Every finding on record at Villa Maria Post Acute and Rehabilitation

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure adequate supervision to prevent one of one sampled resident (Resident #1) from eloping the facility while a Peripherally Inserted Central Catheter (PICC) line remained in place. The deficient practice could place the resident at risk for interruption of prescribed intravenous therapy, catheter-related infection, misuse of the PICC line, overdose, and death.Findings Include: Resident #1 was admitted on [DATE], and discharged on May 18, 2026, with a diagnosis that included cellulitis of the left lower limb, muscle weakness, abnormalities of gait and mobility, assistance with personal care, hypokalemia, opioid abuse, and depressive disorders. An elopement and wandering evaluation completed on April 25, 2026, indicated a score of 5.0, indicating Resident #1 is at low risk for elopement and wandering and has no history of eloping in the last 6 months. A care plan initiated on April 28, 2026, had a focused area for Resident #1 having ineffective coping related to alcohol abuse and substance abuse. Interventions included: encouraging contact with support system (for example: family member, group sponsor). Encourage the resident to make choices and participate in planning of care and scheduled activities. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 was cognitively intact. A discharge summary and post-discharge plan of care were completed on May 18, 2026, at 06:15 AM, which indicated that Resident #1 left the facility without notifying the staff, and the discharge location description indicated that Resident #1 left Against Medical Advise. A nursing note dated May 18, 2026, at 06:47 AM revealed that at 0600, Resident #1 was observed entering another resident's room. At 06:20 AM, a Certified Nursing Assistant (CNA) in the hall wanted to check Resident #1's vitals, but was unable to find Resident #1. All areas were searched for Resident #1, and Resident #1 was not located. An open window was discovered in the room Resident #1 had entered. Assistant Director of Nursing (ADON), the provider, and the police were notified. A nurse note dated May 18, 2026, at 06:30 AM revealed that Police Department was notified that Resident #1 had left the facility while a PICC line remained in place. Another nursing note dated May 18, 2026, at 4:18 PM revealed that Adult Protective Services (APS) was notified of Resident #1 leaving with a PICC line. Documentation indicated Resident #1 was alert and oriented X 4. Further review of the medical record failed to identify documentation that Resident #1 notified staff of a intent to leave prior to exiting the facility or that staff had the opportunity to initiate the facility's AMA process before the resident left the facility. Multiple call attempts were made to Resident #1 on June 18, 2026, at 11:06 AM and 12:31 PM, but she was unreachable due to the phone no longer being in service. A call attempt was made to the Resident #1 on June 19, 2026, at 08:14 AM, but was unreachable because the phone was no longer in service. Multiple call attempts were made to contact the Licensed Practical Nurse (LPN/Staff #3), who was on the shift when Resident #1 eloped. The LPN did not answer her phone. An interview was conducted on June 18, 2026, at 1:07 PM with CNA (Staff #11), who stated that elopement occurs when a resident leaves the facility without staff knowledge. She stated facility staff initiate a Code Yellow, search resident rooms, bathrooms, the facility, and the surrounding grounds, and notify ADON or charge nurse and law enforcement if resident cannot be located. The CNA stated that if the resident goes out of the window, it will be considered elopement, and the risk of a resident who has a history of substance abuse and leaves with a PICC line would be that the resident could get injured. Staff #11 stated Resident #1 had previously expressed a desire to leave the facility with her boyfriend. Staff #11 stated that the resident would yell out and have lots of outbursts. An interview was conducted on June 18, 2026, at 1:30 PM with CNA (Staff #4), who stated that elopement is when a patient tries to leave the facility, and if they leave the emergency exit and dining exit doors, it would be considered elopement. CNA further stated that the facility process for elopement is to search for the resident everywhere, notify the nurse, and they will initiate a code. She stated if resident not found after searching everywhere, police are notified of the missing resident. Staff #4 stated that if the resident with a PICC line goes out of the window, it is considered to be elopement. CNA further stated that she was not aware that Resident #1 tried to leave the facility nor that Resident #1 mentioned leaving the facility; Staff #4 stated she was unaware of leaving out of the window. An interview was conducted on June 18, 2026, at 1:45 PM with Licensed Practical Nurse (LPN/staff #6), who stated that elopement is when someone is at risk of leaving. She states that elopement would be considered if the resident takes off and leaves the facility premises and is not found. She stated that the facility process for elopement is to search the entire property for the resident and surrounding areas, and call around hospitals. If the resident is not alert and has dementia, police will be called and the administrator. Then stated that if they are alert and oriented, police, the administrator, and the provider are notified. She stated the staff document the description of the incident in the resident's chart, what was done to find the resident, and who was notified. She stated that the resident going out of the window is considered to be elopement or AMA. She stated that when a resident wants to leave AMA, they are supposed to sign the form, and some residents do not sign the paperwork. The LPN stated that an AMA resident is educated about the risks of leaving the facility without medical advice and the benefits for them to stay. She stated that if the staff are not aware of the resident leaving, no AMA work would be completed because they would not be aware of them leaving. She stated that the risk of the resident leaving the facility with a PICC line who has a substance abuse history would be infection control and them having access to insert things. LPN stated that she received report on May 18, 2026, from the previous nurse (Staff #3) that Resident #1 went out of the window in another resident's room with a PICC line and that she left AMA. She stated that Staff #3 notified her that management and police were notified. An interview was conducted on June 18, 2026, at 2:16 PM with the Social Services Manager (SSM/staff #7), who stated that her role as social services manager is to take care of residents' discharge planning, ordering services, take care of grievances, and work with residents' insurance. She stated that discharge planning starts as soon as a resident is admitted to the facility, and she meets with the resident 24-48 hours before discharge planning to review the care plan, ask about their needs, and ensure the services needed are in place. She stated that the AMA process is that staff try to educate the resident about the risks and benefits of leaving without medical advice, and if they do leave with AMA, it should be documented. She stated that if the resident does leave, then we try to ensure they are ok for the first three days. Then she stated that elopement is when a resident either wanders or leaves the facility premises, and they are confused or not mentally or physically safe. Staff #7 stated that Resident #1 did not have a discharge date because she did not finish her antibiotics. Staff #7 further stated that she left AMA by going out of the window with a PICC line in place. She stated that she reported to APS about this and did not have to report to the Department of Health Services (DHS) because she was alert and oriented times four and not confused, and that was her decision. She further stated that in Resident #1's case, it would not be considered elopement because she was physically and mentally independent. She stated that Resident #1 leaving with a PICC line would pose a risk because she can use the PICC line for anything and not receive the medication that she needs. A call attempt was made on June 18, 2026, at 2:53 PM to ADON (Staff #9), she did not answer the phone. An interview was conducted on June 18, 2026, at 2:59 PM with the Director of Nursing (DON/Staff #12), who stated that elopement is when a resident is at risk for wandering, has dementia, or is confused and leaves unwitnessed out of the facility. She further stated that elopement is considered when a vulnerable resident leaves the premises of the facility, and the staff is unaware. She further explained that vulnerable residents are any resident who is cognitively impaired or has medical issues that can put them at risk for harm, such as any resident who leaves with a PICC line would be considered an elopement. She stated that her expectation of the staff member when a resident elopes is to search the whole facility, attempt to contact the resident if they can, contact the family or person listed on their records, search the surrounding areas of the facility, notify the provider, notify police, APS, DHS, and notify DON or the administrator in between. She stated that residents can leave the facility with a PICC line, and they have, and when that happens, police and APS are notified. She stated that the AMA discharge process is initiated when the resident either intends to leave without medical advice. She stated that when this happens, the staff try to educate the resident about the benefits of staying and the risk of leaving the facility; the AMA form is signed then. She stated that if the resident is present, they will sign the AMA form. She stated that if they know how the resident left, it would be considered AMA, not elopement, and it would be documented in the resident's chart if risks and benefits are explained to the resident when leaving AMA. DON further stated that Resident #1 had eloped on May 18, 2026, then changed her answer to AMA. DON explained that morning, Resident #1 was in another resident's room, Resident #2's room, and was not found when the CNA wanted to take her vitals, but the window was observed to be open in another resident's room, so that's where she had gone out of