, was admitted on [DATE]. According to the 2/10/26 MDS assessment, diagnoses included CAD, heart failure, hypertension, PVD (peripheral vascular disease), GERD (gastroesophageal reflux disease, renal failure, arthritis and respiratory failure. The assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not receivedB. Record reviewA review of Resident #38's immunization record in the EMR failed to reveal documentation requesting or offering the SARS-COV-2 (COVID 19) vaccination. C. Resident interviewResident #38 was interviewed on 3/25/26 at approximately 4:00 p.m. Resident #38 said she remembered receiving the flu shot at the facility. She said she received a vaccination sheet from the facility on 3/18/26 that documented she was due for a COVID-19 vaccine on 3/18/26. She said she did not remember being offered the COVID-19 vaccine in October 2025, but she said she never refused a shot.VI. Resident #58A. Resident statusResident #58, age greater than 65, was admitted on [DATE]. According to the 3/24/26 MDS assessment diagnoses included CAD, hypertension, heart failure, hyperlipidemia, dementia, fracture, anxiety and depression. The assessment documented the resident was severely cognitively impaired with a BIMS score of three out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not receivedB. Record reviewA review of Resident #12's immunization record in the EMR failed to reveal documentation requesting or offering the SARS-COV-2 (COVID 19) vaccination. VII. Record reviewA COVID-19 2025 document was provided by the director of nursing (DON) on 3/25/26 at approximately 4:00 p.m. The document listed columns titled resident room, resident name, [NAME] (manufacturer), brand and yes or no.-However, the document failed to include education that was provided to the resident regarding the risks and benefits of the COVID-19 vaccine.VIII. Staff interviewsThe infection preventionist (IP) and director of nursing (DON) were interviewed together on 3/25/26 at 3:23 p.m. The IP said the COVID-19 vaccine was offered to residents at the same time as the flu vaccine in the fall (2025). The IP said the residents that wanted the COVID-19 vaccine signed up and the ones who declined did not sign anything. The IP said all the education provided to the residents about the COVID-19 vaccine was verbal.The DON said the facility completed verbal education with the residents when the facility offered the flu and COVID-19 vaccines. The DON said the facility obtained consent for the vaccine for residents who received the vaccine. The DON said the residents were offered the COVID-19 vaccine at the same time as the flu vaccine, and those residents that requested the COVID-19 vaccine received it. The IP said she saved the documentation of the resident refusals of the COVID-19 vaccine (see record review above).

Based on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care to residents who were on enhanced barrier precautions (EBP). Findings include: I. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 3/30/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. II. Facility policy and procedure The Infection Control policy, revised 6/13/26, was received from the nursing home administrator (NHA) on 3/23/26 at 5:36 p.m. The policy read in pertinent part, The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Standard and transmission-based precautions to be followed to prevent spread of infections; When and how isolation should be used for a resident; including but not limited to the type and duration of the isolation, depending upon the infectious agent or organism involved, and a requirement that the isolation should be the least restrictive possible for the resident under the circumstances III. Observations On 3/24/26 at 11:17 a.m. there was a sign on Resident #6's door indicating the resident was on EBP. An unidentified nursing staff member entered the room. The unidentified staff member assisted the resident with dressing and transferring from their bed to chair transfer without donning (putting on) a gown. -The unidentified staff member failed to put on a gown prior to providing Resident #6 with direct care. On 3/24/26 at 3:01 p.m. two unidentified nursing staff members transferred Resident #70 into the shower chair via mechanical lift with gloves on. The resident had a foley catheter and a colostomy bag. -The two unidentified staff members failed to put on gowns prior to providing Resident #70 with direct care. On 3/25/26 at 7:42 a.m. two unidentified staff members were transferring Resident #70 into his mechanical wheelchair from his bed via mechanical lift. -The two unidentified staff members failed to put on gowns prior to providing Resident #70 with direct care. IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/26/26 at 2:19 p.m. She said if a resident was on EBP she would wear gloves and a gown. She said Resident #6 was on EBP because he had a colostomy bag. She said she did not need to wear gloves and a gown when changing linen, dressing the resident or transferring the resident from bed to chair. She said she was provided training from the facility on EBP three weeks ago, but did not remember all the details. She said she was advised that every precaution signage was different and to read all the details and instructions on the sign on a resident's door. Registered nurse (RN) #3 was interviewed on 3/26/26 at 2:47 p.m. RN #3 said Resident #70 had a physician's order for EBPShe said gloves and a gown should be worn by the facility staff when transferring, dressing, providing toileting and shower hygiene. She said the resident was on EBP because he had a suprapubic foley catheter. She said EBP was utilized to protect the resident from infection because they were at a high risk for acquiring an infection. She said she received training on EBP a month ago at a facility skills fair. She said Resident #6 was also on EBP related to a superficial wound on abdominal area. She said the same EBP considerations would apply to Resident #6. The director of nursing (DON), infection preventionist (IP) and the regional clinical resource nurs were interviewed together on 3/26/26 at 3:26 p.m. The IP said she started working at the facility as the infection preventionist in August of 2023. She said her goals were to help prevent the spread of infection to the facility residents. The IP said gloves and a gown should be worn during high-contact resident care activities if a resident had a wound, foley catheter, Intravenous device, feeding tube or tracheostomy. The DON said high-contact resident care activities included dressing, bathing and showering, transferring, changing linens, providing hygiene and assisting with toileting care. The regional clinical resource nurse said she would start education immediately for facility staff regarding the procedures and requirements when a resident was on EBP. V. Additional observations On 3/24/26 at 3:08 p.m. RN #4 entered Resident #76. RN #4 assisted Resident #76 transfer from her chair to go to the bathroom. RN #4 adjusted her legs off of the chair footrest, placed arms around her waist, then assisted Resident #76 to her wheelchair. There was an EBP sign posted on Resident #76`s door. The sign read Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities - dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, trachetomy. Wound care: any skin opening requiring a dressing. -RN #4 failed to wear a gown and gloves when providing direct care to Resident #76. On 3/24/26 at 3:16 p.m. RN #4 entered Resident #76`s room to assist help Resident #76 transfer back to her chair. She adjusted Resident #76's legs to the floor. She placed her arms around Resident #76`s waist and assisted her to pivot back to her chair. -RN #4 failed to wear a gown and gloves when providing direct care to Resident #76. On 3/25/26 at 7:18 a.m. CNA #5 entered Resident #76`s room. He wore gloves. He measured Resident #76`s blood pressure. Then CNA #5 assisted Resident #76 to the bathroom. -CNA #5 failed to don a gown. On 3/25/26 at 11:41 a.m an unidentified CNA entered Resident #76`s room. She placed Resident #76`s heel protector boots. Resident #76 had a wound. -The unidentified CNA failed to put on a gown and gloves when providing direct care to Resident #76. VI. Staff interviews CNA #5 was interviewed on 3/26/26 at 10:52 a.m. He said residents with open wounds, catheter, intravenous therapy, pneumonia or other contagious disease should be on EBP. He said Resident #8 should be on EBP, because he had a PICC. He said staff should wear gown, mask, eyewear or faceshield, and gloves when providing direct care to Resident #8. LPN #3 was interviewed on 3/26/26 at 6:29 p.m. She said residents with catheters, ostomy bags, PICC lines, or open wounds should be on EBP. She said Resident #8 and Resident #76 should be on EBP. The IP was interviewed on 3/26/26 at 3:27 p.m. She said residents with a PICC line should be on EBP. She said residents with open wounds should be on EBP.