the facility. She stated that the police were called; Resident #1 had left through the window with a PICC line, which would be considered AMA, not elopement. DON further stated that the resident came back and was advised to go to the hospital and came on May 23rd to pick up her clothing, and stated nothing was documented in the resident's chart, which should have been. DON stated that there was no AMA form filled out for her; if they knew before she wanted to leave, it would have been filled out. She stated that Resident #1 leaving with a PICC line out of the window could pose risks such as death, increased infection control, and taking drugs with the PICC line access. An interview was conducted on June 19, 2026, at 08:21 AM with the LPN (staff #3), who stated that elopement is when a resident leaves the facility without letting staff know or runs away from the facility. She stated that elopement is considered when a resident is completely out of the facility and nowhere to be found in the facility. She stated that the facility process for elopement is to let the staff know the resident is missing, check the area, and check the parking lot; if not found, let the supervisor know; the supervisor will notify the provider, family, and police. She stated that if the resident leaves out of the window, then that would be considered elopement. She stated the process for AMA is to explain to the resident why they are here, the risk of leaving, the benefits of staying, and if they still refuse, then they will sign the AMA form, the provider will be notified, and the supervisor. LPN stated that if the resident did notify the staff that they want to leave, then it would be considered AMA. She stated that there are many risks if the resident elopes with a PICC line and has a history of substance abuse; there will be a risk of inserting drugs into their PICC line. LPN stated that she recalls the incident with Resident #1, it was morning when LPN was finishing her meds. A CNA was trying to look for Resident #1 to do her vitals, and she saw her going into another resident's room, and went there, and she was not found, but that room's window was open. Then they started to look for Resident #1, looked from room to room, looked in the whole building, outside, and she was not found; then the supervisor, doctor, and police were notified. LPN further stated that she did try to call Resident #1, but her number was not working, but did not document that in the medical records. She further stated that Resident #1 did elope from the facility; it was not AMA. Staff #3 stated that Resident #1 did come back to the facility at midnight that day with a male and wanted her to remove the PICC line; however, Staff #3 advised Resident #1 to go to the hospital to remove the PICC line and left the facility with the male she came with. She stated that this was not documented in the Resident #1 chart since she was no longer a patient and was discharged ; she notified her supervisor. She stated that the risk for Resident #1 in her case would be may overdose on the drugs. Reviewed the policy Elopement/Unsafe Wandering Revised date January 2026, revealed that elopement occurs when a resident leaves the facility premises or safe area without authorization (example: an order for discharge, appointment, or leave of absence), and/or any necessary supervision to do so. Also, it is the policy of the facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement.

Based on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure PASSAR screening and referral were accurate and completed for 6residents (#3, #5, #9, #13, #21, and #55). This deficient practice can result in residents medically related social and emotional needs not being met. The sample size was 8. The census was 56. -Regarding Resident # 9 Resident # 9 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with clinical diagnoses that included borderline personality disorder, post-traumatic stress disorder, chronic pain syndrome, insomnia, recurrent depressive disorders, other specified anxiety disorders, and factitious disorder imposed on self, with predominately physical signs and symptoms. A Pre-admission Screening and Resident Review (PASSR) dated May 1, 2025 from the discharging hospital, completed prior to admission, revealed the resident had no history of Serious Mental Illness (SMI), mental disorders or was prescribed any psychotropic (mental health) medications. The PASSR was marked no regarding 30 day convalescent. However, diagnoses including, borderline personality disorder, post-traumatic stress disorder, recurrent depressive disorders, other specified anxiety disorders, were not included on the PASSR. The clinical record revealed no evidence of a corrected PASRR that included borderline personality disorder, post-traumatic stress disorder, recurrent depressive disorders, other specified anxiety disorder. A care plan dated May 4, 2025 revealed the following areas of focus and discharge goals: Antidepressant medication use: revealed the use of antidepressant medication related to depression as evidenced by self-isolation, and inability to sleep. Anti-anxiety medication use, revealed the resident was to be given antianxiety medications for agitation and restlessness. Substance Use Disorder (SUD) care plan, revealed the resident was to be assisted with access to counseling and support groups to the fullest degree possible. The care plan discharge goals, identified the resident as a PASRR level 1, and included that arrangements were to be made with the required community resources to support independence post-discharge. A care plan focus of Post-Traumatic Stress Disorder (PTSD), initiated on May 6, 2025, revealed the staff was to assist in the development of more appropriate methods of coping and interacting, and to conduct a psychiatric evaluation if indicated. A Social Services Assessment, dated May 8, 2025, identified the resident had a history of PTSD. An admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. The assessment included active diagnoses of anxiety disorder, depression, PTSD, and borderline personality disorder. The assessment also revealed the resident was taking antianxiety, and antidepressant therapy. A consultant psychiatric progress note, date of service May 13, 2025, revealed the resident was recommended to have Dialectical Behavior Therapy (DBT) upon availability for Borderline personality disorder. In addition, the progress note revealed the resident was admitted to the hospital for not feeling safe, after a roommate verbally threatened the resident at a previous facility. A consultant psychiatric progress note, with date of service May 20, 2025, the resident was seen again, for follow up of antidepressant medication changes during hospitalization, and a desire to return to previous primary care providers. A care plan focus regarding confabulation, and false accusation, initiated May 27, 2025, directed the staff to intervene as necessary to protect the rights and safety of others, and to provide Care in Pairs. A physician order listing, dated June 16, 2025 revealed orders dated May 19, 2025 included Topiramate 100 mg twice a day for borderline disorder, Venlafaxine HCL Extended Release 150 mg a day for depression, Hydroxyzine HCL 50 mg as needed for anxiety every eight hours, and Escitalopram Oxalate 10 mg daily for depression. A consultant psychiatric progress note, dated June 25, 2025, revealed the resident's medical and psychiatric illness would not allow the resident to be seen in an outpatient setting. The progress note also revealed the sole role of the psychiatric consultant was to only provide recommendations to the patient's primary care provider during their skilled stay in regards to the resident's psychiatric and mental health. A significant change in status MDS, dated [DATE], related to hospitalization, revealed no behavioral symptoms, and included active diagnoses of anxiety disorder, depression, PTSD, and borderline personality disorder. The assessment also revealed the resident was taking antianxiety, antidepressant, and anticonvulsant therapies. A Social Services Assessment, dated August 7, 2025, revealed the resident had a history of trauma. A consultant psychiatric progress note, dated August 19, 2025, revealed that the situational nature of the resident's depression related to facility concerns and room changes suggests that medication adjustments alone may have limited benefit. A PASSR dated September 24, 2025, completed prior to re-admission, revealed The PASRR revealed the admission met the criteria for 30day convalescent care. The PASRR was marked no regarding the history of Serious Mental Illness (SMI), mental disorders or was prescribed any psychotropic (mental health) medications, despite active diagnoses that included anxiety disorder, depression, PTSD, and borderline personality disorder, and physician orders for antianxiety, antidepressant medications. Review of the Social Services Assessment, dated September 24, 2025, revealed the resident had a history of trauma. Review of the pre-admission History and Physical, dated September 29, 2025, revealed the resident had a history of anxiety states, depression with anxiety, borderline personality disorder, and a history of prescription drug abuse. Review of the PASSR, dated October 8, 2025, completed prior to re admission, revealed the resident met the criteria for 30-day Convalescent Care, and no regarding mental illness. Review of the psychiatric progress note, dated October 14, 2025, revealed the resident continued to experience anxiety when alone and expressed concerns about potentially getting a roommate again. Review of the Social Services Assessment, dated October 15, 2025, revealed a history of trauma that was identified from the prior assessment. Review of the significant change in status MDS, dated [DATE], revealed the resident presented no behavioral symptoms. The assessment included the resident had active diagnoses of anxiety, depression, PTSD, psychotic disorder (other than schizophrenia), borderline personality disorder, and factitious disorder. The assessment also revealed the resident was taking antidepressant therapy. Review of the psychiatric progress note, dated November 18, 2025, revealed the client continued to experience significant loneliness, along with frustration about her limited social support. The progress note documentation also revealed the resident