Based on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#70) of five residents out of 37 sample residents reviewed for respect and dignity.Specifically, the facility failed to ensure Resident #70 was covered appropriately during transport through the facility hallway. Findings include:I. Resident #70A. Resident statusResident #70, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs and a torso caused by a spinal cord injury), diabetes type two, muscle weakness, contractures of the upper left and right arm, major depressive disorder and anxiety.The 2/17/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff for showers, toileting hygiene, upper and lower body dressing and oral hygiene. The resident was dependent on facility staff for chair to chair transfers and tub to shower transfers. B. ObservationsOn 3/24/26 at approximately 3:20 p.m. Resident #70 was being transported by facility staff in a white shower chair in the hallway from one shower room to another shower room. Resident #70 was covered with a white bed sheet exposing his back, lower torso, thighs and feet. Four other facility residents were present in the hallway while Resident #70 were transferred.On 3/24/26 at 3:40 p.m. Resident #70 was transported by facility staff to his room. Resident #70 was covered with two towels in a chair, he was naked underneath and did not have any clothes on. The resident was visible from his bare knee up to his mid waist on each side. There were four residents in the common areas of the hallway in the common area between the units that were visible to the resident. The resident was taken to the shower, a towel was wrapped around his hair.C. Record reviewResident #70's activities of daily living (ADL) care plan, dated 7/4/2020, documented Resident #70 had an activity of daily living self-care performance deficit due to muscle weakness, poor trunk control and cognitive impairment. Pertinent interventions included providing the resident assistance from two facility staff for transferring and shower hygiene. D.Staff Interviews Registered nurse (RN) #3 was interviewed on 3/26/26 at 2:47 p.m. She said residents should always be fully covered after a shower. She said the nursing staff could use sheets and towels to provide privacy. She said the staff were to ensure the resident's skin was not exposed when assisting a resident from the shower back to their room. She said it was important that the facility staff respect the residents because they were people too. The director of nursing (DON) was interviewed on 3/26/26 at 3:19 p.m. She said the facility had an expectation for nursing staff regarding providing facility residents showers assistance. The DON said the staff should cover the resident. The DON said residents should be covered and ensure dignity was preserved. The DON said making sure residents covered after bathing could be done in a variety of ways and it could be as simple as a bath sheet. Certified nurse aide (CNA) #4 was interviewed on 3/26/26 at 6:40 p.m. She said she had worked as a CNA for over 30 years. She said she gave the residents showers as a part of her staff responsibility and daily task. She said she put the resident in the shower chair with their clothes on, assisted the resident into the shower room with a new change of clothes, and after the shower was complete, she would change the resident into the new clothes. She said she never brought a resident in the hall with only a sheet draped over them because she would not want someone doing that to her. She said she wanted to preserve their resident respect and dignity. She said she had seen other staff assist residents out of the shower room with only a sheet on. She said she did not think that was the right thing to do.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#85) of five residents reviewed for abuse out of 13 sample residents.Specifically, facility staff failed to report an allegation of abuse by Resident #85 towards Resident #79 to the facility's abuse coordinator and the State Agency. Findings include:I. Facility policy and procedureThe Abuse-Inservice Training policy, reviewed 6/17/24, was provided by the nursing home administrator (NHA) on 3/23/26 at 9:42 a.m. It read in pertinent part, The facility will maintain an effective training program for all staff, which included, at a minimum, training on abuse, neglect, exploitation of resident property, and dementia management, that is appropriate and effective, as determined by staff need and the facility assessment. Facilities must also provide training to their staff that at a minimum educates staff on procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property. Procedure: Staff orientation and training included the prohibition of all forms of abuse, neglect and exploitation prohibition. The training must address forms of abuse, neglect, misappropriation of resident property, exploitation and dementia management; identifying physical or psychosocial indications of abuse (including injuries from an unknown source), neglect, exploitation and misappropriation of resident property from situations which include, but are not limited to verbal, mental, sexual or physical abuse; and identifying physical or psychosocial indicators of abuse; and facility procedures and federal and state requirements for reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, time frames of reporting, and to whom staff and others must report their knowledge related to any alleged violation without fear of retaliation.II. Resident #85 (assailant) A. Resident statusResident #85, age greater than 65, was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (COPD), congestive heart failure, vascular dementia and peripheral vascular diseaseThe 3/3/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He needed substantial/maximum assistance with hygiene and bathing, and lower body dressing, and set up with other activities of daily living (ADL).The MDS assessment documented the resident had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). The MDS assessment documented the resident's behavior status, care rejection, or wandering was worse compared to the prior assessment.B. Record reviewResident #85's psychosocial care plan, revised 5/22/23, documented the resident had a psychosocial wellbeing problem/low mood related to labile mood due to his diagnosis of dementia with behaviors. The resident had a history of isolation and decreased socialization. Pertinent interventions, initiated 8/12/19, included that when conflict arose, to remove residents to a calm safe environment and allow the resident to vent and share his feelings. A review of the state reporting portal failed to reveal an allegation of abuse was reported.III. Resident #79 (victim)A. Resident statusResident #79, age greater than 65, was admitted on [DATE]. According to the 2/2/26 MDS assessment diagnoses included cancer, hypertension, peripheral vascular disease and renal failure.The MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She needed supervision with shower transfers and was independent with all other activities of daily living.The MDS assessment documented the resident had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) The MDS assessment documented the resident rejected care. B. Resident interviewResident #79 was interviewed on 3/24/26 at 3:51 p.m. Resident #79 said Resident #85 had called her names. She said he called her an explicit word and made an obscene hand gesture toward her. Resident #79 said the incident happened approximately two to three weeks ago. Resident #79 said she told the social worker and a unit manager. She said she quit going to the unit manager because nothing was done, but the NHA did something about it.-However, staff interviews (see below) revealed allegations of abuse were not reported to the NHA and the facility was unable to provide documentation the allegations were reported to the State Agency.IV. Staff interviewsThe NHA was interviewed on 3/24/26 at approximately 4:00 p.m. The NHA said the staff had not reported an incident between Resident #85 and Resident #79 as reported by Resident #79 (see resident interview above).The concierge was interviewed on 3/26/25 at 3:32 p.m. The concierge said she had observed behaviors for Resident #85. She said Resident #85 told her he just did not like Resident #79. The concierge said on 3/25/26 she was approached by the activities director. The concierge said the activities director asked the concierge on 3/25/26 if she saw Resident #85 call Resident #79 an explicit word and make an obscene gesture the previous day (on 3/24/26 - during the survey). The concierge said the activities director told her it happened again during Bingo (during the survey). Registered nurse (RN) #2 was interviewed on 3/26/25 at 3:30 p.m. RN #2 said she had seen Resident #85 make an obscene gesture toward Resident #79 and Resident #79 did see him. RN #2 said the incident happened at the end of February 2026. RN #2 said she did not report the incident to anyone. She said she did not know that she had to report the incident to the NHA at the time of the incident, but learned she should have reported it after she received abuse education (after the incident).The NHA was interviewed again on 3/26/26 at 3:45 p.m. The NHA said staff had not reported to him any allegations of incidents between Resident #85 and Resident #79 that occurred during the survey.The NHA and the director of nursing (DON) were interviewed together on 3/26/26 at approximately 6:30 p.m. The NHA said he was the abuse coordinator for the facility and staff should report allegations of abuse to him. The DON said the abuse coordinator's phone number was posted throughout the facility. The DON said if the staff were unable to reach the NHA they could call her if needed.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#4 and #58) of three residents reviewed for accidents out of 36 sample residents.Specifically, the facility failed to ensure Resident #4 and Resident #58's fall interventions were consistently implemented. Findings include: I. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included muscle weakness, dementia, respiratory failure, muscle weakness, and a history of falling. The12/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of five out of 15. The resident required substantial to maximum assistance with chair-to-chair transfers, toileting hygiene, and lower body dressing. The MDS assessment indicated Resident #4 had a recent fall at the facility. B. Observations On 3/24/26 at 11:30 a.m. Resident #4 was in his bed There was not a fall mat next to his bed. The resident was wearing black socks that were not non-skid socks. During a continuous observation on 3/24/26, beginning at 2:19 p.m. and ending at 4:15 p.m., the following was observed: At 2:19 p.m. Resident #4 was lying in his bed with his room door open. There was not a fall mat next to the resident's bed. There was a fall mat behind the chair in the resident's room. The resident had regular socks on both feet. At 2:22 p.m. Resident #4 turned his call light on above his bedroom door for staff assistance. At 2:23 p.m. an unidentified staff member walked past the Resident #4's room with his call light on above his bedroom door. At 2:30 p.m. the maintenance director answered the resident's call light and asked the resident if he needed anything. The resident replied and said he did not need anything. Staff did not put the fall mat in place. At 2:33 p.m. Resident #4 was sitting on the edge of the bed when the same unidentified CNA entered the resident's room and asked the resident if he needed anything. The resident said he wanted a banana. There was not a fall mat next to the resident's bed. The fall mat was folded behind the resident's chair. The resident was wearing regular socks on both feet. At 3:58 p.m. Resident #4 put on his call light for assistance. On 3/25/26 at 7:40 a.m Resident #4 was lying in his bed on his left side facing his bedroom wall. The resident was not wearing non-slip socks. The fall mat remained folded behind the resident's chair. C. Record review The fall care plan, initiated 4/8/24 and revised 6/1/25, revealed Resident #4 was at risk for falls related to impaired mobility, cognitive deficit, poor safety awareness, use of high risk medications, history of falling, adjustment to new environment and advanced age. Pertinent interventions included ensuring the resident was wearing non-slip socks (initiated 8/5/24), placing the bed in low position (initiated 4/8/24) and placing fall mat next to the resident's bed (initiated 1/9/26). -However, the fall mat was not consistently in place and the resident was not wearing non-slip socks (see observations above). A nursing progress note, dated 2/22/26 at 12:31 p.m., revealed the resident had an unwitnessed fall. According to the note the resident was heard yelling for help when facility staff entered the room. The resident was found sitting on the floor in front of his bed wearing socks with no shoes and trying to sit on the wheelchair to go to the bathroom. The resident was placed in his bed by facility staff using a mechanical lift. The resident was assessed with no injury, neurological checks were initiated and the resident's call light was placed within reach. The 2/22/26 facility investigation for Resident #4's fall was received from the NHA on 3/26/26 at approximately 1:30 p.m. The investigation documented that on 3/19/26 Resident #4 was found in his room on the floor next to his bed and reported to have an unwitnessed fall by facility staff. The investigation noted the resident's fall care plan was reviewed and updated. A nursing progress note, dated 3/19/26 at 10:00 a.m., revealed the resident had an unwitnessed fall. The staff found the resident on the floor next to his bed and the resident was unable to describe the incident according to staff. The resident was assessed with no injuries. The resident was assisted back to his bed and was provided a floor mat. Neurological checks were initiated. The 3/19/26 facility investigation for Resident #4's fall was received from the NHA on 3/26/26 at approximately 1:30 p.m. The investigation documented that on 3/19/26 Resident #4 was found in his room on the floor next to his bed and reported to have an unwitnessed fall by facility staff. The investigation noted the resident fall care plan was reviewed and updated. A nursing progress note, dated 3/24/26 at 2:09 a.m., revealed the resident had an unwitness fall. The resident was found by facility staff on his knees in front of his bed on the floor. The resident had bruising on his knees with no complaints of pain and no injury to the head was noted. The resident was assessed and found to have no injuries and was assisted back to bed by facility staff. Neurological assessments were initiated and the resident would be monitored per facility protocol A fall assessment, dated 3/24/26, revealed Resident #4 had three or more falls in the past 90 days. The 3/24/26 facility investigation for Resident #4's fall was received from the NHA on 3/26/26 at approximately 1:30 p.m. The investigation documented that on 3/24/26 Resident #4 was reported to have an unwitnessed fall. Nursing staff reported hearing yelling from Resident #4's room. The resident was assessed with no injuries noted. The investigation noted the fall care plan was reviewed and updated. -The investigation report failed to mention if the resident had his fall mat in place at the time he was found by facility staff. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/26/26 at 2:19 p.m. She said Resident #4 was a fall risk. She said the resident had fallen at the facility in the past. She said she could locate fall interventions in the resident's chart and obtain a verbal report from the nurse. She said some of the interventions for Resident #4 include maintaining a low bed and making sure he had his fall mat next to his bed. She said she checks on the resident often when the resident was in his bed to make sure the resident's fall mat and non-skid socks were in place. Registered nurse (RN) #3 was interviewed on 3/26/26 at 2:47 p.m. She said Resident #1 was a fall risk because he became confused. She said the resident would roll over out of his bed onto the floor. She said because Resident #4 rolled out of his bed, the facility nursing staff used a fall mat and non-skid socks as fall prevention interventions. She said the nursing staff were responsible for ensuring that these fall prevention measures were in place. She said fall prevention interventions should be added to the residents care plan for nursing staff to access. The director of nursing (DON) and the regional clinical resource nurse were interviewed together on 3/26/26 at 4:42 p.m. The DON said Resident #4 had sustained multiple unwitnessed falls at the facility. She said the resident often rolled out of bed while trying to transfer to his wheelchair. The DON said Resident #4 should have his non-skid socks on and his fall mat next to his bed, because it was one of his fall interventions. The DON said it was the responsibility of all facility nursing staff to ensure Resident #4 had his fall intervention in place such as his fall mat and non-skid socks. The regional clinical resource nurse said the fall mat was important because it would lessen the likelihood of a possible injury in the event of the resident having another fall. II. Resident #58 A. Resident status Resident #58, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included hypertensive heart disease with heart failure, endocarditis (bacterial infection of the heart), chronic obstructive pulmonary disease (COPD), restless leg syndrome, and burst fracture of T11-T12 (middle spine) vertebrae. The 3/15/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. The resident needed substantial assistance or was dependent on staff for all activities of daily living (ADLs). B. Observations On 3/24/26 at 9:20 a.m. Resident #58 was in bed. The resident did not have a fall mat on the floor by his bed. The fall mat was folded in the corner of the room against the wall. On 3/24/26 at 4:32 p.m. Resident #58 was in bed. The resident did not have a fall mat on the floor by his bed. The fall mat was folded in the corner of the room against the wall. At 4:36 p.m. an unidentified staff member passed by Resident #58's room and did not move the fall mat to the floor by the resident's bed. On 3/25/26 at 10:26 a.m. Resident #58 was in bed. The resident did not have a fall mat on the floor by his bed. The fall mat was folded in the corner of the room against the wall. C. Record review Resident #58's fall care plan, revised 12/21/25, documented he was at risk for falls due to his advanced age, use of high risk medications, and he required assistance with ADLs. He had a history of falls. Pertinent interventions initiated 12/23/24 included placing a fall mat next to his bed. Resident #58's Kardex (staff directive tool) documented safety interventions that included anticipating the resident's needs and a fall mat in place. D. Staff interviews RN #2 was interviewed on 3/26/26 at 3:30 p.m. RN #2 said fall interventions for the residents were the responsibility of all the staff. RN #2 said she was not aware that Resident #58 needed his fall mat on the floor when he was in bed. The DON was interviewed on 3/26/26 at 3:50 p.m. The DON said the CNAs had information about a resident's fall interventions on the Kardex, and the nurses had access to a resident's fall interventions on the care plan. The DON said the unit managers spot check to ensure the fall interventions were in place and that the resident's representative sometimes moved the resident's fall mat. The DON said Resident #58 had the fall mat intervention in place because of a previous fall and he was admitted with a diagnosis of a fracture. The DON said the fall mat was in place to prevent further injury.

Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for two (#4 and #1) of four residents reviewed for oxygen services out of 37 sample residents. Specifically, the facility failed to ensure staff administered oxygen to Resident #4 and Resident #1 per physician's order. Findings include: I. Professional reference According to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 2021, accessed on 3/31/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11) Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment. II. Facility policy and procedure The Oxygen Administration policy, revised date 3/3/26, was received from the nursing home administrator (NHA) 3/25/26 at 6:56 p.m. It read in pertinent part, Oxygen therapy is the administration of oxygen at concentrations with the intent of treating or preventing symptoms and manifestations of hypoxia. To ensure that oxygen was administered and stored safely within the facility or in an outside storage area. Oxygen orders should include a specific leader flow required by the resident. Residents receiving oxygen at 4 liters per minute (LPM) or greater via concentrator should be connected to humidifiers. I. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included muscle weakness, dementia, respiratory failure, congestive heart failure, muscle weakness, and a history of falling. The 12/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of five out of 15. The resident required substantial to maximum assistance with chair-to-chair transfers, toileting hygiene, and lower body dressing. The MDS assessment indicated Resident #4 was receiving oxygen therapy. B. Observations On 3/24/26 at 11:30 a.m. Resident #4 was in his bed, lying on his back. The resident bed was positioned in the lowest position. The resident had an oxygen concentrator next to his bed in the off position. There was a nasal cannula connected to the oxygen concentrator. The resident was not receiving oxygen. During a continuous observation on 3/24/26, beginning at 2:19 p.m. and ending at 4:15 p.m., the following was observed: At 2:19 p.m. Resident #4 was in his room, lying on his bed with his room door open. The oxygen concentrator in the resident's room was turned off. At 2:22 p.m. the resident turned on his call light for staff assistance. At 2:23 p.m. an unidentified staff member walked past the resident's room with his light on. At 2:30 p.m. The maintenance director staff answered the resident's call light and asked the resident if he needed anything. The resident replied and said he did not need anything. The facility staff responding to the residents' call light did not apply oxygen to the resident. At 2:36 p.m. certified nurse aide (CNA) #3 transferred the resident into his wheelchair with a gatebelt. CNA #3 assisted the resident with putting his sneakers on his feet before the resident's transfer. An unidentified CNA took the resident to the bathroom to change his pants that were wet with urine. The facility staff did not apply oxygen to the resident At 2:50 p.m. The unidentified CNA assisted the resident to the kitchen to get him a banana. At 3:05 p.m. Resident #4 sat in his wheelchair in the center common area. The resident did not have his oxygen on. At 3:12 p.m. an unidentified nurse gave the resident medication and took his blood pressure and pulse. The resident sat in his wheelchair without oxygen with a nasal cannula on his nose. At 3:56 p.m. Resident #4 was assisted back to his room by the MTD and left in his room. The resident was not assisted with applying his oxygen. At 3:58 p.m. the resident put on his call light for assistance. At 4:15 p.m. an unidentified facility staff responded to the resident's call bell and assisted the resident out of his room, and took the resident into the dining room without his oxygen. On 3/25/26 at 7:40 a.m. Resident #4 was in his room lying on his bed. The oxygen concentrator next to his bed was turned off. C. Record review A review of Resident #4's March 2026 CPO revealed the following physician's orders: -Oxygen at 4 LPM continuously per nasal cannula related to congestive heart failure and hypoxia (low oxygen in the tissues). Every shift for hypoxia. Ordered 3/23/26 -Monitor the resident for signs and symptoms of shortness of breath when lying flat or avoid lying flat due to signs and symptoms of shortness of breath (increased respiratory rate, pursed lip breathing, a prolonged expiratory phase, audible respirations, gasping for air, interrupted speech pattern, use of accessory muscles, anxiety, restlessness etc.) Monitor every shift. Ordered 3/21/26 -However, observations revealed Resident #4's oxygen was not not administered per physician orders (see observations above). Resident #16's oxygen care plan, initiated 10/10/25, indicated the resident had oxygen therapy related to ineffective gas exchange secondary to hypoxia and respiratory failure. Pertinent interventions included providing residents with extension tubing or portable oxygen apparatus, oxygen via nasal cannula per physician orders, monitoring for signs/symptoms of respiratory distress and report to physician as needed (PRN): respirations, pulse oximetry (measures oxygen saturation, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), lethargy, confusion, atelectasis (lung collapse), hemoptysis (coughing up blood), cough, pleuritic (inflammation of lung lining) pain, accessory muscle usage, and skin color. Review of the March 2026 medication administration record (MAR) revealed nursing staff were documenting and signing off that Resident #4 was receiving oxygen at 4 LPM. -However, on 3/24/26 and 3/26/26, the resident's oxygen flow rate was not applied to the resident. (see observations above). D. Staff interviews Registered nurse (RN) #1 was interviewed on 3/24/26 at 4:32 p.m. RN #1 said she worked full-time in the facility and was very familiar with facility procedures. She said the nursing staff were responsible for checking the physician's orders every day for each resident on her assignment. She said she was unsure if Resident #4 needed to wear oxygen. She said Resident #4 had an order for oxygen at 4 LPM via nasal cannula. She said if a resident had an order for oxygen, then the resident should have the oxygen on to ensure the resident did not have difficulty breathing. She said she would put the oxygen on the resident and call the doctor for a clarification to check if the resident should still have the oxygen order. She said the oxygen order for Resident #4 may have been a temporary order. RN #2 was interviewed on 3/25/26 at 4:00 p.m. She said Resident #4 did not usually wear oxygen. She said she would check and verify the resident had an order for oxygen. She said the resident had an order for oxygen to be worn a 4 LPM via nasal cannula. She said she would place the oxygen on the resident. She said it was the nurses responsibility to make sure oxygen orders were carried out. The director of nursing (DON) was interviewed on 3/25/26 at 4:11p.m. The DON said the nurses would obtain a physician's order with oxygen setting if a resident required oxygen therapy. The DON said the nursing staff were responsible for monitoring the resident's oxygen saturation with a pulse oximeter and assessing the resident's physical response to oxygen therapy. She said the nurse and the therapy staff were both responsible for monitoring the residents while on oxygen therapy. The DON said the CNA collected vital signs including oxygen level every shift and as needed and reported to the nurses if the oxygen level were below 90%. The DON said oxygen therapy settings with interventions should be included in the residents care plan for the nurses to reference and the Kardex (staff directive tool) for the CNAs to reference. She said the therapy department could also access the care plan. She said the nursing staff and the therapy staff were responsible for checking the residents at the beginning of the shift to ensure the correct settings were enabled on oxygen devices. The DON said it was important to follow oxygen orders for the safety of the residents. She said hypoxia (low oxygen in the tissues) could cause inability to breathe, increased heart rate and confusion. She said she was notified of the oxygen concern of the residents and started re-education for the facility staff on the importance of monitoring residents who require oxygen therapy on 3/23/36. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2026 CPO, diagnoses included emphysema, acute respiratory failure with hypoxia, pneumonia, hypertensive heart disease with heart failure, pulmonary hypertension, and dependence on supplemental oxygen. The 3/3/26 MDS assessment revealed Resident #1 had no cognitive impairments with a BIMS score of 14out of 15. She required setup assistance with eating and required substantial assistance with toileting, moderate to maximal assistance with dressing and moderate assistance with personal hygiene. The MDS assessment revealed that the resident required continuous oxygen at 4 LPM with a nasal cannula. B. Observations On 3/23/26 at 10:10 a.m. Resident #1 was sitting in her room. The resident's oxygen concentrator was set to 1 LPM. -However, Resident #1`s oxygen flow rate was supposed to be 4 LPM, per physician's orders (see record review below). At approximately 3:45 p.m. Resident #1 was sitting in her room. The resident's oxygen concentrator remained set at 1 LPM. At approximately 4:30 p.m Resident #1 was sitting in her room. The resident oxygen concentrator remained set at 1 LPM. At 4:43 Resident #1 oxygen concentration was set to 1 LPM. RN #5 said that the oxygen level was set to 1.5 LPM. C. Record review The respiratory care plan, dated 3/4/26, documented that the resident had oxygen therapy. The interventions included the use of supplemental oxygen at 4 LPM continuously via nasal cannula. Review of Resident #1's March 2026 CPO revealed the following physician's order: Oxygen at 4 LPM continuously via nasal cannula, ordered 3/5/26. A nurse progress note, dated 3/21/26 at 4:18 p.m., documented Resident #1 was on 2 liters of oxygen via nasal cannula. She maintained oxygen saturation at 96% on that morning. She did not show shortness of breath or signs of respiratory distress. A nurse progress note, dated 3/22/26 at 6:21 p.m., documented Resident #1 was alert and oriented times two to three. She cooperated with the plan of care. She showed no sign or symptoms of shortness of breath. III. Staff interviews RN #4 was interviewed on 3/23/26 at 4:52 p.m. She said that Resident #1 was prescribed 4 LPM of oxygen. She said occupational therapy might have titrated the oxygen level to 1 LPM. She said there was no documentation of current titration in the progress notes. She said staff were supposed to follow the physician`s order until it was determined that the oxygen level could be adjusted to a lower setting. She said the oxygen level should be set to 4 LPM as the physician`s order said. She said she was not informed about any changes in the physician`s order. The unit manager was interviewed on 3/25/26 at 2.50 p.m. She said that Resident #1 definitely needed 4 LPM. She said the staff followed the physician`s order for setting oxygen levels. She said that Resident #1 participated in therapy on the day of the observation. She said staff must have made an error when they connected Resident #1`s oxygen tube to the concentrator. She said it was important to keep an eye on the residents` oxygen levels for safety reasons. She said the CNAs were responsible for connecting the oxygen tube to the concentrator and to fill the tanks. She said the oxygen tube was changed on Sundays. The DON was interviewed on 3/25/26 at 4:18 p.m. The DON said the facility received the oxygen order from the physician. She said the nurses were responsible to follow, monitor, assess, and set oxygen level settings. She said the CNAs were responsible for collecting vital signs at the beginning of every shift. She said the CNAs were responsible to check the oxygen setting and report to the nurse if it was abnormal. She said the CNAs could not change oxygen settings. She said the CNAs could apply cannula, fill portable oxygen tanks, and change oxygen tubing. She said theCNAs should be able to notice signs of shortness of breath. She said the care plan and the Kardex indicated the oxygen setting. She said CNAs were able to access the Kardex. She said nurses were able to access the care plan and the Kardex. She said the therapist was able to access the care plan. She said the oxygen setting was documented in the point of care system. She said following the oxygen order was the most important thing to be able to breathe.