experienced nightmares, sleep disturbances, and had a recent hospitalization related trauma (October 8, 2025). The progress note revealed the provider suggested the resident needed to reach out to the insurance provider, to find a therapist, who specialized in Borderline Personality Disorder. The clinical revealed no evidence that a Level I PASRR was completed after the 30-day convalescent period, ending November 8, 2025. Review of facility documentation, revealed that a PASRR Level I was created January 22, 2026 at 9:38 p.m. A Social Services Manager job description, for Staff # 104, dated November 11, 2024, revealed the primary purpose of the job position was to plan, organize, develop, and direct the overall operation of the Social Service Department to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. An interview was conducted on January 21, 2026, at approximately 2:33 p.m. with the Director of Social Services (DSS/Staff #104). After review of the clinical record, and the PASSR paper binder, the DSS stated that the PASSRs on record for Resident #9 were completed by the referring facilities, and stated that the PASSR after 30 days of initial admission was not completed. She also stated that review of the current PASSRs in the resident's record did not accurately reflect the behavioral health diagnoses of anxiety, depression, PTSD, and borderline personality disorder. In addition, the director stated that she would have included the medications related to behavioral health in the assessment, and that receiving care from behavioral health, did not exclude the resident from PASSR Level I screening. An interview was conducted with the Clinical Resource (Staff #99) on January 23, 2026 at approximately 10:05 a.m. The DON by proxy revealed the facility has conducted a review of Resident # 9's clinical record and submitted all the PASSR's on record to the survey team, which now included an updated PASSR initiated by the facility to help meet facility expectation. -Regarding Resident #13: Resident #13 was admitted [DATE], with diagnoses of post-traumatic stress disorder and other psychoactive substance abuse in remission, and re-admitted [DATE], with additional diagnoses of generalized anxiety disorder and other bipolar disorder. An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating intact cognition. Section I revealed Resident #13 had active diagnoses of post-traumatic stress disorder (PTSD), depression (other than bipolar), and generalized anxiety disorder. Electronic Medication Administration Record (eMAR) progress notes dated January 17, 2025, revealed Resident #17 continued to complain of anxiety, and the provider was notified, and that as needed (PRN) anti-anxiety medication was ineffective. An eMAR progress note dated January 17, 2025, revealed the resident stated suicidal ideation to staff, and that crisis mobile response was called and talked to the resident, and that the resident was safe to stay at the facility. A Nurse Practitioner (NP) / Physician Assistant (PA) Progress Note dated January 21, 2025, revealed the resident was admitted to the facility after hospitalization at a behavioral hospital for suicidal ideation. A Pre-admission Screening and Resident Review (PASARR) Level I Screening Tool dated February 5, 2025, revealed the resident did not meet admission criteria for 30-day convalescent care, nor did the resident meet criteria for respite admission for up to 30 days. Section B revealed that the resident did not have a diagnosis of major depression or bipolar disorder. The document revealed the resident did have anxiety disorder, depression (mild or situational), and a substance related disorder. Additionally, the documentation included that the resident did not have inpatient psychiatric hospitalization currently or within the past two years, and the resident did not have suicide attempt or ideation currently or within the past two years. Section D revealed that no referral was necessary for any Level II PASARR screening. However, the clinical record revealed that resident had been recently discharged from a behavioral hospital, and voiced suicidal ideation to staff on January 17, 2025. A Nursing note dated February 7, 2025, revealed Resident #13 was discharged home, transported by her daughter. A Nursing note dated February 21, 2025, revealed Resident #13 re-admitted to the facility. A care plan focus initiated February 23, 2025, revealed Resident #13 had a history of PTSD, with interventions that included to approach in calm manner, explain all procedures before starting to allow resident to adjust to changes, and for caregivers to provide opportunity for positive interaction and attention. A Late Entry NP / PA Progress Note dated February 24, 2025, revealed Resident #13 re-admitted to the facility after hospitalization status post fall at home, with diagnoses that included depression, bipolar disorder, anxiety, and polysubstance abuse. A psychiatric evaluation note dated February 25, 2025, revealed Resident #13 had recent inpatient hospitalization in January 2025 due to suicidal ideation. The documentation revealed Resident #13 had diagnoses of bipolar disorder, unspecified, major depressive disorder, recurrent, chronic post-traumatic stress disorder, generalized anxiety disorder, and cannabis abuse. A care plan focus initiated February 25, 2025, revealed Resident #13 used anticonvulsant medication for bipolar disorder as evidence by labile moods. An intervention included for behavioral health / psychiatric services as needed. An admission MDS assessment dated [DATE], revealed Resident #13 had a BIMS score of 15, indicating intact cognition. Section I revealed Resident #13 had active diagnoses of PTSD, bipolar disorder, and generalized anxiety disorder. Section N revealed Resident #13 was receiving anti-anxiety, antidepressant, and anti-convulsant medication. A PASARR Level I Screening Tool dated February March 20, 2025, revealed the PASARR Level 1 review was due to conclusion of a time limit approval. The documentation revealed the resident did not meet admission criteria for 30-day convalescent care, nor did the resident meet criteria for respite admission for up to 30 days. Section B revealed Resident #13 had bipolar disorder and anxiety disorder. The document revealed the resident did not have depression (mild or situational), nor did the resident have a substance related disorder. Additionally, the documentation included that the resident did not have inpatient psychiatric hospitalization currently or within the past two years, and the resident did not have suicide attempt or ideation currently or within the past two years. Section D revealed that no referral was necessary for any Level II PASARR screening. The clinical record revealed no evidence of a PASARR Level II referral. -Regarding Resident #5: Resident #5 was admitted to the facility September 27, 2022, with diagnoses of type 2 diabetes mellitus, depression, and heart failure. Review of Resident #5's medical diagnoses list revealed an added diagnosis of bipolar disorder, dated March 10, 2023. A Nursing Note dated March 11, 2023, revealed Resident #5 was showing signs of altered mental status, screaming at someone to stop talking while covering his ears in hall, and yelling at certified nursing assistant (CNA) and the nurse, and that the resident insisted on being placed into a bed in the room despite no bed being in the area. The documentation revealed that the staff explained to the resident that there was no bed in that area, and the resident was adamant that there was. The note revealed the provider was notified, who ordered a psychiatric consult. A quarterly MDS assessment dated [DATE], revealed Resident #5 had an active diagnosis of depression. However, despite bipolar disorder being added to the resident's medical diagnoses list in the clinical record, the assessment revealed the resident did not have an active diagnosis of bipolar disorder. A PASARR Level I Screening Tool dated April 2, 2023, revealed Resident #5 had major depression, and mild or situational depression. However, the documentation revealed that Resident #5 did not have bipolar disorder. The documentation revealed that the resident was prescribed bupropion 75 mg to treat major depressive disorder. Section D revealed that no referral was necessary for any Level II PASARR screening. The clinical record revealed no evidence of a PASARR Level II referral. -Regarding Resident #21: Resident #21 admitted to the facility January 29, 2025, and re-admitted on [DATE], with diagnoses that included other specified anxiety disorders, other schizophrenia, other recurrent depressive disorders, post-traumatic stress disorder (chronic), chronic obstructive pulmonary disease, dysphagia, and dependence on supplemental oxygen. A PASARR Level I Screening Tool dated January 5, 2025, from the discharging hospital revealed the resident did not meet admission criteria for 30-day convalescent care, nor did the resident meet criteria for respite admission for up to 30 days, and the resident did not have a dementia / Alzheimer's diagnosis. Section B revealed Resident #21 had bipolar disorder (manic depression) and personality disorder. The documentation revealed the resident was prescribed psychotropic medication. The documentation revealed no determination whether a PASARR Level 2 referral was needed. An admission MDS assessment dated [DATE], revealed Resident #21 had a BIMS assessment score of 12, indicating moderate cognitive impairment. The documentation revealed Resident #21 had active diagnoses of anxiety disorder, depression, and schizophrenia. The assessment revealed that Resident #21 did not have post-traumatic stress disorder. Section N revealed the resident was taking antianxiety medication, antidepressant medication, antipsychotic medication, and anticonvulsant medication. A PASARR Level I Screening Tool dated February 28, 2025, revealed the resident did not meet admission criteria for 30-day convalescent care, nor did the resident meet criteria for respite admission for up to 30 days, and did not have a primary diagnosis of dementia or Alzheimer's disease. Section B revealed Resident #21 had schizophrenia and anxiety disorder, however, the assessment revealed the resident did not have depression. Despite the documentation in the admission MDS assessment that the resident was taking antianxiety, antidepressant, antipsychotic, and anticonvulsant medication, the