Based on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in two of five medication carts.Specifically, the facility failed to ensure expired medications were removed from the medication cart and disposed of. Findings include:I. Facility policy and procedureThe Storage of Medication policy, revised 6/30/25, was received from the nursing home administrator on 3/25/26 at 6:39 p.m. It revealed in pertinent part, The facility should ensure that only authorized facility staff, as defined by the facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. The facility should ensure medications and biologicals were stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. The facility should ensure infusion therapy products and supplies were stored separately from other medications and biologicals, under appropriate temperature and sterility conditions, according to the manufacturer or supplier recommendations.II. ObservationsOn 3/25/26 at 8:24 a.m. the medication cart on 100 Hall was observed with license practical nurse (LPN) #1. The drawer on the medication cart for Resident #82 contained the following: Methocarbamol Oral Tablet 500 milligram (mg). The order read: Give 1 tablet by mouth every six hours as needed for leg pain for five Days. Order on 1/13/26 and discontinued on 1/18/26. -The medication was not disposed of despite the medication being discontinued for two months. On 3/25/26 at 11:09 a.m. the medication cart on 500 Hall was observed with LPN #2. The medication cart contained guaifenesin tablet extended release. The medication expired on 3/16/26. III. Staff interviewsLPN #1 was interviewed on 3/25/26 at 8:35 a.m. She said the discontinued medication for Resident #82 should not be in the medication cart. She said nurses were responsible for removing discontinued medications. LPN #1 said the medication should have been discarded after the completion of the order. She said the medication should have been removed from the medication cart. She said when a medication was discontinued the nursing staff were supposed to put it in the basket for discontinued medications in the medication storage room. She said she would remove the medication from her medication cart and advise the director of nursing (DON) to dispose of the medication. LPN #1 said the resident was not administered the medication after the medication was discontinued. LPN #2 was interviewed on 3/25/26 at 11:09 a.m. LPN #2 said she thinks the medication for Resident #27 was left in the medication cart because the resident would often have an order for this medication. She said this was only a speculation and that she was not completely sure why this medication was left in her medication cart. She said it was a facility standard of practice to discard any medication for facility residents that have been discontinued or expired. She said she was trained by the facility to always check the medication expiration date and the Physicians orders to ensure the safety of facility residents The DON was interviewed on 3/25/26 at 4:35 p.m. She said the unit managers were responsible for ensuring the nursing medication carts were free from storing discontinued and expired medications. The DON said the unit managers made weekly rounds to dispose of the discontinued medications. The DON said medications that were left in the cart were overlooked. She said it was important to remove discontinued medications to decrease the chance of the occurrence of medication errors. The DON said she also did medication audits of the storage rooms and the med carts to further ensure medications were stored as ordered. The DON said she would provide education starting today for the nursing staff and the unit managers on the importance of what to do with expired and discontinued medications.

Based on record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#1, #2 and #3) of four residents reviewed for bathing out of four sample residents. Specifically, the facility failed to ensure Resident #1, Resident #2 and Resident #3, who were dependent on staff for bathing, received their scheduled showers. Cross-reference F725: failure to have adequate nurse staffing. Findings include: I. Facility policy and procedure The Activities Of Daily Living (ADLs) policy, revised 2/12/24, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, The resident will receive assistance as needed to complete ADLs. A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), age-related osteoporosis, neuromuscular dysfunction of the bladder (urinary incontinence), muscle weakness and irritable bowel syndrome. The 2/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behaviors and did not reject care. She had impairment to one side of her upper and lower extremities. She used a motorized wheelchair and was dependent on staff for bathing and toileting hygiene. She was occasionally incontinent of bowel and bladder. B. Resident interview Resident #1 was interviewed on 3/19/25 at 10:15 a.m. She said the facility did not have enough staff to care for her needs. She said when the facility had only two certified nurse aides (CNA) working, showers were not provided. She said she was supposed to receive her showers on Tuesday, Thursday, Saturday and Sunday. C. Resident representative interview Resident #2's representative was interviewed on 3/19/25 at 2:09 p.m. The representative said Resident #2 was not receiving adequate showers the last few months. She said she had to call the facility to get staff to shower the resident. She said she felt the resident had been receiving more showers in March 2025. D. Record review The ADL care plan, revised on 8/29/23, revealed Resident #1 had an ADL self care deficit related to weakness, impaired range of motion, occasional incontinence, diagnosis of MS, depression, left sided weakness and contracture (restricts normal movement) to the left hand and left elbow. Interventions included providing total staff assistance with bathing four times a week with a female care giver. Review of the January 2025 through March 2025 shower logs revealed the following: The January 2025 (1/19/25 to 1/31/25) shower documentation revealed Resident #1 was provided bathing on one of six opportunities. The February 2025 (2/1/25 to 2/28/25) shower documentation revealed Resident #1 was provided bathing on two of 16 opportunities. The March 2025 (3/1/25 to 3/19/25) shower documentation revealed Resident #1 was provided bathing on three of 11 opportunities. III. Resident #2 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included diabetes, dementia, cancer and liver failure. The 12/20/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. She required supervision assistance with toileting and dressing. She required partial assistance with bathing. B. Record review The ADL care plan, revised on 12/16/24, revealed Resident #2 had an ADL self care deficit related to dementia, impaired balance, limited mobility and muscle weakness. Interventions included assisting the resident with ADLs as needed and praising the resident for all efforts of self care. -Review of the comprehensive care plan did not reveal documentation that indicated the resident's shower preferences and assistance needed. Review of the January 2025 through March 2025 shower logs revealed the following: The January 2025 (1/19/25 to 1/31/25) shower documentation revealed Resident #1 was provided bathing on one of four opportunities. The February 2025 (2/1/25 to 2/28/25) shower documentation revealed Resident #1 was provided bathing on two of eight opportunities. The March 2025 (3/1/25 to 3/19/25) shower documentation revealed Resident #1 was provided bathing on two of five opportunities. IV. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia, anxiety and kidney disease. The 2/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required maximal assistance with toileting, dressing and bathing. B. Record review The ADL care plan, revised on 8/5/24, revealed Resident #3 had an ADL self care deficit related to weakness, decreased mobility, usage of high high risk medications, obesity and depression. Interventions included assisting the resident with ADLs as needed and providing the resident showers two times a week on Tuesday and Saturday. Review of the January 2025 through March 2025 shower logs revealed the following: The January 2025 (1/19/25 to 1/31/25) shower documentation revealed Resident #1 was provided no bathing out of three opportunities. The February 2025 (2/1/25 to 2/28/25) shower documentation revealed Resident #1 was provided no bathing out of seven opportunities. The March 2025 (3/1/25 to 3/19/25) shower documentation revealed Resident #1 was provided bathing on five of six opportunities. V. Staff interviews CNA #1 was interviewed on 3/19/25 at 1:33 p.m. CNA #1 said the facility had been short on CNA staff for over a year. CNA #1 said sometimes the facility only had two CNAs to work the unit with 50 residents. She said the shortage prevented the CNAs from doing their assigned showers for the residents. She said in February 2025 she worked a shift by herself to care for 45 residents. She said two residents required two person assistance with mechanical transfers She said when she brought the staffing concerns to the management, she was told to just do what she could. She said Resident #1 needed two staff members for bathing. She said when the CNA did not have another staff member to help, they had to take care of her alone. She said the day prior (3/18/25), a CNA worked alone for two hours, and cared for 24 residents alone. She said most of the nurses did not want to assist the residents with personal care. CNA #2 was interviewed on 3/19/25 at 2:30 p.m. CNA #2 said the main floor census was 50 residents and there should be three to four CNAs scheduled. She said she wished the facility would use agency staff when they were short staffed. She said the facility CNAs were unable to complete the resident cares. She said when the unit was short staffed, the CNA did not have time to complete the scheduled showers. She said only two CNAs had been working the prior two days on the evening shift. She said the CNAs did the best they could to care for the residents, but there were times when incontinence care and oral care did not always get done. She said at times the restorative CNA was pulled to work the floor. She said the management did not help work the floor when they were short staffed. CNA #3 was interviewed on 3/19/25 at 2:35 p.m. CNA #3 said the facility did not have enough staff to complete their work. She said the unit was short staffed often. She said sometimes the CNAs were unable to provide the scheduled showers, since the unit was short staffed. She said when they only had two CNAs staffed to work the unit, scheduled showers did not get done. CNA #4 was interviewed on 3/19/25 at 2:45 p.m. CNA #4 said the unit was usually staffed with two to three CNAs. He said the shortage of CNAs had caused the CNAs to not be able to provide the care the residents needed in a timely manner. He said the shortage would delay personal care and the CNAs would not be able to provide the scheduled showers. He said when only two CNAs were working the unit, the CNAs would try and find the nurse to assist. However, he said that could take 20 to 30 minutes. He said when the CNAs would take their concerns to the management, they were told to work it out. Licensed practical nurse (LPN) #1 was interviewed on 3/19/25 at 2:50 p.m. LPN #1 said the facility had been short on CNAs for a while. She said frequently there were only two CNAs working the unit for forty some residents. She said she would try to help the CNAs but had physical limitations. She said when the unit was short staffed it delayed resident care and showers. She said at times a resident who was a two person assistant would have to wait until the next CNA to come on shift to assist with changing the resident. She said the residents would have to stay wet or soiled until a second CNA was available to help. The DON was interviewed on 3/19/25 at 3:37 p.m. The DON said she did not know why showers were not being completed, but thought it may be a documentation error. She said she was super confident about the facility staffing. She said if a CNA called off for their shift, managers would help with transfers and showers. She said the facility would utilize agency staff if needed. She said she was not aware there was an issue with residents not getting their showers. She thought the residents were getting their showers. The regional vice president (RVP) was interviewed on 3/19/25 at 3:55 p.m. She said missed showers were related to documentation issues. She said the DON needed to provide education related to documentation and how they were managing their time.

Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to ensure residents received their showers as scheduled and incontinence care in a timely manner for residents dependent on staff for their care. Cross reference F677: failure to provide activities of daily living for dependent residents. Findings include: I. Facility policy and procedure The Staffing policy, revised 8/7/23, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, The facility maintains adequate staff on each shift to meet the residents' needs. The facility utilizes the facility assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met. II. Resident and family interviews Resident #1 was interviewed on 3/19/25 at 10:15 a.m. She said the facility did not have enough staff to care for her needs. She said when the facility was short staffed and had only two certified nurse aides (CNA) working, she did not receive her showers and incontinence care was not provided. She said it could take up to 45 minutes to receive incontinence care. She said she was supposed to receive her shower on Tuesday, Thursday, Saturday and Sunday. Resident #2's representative was interviewed on 3/19/25 at 2:09 p.m. The representative said the Resident #2 was not receiving adequate showers the last few months. She said she had to call the facility to get staff to provide showers to the resident. She said she had to call multiple days in a row. She felt the facility did not have enough staff to complete the resident cares. She said she felt the resident had been receiving more showers in March 2025. III. Facility assessment The facility assessment, dated 11/20/24, was provided by the NHA on 3/19/25 at 10:44 a.m. The facility assessment documented the care needs of 78 to 85 residents in the facility. The facility assessment documented the direct care staffing information. The desired per patient day (PPD) for certified nurse aides (CNAs) was 2.26 hours. It documented the assignments were reviewed daily based on resident needs and available staffing. IV. Grievances The January 2025 to March 2025 grievances revealed the following: A grievance dated 1/5/25 documented the CNA did not set up the residents meal tray or chop up the food. The CNA was educated on assisting the residents with their meals A grievance dated 1/6/25 documented there was no restorative CNA for two weeks and no CNA for the day. The facility stated the resident did receive her restorative services. A grievance dated 1/23/25 and 1/30/25 documented the CNAs complained to the residents about being short staffed. The facility educated the CNAs to not discuss staffing issues with the residents. A grievance dated 2/8/25 documented the resident had to call the front desk to request to get out of bed. The resident said it was a miscommunication with staff. A grievance dated 3/5/25 documented the family was concerned with the resident not receiving timely care. The facility educated the nursing staff on the timeliness of giving care to the residents. A grievance dated 3/7/25 documented the CNA rushed her while providing care. The CNA was moved to a different assignment. The facility did not look into staffing issues. V. Staff Interviews CNA #1 was interviewed on 3/19/25 at 1:33 p.m. CNA #1 said the facility had been short on CNA staff for over a year. CNA #1 said sometimes the facility only had two CNAs to work the unit with 50 residents. She said the shortage prevented the CNAs from doing their assigned showers for the residents. She said in February 2025 she worked a shift by herself to care for 45 residents. She said this included two residents who required two person assistance with mechanical transfers, two residents with foley catheters, four residents with colostomy bags and one resident who required total assistance. She said when a resident was a two person assistance and the facility was short staffed the resident was left in bed soiled. She said this happened because the CNA either did not have time or help to provide incontinence care to the resident or there were not two staff members to help. She said when she brought the staffing concerns to the management, she was told to just do what she could. She said Resident #1 needed two staff members for bathing and toileting. She said when the CNA did not have another staff member to help, they had to take care of her alone. She said the day prior (3/18/25), a CNA worked alone for two hours,and cared for 24 residents alone. She said most of the nurses did not want to assist the residents with personal care. CNA #2 was interviewed on 3/19/25 at 2:30 p.m. CNA #2 said the main floor census was 50 residents and there should be three to four CNAs scheduled. She said she wished the facility would use agency staff when they were short staffed. She said the facility CNAs were unable to complete the resident cares. She said when the unit was short staffed, the CNA did not have time to complete scheduled showers. She said only two CNAs had been working the prior two days on the evening shift. She said the CNAs did the best they could to care for the residents, but there were times when incontinence care and oral care did not always get done. She said at times the restorative CNA was pulled to work the floor. She said the management did not help work the floor when they were short staffed. CNA #3 was interviewed on 3/19/25 at 2:35 p.m. CNA #3 said the facility did not have enough staff to complete their work. She said the unit was short staffed often. She said sometimes the CNAs were unable to provide scheduled showers, since the unit was short staffed. She said when the facility was short staffed the CNAs had to rush the residents care. She said many times she had to stay late after her shift to finish her charting. She said the day shift was supposed to be staffed with four to five CNAs. She said when they only had two CNAs to work the unit, scheduled showers did not get done. She said at times they were unable to provide incontinent care and would have to pass it on to the evening shift. She said when only two CNAs were working and a resident required a two person transfer, the one CNA would have to wait for the second CNA to be available to help with the transfer, which could take up to an hour. CNA #4 was interviewed on 3/19/25 at 2:45 p.m. CNA #4 said the unit was usually staffed with two to three CNAs. He said the shortage of CNAs had caused CNAs to not be able to provide the care the residents needed in a timely manner. He said the shortage would delay personal care and the CNAs would not be able to provide the scheduled showers. He said when only two CNAs were working the unit the CNA would try and find the nurse to assist. However, he said that could take 20 to 30 minutes. He said in regard to incontinence care, the CNAs would have to triage the residents who had a bowel movement to be changed over residents who were wet. He said when the CNAs would take their concerns to the management, they were told to work it out. Licensed practical nurse (LPN) #1 was interviewed on 3/19/25 at 2:50 p.m. LPN #1 said the facility had been short on CNAs for a while. She said frequently there were only two CNAs working the unit for forty some residents. She said she would try to help the CNAs but had physical limitations. She said when the unit was short staffed it delayed resident care and showers. She said at times a resident who required two person assistant would have to wait until the next CNA to come on shift to assist with changing the resident. She said the residents would have to stay wet or soiled until a second CNA was available to help. The DON was interviewed on 3/19/25 at 3:37 p.m. The DON said she did not know why showers were not being completed, but thought it may be a documentation error. She said she was super confident about the facility staffing. She said if a CNA called off for their shift, managers would help with transfers and showers. She said the facility would utilize agency staff if needed. She said she was not aware there was an issue with showers and ADL care. She believed the residents were receiving care. She said the facility met the minimum state staffing regulation. The regional vice president (RVP) was interviewed on 3/19/25 at 3:55 p.m. The RVP said the NHA had only been working at the facility for three days. She said the facility did not have any concerns with staffing. She said the facility had experienced some staff turnover and had hired some new staff. She said missed showers were related to documentation issues. She said the DON needed to provide education related to documentation and how the staff were managing their time. She said staffing was the facility's main focus and had increased the CNA pay. She said she worried about the perception of the families and staff related to staffing.

Based on observations, interviews and record review the facility failed to provide a safe, functional and comfortable environment to meet resident needs in six of nine resident rooms. Specifically, the facility failed to: -Ensure resident room temperatures on the 100 unit resident hallway were between 71-81 degrees Fahrenheit. -Fix a broken furnace blower on the 100 unit hallway, which would have provided back up heat to the facility rooms when thermostats were below 71 degrees; and, -Ensure the resident's living room area on the 100 unit had heat between 71-81 degrees. Findings include: I. Facility policy and procedure The Keeping a Resident's Room in Order policy, revised 7/17/23, was provided by the director of nursing on 3/27/24 at 11:14 a.m. It revealed in pertinent part that the facility was to follow federal regulations and provide, Comfortable and safe temperature levels. Maintain a temperature range of 71 to 81 F. It is the responsibility of all staff to create a 'homelike' environment. Ensure the room is a comfortable temperature for the resident. II. Observations On 3/25/24 at 3:30 p.m. the room temperatures were taken in several random rooms on unit G where the 100 rooms were. The city the facility was in had experienced a snowstorm on 3/25/24 with a recorded weather temperature of 27 degrees for daytime and 25 degrees that evening. The following six room temperatures were taken in Fahrenheit (F): room [ROOM NUMBER] was 67.6 degrees; room [ROOM NUMBER] was 67.8 degrees; room [ROOM NUMBER] was 69.7 degrees; room [ROOM NUMBER] was 68.4 degrees; room [ROOM NUMBER] was 68.3 degrees; and, room [ROOM NUMBER] was 68.8 degrees. The 100-unit hallway's resident living room/common area was 62.1 degrees. III. Resident interview Resident #1 was interviewed on 3/25/24 at 2:30 p.m. He said he was in a room on the 100 hallway but his room was too cold in the winter. He said he complained to the facility staff about how cold his room was and he wanted it warmer. He said the facility offered to put him in a room on a different hallway. He said he did not know why they did not just fix the heat problem but his new room was warmer and had working heat. IV. Staff interviews The director of maintenance (DOM) was interviewed on 3/25/24 at 5:00 p.m. He said he came back into the facility when he heard from the DON that some rooms were below 71 degrees. He said he would fix all six rooms and the living room area on the 100 unit where the heat was below the temperatures that they should be. The DON was interviewed on 3/25/24 at 5:00 p.m. She said she would make sure the temperatures were fixed in the six rooms where the heat was below 71 degrees. She said she would offer and provide extra blankets to each resident on the 100 hallway. She said if the heat could not be fixed she would offer any resident in a room that had a temperature below 71 degree room to be moved to a room that was warmer. She said each of the rooms did feel cold. The DOM was interviewed again on 3/26/24 at 9:15 a.m. He said he had spent a few hours last night fixing the temperatures in the six rooms that were below 71 degrees and the living room area on the 100 unit. He said he liked to take a room temperature with the temperature gun while standing in the middle of a room while he aimed the temperature gun at a piece of paper a few inches in front of his face. He said that was not on the instruction manual of the temperature gun to take room temperatures that way. He said he would provide the temperature gun directions (see below). He said last night the temperatures were found below 71 degrees were taken in random areas of the room and not on a piece of paper. He said even though the temperatures taken were in random areas of the rooms, the temperature measurements were still correct and the rooms were below 71 degrees. He said he found heating units and thermostats in rooms not working properly. He said he worked on each heating unit in each of the resident's rooms that were below 71 degrees. He said each heater unit called a packaged terminal air conditioners (PTAC) for both heat and cool air needed to be adjusted and some of the thermostats. He said all six rooms had low temperatures last night. He said all six units were currently fixed or adjusted and working properly. He said he kept a record review of temperatures of rooms last night after he fixed or adjusted the heating units or thermostats. He said he would provide the documentation (see record review below). He said the facility had a furnace system. He said had the furnace system worked correctly; the heat would have turned on the ceiling heater vent when the individualized room thermostats went below 71 degrees. He said on the 100 unit hallway the blower in the furnace was broken. He said he called the professional plumber last night to schedule an appointment to come out to the facility but he had not heard back from the plumbing company yet. He said he would provide the appointment details of when the professional plumber would come to the facility. He said had the blower not been broken, the secondary heat would have kicked on and the resident's rooms would have had correct temperatures. He said the blower was out so the furnace was not kicking on when the heat went below 71 degrees. He said, The facility had an extra heat weapon, a backup that was not utilized because of the broken blower. He said Resident #1 complained a few weeks prior of the heat in his room on the 100 unit not working and the facility moved him onto a different hallway to live. He said the living room area on the 100 hallway had two PTAC units for heat and one was broken and the other one did not turn on. He said last night he put plastic on the outside of two of the three windows and today he was going to cover the third living room area window with plastic. He said the plastic over the windows helped retain the heat in the living room and it made a noticeable difference. He said he made sure the one working heating unit, PTAC in the living room was heating the room properly. He said he was able to get the heat in the living room area to rise 10 degrees from 62.1 to 72.1 F. He said sometimes there was a problem with staff who decided to adjust the hallway and resident room thermostats. He said he was going to provide an education today to the floor staff to not adjust or turn off the thermostats. He said he would educate the staff to keep all thermostats between 71 and 81 degrees. He said last night one resident's room thermostat was completely turned off. He said the resident was unable to get out of bed and turn off the thermostat so it had to be a staff person. V. Record review The DOM provided the temperature logs of the rooms and what he did to fix each room's heat. The DOM provided instructions for the temperature gun on 3/26/24 at 11:22 a.m. The following rooms had the individual heater units PTACs and thermostat adjusted on 3/25/24 between 5:43 p.m. and 5:50 p.m. Each of the following rooms had temperatures between 71 and 81 degrees Fahrenheit. -The DOM's recorded temperature log began about two hours after the initial temperatures below 71 degrees were observed. room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. The instructions for the temperature gun did not reveal to hold a piece of paper in the middle of the room and aim the gun's red light at the paper for a correct temperature. The DOM said it was his preference to obtain temperatures that way. The instructions revealed, Aim the instrument at the object to be measured and pull the trigger. Press the button F/C button to alternate between Fahrenheit and Celsius. The distance to spot ratio did not reveal to hold a piece of paper in front of the gun as the true temperature of the room. The original temperatures taken which revealed temperatures below 71 degrees were taken in different sections of the rooms and not on a piece of paper. VI. Facility follow-up On 3/26/26 the DOM provided an education to staff members. It revealed that staff members should not turn off the thermostats in the building unless it was an emergency. Temperatures were to be between 71-81 degrees Fahrenheit. On 3/26/24 at 11:22 a.m. the DOM provided an email from a professional heating company, which documented, I am writing to let you know that I am coming out to look at the F wing furnace. To give a quote for repair or replace. -The exact date and time of the appointment was not provided by the DOM.