documentation revealed the resident was not prescribed any psychotropic medications now or within the last 6 months. Section D revealed that no referral was necessary for any Level II PASARR screening. A Psychiatry Progress Note dated June 3, 2025, revealed Resident #21 had diagnoses of paranoid schizophrenia, unspecified mood disorder, major depressive disorder (recurrent and mild), PTSD, and anxiety. Additionally, the documentation revealed that the resident had a history of polysubstance abuse in remission. A PASARR Level I Screening Tool dated June 3, 2025, revealed Resident #21 did not meet admission criteria for 30-day convalescent care, nor did the resident meet criteria for respite admission for up to 30 days, and did not have a primary diagnosis of dementia or Alzheimer's disease. The documentation revealed the resident had no recent psychiatric or behavioral evaluation. Section B revealed Resident #21 had schizophrenia, however, the assessment revealed the resident did not have depression, personality disorder, anxiety, or any other mental disorder. Despite this, the documentation included that the resident was taking mirtazapine 15 mg for depression, buspirone 5 mg for anxiety, trazodone 100 mg for depression, clonazepam 0.5 mg for anxiety, and risperdal 2 mg for schizophrenia. Section D of the documentation was left blank, revealing no determination whether a Level II PASARR referral was necessary or not. The document was signed by Staff #104. The clinical record revealed no evidence of a PASARR Level II referral for Resident #21. A formal request was submitted to the facility on January 21, 2026, for any PASARR Level II referral for Residents #13, #5, and #21. The facility provided a statement that there were none. An interview was conducted on January 21, 2026, with the Social Services Director / Case Manager (Staff #104) who stated that the facility's process for identifying a resident with a mental disorder or intellectual disorder was that she, along with clinical managers, and the Director of Nursing (DON), review the clinical record for applicable diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia. Staff #104 also stated that she reviews the clinical record for any psychiatric medications. The clinical record was reviewed for Resident #13, and Staff #104 stated that the resident's most recent PASARR Level I screen was completed on March 20, 2025, and that the resident's diagnoses included bipolar disorder, anxiety, and PTSD, and that the resident should have had a PASARR Level 2 referral submitted, and that there was none found. The clinical record was reviewed for Resident #5, and Staff #104 stated that Resident #5's diagnoses included depression and bipolar disorder, and that the resident should have had a PASARR Level II referral, and that there was none submitted for Resident #5. Regarding Resident #21, Staff #104 reviewed the PASARR Level 1 screen completed June 3, 2025, and stated that the only diagnoses marked was schizophrenia. The clinical record was reviewed, and Staff #104 stated that Resident #21 also had diagnoses of anxiety, PTSD, and recurrent depressive disorder. Staff #104 stated Resident #21 should have had a Level 2 referral sent and that it had not been completed. Regarding Resident #3: Resident #3 was originally admitted on [DATE], and re-admitted on [DATE], with the diagnosis that included anxiety disorder; bipolar disorder, current episode depressed, mild or moderate severity, unspecified; and schizophrenia, unspecified. A care plan focus, initiated on June 30, 2023, and last revised on November 13, 2025, revealed that Resident #3 had the potential for a behavior problem with a history of defecating and urinating on the floor and the trash can, declining to wear briefs or an undergarment, and smeared feces on the wall in his room. The care plan focus also revealed that Resident #3 will have no episodes of defecating on the floor and remain appropriately dressed, and will follow up with a psychiatric provider as indicated. A care plan focus, initiated on March 7, 2024, and last revised on February 4, 2025, revealed that Resident #3 was to be administered psychotropic medications related to the diagnosis of schizophrenia, as evidenced by auditory hallucinations. A care plan focus, initiated on August 16, 2024, and last revised on November 13, 2025, revealed that Resident #3 was to be administered antidepressant medications related to depression as evidenced by a labile mood. A PASSAR (Pre-admission Screening and Resident Review) form dated January 22, 2025, revealed that Resident #3 had a diagnosis of schizophrenia, bipolar disorder, and anxiety disorder; and the prescription medications of bupropion 300 mg for bipolar disorder, fluphenazine 5mg for hallucinations. Section D, Referral Determination also indicated that a Level II PASSAR screen was not referred for evaluation. Review of the clinical record revealed no evidence of a Level II PASSAR evaluation. Another PASSAR form dated September 18, 2025, revealed no evidence of the resident's mental illness diagnosis on the form, and no prescription medications related to behavioral symptoms were identified and indicated on the form. Section D, Referral Determination indicated that a Level II PASSAR screen was not referred for evaluation. Further review of the clinical record revealed no evidence of a Level II PASSAR evaluation. An order dated October 1, 2025, revealed Resident #3 was ordered Bupropion HCl ER (XL) tablet extended release 24-hour 300 mg by mouth one time a day for depression, labile mood. An order dated October 1, 2025, revealed Resident #3 was ordered Fluphenazine HCl oral tablet 5 mg by mouth in the morning for schizophrenia as evidenced by auditory hallucinations. An order dated October 1, 2025, revealed Resident #3 was ordered Fluphenazine HCl oral tablet 10 mg by mouth at bedtime for schizophrenia as evidenced by auditory hallucinations. A quarterly MDS (Minimum Data Set) assessment, dated November 1, 2025, revealed that Resident #3 had a BIMS (Brief Interview for Mental Status) score of 14, indicating cognitive intactness. The MDS assessment also revealed that Resident #3 had been diagnosed with anxiety disorder, bipolar disorder, and schizophrenia. The MDS assessment also revealed that Resident #3 took antipsychotics and antidepressants during the 7 days before the completion of the assessment. An interview was conducted on January 21, 2026, at approximately 2:33 p.m. with the Director of Social Services (DSS/Staff #104). Regarding the PASSAR for Resident #3, The Director of Social Services reviewed the medical diagnosis and medications related to behavioral concerns and stated that she should have submitted a Level II PASSAR, given the resident had been diagnosed with anxiety disorder, bipolar disorder, current episode depressed, mild or moderate severity, and schizophrenia, paired with the ordered antipsychotic and an antidepressant. The Director of Social Services reviewed clinical record and stated that the Level I PASSAR form had been completed on January 22, 2025, and stated that the form included the diagnosis of schizophrenia, bipolar disorder, and anxiety disorder, and that a Level II PASSAR screening had not been submitted. The Director of Social Services also reviewed the Level I PASSAR form completed on September 18, 2025, and stated that the form did not include the behavioral diagnosis and the medications ordered for behavioral disturbances that were a part of Resident #3's care and services, which indicated that the Level I PASSAR form had not been completed correctly. Regarding Resident #55: Resident #55 was admitted on [DATE], with the diagnosis that included aphasia following cerebral infarction; other specified anxiety disorders; other recurrent depressive disorders; unspecific mood disorder; unspecified personality and behavioral disorder due to unknown physiological condition; and adjustment disorder. A PASSAR form dated April 28, 2025, revealed that Resident #55 had a diagnosis of anxiety and depression. Section D, Referral Determination also indicated that a Level II PASSAR screen was not referred for evaluation. Further review of the clinical record revealed no evidence of a Level II PASSAR evaluation. An order dated May 7, 2025, revealed Resident #55 was ordered Depakote oral tablet, delayed release 125 mg, two tablets two times a day by mouth for mood disorder as evidenced by labile mood. A care plan focus, initiated on May 11, 2025, and last revised on May 11, 2025, revealed that Resident #55 was to be administered psychotropic medications related to mood disorder as evidenced by labile mood. A care plan focus, initiated on May 26, 2025, and last revised on May 26, 2025, revealed that Resident #55 was to be administered anticonvulsant medication related to mood disorder as evidenced by labile mood. Another PASSAR form dated May 30, 2025, revealed that no diagnosis had been included in this form, and no prescription medications related to behavioral symptoms were identified and indicated on the form. Section D, Referral Determination also indicated that a Level II PASSAR screen was not referred for evaluation. Review of the clinical record revealed no evidence of a LEVEL II PASSAR evaluation. A modified quarterly MDS assessment dated [DATE], revealed that Resident #55 had a BIMS (Brief Interview for Mental Status) score of 15, indicating cognitive intactness. The MDS assessment also revealed that Resident #55 had been diagnosed with anxiety disorder and depression. The assessment also revealed that Resident #55 took anticonvulsants during the 7 days before the completion of the assessment. A formal request was submitted to the facility on January 21, 2026, for any PASARR Level II referral for Residents #3 and #55. The facility provided a statement that there were none. An interview was conducted on January 21, 2026, at approximately 2:33 p.m. with the Director of Social Services (DSS/Staff #104) who that the PASSRs in the clinical record were completed by the referring facilities. The Director of Social Services stated that the facility's process for identifying a resident with a mental disorder or intellectual disorder included that she, along with clinical managers and the Director of Nursing (DON), review the clinical record for applicable diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia. The Director of Social Services also stated that she reviews the