Based on observations, interviews and record review, the facility failed to ensure appropriate services and assistance to maintain or prevent further decrease in range of motion was provided for one (#1) of three residents out of seven sample residents. Specifically, the facility failed to: -Follow programs physical therapy (PT) and occupational therapy (OT) had written for restorative nursing to provide for Resident #1 who required range of motion (ROM) services; and, -Have trained staff provide consistent ROM for Resident #1 who needed the exercises to maintain his physical abilities or help to prevent further decrease in his ROM. Findings include: I. Facility policy and procedure The Restorative Nursing policy, revised 9/11/23, was provided by email by the director of nursing (DON) on 3/27/24 at 11:14 a.m. It revealed in pertinent part, To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities. Restorative programs may be initiated by nursing and/or therapy. Restorative nursing program-Refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A patient may be started on a restorative nursing program when he or she is admitted with restorative needs, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of stay or in conjunction with formalized rehabilitation therapy. Generally, restorative nursing programs can be initiated when a patient is discharged from a formalized physical, occupational or speech rehabilitation therapy. Generally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. Nursing assistants/aides must be trained in the techniques that promote patient involvement in the activity. Other Staff or Volunteers who are trained may be assigned to work with specific patients. Accurate and thorough assessment of the patient is fundamental in determining the patient's need for restorative services. Provide resident/caregiver teaching regarding the restorative care plan. The trained CNA (certified nurse aide) will document provided techniques per the restorative care plan in the medical record. The licensed nurse will conduct an evaluation on a routine basis, to include progress towards goal and response to the program. Any changes will be documented in the medical record. The restorative care plan and care directive will be reviewed/revised as indicated. II. Resident #1 A Resident status Resident #1, age 74, was admitted on [DATE] and 7/13/23. According to the March 2024 computerized physician orders (CPO), the diagnoses included Gillain-Barre Syndrome (immune system harms body's nerves, causing muscle weakness and sometimes paralysis), atrial fibrillation, hypertensive heart disease with heart failure, abnormal posture, muscle weakness, multifocal motor neuropathy (weakness in the hands), foot drop right and left foot (difficulty lifting the front part of the foot) and polyneuropathy. The 1/4/24 minimum data set (MDS) assessment revealed the resident had short and long term memory problems. He was able to assess the location of his room, staff names and faces, and where he lived. He was independent with his decision making and was his own responsible party. He did not reject care from staff. He had limited range of motion in his upper extremities. He required maximum assistance for eating. He was dependent on staff for showers, toileting, upper and lower body dressing, putting on and off footwear, and personal hygiene. He was always incontinent of bowel and bladder. He used a motorized wheelchair. He received zero minutes of restorative nursing programs for both active and passive ROM. B. Resident interview Resident #1 was interviewed on 3/26/24 at 11:35 a.m. He said he had the restorative staff exercise him only a few times over the last several months. He said he facility rarely provided that service because he was told there was not enough staff to do the job. He said his hands were to be stretched and he said he liked when the staff worked with his feet. He said one time recently he rode an exercise bike and did well. He said, I have a bad disease and even if I don't get cured, I certainly don't want to get worse. I think some exercises would help me maintain my body. But they don't have the time to help me. There is one restorative certified nurse aide (RCNA) but he always gets pulled to work on the floor as a CNA. Resident #1's family member was interviewed on 3/26/24 at 11:45 a.m. She said Resident #1 just needed some ROM therapy. She said he felt good when someone worked with him. She said she did not know how to get the facility staff to be able to do this service. C. Record review The restorative program documentation of resident visits was provided by the DON on 3/26/24 at 1:00 p.m. It revealed Resident #1 had a restorative program which PT and OT wrote which began on 8/21/23 and was updated 3/22/24 by the OT. It revealed the resident had received his highest level of achievement from physical therapy and was to have a restorative program five times per week unless otherwise specified. The documentation revealed the following: -Upper and lower body exercises assisted in bed; -For legs use the motorized exercise bike; -Encourage Resident #1 to push himself in his wheelchair; and, -Hand ROM for contracture-stretching (stretching added by OT see interview below). The 2024 ROM services provided documented: January 2024 no ROM services were provided for the entire month. 2/20/24 restorative staff worked on lower extremities. -He received ROM services one time in February 2024. 3/4/24 Resident used (a) motorized exercise bike for 15 minutes and it was documented that he did good on his lower extremities. 3/16/24 received ROM for both upper and lower extremities. -There was no comprehensive care plan for restorative or ROM services for Resident #1 (see below facility follow-up DON interview). III. Staff interviews The DON was interviewed on 3/26/24 at 1:00 p.m. She said the facility had a restorative program and she was the restorative director. She said both in January and February 2024 the residents received very little to no ROM exercises from restorative nursing. She said she had two staff members who were designated specifically to provide the service as RCNAs. She said one of the RCNA was on leave and the other RCNA was often needed to work in the facility as a CNA because of staff shortages. She said in March 2024 some ROM programs for the residents began again, but it was not consistent. She said the only place the visits from the RCNAs were documented was in a hard binder. She said it was her goal to put the documentation in a spot in the electronic medical records (EMRs) for the ROM task. She said if someone was visited for restorative services it was in the binder. She said the binder had accurate documentation of lack of visits. She said in April 2024 the facility would have a nurse dedicated to be the restorative coordinator. The occupational therapist (OT) was interviewed on 3/26/24 at 2:21 p.m. She said she wrote a restorative program for Resident #1. She said Resident #1 should have had the restorative program she and others wrote for him since 8/21/23. She said the program was written and was to be ongoing from 8/21/23. She said she reevaluated Resident #1 on 3/22/24. She said he had hand contractures and she wanted the restorative staff to know Resident #1 needed his hands stretched. She said Resident #1 was always willing to exercise. She said Resident #1 always had a good attitude when he exercised and appreciated when anyone helped him. She said a restorative program for ROM activities was important for Resident #1. She said the program for ROM was for Resident #1 to maintain his health. She said ROM would help Resident #1 either not decline in his physical health or not decline as quickly. She said Resident #1 had a disease that benefited from ROM exercises. The director of rehab (DOR) was interviewed on 3/26/24 at 2:58 p.m. She said a restorative program was written for residents when their therapy services ended. She said PT or OT may end for a resident because they went as far as they could with improvements with therapy services or maybe a resident's insurance company would not pay any more. She said Resident #1 would benefit from a ROM restorative program to maintain the function in his body that he did have. She said maintaining a program can help residents not decline or decline as quickly. She did not know why Resident #1 did not receive the restorative programs her department had written for him. The RCNA was interviewed on 3/26/24 at 3:44 p.m. He said he did not do restorative often because when he came to work he was usually told to work as a CNA and not do ROM with the residents. He said once in a while he can function as an RCNA maybe one time per week. He said whatever he had done with the residents he hand wrote in the restorative progress notebook. He said he always wrote in it after each visit with a resident. He said if there were gaps of visits it was because he was pulled to the floor and could not be a restorative aide. CNA #1 was interviewed on 3/26/24 at 5:35 p.m. She said CNAs did not do ROM exercises or restorative with the residents. She said the CNAs were never told to do restorative or range of motion exercises as part of their duties. The RCNA was interviewed again on 3/27/24 at 9:45 a.m. He said he was not providing ROM services today because when he came to work he was told to be a CNA who worked on the floor. He said he did not provide restorative treatments generally when he came to work. The DON was interviewed again on 3/27/24 at 10:09 a.m. She said she would work on an immediate project to make the restorative record able to be documented in the EMRs. She said she was revising every resident's care plan to add restorative ROM services. She said she would have a formal meeting with the DOR to discuss their restorative programs they developed for residents. She said she would like the facility to provide ROM exercises for the residents several times per week.

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 11.11%, which was three errors out of 27 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. According to the Advair Diskus (inhaler) package, retrieved on 12/19/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021077Orig1s054pkglbl.pdf rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. According to the Humalog mix 75/25 insulin (medication used for glucose regulation) package insert retrieved on 12/21/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021017s141s143lbl.pdf Dosage and administration Humalog 75/25 was a suspension that must be resuspended immediately before use. Resuspension was easier when the insulin had reached room temperatures. To resuspend the vial, carefully invert the vial at least 20 times until the suspension appears uniformly white and cloudy then inject immediately. II. Facility policy and procedure The Administration of Medications policy, revised on 7/14/23, received from the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. revealed in pertinent part, all medications were administered safely and appropriately per physician order. Be aware of high- alert and hazardous medications. High alert medications include but were not limited to: insulins all formulations and strengths. III. Observations and staff interviews On 12/13/23 at 9:00 a.m. registered nurse (RN) #1 was observed administering medications to Resident #133. Resident #133 had two inhalers ordered: -Advair Diskus 250-50 milligrams (mg) one puff twice daily; and, -Tiotropium Bromide inhalation capsule 18 micrograms (mcg) once daily. RN #1 administered Advair Diskus first and did not have the resident rinse her mouth then immediately after he administered the Tiotropium Bromide inhalation inhaler. -RN#1 failed to offer the resident to rinse their mouth after Advair was administered. On 12/13/23 at 9:05 a.m. RN #1 was observed administering medications to Resident #132. Resident #132 had an order for Humalog 75/35 insulin (combination of two insulin medications) 30 units subcutaneously two times a day for diabetes. RN #1 cleansed the top of the vial with an alcohol swab and drew up 30 units of insulin into the syringe. -RN #1 failed to resuspend the insulin in the vial to ensure it was mixed correctly prior to drawing up the insulin. RN #1 was interviewed on 12/13/23 at 9:11 a.m. He said there was no direction to have resident rinse mouth after the Advair Diskus was administered and he was not aware of the need to have a resident rinse their mouth out after administration. RN #1 said was unaware of the need to roll a mixed insulin vial prior to drawing it up. RN #1 said if a resident did not get the correct amount of insulin it could lead to low blood sugar or high blood sugar. On 12/13/23 at 9:29 a.m. RN #3 was observed administering medications to Resident #121. Resident #121 had an order for Tylenol 500 mg ordered. RN #3 dispensed two 325 mg tablets of Tylenol in the medication cup. RN #3 was stopped from administering medication to the resident and asked to review the medication dispensed versus the order. RN #2 pulled out the two tabs of 325 mg Tylenol and dispensed a 500 mg tablet of Tylenol to be administered to Resident #121. RN #3 was interviewed on 12/13/23 at 9:34 a.m. She said she must have not paid attention to the dose of the medication she was dispensing. RN #2 said she could have administered the wrong dose of Tylenol had she not been stopped and she would have had to ask the supervisor about the process if a medication error had occurred. The director of nursing (DON) was interviewed on 12/14/23 at 12:16 p.m. She said a nurse administering medications must follow physician orders and the five rights of medication administration: right patient, medication, dose, route and time. The DON said following the five rights of medication administration will help prevent medication errors. The DON said there were some inhalers that required a resident to rinse their mouth out after use to prevent thrush (yeast infection). The director of nursing (DON) was interviewed on 12/14/23 at 2:08 p.m. She said mixed insulins were to be administered in the same way as insulins that were not mixed. The DON was not aware of the need to resuspend mixed insulin in vials prior to drawing insulin up for administration. The DON said a resident could have hyperglycemia (high blood glucose level) or hypoglycemia (low blood glucose level) if insulin was not administered correctly.

Based on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Ensure wound dressing supplies were not stored open next to medications in medication cart; -Ensure expired or discontinued medications were removed from medication carts and medication refrigerators; -Ensure medication that was stored in the refrigerator were stored at correct temperatures; -Ensure food were not stored in the medication refrigerators; and, -Ensure medication carts were kept locked. Findings include: I. Facility policy and procedure The Storage and Expiration Dating of Medications, Biologicals, revised on 8/7/23, received from the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. It revealed in pertinent part, facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses and other personnel authorized to administer medications in compliance with applicable law. Facility should ensure that all medications and biologics were stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Facility should ensure that all medications and biologics, including treatment items, were securely stored in locked cabinets/carts or locked medication rooms that were inaccessible by residents and visitors. Facility should ensure that food was not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals were stored. Facility should ensure that medications and biologicals that; (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines. If a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discharged within 28 days unless the manufacturer specifies a different date for that open vial. Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents were stored separately, away from use, until destroyed or returned to the provider. Facility should destroy or return all discontinued medication, outdated/expired medications or biologics. Facility should ensure that medications and biologics were stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Refrigeration 36-46 degrees fahrenheit. II. Observations and staff interviews On 12/11/23 at 12:10 p.m. medication cart #2 on the L wing was o unlocked at the nurses station and no licensed nurse in view of the medication cart. -At 12:14 p.m. two visitors entered the L wing from the outside walking right up to the unlocked medication cart sitting right in front of the door. Registered nurse (RN) RN #1 was interviewed on 12/11/23 at 12:18 p.m. He said medications were to be locked up when a nurse was not around to keep them safe and he did not realize he left the medication cart unlocked. On 12/12/23 at 3:45 p.m. Medication cart #1 on the L wing was reviewed withRN #2. The following was observed: -There were two open packages of Xeroform dressings next to oral medications; -One tube of Hydrocortisone 1% cream stored next to inhalers with no resident name on it; -One bottle of Atovaquone (prevent pneumonitis) 750 milligrams (mg) per milliliter (ml); -One bottle of Prevymis (anti-transplant rejection medication) 480 mg tabs; -One bottle of Melatonin (sleep aid) 3 mg belonging to residents; and, -One insulin glargine pen with no open date. RN #2 said dressings should not be stored next to oral medication, especially when they are open due to contamination and infection control concerns. RN #2 said topical creams should be stored away from medications that were inhaled for infection control concerns. RN #2 said insulin should be dated upon opening as they were only good for 28 days from first access and after 28 days they must be discarded. RN #2 said the bottles of medication belonged to a resident that was discharged from the facility over a week ago and should have been removed from the medication cart. On 12/12/23 at 4:24 p.m. the medication cart on the H wing was reviewed with RN #3 and licensed practical nurse (LPN) #3.The following was observed: -A plastic container with no patient name on it. Inside the container were two Lantus insulin pens and one Novolog insulin pen with no open dates or names on them; -An insulin glargine pen belonging to resident; and, -A Lispro insulin pen that did not have an open date. RN #3 said she did not know who the plastic container with three insulin pens belonged to. LPN #3 said the container containing three insulin pens belonged to a resident who brought them from home and she knew this because another nurse told her they belonged to that resident. LPN #3 said medications should have a resident name on them to know who they belonged to and insulins should have an open date to indicate the date it was first used as it was only good for 28 days. On 12/13/23 at 9:29 a.m. during medication administration RN #3 left two 325 mg tablets of Tylenol on top of the medication cart on H wing while she administered medications to a resident. The medication was not left in sight of RN #3. -The medication was left unattended on the medication cart. On 12/13/23 at 11:39 a.m. RN #1 left medication cart 2 on the L wing medication cart unlocked while he took a blood sugar reading of a resident. -The medication cart was left unlocked and unattended by a licensed nurse. On 12/14/23 at 9:17 a.m. the L wing medication rooms were reviewed with RN #4. The refrigerator temp was 48 degrees fahrenheit verified by RN #4. The refrigerator also contained one vial of Humalog insulin with no open date or resident name on it. RN #4 stated the medication refrigerator temperature was 48 degrees fahrenheit and was out of range for safety reasons. RN #3 said the vial of Humalog insulin needed to be labeled with the date it was opened and a resident name. RN #4 said insulin vials were only good for 28 days and the date would indicate when it could no longer be used. On 12/14/23 at 9:27 a.m. the 100, 200, 300 and 400 wing medication room was reviewed with LPN #1. The following was observed in the medication refrigerator: -A bottle of Vancomycin Hydrochlorothiazide oral solution 250 mg/5 ml that had expired 12/8/23; and, -There were five chocolate pudding cups and four applesauce cups in the medication refrigerator. LPN #1 said expired medications should be disposed of when they expire so they were not administered accidentally. LPN #1 said food and medications should not be stored in the same refrigerator due to infection control risks. The director of nursing (DON) was interviewed on 12/14/23 at 9:34 a.m. She said the medications in the refrigerator on the L wing would be removed and placed into another refrigerator until the facility could determine if the refrigerator was malfunctioning or needed to be replaced. The DON said the medications that were in the medication refrigerator on the L wing would be destroyed and reordered as the facility was unable to determine how long they were stored at the incorrect temp. The DON said medications and food were not to be stored in the same refrigerator due to potential infection control risks. The DON said it was the responsibility of night shift nurses to monitor the temperature of the refrigerators and to clean out expired and discontinued medications from the refrigerators and the medication carts. The DON said insulin pens and vials should have the residents name and date the medications were opened due to insulin only being good for 28 days. The DON said dressing supplies should not be stored next to medications, medications should be stored in the medication cart by type of medication like orals in one section, inhalers in another and topicals in another section to prevent contamination among medications. The DON said medication carts and rooms needed to be kept locked to prevent residents or visitors access to medications.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure glucometers were cleaned according to standards of practice. Findings include: I. Professional reference According to Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved on 12/27/23 from: https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html It revealed in pertinent part, Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. According to the Assure Prism Cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring system retrieved on 12/27/23 from: https://transmedco.com/content/Assure_Prism%20Cleaning_Disinfecting.pdf It revealed in pertinent part, to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. The cleaning procedure was needed to clean dirt, blood and other bodily fluids off the exterior of the meter. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter. Clorox Germicidal wipes, Dispatch Hospital cleaner disinfectant towels with Bleach, and Super Sani-Cloth germicidal disposable wipes. Wipe the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens. Allow exteriors to remain wet for the appropriate contact time then wipe the meter using a dry cloth. Contact time Super Sani-Cloth germicidal disposable wipes two minutes. II. Observations and staff interviews On 12/13/23 at 11:39 a.m. registered nurse (RN) #1 was observed passing medications to Resident #132 who required a blood sugar reading. RN #1 opened the medication cart and collected a glucometer from the top drawer along with an alcohol swab and a lancet. RN #1 entered Resident #132 room advised the resident a glucose reading was needed. RN #1 took the glucose reading, returned to the medication cart, placed the glucometer in the top drawer of the medication cart, locked the drawer and walked away from the medication cart. -RN #1 failed to disinfect the glucometer after using it. RN #1 was interviewed on 12/13/23 at 11:50 a.m. when he returned to his medication cart. RN #1 said there were three diabetic residents assigned to this medication cart who got their blood glucose checked three to four times a day. RN #1 said there was only one glucometer on the medication cart and it was the night shift nurses responsibility to clean the glucometer every night and he did not need to clean it between residents. RN #1 said he could clean the glucometer with an alcohol swab. On 12/13/23 at 12:32 p.m. the H wing medication cart was observed to have three glucometers loose in the top drawer of the medication cart. RN #3 said there were four diabetic residents assigned to this medication cart. RN #3 said she would just get any glucometer out of the drawer to check a resident's blood glucose level as they were not resident specific and would clean the glucometer with an alcohol swab after each use. On 12/13/23 at 12:40 p.m. RN #4 was working cart one on the L wing and she said she had two diabetic residents on her cart and had only one glucometer. RN #4 said she cleaned the glucometers with an alcohol swab. The director of nursing (DON) was interviewed on 12/13/23 at 2:08 p.m. she said we have glucometers for individual residents and they were to be cleaned after every use. The DON said the licensed nurses were responsible to clean the glucometer with the purple Super Sani Cloth Wipes that were antibacterial, antiviral. The DON said the surface of the glucometer must remain wet for two minutes and then allowed to air dry to properly disinfect them. The DON said alcohol swabs did not clean the glucometers appropriately. The DON said she would start staff education immediately.