clinical record for any psychiatric medications. The Social Services Director further stated that a resident who had more than one or two psychiatric diagnoses and was in the facility for longer than 30 days, a Level II PASSAR would automatically be submitted referral. The Director of Social Services stated she was the staff member responsible for completing PASARR Level I screens and submitting PASARR Level II referrals. In addition, The Director of Social services state that she would have included the medications related to behavioral health in the assessment, and that receiving care from behavioral health did not exclude the resident from PASSR Level I screening. Staff # 104 stated that it was the responsibility of their facility to make sure PASSR documentation was accurate and complete in order to ensure the resident would receive the behavioral health services needed. The Director of Social Services stated that if the PASARR screening and referral process was inaccurate or not completed, then a resident may not receive the services that they need. Regarding audits, Staff # 104 stated that the facility's assigned PASRR resource conducts random reviews approximately every three months, if missing dates or incomplete documentation are identified, the facility is notified to make corrections. She reported that these reviews are infrequent and occur at random intervals. Staff # 104 stated that she was uncertain regarding how often PASRR screenings must be updated, and how to track residents who may require both mental illness and intellectual disability Level II evaluations. The Director of Social Services stated that she recognized the importance of ensuring that any specialized services identified through Level II evaluations are incorporated into the resident's care plan. The Director of Social services stated that she initially felt confident in her PASRR processes; however, in retrospect, she believed that formal training, routine audits, and regular performance evaluations would have helped identify knowledge gaps earlier and improve compliance. Staff # 104 revealed that a performance feedback meeting scheduled for December 2025 was postponed and that she had not received a formal performance evaluation since being hired in 2024. The Director of Social Services stated that accurate PASRR completion is critical to resident safety and quality of care and revealed that insufficient training and oversight could result in inaccurate PASRR documentation, potentially leading to residents not receiving necessary services o

Number of residents sampled: 15Number of residents cited: 2Universe: 56Based on review of records, staff interviews and review of policy and procedures, the facility failed to ensure that timely care and services, including physician notification and a physician order for oxygen, were provided upon a change of condition for one resident (#50). The deficient practice could lead to a medical decline and/or physical harm of a resident.Findings include:Resident #50 was admitted to the facility November 14, 2025, with diagnoses of type 2 diabetes mellitus, chronic pain syndrome, spinal stenosis, malignant neoplasm of overlapping sites of right female breast, and pressure ulcer of sacral region, stage 4.A care plan focus initiated November 18, 2025, revealed Resident #50 had an alteration in gastro-intestinal status due to colostomy, with an intervention to monitor vital signs as ordered and record, and to notify provider of significant abnormalities.Despite the care plan intervention to monitor vital signs as ordered and record, review of the clinical record revealed no evidence of a physician order for monitoring vital signs.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #50 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Section O revealed the resident had not received oxygen therapy on admission or while a resident within the last 14 days.Review of an oxygen (O2) saturation vitals log revealed the following entries for January 2026:January 3: 95.0% on room air (RA)January 4: 94.0% on RAJanuary 10: 94.0% on RAJanuary 11: 94.0% on RAJanuary 17: 94.0% on RA A hospice note dated January 19, 2026, revealed that Resident #50 appeared lethargic and continued to have cough and increased secretions. The note revealed oxygen saturation at 87% on RA, and that the nurse attempted to apply oxygen via nasal cannula, however the oxygen concentrator was missing water, so staff was notified to fill the water, and then oxygen was applied to Resident #50 on 2L. However, Physician orders dated November 14, 2025 through January 20, 2026, revealed no evidence o orders for administration of oxygen.Review of the Medication / Treatment Administration Record (MAR/TAR) for January 2026, revealed Resident #50's blood pressure, temperature, pulse, and respirations were recorded on the MAR/TAR every day shift and night shift. However, there was no evidence on the MAR/TAR of monitoring or recording oxygen saturation, until January 21, 2026.A review of the electronic medical record as of January 21, 2026, at 9:40 a.m. revealed no evidence of oxygen saturation monitored and documented for Resident #50 from January 17, 2026 until January 21, 2026. Additionally, there was no evidence in the electronic medical record of uploaded hospice notes for the hospice nurse visits on January 19 or January 21, 2026.A physician order dated January 21, 2026, at 2:41 p.m. included for oxygen at 2L via nasal cannula for diagnosis of hypoxia. The order was discontinued at 6:06 p.m.Another physician order dated January 21, 2026, at 6:06 p.m. included for oxygen at 2L via nasal cannula for diagnosis of supplemental end of life care.A Nursing note dated January 21, 2026, at 6:06 p.m. revealed Resident #50 was placed on oxygen via nasal cannula by hospice, and that the oxygen was ordered for comfort measures.A care plan focus initiated January 21, 2026, revealed Resident #50 had oxygen therapy due to ineffective gas exchange, with a goal to have no signs or symptoms of poor oxygen absorption through the review date. Interventions included to monitor for signs and symptoms of respiratory distress and report to physician as needed, including respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color.A formal request was submitted to the facility on January 22, 2026, at 2:40 p.m. for all hospice records from start of care to present for Resident #50.Review of a Hospice Recert Summary Report dated January 22, 2026, revealed the following documentation which included hospice coordination notes, vital signs log, and physician orders:January 6, 2026: Resident #50 stated she was feeling good today and verbalized that she wanted to get up for lunch.January 13, 2026: Upon arrival, Resident #50 opened her eyes only briefly during the visit and was lethargic and nonverbal, and that Resident #50 may be declining. The documentation included oxygen saturation was 93% on RA.January 15, 2026: Resident #50 was difficult to awaken and lethargic, and stated she did not feel good. The note included that oxygen saturation was at 90% on room air and oxygen was ordered for Resident #50. The note also revealed that Resident #50 was added to decline list. Despite the documentation that oxygen was ordered for Resident #50, there was no evidence of a physician order for oxygen either in the hospice records or the facility's medical record on January 15, 2026.A physician order dated January 15, 2026, included for emergent as needed (PRN) nursing visit due to change in decline status.January 19, 2026: Resident #50 appeared lethargic and continued to have cough and increased secretions. The note revealed oxygen saturation at 87% on RA, and that the nurse attempted to apply oxygen via nasal cannula, however the oxygen concentrator was missing water, so staff was notified to fill the water, and then oxygen was applied to Resident #50 on 2L. There was no evidence of a physician order for oxygen on January 19, 2026.A physician order dated January 20, 2026, included for licensed practical nurse (LPN) visit to be done January 22, 2026, instead of registered nurse (RN), and for registered nurse case manager (RNCM) to visit resident twice a week.A physician order dated January 21, 2026 included to give oxygen via nasal cannula at 2L, may titrate between 2-4L to maintain oxygen saturation above 90%. Despite the hospice documentation on January 19, 2026, that Resident #50 was hypoxic with oxygen saturation of 87%, there was no evidence in the clinical record or hospice documentation that a physician was notified of a change of condition or that change of condition monitoring was ordered. Additionally, there was no evidence of a physician order for oxygen until January 21, 2026.An observation was conducted on January 20, 2026, at 10:00 a.m. of Resident #50 laying in the bed in her room. Resident #50 had an oxygen concentrator next to her bed, which was turned on and set to 2L. The nasal cannula was not on the resident, and was draped over the top of the concentrator. The resident opened her eyes and stated she was very tired, and then closed her eyes, and was unable to answer further questions.Another observation was conducted on January 21, 2026, at 9:35 a.m. of Resident #50 laying in the bed in her room, with the oxygen concentrator turned on and set to 2L. The resident was wearing the nasal cannula in her nose. The resident was unable to open her eyes for more than a few seconds and could not answer questions.An interview was conducted on January 21, 2026, at 1:52 p.m. with a licensed practical nurse (LPN / Staff #45), who stated that Resident #50 was on hospice services and that she would know to look for any hospice orders or hospice care plans in the resident's hospice binder at the nurses' station. Staff #45 then looked for Resident #50's hospice binder at the nurses' station, then stated Resident #50 did not have a hospice binder. Additionally, Staff #45 stated that a hospice nurse was just in the facility two days prior on January 19, 2026, and that anything that hospice ordered would be included in the orders in the electronic medical record (EMR). Staff #45 then reviewed Resident #50's clinical record and stated that there was no physician order for oxygen therapy, and no care plan for oxygen therapy. Resident #50 was then observed together in the resident's room with Staff #45, and Staff #45 stated that the resident was on oxygen and the dose was 2L, and that