Based on interviews and record review, the facility failed to obtain informed consent for the use of psychotropic medication for two (#62 and #134) of five residents reviewed for unnecessary medication of out 44 sample residents. Specifically, the facility failed to ensure informed consent which included reason for medication use, risks and benefits associated with use and any black box warning was obtained from the resident or resident representative prior to the resident's use of a psychotropic medication for Resident #62 and Resident #134. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy, revised on 10/24/22, was received by the nursing home administrator (NHA) on 12/18/23 at 11:30 a.m. It read in pertinent part: Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications. II. Resident #62 A. Resident status Resident #62, age 83, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), the diagnoses included anemia (low blood count), muscle weakness and protein-calorie malnutrition. The 10/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required setup or clean up only by staff for eating. B. Record review The protein calorie malnutrition care plan, initiated on 10/31/23 and revised on 12/5/23, documented Resident #62 had inadequate intake for an unknown amount of time due to weight loss, history of declining meals and past medical history of dysphagia (difficulty speaking) including missing teeth. It indicated food intake would be greater than 60 percent through the next review date. The interventions included: providing the diet as ordered, monitoring for difficulties swallowing or chewing and offering salads, yogurt or hamburgers. -The comprehensive care plan failed to include the use of the Mirtazapine-antidepressant medication to increase appetite. The 11/7/23 physician progress note revealed Resident #62 was seen per nursing request due to decreased appetite. The physician assessment and plan indicated a discussion was had with Resident #62 about the importance of nutrition for fighting infection and recovery and that Remeron (mirtazapine) 7.5 milligrams (MG) would be added to increase appetite. The November CPO the following order: -Mirtazapine tablet 7.5 mg once a day, ordered 11/7/23. On 11/14/23 the Mirtazapine 7.5 mg tablet was increased to twice a day. The order was discontinued on 12/13/23. -Although the physician note indicated a discussion was had on importance of nutrition for fighting infection there was no evidence the facility or physician discussed the risks, benefits or black box warning of medication. A request for the consent form for the use of Mirtazapine 7.5 mg for Resident #62 was requested on 12/13/23 at 12:30 p.m. The NHA said she was unable to locate the consent form. The NHA said she visited with Resident #62 on 12/13/23. The NHA said Resident #62 declined the use of the Mirtazapine.use of the medication. III. Staff Interview The director of nursing (DON) was interviewed on 12/14/22 at 12:40 p.m. She said residents had the right to make informed decisions about their medical care including medications. The DON said consent for the use of medications was important because there could be adverse side effects to medications and it was the right of the resident to refuse the medication. The DON said medications should not be administered prior to obtaining consent from the resident or resident's representative. She said the physician or licensed nurses was responsible for ensuring the resident consented to taking the medication before it was administered. She said residents could verbally consent to taking the medication and there would be documentation if the resident verbally consented to taking the medication. The DON said if an order was placed staff must wait to administer the medication until the resident or resident representative consented to the medication use. 38185 IV. Resident #134 A. Resident status Resident #134, age 70, was admitted on [DATE]. According to the November 2023 CPOs, the diagnoses included Parkinson's disease and depression. The 12/9/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required staff assistance with activities of daily living. B. Resident interview Resident #134 was interviewed on 12/11/23 at 11:29 a.m. She said the facility had not reviewed her plan of care with her since her admission to the facility. She said the facility staff had not reviewed her medications and she was unaware of what she was prescribed. C. Record review The December 2023 CPO revealed the following physician orders: -Seroquel 25 mg (milligram) - give one tablet by mouth at bedtime for dementia with behaviors, ordered 12/7/23; and, -Mirtazapine Oral Tablet 30 mg - give one tablet by mouth at bedtime for depression - ordered 12/7/23. The December medication administration record (MAR) documented that the resident had received both the Seroquel and Mirtazapine medications since admission on 12/7/23. A review of the resident's medical record did not reveal documentation that the facility had obtained consent from the resident or resident representative for the Seroquel and Mirtazapine medications. D. Staff interviews The nursing home administrator (NHA) was interviewed on 12/13/23 at 2:07 p.m. She said consents for psychotropic medications should be completed by the admitting nurse during the admission paperwork. She said consent should be obtained prior to administering the medications. The NHA said the consents for Resident #134 to take Seroquel and Mirtazapine had been completed on that day (12/13/23). She said the resident had received six days of medication prior to obtaining the resident's consent to take the medications.

Based on interviews and record review, the facility failed to honor resident choices for two (#66 and #134) of two out of 44 sample residents. Specifically, the facility failed to: -Provide a schedule for Resident #66 for rehabilitation services so he felt like he could leave his room, attend group activities and socialize with others; and, -Ensure Resident #134 and Resident #66 received bathing according to their preference. Findings include: I. Resident #66 status Resident #66, age 75, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (right sided weakness after a stroke), cognitive communication deficit, bipolar disorder, major depressive disorder and anxiety disorder. The 11/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He had impairment on one side affecting his upper and lower extremities. He required substantial dependence on staff for assistance with activities of daily living. It indicated that it was very important to the resident to choose what clothes to wear, take care of your personal belongings, choose between a shower or bed bath, and choose his own bedtime. It indicated that it was somewhat important to listen to music, keeping up with the news, doing things with groups of people and participating in religious services. A. Resident interview Resident #66 and his spouse were interviewed on 12/11/23 at 3:03 p.m. He said he felt he had difficulty getting to know any other residents at the facility or socialize since he was admitted to the facility because he constantly stayed in his room, waiting for his rehabilitation services. He said he had asked for his rehabilitation to be scheduled or given an approximate time, however was told they would not be able to provide a schedule. He said he felt that if he left his room to attend activities, go to the dining room, or socialize with others, he would miss his physical and occupational therapy, which was the reason he was at the facility. He said he was used to socializing and was very lonely throughout the day. Resident #66's spouse said that Resident #66 was a very social person and he would call her constantly throughout the day saying he was lonely and bored from watching television all day. She said she did not understand why the rehabilitation staff could not give him an approximate time so he was able to attend activities and eat in the dining room. Resident #66 said he had received only one shower and one sponge bath at the sink with the occupational therapist since he was admitted to the facility on [DATE]. He said he was told he would receive bathing twice per week. He said he did not feel that a sponge bath was proper bathing and preferred to receive a shower. He said he would like a minimum of two showers per week. He said when he was admitted , he was told he would receive showers on Sundays and Thursdays, however that had not happened. He said he was not asked his preferences upon his admission to the facility. B. Record review The discharge care plan, initiated on 11/27/23, documented the resident anticipated being a short stay resident at the facility with a goal to return home to live with his spouse. The intervention included encouraging the resident to participate with therapies as scheduled to reach his goal to discharge to the community. The activity care plan, initiated on 11/21/23, documented the resident liked to keep up his appearance with being shaved and getting his haircut, like to keep up on current events and enjoyed classical and jazz music and art. A review of the resident's medical record did not reveal documentation that a schedule had been created for the resident to receive therapy services so he was able to attend group activities, eat in the dining room and socialize with other residents. Bathing documentation for November 2023 and December 2023 indicated the resident received a shower on 12/10/23. The 12/7/23 occupational therapy notes documented that the resident was provided a sponge bath at the sink on that date. The facility was unable to provide any additional documentation to indicate the resident had received bathing on any other days other than 12/7/23 and 12/10/23. The resident's medical record did not indicate the resident's preferences in receiving a bed bath or a shower. II. Resident #134 status Resident #134, age 70, was admitted on [DATE]. According to the November 2023 CPO, the diagnoses included Parkinson's disease (degeneration of the brain) and depression. The 12/9/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required staff assistance with activities of daily living. She required substantial to maximum assistance for showering. A. Resident interview Resident #134 was interviewed on 12/11/23 at 11:29 a.m. She said she only received bathing when she was told. She said she was admitted to the facility last Thursday (12/7/23) and was told she could receive a shower twice per week. She said Sunday, 12/10/23, she was given a bed bath. She said she wanted a shower, but was told by the certified nurse aide (CNA) that she had to have a bed bath. She said she told the CNA she wanted her hair washed and was told she would have to wait until her next shower day. She said she felt like she did not have any control over her schedule and had to do whatever she was told by the facility staff. She said she was never asked her preferences upon her admission to the facility. She said the facility staff had not reviewed her plan of care with her or her family. Cross references F655: the facility failed to ensure the resident was involved in the development of the baseline care plan and provided a copy. B. Record review The activities of daily living (ADL) care plan, initiated on 12/11/23, documented the resident required assistance and therapy services to maintain or attain her highest level of function. The December 2023 ADL tasks documented that the resident received a bed bath on 12/10/23. A review of the resident's medical record did not reveal documentation of the resident's preference between a bed bath and a shower. III. Staff interviews The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 12/13/23 at 2:07 p.m. The DON said they were unable to find additional shower documentation for Resident #66. The DON said showers were documented in the CNA tasks in the resident's medical record. She said each resident's shower schedule should be indicated in the care plan and on the CNA task sheet. She said preference sheets were unable to be located for Resident #66 and Resident #134. CNA #1 was interviewed on 12/13/23 at 2:25 p.m. She said each resident's preferences were determined upon admission to the facility. She said there was a preference sheet that was filled out by either the nurse or CNA which included their preference in a bed bath, shower and how many days per week. CNA #1 said she did not know if a preference sheet had been completed for Resident #66 or Resident #134. CNA #1 said she was not aware of a daily schedule for Resident #66. She said she did not know he wanted to attend group activities, eat in the dining room or socialize with others. She said typically the residents admitted for therapy services kept to themselves. She said she had not asked Resident #66 his preferences. The case manager (CM) was interviewed on 12/13/23 at 2:42 p.m. She said, the day of a residents' admission to the facility, the resident's preferences should be obtained by the admission nurse. She said other disciplines could assist with obtaining preferences, such as activities, the CM or social services. She said preferences included how many times per week for bathing and a bed bath versus a shower. The director of rehabilitation (DOR) was interviewed on 12/13/23 at 3:30 p.m. She said the facility did not schedule therapy for residents. She said the schedule was constantly changing so it would be impossible to schedule a particular resident. The DOR said Resident #66 had told her last week that he was lonely and bored at the facility. She said he had asked if they could schedule his therapy and she told him she would not be able to do that. The DOR said she could have determined for Resident #66 to be the first or last resident of the day so he could attend different activities throughout the day and socialize with other residents. She confirmed Resident #66 ' s mental health was as important as his physical health. The DOR said she did not collaborate with activities or any other department when Resident #66 expressed his concern and request. The activity director (AD) and the activity assistant (AA) were interviewed on 12/13/23 at 3:30 p.m. The AD said when a resident was admitted to the facility, an activity staff member would meet with them, obtain their likes, dislikes and preferences and review the activity calendar. She said nursing was responsible for asking the residents their bathing preferences. The AD said Resident #66 had not attended group activities since his admission, until last week. She said she had not kept a participation log for Resident #66. The AD said she had not collaborated with therapy to ensure he could socialize with other residents and attend group activities. She said no one had talked to her about it. The NHA was interviewed on 12/14/23 at 4:00 p.m. She said the admission nurse was responsible for filling out a form that included each resident's bathing preferences. She said each resident's preferences should be obtained upon admission and then placed on the shower schedule according to their preferences. She said the comprehensive care plan should also include each residents' preferences. The NHA said scheduling rehab services was difficult due to resident refusals at times. She said when Resident #66 made the DOR aware he was upset that he had to sit in his room all day to wait for therapy; she should have attempted to give him an approximate time frame for therapy. She said Resident #66 should be able to attend group activities, eat in the dining room and socialize with other residents. The NHA said she thought the resident had been attending group activities this past week. However, based on the activity director's interview, the facility was unable to provide participation logs that documented he attended.

Based on record review and interviews, the facility failed to develop an acute/baseline care plan for two (#139 and #134) of two reviewed for baseline care plans out of 44 sample residents. Specifically, the facility failed to ensure resident involvement in the development and provide a copy to Resident #139 and Resident #134. Findings include: I. Facility policy and procedure The Care Planning - Baseline, Comprehensive and Routine Updates policy and procedure, reviewed on 12/5/22, was provided by the nursing home administrator (NHA) on 12/18/23 at 9:30 a.m. It revealed in pertinent part, Completion and implementation of the baseline care plan with 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. Federal regulations require a baseline care plan to be developed and implemented for each resident. The baseline care plan must include the minimum health care information necessary to properly care for each resident immediately upon admission and a summary must be presented to the resident or their representative that includes the initial goals of the resident, a summary of the resident's medications and dietary instructions, services, and treatments to be administered by the facility, and any updates. II. Resident #139 status Resident #139, age 72, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), the diagnoses included type two diabetes, pain, pneumonia, acute kidney failure and depression. The 12/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required substantial to maximum assistance with activities of daily living. It did not indicate the resident's goals and preferences for discharge. A. Resident interview Resident #139 was interviewed on 12/11/23 at 2:55 p.m. She said the facility had not involved her in the development of an initial care plan upon her admission on 12/7/23. She said a facility case manager had not come and spoken with her. She said she was confused as to her insurance coverage, how long she would be at the facility and what services she would be receiving. She said she had not received any information and was very frustrated. B. Record review The baseline care plan indicated it had been developed on 12/7/23. The questions for the resident to answer, such as, what are one to two things you feel are important that we know about you? What are you most worried about? What do you perceive your strengths are regarding your healthcare needs? What do you perceive are barriers to your healthcare needs and recovery?, were left blank. It did not indicate the baseline care plan had been provided to the resident. A review of the resident's medical record did not reveal documentation that facility staff had met with the resident since her admission to the facility, reviewed her plan of care or her discharge plan. III. Resident #134 status Resident #134, age 70, was admitted on [DATE]. According to the November 2023 CPO, the diagnoses included Parkinson's disease (degeneration of the brain) and depression. The 12/9/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required staff assistance with activities of daily living. She required substantial to maximum assistance for showering. A. Resident interview Resident #134 was interviewed on 12/11/23 at 11:29 a.m. She said she only received bathing when she was told. She said she was admitted to the facility last Thursday (12/7/23) and was told she could receive a shower twice per week. She said Sunday, 12/10/23, she was given a bed bath. She said she wanted a shower but was told by the certified nurse aide (CNA) that she had to have a bed bath. She said she told the CNA she wanted her hair washed, and was told she would have to wait until her next shower day. She said she felt like she did not have any control over her schedule and had to do whatever she was told by the facility staff. She said she was never asked her preferences upon her admission to the facility. She said the facility staff had not reviewed her plan of care with her or her family. B. Record review The baseline care plan indicated it had been developed on 12/7/23. The questions for the resident to answer, such as, what are one to two things you feel are important that we know about you? What are you most worried about? What do you perceive your strengths are regarding your healthcare needs? What do you perceive are barriers to your healthcare needs and recovery?, were left blank. It did not indicate the baseline care plan had been provided to the resident. A review of the resident's medical record did not reveal documentation that facility staff had met with the resident to review her plan of care. IV. Staff interviews The case manager (CM) was interviewed on 12/13/23 at 2:42 p.m. She said the baseline care plan should be developed within 48 hours of the resident's admission to the facility. She said the resident should be involved in the development of the baseline care plan. She said the baseline care plan should include a review of the resident's medications, goals, barriers, medical conditions and discharge plans. The CM said the facility held a care conference to review the baseline care plan with the resident. She said the care conference should be documented in the resident's medical record. She said each resident should be provided a copy of the baseline care plan. The CM said she had not met with Resident #139 since her admission on 12/7/23. She said she had not provided the resident with insurance information or gone over her plan of care. She said she had spoken with the resident at all. The CM said she had not reviewed Resident #134's plan of care with her. She said the facility had not conducted an initial care conference with the resident or her representative. The CM said the questions on the baseline care plan should be completed to show the involvement of the resident in its development. The NHA was interviewed on 12/14/23 at 4:00 p.m. She said the baseline care plan should be developed within 48 hours of the resident ' s admission to the facility. She said the resident should be involved in the development and provided a copy. The NHA said the questions on the baseline care plan should be completed to show the resident ' s involvement in the development. The NHA said she was unable to find documentation to indicate Resident #139 and Resident #134 had been provided a copy of their baseline care plan.

Based on observations and interviews the facility failed to ensure medications were dispensed according to professional standards of practice. Specifically, the facility failed to follow accepted standards of practice for medication administration by setting up three medications prior to administration. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Administration of Medications policy and procedure, revised on 7/14/21, received from the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. revealed in pertinent part, all medications were administered safely and appropriately per physician order. III. Observations On 12/13/23 at 8:56 a.m. registered nurse (RN) #1 was observed leaving an unidentified residents room and walked up to medication cart #2 on the L wing. RN #1 opened the top drawer of the medication cart and pulled a medication cup, from the top drawer, that areready had medication dispensed inothe cup and immediately entered another unidentified resident's room with the medication cup. The nurse exited the resident room withan empty medication cup. At 9:00 a.m. RN #1 returned to his medication cart and opened the top drawer where two additional medication cups were observed with medications already dispensed into the cups. The medication cups were labled with a number and contained several oral medications in each of the cups. RN #1 retrieved one of the medication cup and was leaving the medication cart to administer the medications to a resident. RN #1 was asked to identify the medications in the cup prior to administering them to residents during medication administration observation. IV. Staff interviews RN #1 was interviewed on 12/13/23 at 9:01 a.m. RN #1 said he had pre poured the three residents medications and was waiting for the residents to wake up to administer the medication. RN #1 said he only had two more residents to administer morning medications to at this time. RN #1 said he likes to be prepared for when they get up so he can get his medications passed on time and prior to residents being taken to therapy sessions. The director of nursing (DON) was interviewed on 12/14/23 at 12:16 p.m. The DON said pre-pouring medications was not standard practice as it opens room for errors to occur like not getting correct medication and getting medications late. The DON said nurses should be following the five rights of medication administration: right patient, drug, dose, route and time.

Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#62) of one resident reviewed for pain out of 44 sample residents. Specifically, the facility failed to ensure parameters were in place for use of a scheduled topical pain medication for Resident #62. Findings include: I. Facility policy and procedure The Administration of Medications with a revision date 7/14/21, was received by the nursing home administrator (NHA) on 12/18/23 at 11:30 a.m. It read in pertinent part, A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis or indication for use is required for administration of medication. Any order that is incomplete, illegible or unclear, should be clarified II. Resident status Resident #62, age 83, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), the diagnoses included fracture of the T11 and T12 vertebra (lowest part of your abdomen just above the level of your hip bones and the lower section of your middle back). The 10/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He was dependent on staff with toileting hygiene and lower body dressing and required moderate assistance with personal hygiene. III. Resident interview Resident #62 was interviewed on 12/15/23 at 10:30 a.m. He said his pain is located at his lower back. She said he had fractured his spine at T11 and T12 vertebrae in a helicopter accident. He said he had never injured his T2 vertebrae. He said there was one nurse who worked during most days who knew where to put Diclofenac gel. He said other nurses had to ask him where he was having pain prior to applying Diclofenac gel. IV. Record review The December 2023 CPO revealed the following orders for pain management: -Acceptable level of pain, numerical scale 2 through 10, location of pain, T2 fracture numeric pain scale, attempt non-medication interventions prior to administering as needed pain medications not to exceed 3,000 milligrams (mg) Acetaminophen in a 24 hour period from all sources, ordered on 2/26/23. -Diclofenac Sodium External Gel 1 % (percent) (nonsteroidal anti-inflammatory drug used to treat acute pain) be applied to the affected area topically four times a day for pain, ordered on 10/25/23. -Acetaminophen Tablet 325 mg, give two tablets by mouth every six hours as needed for pain, ordered 10/25/23. -Diclofenac Sodium External Gel 1 % be applied to the affected area topically four times a day for pain lower back apply 2 grams (2.25 inches), ordered on 12/13/23 (This order clarificaton was made during the survey process on 12/13/23). The pain/discomfort care plan, revised on 11/10/23, revealed Resident #62 had a T12 fracture. It indicated the resident would express relief from pain. The interventions included: evaluating effectiveness of pain interventions and providing pain medications as ordered. The NHA provided the pharmacy recommendations on 12/13/23 for the month of November 2023. It revealed the pharmacist recommended the order for the Diclofenac 1% gel be updated to reflect the amount of medication being administered and to identify location of the affected area on 11/27/23. The recommendation went on to include that not more than 16 grams be used on any lower extremity or 8 grams to any upper extremity, and not to exceed 32 grams per day over all affected areas. The facility failed ot follow up on the pharmacy recommondations until the oversigth was identified othte faclity. V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 12/13/23 at 2:14 p.m. She said she applied the Diclofenac 1% gel to Resident #62's lower back for pain. She said she did not know the exact cause of pain for Resident #62. She said she used the application strip that came in the box of the medication to measure the amount of medication to apply. LPN #3 said she applied two grams of Diclofenac gel to Resident #62's lower back. LPN #3 said the application strip recommended two grams of Diclofenac gel for use on the upper body. LPN #3 said the CPO did not indicate where to apply the Diclofenac gel or the amount of medication to be administered. She said she knew where to put the medication and how much was used because she worked with the resident since his admission in October of 2023. She said an order for a topical medication should indicate where to apply medication and how much to use. She said this was important to avoid a medication error. The director of nursing (DON) was interviewed on 12/13/23 at 2:24 p.m. She said she received recommendations from the pharmacy through email and provided it to the resident's physician for review. She said she had not seen the recommendation for Resident #62's Diclofenac order to be clarified prior to this day. She said nursing would be able to identify the affected location by looking at the acceptable level of pain scale order. She said nursing would know what amount to use by referring to the manufacturer's recommendations. -However, the acceptable level of pain documented in Resident #62's electronic medical record did not indicate location to be used on, amount to be used or daily amount to not be exceeded for Diclofenac 1% gel order. According to the December 2023 CPO Resident #62 fractured his T11 and T12 vertebra. The doctor of pharmacy (PharmD) was interviewed on 12/14/23 at 10:00 a.m. She said she made a recommendation for Resident #62 ' s Diclofenac 1% gel order to include parameters to specify the amount to be applied, affected area(s) to apply, and an amount not to be exceeded. She said the recommendation was uploaded to a portal the facility had access to. The clinical director of pharmacy (CDP) was interviewed on 12/14/23 at 11:00 a.m. He said it was his personal preference that an order for a topical pain medication included the affected area of pain and amount of topical to be used. The CDP said the standard application order for Diclofenac 1% gel was between two and four grams. He said the application amount would depend on the location of the affected area. He said if a pharmacist made a recommendation that an order for a topical pain medication be clarified to include amount and location it should be included in the order.

Based on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one resident (#8) of one resident reviewed for dialysis out of 44 sample residents. Specifically, the facility failed to: -Ensure communication forms between the facility and the dialysis center were completed consistently and accurately for Resident #8; and, -Ensure bruit and thrill were assessed upon return from dialysis and not signed as completed prior to Resident #8 return. Findings include: I. Facility policy and procedure The Hemodialysis Off Site policy, reviewed on 8/23/23, received from the nursing home administrator (NHA) on 12/18/23 at 10:47 a.m. revealed in pertinent part the facility assures that each resident receives care and services for the provision of offsite hemodialysis dialysis consistent with professional standards of practice. Ongoing assessments of the residents condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility; and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Day of dialysis observe vascular access site prior to dialysis and initiate the pre/post dialysis communication form to be sent to the dialysis clinic with the resident. Post dialysis: obtain vital signs of the resident upon return from dialysis and complete the pre/post dialysis communication form. Monitor vascular access sites on a routine basis. II. Resident #8 A. Resident status Resident #8, under the age of 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO) diagnoses included end stage renal disease (abnormal kidney function), type two diabetes mellitus (abnormal glucose levels) and cellulitis of right lower limb (infection of the skin tissue). The 11/14/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with eating, dressing, transfers, toileting and personal hygiene. The MDS assessment documented the resident received hemodialysis. B. Record review The December 2023 CPO documented the following orders: -Dialysis patients received dialysis Monday, Wednesday and Friday chair time 5:00 a.m. to 9:40 a.m. Do not take blood pressure in the left arm with fistula/shunt ordered 6/1/23; and, -Dialysis resident assess bruit/thrill upon return from dialysis every Monday, Wednesday and Friday, ordered 11/25/23. The 11/14/23 comprehensive care plan documented Resident #8 received dialysis for end stage renal disease the interventions included: assessing the shunt site for bruit and thrill, providing dialysis treatments as ordered, ensuring blood pressure was not taken on left arm, observing for bleeding at dialysis access site and providing a therapeutic diet as ordered. Resident #8's dialysis communication book documented post assessments were not completed by a licensed nurse on 12/11/23, 12/8/23, 12/6/23, 12/4/23, 11/27/23, 11/24/23, 11/17/23, 11/13/23, 11/10/23 and 10/27/23. The dialysis communication book revealed there were no pre-dialysis assessments completed on 11/13/23 and 10/27/23. A review of the timestamp medication administration record (MAR) for Resident #8 was completed on 12/13/23. The MAR documented the licensed nurse had completed the bruit and thrill assessment on 12/13/23 at 6:23 a.m. The dialysis communication form for 12/13/23 showed the post dialysis assessment was completed at 10:27 a.m. -However, the resident did not return to the the facility until 10:33 a.m. (see observation below). C. Resident interview Resident #8 was interviewed on 12/11/23 at 3:20 p.m. He said his dialysis site was not always checked by a nurse prior to going to dialysis or when he came back from dialysis. D. Observation On 12/13/23 at 10:29 a.m. Resident #8 was observed returning from dialysis through the front doors of the facility with a walker used for ambulation. The walker had a lunch pail and blankets draped over it Resident #8 went directly to his room and sat in his wheelchair and changed his oxygen from the portable oxygen canister to the room concentrator. -At 10:33 a.m. a unidentified certified nurse aide (CNA) walked by his room and Resident #8 said I am back, the CNA said welcome back and continued to walk down the hallway. -At 10:36 a.m. the CNA returned to Resident #8 ' s room and assisted him with getting lunch ordered and fixing his bed. -The floor nurse did not assess the resident upon his return from dialysis to check the dialysis fistula site for patency by checking the bruit and thrill or assess the resident's vital signs. E. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 12/13/23 at 2:44 p.m. She said Resident #8 left before her shift started and returned around 10:30 or 11:00 a.m. from dialysis. LPN #2 said when Resident #8 returned to the facility his assigned nurse would check his arm for dressing and would assess for bruit and thrill. LPN #2 said the resident would normally refused to have his weight checked as he had it checked at the dialysis center just before coming back. LPN #2 referred to the dialysis book for paper documentation of the pre and post dialysis assessments. LPN #2 reviewed Resident #8 ' s dialysis book and acknowledged the paper documentation was incomplete (see record review above). LPN #2 said if an order read to be done after return from dialysis that's when it should be completed and then documented in the electronic medical record LPN #2 said this order could not be documented as completed until the resident returned to the facility from dialysis -However, LPN #2 had signed the MAR at 6:23 a.m. and the dialysis communication sheet at 10:27 a.m. that she had assessed the bruit and thrill when the resident did not return to the facility until 10:29 a.m (see record review and observations above). The director of nursing (DON) was interviewed on 12/14/23 at 11:47 a.m. She said the licensed nurses needed to fill out a dialysis communication form with pre and post dialysis vitals every day the resident goes to dialysis. The DON said bruit and thrill should be assessed upon residents return from dialysis and documented in the electronic medical record at that time. The DON said physician orders should not be signed out as completed until it was completed.