she believed a hospice staff who was just there earlier this morning had applied it.An interview was conducted on January 22, 2026, at 1:22 p.m. with the Assistant Director of Nursing (ADON / Staff #25) who stated that if a resident who previously was not on oxygen therapy had a change of condition to now require oxygen, then the provider should be notified right away and the resident would have a physician order for change of condition monitoring. Additionally, Staff #25 stated that if a resident was on oxygen therapy, then there would need to be a physician order, and that the expectation for notifying the physician and receiving the order for oxygen should be done right away but at least by the end of the shift. Additionally, Staff #25 stated that there would be a specific care plan for oxygen as well. Staff #25 stated that if a resident was on oxygen therapy, then oxygen saturation would be monitored every shift to ensure the resident was maintaining oxygen saturation within normal limits. Staff #25 stated that if a resident were administered oxygen and did not need it, then it could be harmful, as it may cause the resident to then rely on the oxygen. Staff #25 stated if a resident on oxygen did not have oxygen saturation monitored, then the resident could be hypoxic and staff would not know. The clinical record for Resident #50 was reviewed together and Staff #25 stated that the first oxygen order for Resident #50 was placed on January 21, 2026, for oxygen at 2L.A telephonic interview was conducted with the hospice clinical liaison RN (Staff #305) on January 22, 2026, at 1:58 p.m. Staff #305 stated that the hospice company communicates with the facility via documentation that is sent over via email to the medical records director every other week. Additionally, Staff #305 stated that for each of the hospice residents, there should be a hospice binder that is kept by the facility, where hospice staff will add notes regarding care and any updates on the residents.A telephonic interview was conducted with a hospice RN (Staff #301) on January 22, 2025, at 2:26 P.M, who stated that she was the nurse who visited Resident #50 on January 19, 2026, and that she took the resident's vital signs and noted that the resident was hypoxic, with oxygen saturation around 88-90%, and that the resident had an oxygen concentrator at bedside already upon Staff #301 entering the room, and that Staff #301 did not know who had brought the concentrator into the resident's room or when. Staff #301 stated that she also noted that the resident's distilled water reservoir on the concentrator was empty, so she notified facility staff that the resident needed more distilled water in the concentrator.A follow-up interview was conducted with an LPN (Staff #45) on January 23, 2026, at 8:07 a.m. who stated that she was the floor nurse for Resident #50 on January 19, 2026, and that she came in late that day and did not receive report. Staff #45 stated that the hospice nurse (Staff #301) did not talk to her about oxygen for Resident #50. Staff #45 stated that the first she knew of Resident #50 being on oxygen was during the interview and room observation of Resident #50 with the state surveyor on January 21, 2026 at 1:52 p.m.An interview was conducted with the Director of Nursing (DON / Staff #100) on January 23, 2026, at 8:21 a.m. who stated that the facility's process to ensure that a change of condition or medical decline of a resident was not missed was to monitor the resident's care plan interventions and to assess the resident's vital signs. The DON stated that the facility monitors long-term care resident's vital signs monthly and if there was a change of condition, then vital signs would be assessed every shift. Staff #100 also stated that if a resident was on oxygen therapy, then oxygen saturation would be assessed every shift. Additionally, for a change of condition, Staff #100 stated there would be a physician order placed for change of condition monitoring and a progress note in the medical record that included that the physician was notified of the change. Staff #100 stated that if a resident was administered oxygen, then there would be a physician order for the oxygen. Regarding Resident #50, the DON stated that she believed the resident was placed on oxygen by the hospice nurse the morning of January 21, 2026, and the physician order for oxygen was also placed that day. The DON stated that she believed the oxygen was for comfort measures and that she was not aware of any episodes of hypoxia for Resident #50. The clinical record was reviewed, and the DON stated that it was not in the clinical record that the provider was notified of any change of condition for Resident #50, but she assumed it was in the hospice nurse's notes that a provider was notified. The DON stated that Resident #50's oxygen saturation was documented to be 94% on January 21, 2026, and prior to that, the most recent reading in the clinical record was 94% on January 17, 2026. The DON stated that the importance of staff notifying a physician right away if a resident had a change of condition such as an episode of hypoxia would be to make the physician aware and include any adjustments to the plan of care. The DON stated that if a resident was hypoxic and the provider was not made aware, then the resident could have discomfort, pain, or an adverse outcome.Review of the facility policy titled Vital Signs, Weight and Height, revised May 2025, revealed the resident's vital signs shall be recorded as the physician's orders indicate, or as frequently as the resident's condition warrants.Review of the facility policy titled Change of Condition Reporting, revised June 2025, revealed it is the policy of this facility that all changes in resident condition will be communicated to the physician. For Acute Medical Changes:1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request forphysician visit promptly and/or acute care evaluation. The licensed nurse in charge willnotify the physician.2. If unable to contact attending physician or alternate physician timely, notify MedicalDirector for follow-up to change in resident condition.3. The responsible party will be notified that there has been a change in the resident'scondition and what steps are being taken.For Routine Medical Change:1. Unusual signs and symptoms will be communicated to the physician promptly. Routine changes are minor changes in physical and mental behavior, abnormal laboratory and xray results that are not life threatening.2. The nurse in charge is responsible for notification of physician prior to end of assignedshift when a significant change in resident's condition is noted.3. If unable to reach physician, all calls to physicians or exchanges requesting callbacks will be documented on the nursing progress notes.4. If the physician has not returned the call by the end of the shift, the on-coming nurse will be notified for follow-up.5. If unable to contact attending physician or alternate timely, notify Medical Director forresponse and follow-up to change in resident status.6. Document resident change of condition and response in nursing progress notes andupdate resident Care Plan, as indicated.7. All attempts to reach the physician and responsible party will be documented in thenursing progress notes. Documentation will include time and response.For Follow-Up: 1. The licensed nurse responsible for the Resident will continue assessment anddocumentation every shift for at least seventy-two (72) hours or until condition hasstabilized.2. Residents with acute medical changes (and some routine changes), will have progress and needs clearly communicated to each shift every shift for at least seventy-two (72) hours or until condition has stabled.3. Comprehensive Care Plan will be updated/ revised accordingly. Review of the facility policy titled Oxygen Administration, revised January 2026, revealed it is the policy of the facility that oxygen therapy is administered by licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. The resident's clinical record will include: 1. That oxygen is to be administered.2. When and how often oxygen is to be administered.3. The type of oxygen device to use (i.e., mask, nasal)4. Any special procedures or treatment to be administered.5. Charting and documentation related to oxygen use6. Oxygen concentrators will be maintained in room when oxygen ordered Review of the facility policy titled Physician Orders, revised May 2025, revealed it is the policy of this facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs, and to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. Verbal orders for drugs, treatments, procedures shall be received only by licensed nurses, psychiatric technicians, pharmacists, nurse practitioners, physicians, physicians' assistants (from their supervising physician only), and certified respiratory therapists when the orders relate specifically to respiratory care. Verbal orders must be recorded in the resident's chart by the person receiving the order and must include the date and time of the order. Medication, treatment or related procedure orders are transcribed in the eMAR/TAR (electronic MAR/TAR) accordingly.Review of the facility policy titled End of Life Care; Hospice, revised May, 2025, revealed it is the policy of the facility to provide end of life care for dying residents that emphasizes prevention and relief of symptoms as well as compassionate attention to the resident's dignity and preferences. Through continuing interdisciplinary assessment, individualized plans will be developed and implemented to address the resident's physical, intellectual, emotional, social, spiritual, and practical needs. A care plan will be developed based on the individualized assessments, the desires of the resident/surrogate decision-maker, and the physician's orders. Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan, to include collaboration with the hospice. Significant Change in Status Assessments may be deferred once identification of end-stage disease status is made unless the significant change is unrelated to the terminal illness. However, the facility will continue to provide necessary care and services to assist the resident to achieve his or her highest practicable well-being, to identify and respond to problems and needs associated with the terminal condition, and to update and implement an individualized, interdisciplinary plan of care.