Based on observations, record review and resident/staff interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being of one (#142) out of 47 sample residents. Specifically: -Resident #142's pain was not adequately managed, contributing to the resident experiencing unrelieved leg pain. -Resident #142's skin condition was not adequately addressed. Findings include: I. Pain A. The facility's Pain Management procedure read, in pertinent part: "...The "Pain Assessment" form will ... be completed quarterly or with a significant change ...when the resident reports pain the nurse assesses the pain using a scale of one to ten or the Wong Baker faces scale for the non-verbal residents. Based on their response and if applicable, non-med(ication) interventions are provided or the resident is medicated with the ordered PRN (as needed) medication. All medications used for pain that are not scheduled are recorded on the form know as the "Pain Flow Sheet" to follow up on effectiveness of medication." B. Resident #142 Resident #142, age 57, was admitted to the facility on [DATE]. According to the 5/12 Computerized Physician order [REDACTED]. According to the most recent Minimum Data Set (MDS), dated [DATE], the resident had minimal cognitive impairments. He required extensive assistance of one with bed mobility and transfers and was totally dependent with the help of one with personal hygiene. He had no behavior symptoms. The MDS indicated the resident had not experienced pain within five days of the completion of the assessment. The MDS also indicated the resident was not on a scheduled pain medication and had not received any as needed pain medications. 1. Pain Management Plan A care plan for pain, initiated on 2/29/12, identified the resident experienced the presence of occasional pain related to fall, compression fracture. The goal was for the resident to verbalize pain was decreased to a level of 3 or less. The interventions for pain included to: -evaluate pain using verbal pain scale of 1-10, -administer pain medications as ordered, -assist with diversion activities, -assist to change position, -monitor for worsening pain symptoms and report to the physician, -quarterly pain assessments and -evaluate pain every shift. The Medication Administration (MAR) record included a pain assessment form. The form directed a pain assessment every shift. The resident's pain was to be evaluated every shift using a verbal pain scale of 0-10, and staff was to document the results on the pain assessment form (PAF). -The PAF documented interventions to relieve pain were to reposition the resident, offer food/fluid, to take the resident to an activity and to offer pain medications. -The pain assessment documented: 0= no pain, 1-3 = mild pain; 4-6 = moderate pain; 7-10 excruciating pain. The resident's Computerized Physician order [REDACTED]. --[MEDICATION NAME] 100 mg capsule. One capsule orally twice a day for pain. --[MEDICATION NAME] HCL 5 mg tablet every four hours as needed for pain 1-5. --[MEDICATION NAME] HCL 5 mg tablet. Two tablets orally every four hours as needed for pain 6-10. --[MEDICATION NAME] 50 mg tablet. Two tablets orally every six hours as needed for pain. --Tylenol 650 mg. 1 caplet orally every four hours as needed for pain. --[MEDICATION NAME] balm ointment (Bengay) to be applied twice daily to affected areas as needed for cramping. The 5/12 CPO documented an order, "Do not give pain meds for 4 hours prior to going to [MEDICAL TREATMENT] (start date 2/10/12) ..." 2. Repeated documentation of moderate to excruciating pain The resident's recent PAF were reviewed and revealed the resident repeatedly experienced moderate to excruciating pain in the resident's right leg. Review of the Pain Flow sheet (PFS) documented the resident frequently had pain at a moderate or excruciating pain level, for which the resident was administered 10 mg of [MEDICATION NAME]. The PFS included the pain scale from the PAF. 4/12: --4/8/12 2:20 a.m.=9 --4/8/12 9:15 p.m.=8 --4/9/12 1:00 p.m. =8 --4/9/12 5:30 p.m.=8 --4/9/12 10:00 p.m.=8 --4/10/12 5:00 p.m.=8 --4/12/12 8:30 p.m.=4 --4/14/12 6:00 p.m.=8 --4/15/12 7:55 p.m.=9 --4/16/12 5;15 p.m.=8 --4/16/12 9:30 p.m.=8 --4/17/12 2:00 a.m.=10 --4/17/12 8:20 a.m.=10 --4/17/12 9:00 p.m.=8 --4/18/12 8:20 a.m.=8 --4/18/12 12:20 p.m.=7 -4/21/12 2:45 a.m.=8 --4/23/12 (no time)=10 --4/23/12 (no time) =8 --4/23/12 8:30 p.m.=8 --4/24/12 7:30 a.m.=8 --4/27/12 11:30 a.m.=6 --4/28/12 12:00 a.m.=8 --4/29/12 5:30 p.m.=9 --4/30/12 6:15 a.m.=9 --4/30/12 12:30 p.m.=8 --4/30/12 7:00 p.m.=8 5/12: --5/1/12 1:00 a.m.= 8 --5/1/12 7:30 a.m. =8 --5/2/12 5:45 p.m. =9/10 --5/5/12 6:30 a.m.=10 --5/6/12 8:00 a.m. =7 --5/7/12 11:00 a.m. =8 --5/7/12 3:00 p.m.=8 --5/9/12 10:00 p.m.=8 --5/10/12 4:00 p.m.=8 --5/10/12 3:50 p.m.=8 --5/11/12 9:30 a.m.=8 --5/11/12 3:10 a.m.=8 --5/11/12 9:00 p.m.=8 --5/12/12 6:00 a.m. =8 --5/12/12 5:30 p.m.=8 --5/13/12 7:25 p.m.=8 --5/14/12 2:00 a.m.=10 --5/14/12 8:00 a.m.=8 --5/14/12 4:45 p.m.=10 --5/15/12 2:00 a.m.=10 --5/15/12 6:00 a.m.=10 --5/15/12 6:45 a.m.=8 --5/16/12 no time documented=10 --5/16/12 10:30 a.m.=10 --5/16/12 11:30 a.m. =10 [MEDICATION NAME] 100 mg administered --5/16/12 5:00 p.m. =10 The resident was administered 10 mg of [MEDICATION NAME] each instance except on 5/16/12 at 11:30 a.m. In all cases the location of the pain was "right thigh.. .right leg." 3. Facility Response to Resident's Pain a. physician progress notes [REDACTED]. A physician's progress note, dated 4/6/12, documented joint pain, lower leg. The recommendations given included: [MEDICATION NAME] for pain. A physician's progress note, dated 4/14/12, documented joint pain, lower leg. The recommendations given include: [MEDICATION NAME] for pain. A physician's progress note, dated 5/4/12, identified the resident had a current problem of joint pain, lower leg. The recommendations were to give [MEDICATION NAME] for pain b. MAR -Review of the MAR indicated [REDACTED]. c. TAR Review of the treatment administration record (TAR) revealed no documentation that Bengay was applied. d. Pain Flow Sheet Review of the pain flow sheet documented repositioning as the sole non-medication intervention for all cases. 4. Failure to comprehensively assess, communicate and ensure management of resident #142's pain a. Assessment The most recent pain assessment was dated 2/21/12 at 7:45 p.m. The assessment documented the resident was currently in pain, had a risk for pain, experienced pain in the past. The assessment documented the resident was not reluctant to verbalize or express pain. The assessment documented the origin of pain was back pain and lower left extremity. The assessment documented the resident was prescribed effective pain medications and non-medication interventions. Movement made the pain worse according to the assessment. There was no documentation that the resident's pain had been comprehensively assessed since 2/12/12, even though the resident's pain was frequently documented as moderate (pain level of 4-6) or excruciating (pain level 7 -10) for the last two months. Moreover, although the physician indicated s/he was aware of the resident's pain, there was no documentation in the progress notes that the physician was aware that the [MEDICATION NAME], as ordered, was not managing the resident's pain. 5. Observations and Interviews a. On 5/10/12 at 9:18 a.m., the resident was observed rubbing his right leg. Throughout an interview with the resident from 9:13 a.m. to 9:28 a.m., the resident continued to deep rub his upper thigh. The resident stated that he was having pain in his right leg. He stated that he used Bengay for the pain and while it helped, the pain was "always there." The resident stated that he went to [MEDICAL TREATMENT] three days a week and usually left the facility around 9:30 a.m. b. On 5/16/12 at approximately 9:30 a.m., the resident again was observed to be rubbing his right upper thigh. -The resident stated he had used his Bengay that morning, and had received oral pain medication at about 6:00 a.m. The resident stated he kept the Bengay in his drawer and applied it himself. The resident stated that his pain level was approximately 10 out of 10. -The resident stated that a warm bath would help both his skin (see below) and his muscles. However, when he had requested a warm bath, the certified nurse aide (CNA) informed him that it was too much work to clean the tub, fill the tub, and clean the tub after the resident was done bathing. The resident stated that he had not been offered any non-pharmaceutical interventions for the pain. c. On 5/16/12 at 9:52 a.m., the licensed practical nurse (LPN) was interviewed. The LPN stated that she floated throughout the building. The LPN was informed the resident reported he was experiencing pain at a level of 10 out of 10 (see above). -The LPN said the resident had received an as needed [MEDICATION NAME] for pain that morning. She stated that the resident's medication card was empty and that the last dose (2 tabs) was given at 6:30 a.m. She stated they were waiting for the pharmacy to deliver on the first run which was at 6:00 p.m. (according to the LPN). The LPN stated that the charge nurse had notified the pharmacy; however, staff had not received the faxed version of authorization to remove the [MEDICATION NAME] from the emergency kit. -The LPN stated the resident had an order for [REDACTED]. -The LPN stated that she had not heard the resident was having pain. d. On 5/16/12 at 10:13 a.m., the LPN went in to assess the resident. -The resident told the LPN that his leg hurt and said he had told the CNA he needed something for pain at around 9:30 a.m. He stated that the pain level was over 10. The LPN stated that she would get the medication for the resident. The resident asked to sit up in bed and the LPN assisted the resident to a sitting position. -The LPN went to the MAR indicated [REDACTED]. The LPN stated that no one had told her earlier that the resident was in pain. She stated that she would pull [MEDICATION NAME] from the emergency kit. e. On 5/16/12 at 10:30 a.m., the resident was administered two [MEDICATION NAME] (5 mg each). The resident stated the pain in his right leg was sharp and internal. The LPN was interviewed after the administration of the [MEDICATION NAME]. The LPN stated the [MEDICATION NAME] was used for break-through pain and that it could be given every six hours. The LPN stated the resident did not have any continuous medications. She stated that she would call the physician to alert him to the resident's pain level. On 5/16/12 at 10:45 a.m., the charge nurse (CN) called the physician to inquire about a scheduled dose of pain medications. The physician provided a new order for [MEDICATION NAME] 10 mg orally twice daily. 6. Additional Staff Interviews On 5/16/12 at 10:45 a.m., the CN stated that she had not heard in report that the resident had been having an increase in pain at an 8 level. She stated that if she'd known, she would have called the physician sooner. She stated pain medications were not discussed during report. She stated that she was unaware that the resident had requested a "sonic bath" (warm bath in a jetted tub). She stated that the warm water would help his pain. She stated that the nurse was to offer a position change and offer a warm towel for non-pharmaceutical interventions. On 5/16/12 at approximately 3:00 p.m., the director of nurses (DON) and the assistant director of nurses (ADON) were interviewed. -The DON stated pain assessments were completed quarterly as well as with any change of condition. She stated the resident was on [MEDICATION NAME] 100 mg twice a day for pain. She stated that in 12/11, the [MEDICAL TREATMENT] center had requested that the pain medication not be administered prior to [MEDICAL TREATMENT]. -The DON, after reviewing the medical record, stated the [MEDICATION NAME] as needed was added on 4/2/12. The DON confirmed that the physician should have been notified when the resident's pain was not being adequately covered. She stated that in 2/12, the resident had a procedure (Doppler) and x-ray to rule out a [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED]. -The DON stated residents in the long-term care were discussed monthly as part of a quality assurance program. The resident's pain was not discussed in the 4/12 meeting. -The ADON stated the CN stated the Bengay was given to the resident in a small cup for him to rub onto his affected areas. However, after reviewing the 5/12 TAR, the DON stated the expectation was for the nurses to put the Bengay on the resident and to document its administration. -On 5/16/12 at approximately 3:30 p.m., the unit manager (UM) was interviewed. The UM stated that she was aware that the resident had pain in his lower right leg. The UM said s/he had not called the physician to notify him/her of the resident's pain. II. Skin A. Resident #142 1. See resident admission and [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS), dated [DATE], (see above), the resident had minimal cognitive impairments, required extensive assistance of one with bed mobility and transfers, and was totally dependent with the help of one with personal hygiene. The resident was at risk for pressure sores. The resident received [MEDICAL TREATMENT] three times a week. B. Observations and Resident Interview On 5/10/12 at 9:39 a.m., the resident was observed to have a bandage, approximately 2 X 4 inches on each of his cheeks. The resident stated that he becomes nervous and scratches his face. The resident stated that he used [MEDICATION NAME] (a skin cream) on his face. On 5/14/12 at 8:39 a.m., the resident was observed without the facial bandages. The resident had an open [MEDICAL CONDITION] on each of his cheeks. The open [MEDICAL CONDITION] were approximately the size of a quarter. The resident stated the [MEDICATION NAME] helps his itch and that he places it on his back and face. On 5/14/12 at approximately 11:00 a.m., resident #142's back was observed. The resident was seated in his wheelchair with his shirt off. He had two open areas on his upper back that were visible from several feet away. The charge nurse was walking by as the open areas were observed. The charge nurse stated the open areas on the resident's back were a result of his scratching. On 5/16/12 at approximately 9:30 a.m., the resident again was observed without his facial bandages. The open areas on his face were partially scabbed and partially bleeding. The resident stated that he took [MEDICATION NAME] (anti-anxiety medication) before [MEDICAL TREATMENT], but that he did not want to take it other than the three ([MEDICAL TREATMENT]) days as he was fearful it would stop working for him. On 5/16/12 at approximately 1:30 p.m., the resident was observed to have two bandages on his face. C. Record Review According to the 5/12 CPO, the resident had a physician order [REDACTED]. The resident was also prescribed [MEDICATION NAME] 1 mg to be given three times a week prior to [MEDICAL TREATMENT]. The 5/12 CPO revealed an order that read, "for [MEDICAL CONDITION] cover with [MEDICATION NAME] dressing cleanse with wound cleanser, apply [MEDICATION NAME] and cover daily (start date 2/10/12)." Review of the social service assessment, dated 5/15/12, documented the resident had anxiety prior to [MEDICAL TREATMENT], and that his mood/behavior appear to be stable at this time. A care plan, initiated on 2/29/12, identified the resident had skin integrity related problems. The care plan documented, "(name of resident) continues to pick at skin. He has scabs to entire body from picking related to [MEDICAL TREATMENT]." The goal was for the resident to minimize risk of infection. The interventions for skin included to: -complete weekly skin assessments, -remind resident not to pick or scratch at skin; -educate the importance of infection control; -cover scabs and open areas as resident picks. The 4/22/12 monthly nursing summary documented the resident had open areas on his cheeks and scabs all over his body. The affected areas were not specifically identified. The weekly skin assessments, dated 4/12 and 5/12, documented the resident had multiple open areas, scabs and scars. The weekly skin assessment tool instructed for the open areas to be identified on a documentation body. However, there was no documentation of the location of the open areas. Review of the TAR showed the current treatment order (see above). Although, the TAR had an "FYI (for your information)" the TAR did not show any initials that the treatment was completed. D. Failure to Assess, Monitor and Comprehensively Address Skin Issues 1. See above skin assessments, TAR and 4/22/12 nursing summary. The medical record failed to show any documentation that the open [MEDICAL CONDITION] were being tracked for size, depth or condition. 2. The most recent physician's note, dated 5/4/12, failed to show the [MEDICAL CONDITION] were addressed. 3. Cross-reference F312; ADLs. Observations on several days revealed the resident had dried dark substance under his fingernails. E. Interviews The charge nurse (CN) was interviewed on 5/16/12 at 11:00 a.m. -The CN stated the resident had wounds when he was admitted from the rehabilitation unit. She stated that he had a lot of anxiety and the itching came from his kidney disease. She stated the resident picked off the dressings. The CN stated that she had not asked the physician what other treatments could be implemented to help with the scratching. -The CN said the resident receives [MEDICATION NAME] and also [MEDICATION NAME], and that the nurses give him "patches" to put on himself. She stated all shifts should assess the [MEDICAL CONDITION] and note any infection. She confirmed measurements were not documented, unless they showed infection. -The CN stated that she would schedule a bath for the resident as the warm water would help his skin. The LPN completing skin treatments was interviewed on 5/16/12 at approximately 1:30 p.m. The LPN stated that she treated the resident's cheeks according to the physician orders; however, she did not complete the treatment on his back. The unit manager (UM) was interviewed on 5/16/12 at approximately 3:00 p.m. The UM stated that she was unaware the TAR was not documented when the treatment was completed. The treatment was for all [MEDICAL CONDITION].