Based on observations, interviews, facility documentation and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for two of three medication carts sampled. The deficient practice could result in inventory loss and potential diversion. An observation of the 100 Medication Cart narcotic reconciliation log was conducted on January 20, 2025 at 2:52 p.m., and reviewed with with Licensed Practical Nurse (LPN/Staff #45),who revealed the missing nurse signature entries on 6 shifts from January 1-19, 2026, were not supposed to be left blank. An observation of the 300 Medication Cart Narcotic reconciliation log was conducted on January 20, 2025 at 3:05 p.m., and reviewed with LPN/Staff #140, revealed the missing nurse signature entries on 5 shifts from January 1-19, 2026, were not supposed to be left blank. The facility's in-service sign-in sheets revealed that education on daily narcotic log sign-in and sign-out procedures was provided by the Assistant Director of Nursing (ADON/Staff #25) was conducted between January 20-21, 2026 during three different sessions.The Quality Improvement Tool (QIT)/ Nurse Sign-Off sheet for Narcotic Cards-Medication carts, revealed the ADON conducted audits for the Medication Cart 100 and Medication Cart 300s on January 21, 2026.An interview was conducted on January 20, 2026, at 3:12 p.m. with an LPN/Staff #140. The LPN stated that two nurses are required to complete the medication cart narcotic count and reconciliation log to ensure accountability, verify that the residents receive required medications, and to prevent narcotics from becoming missing or misappropriated. The LPN stated that there should be no missing signature entries on the logs from January 1-19, because it cannot be proved that two nurses performed the count for those shifts. An interview was conducted on January 22, 2026 at 11:54 a.m. with the ADON. The ADON stated that she conducted in-services with the nursing staff on the proper procedure and importance of conducting narcotic counts properly. In addition, the ADON also revealed that she was assigned to perform an audit of the medication cart narcotic reconciliation, due to the missing nurse signature entries discovered by the surveyor, during the current survey period. The ADON revealed that the expectation is for nursing staff to conduct a dual licensed nurse count of all narcotics at change of shift to ensure accuracy, and minimize the risk of diversion.An interview was conducted on January 23, 2026 at 8:15 a.m. with the Director of Nursing (DON/Staff #100). The DON revealed that the requested narcotic reconciliation logs with the missing entries, that failed to meet facility expectations, have been submitted to the survey team. The DON stated that in response, the facility immediately conducted in-services to ensure the nurses properly executed narcotic count reconciliations every shift. The DON stated she has the expectation that each card/bottle be properly counted and documented by two licensed nurses at the exchange of the medication carts to ensure all narcotics are accurately accounted for to avoid any narcotic count discrepancies. The facility's Medication Access and Storage, E kit access policy, revised June 2025, instructed staff to reconcile controlled medications at least every shift by the incoming and outgoing licensed nurses at change of shifts.

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure the clinical record for one resident (# 9), contained an accurate representation of the actual experiences of a resident with an allegation of resident to resident abuse, and was accurate, complete and readily available for one resident (#50). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents.Findings include: -Regarding Resident # 9 Resident # 9 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with clinical diagnoses that included borderline personality disorder, post-traumatic stress disorder, chronic pain syndrome, insomnia, recurrent depressive disorders, other specified anxiety disorders, and factitious disorder imposed on self, with predominately physical signs and symptoms. An admission Minimum Data Set assessment, dated May 8, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. The assessment included active diagnoses of anxiety disorder, depression, PTSD, and borderline personality disorder. The assessment also revealed the resident was taking antianxiety, and antidepressant therapy. A consultant psychiatric progress note, date of service May 13, 2025, revealed the resident was recommended to have Dialectical Behavior Therapy (DBT) upon availability for Borderline personality disorder. In addition, the progress note revealed the resident was admitted to the hospital for not feeling safe, after a roommate verbally threatened the resident at a previous facility. A care plan focus: confabulation, and false accusation care plan, initiated May 27, 2025, directed the staff to intervene as necessary to protect the rights and safety of others, and to provide Care in Pairs A Grievance Resolution Form, dated January 8, 2026, revealed the resident felt the ADON mishandled the resident's room placement on purpose on January 3, 2026. The grievance found that the roommate complained of the amount of dolls and belongings the resident was bringing into resident # 10's room. A Facility Reported Incident Form – Follow-up Report, submitted January 28, 2026, concluded that the allegation of abuse was not verified. The report revealed that Licensed Practical Nurses (LPN) # 76 and # 52; and Certified Nurse Assistant (CNA/Staff #126) denied that any altercation took place between residents #9 and # 10. The report revealed that based on interviews, documentation, and staff response, that the incident involved a verbal disagreement between the two residents. However, the resident's clinical record revealed no evidence regarding the verbal disagreement, prior to the conclusion of the survey period. A police department web report narrative, retrieved February 4, 2026, web revealed resident #9, alleged that resident #10 threatened to suffocate her. As of report retrieval date, the investigation is still pending. Review of the clinical record, revealed no evidence involving room changes or verbal disagreements during the 72-hour significant change of condition period from January 3, 2026 through January 6, 2026. An interview was conducted with Resident #9 on January 21, 2026, at 10:20 a.m. Resident #9 stated she was upset with the Assistant Director of Nursing (ADON/Staff #25) for placing her in two roommate situations within a few days that she felt compromised her mental health and safety. The resident reported she was first placed with a roommate who was claustrophobic and required the door to remain open. The resident stated this was distressing due to her neurological condition, which causes extreme pain when exposed to loud noises and requires the door to be closed. The resident stated she was later relocated to a room with Resident #10, who she stated made fun of her and threatened to suffocate her. Resident #9 stated she reported the behavior to the CNA caring for her and described repeated verbal altercations, including a screaming match. Following this incident, the ADON was contacted and Resident #9 was moved to her current room. Resident #9 stated that she has PTSD, and as a result of the incident, she experienced an episode of night terrors. An interview was conducted with the Executive Director (ED/Staff # 103) on January 21, 2026, at approximately 11:00 a.m. The ED stated that this was the first time hearing of the allegation of resident to resident abuse, and follow-up on the allegation according to facility policy. An interview was conducted on January 21, 2026 at 11:54 a.m. with the ADON (Staff #25). The ADON revealed that she is no longer allowed to be the primary point of contact for resident #9, per the resident's request, due to the resident feeling that she did not look out for the resident's best interest in regards to room change placement. The ADON stated that adverse behaviors or events that result from roommate changes are to be documented into the progress note, as it is important to document the steps taken in order to care for and defuse the situation. Roommate challenges are also reported to the case management for follow complaint and grievance follow up. The ADON stated having great familiarity with resident #9 over the past year, and that the facility tries its best to accommodate for the resident's need. The ADON recalled that the first room choice failed due to the resident being unhappy that the room door was not allowed to be closed. The ADON stated that admissions had already spoken with the family, prior to the resident's return, however she voiced not being sure if the aspect of the room door was explained to her. The ADON recalled receiving a phone call from Licensed Practical Nurse (LPN # 52) , and hearing the resident crying and hollering in the background. The ADON stated that she was unable to determine what the resident was saying over the phone, but because the resident was upset, the ADON revealed making the decision to move her into the room with resident # 10. Later that same day, the ADON stated that the staff called back again, because resident #9 became upset again. The ADON revealed being told that the roommate asked the resident if she was a child, and also stated that Don't worry you will die here anyway. The ADON stated she did not feel this was a death threat, but rather she felt it was referring that the facility was a long-term care facility. The ADON stated that she would have expected for these incidents to recorded in the progress notes, and that for room changes, there is an order placed for 72-hour monitoring of vital signs, and documentation as to how the resident is adapting to the change. Upon return to work, the ADON stated there was no report of any threatening conversation that occurred between resident # 9 and #10, otherwise the expectation was that would have been documented according to facility procedure and reported to the abuse coordinator. An interview was conducted on January 21, 2026 at approximately 1:50 p.m., with Licensed Practical Nurse (LPN/Staff # 52). The LPN recalled, that while he was charting, he could hear resident # 9 yelling. The LPN stated that resident # 9 occasionally exhibits behavioral outbursts at times, but revealed being uncertain initially, as to why the resident was upset with the roommate change, since she initially agreed to it. The LPN revealed receiving report from a Certified Nurse Assistant, that the commotion was due to resident #9 not wanting to stay in the same room as resident # 10, because the roommate referred to her as having childish behavior, due to resident # 9 having so many dolls at age [AGE]. The LPN admitted to receiving report from the CNA, but due to handling other responsibilities was unable to get around to it. In addition, the LPN stated that since the incident was initially not considered acute, and the episode quickly de-escalated, the episode was not documented. The LPN stated that the event was verbally reported to the oncoming nurse, and he also received instruction on how to handle the incident, via phone with the ADON. In hindsight, the LPN stated that he should have documented this as a behavioral incident, and could have been used as a source during investigation of an abuse allegation. The LPN further stated that he would have documented that resident # 9 exhibition of the behavioral distress that occurred during the room change attempt. The LPN also revealed that this event, constituted a change of condition, due to the room change, and behavioral escalations, meet criteria for change-of-condition documentation under the assessment tab, even though the room change ultimately did not occur. An interview was conducted on January 21, 2026 at 2:10 p.m. with Resident #12. Resident #12 revealed resident # 9 was placed in her room, after being re-admitted from the hospital. The resident stated that she was diagnosed with claustrophobia and needed to have the room door open, and that resident # 9 had a full on panic attack, while she was in the room, so LPN/Staff # 52 had to call the ADON/Staff # 25 to get the resident settled and moved somewhere else. An interview was conducted on January 21, 2026 at approximately 2:20 p.m. with the second roommate attempt (Resident # 10). The roommate stated that resident #9 was a strange duck, and that a roommate situation between the two was attempted, but drastically failed. The resident stated she did not threaten the roommate, but rather encouraged her to follow the rules of the facility, as the facility was a pretty nice place to be. The roommate recalled telling resident #9 about her experience at the facility, and stated the resident responded and stated Fuck That!. The roommate stated that she did have to tell the resident that she doesn't kiss ass, but doesn't take it up the [NAME] either!!. The roommate did not admit to yelling, but stated there was a verbal back and forth that occurred, and that staff did come to intervene. An interview was conducted on January 21, 2026, at approximately 2:33 p.m. with the Director of Social Services (DSS/Staff #104). The Director stated that when conducting assessments or investigating grievances, she reviews the clinical record for documentation of behavioral episodes as part of information gathering process. The Director stated she had the expectation that documentation related to the difficulties experienced by Resident #9 regarding room changes would have been present in the clinical record. She further stated that written documentation supports the development of a PASSR updates and for investigations of complaints, grievances, or allegations. An interview was conducted on January 23, 2026 at 8:15a.m. with the Director of Nursing (DON/Staff # 100). The DON revealed that based on the information provided, and review of the clinical record relevant to resident #9's allegation, the facility expectation for documentation was not met. The DON stated that resident events, behaviors, and changes are to be documented in the medical record, so if additional concerns arise later, documentation can help address and validate those concerns. In addition, the DON stated that the lack of documentation can impact third-party reviewers' ability to validate events accurate and timely which can impact resident impact, and plans of care. The DON revealed that room changes qualified for change in condition, and required 72-hour documentation of the findings. The DON stated that the incident was recorded in the grievance log, however, she did expect staff to document resident # 9, significant change of condition according to facility policy. An interview was conducted on January 23, 2026 at approximately 9:27 a.m. with Certified Nurse Assistant (CNA/Staff #68). The CNA revealed that accurate documentation is essential, especially when it comes to resident behaviors, and changes in a resident's condition so the care team stays informed, and helps ensure resident safety. The CNA stated that when a change in condition occurs, it is updated in the care plan, and without timely documentation, outdated interventions may continue, putting the resident at risk. The facility's Change of Condition Reporting policy, reviewed June 2025, revealed that all nursing actions, physician contacts, and resident assessment information will be documented in the nursing progress notes. The facility's Documentation and Charting policy, reviewed July 2025, revealed the facility will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms., as well as the progress of the resident's care. The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy, reviewed December 2025, directs the facility to maintain evidence that all allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property are thoroughly investigated. -Regarding Resident #50: Resident #50 was admitted to the facility November 14, 2025, with diagnoses of type 2 diabetes mellitus, chronic pain syndrome, spinal stenosis, malignant neoplasm of overlapping sites of right female breast, and pressure ulcer of sacral region, stage 4. A care plan focus initiated November 18, 2025, revealed Resident #50 had an alteration in gastro-intestinal status due to colostomy, with an intervention to monitor vital signs as ordered and record, and to notify provider of significant abnormalities. Despite the care plan intervention to monitor vital signs as ordered and record, review of the clinical record revealed no evidence of a physician order for monitoring vital signs. An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #50 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Section O revealed the resident had not received oxygen therapy on admission or while a resident within the last 14 days. Review of the Medication / Treatment Administration Record (MAR/TAR) for January 2026, revealed Resident #50's blood pressure, temperature, pulse, and respirations were recorded on the MAR/TAR every day shift and night shift. However, there was no evidence on the MAR/TAR of monitoring or recording oxygen saturation, until January 21, 2026. A review of the electronic medical record as of January 21, 2026, at 9:40 a.m. revealed no evidence of oxygen saturation monitored and documented for Resident #50 from January 17, 2026 until January 21, 2026. Additionally, there was no evidence in the electronic medical record of uploaded hospice notes for hospice nurse visits on January 19 or January 21, 2026. Also, there was no evidence of a care plan for oxygen therapy for Resident #50. A physician order dated January 21, 2026, at 6:06 p.m. included for oxygen at 2L via nasal cannula for diagnosis of supplemental end of life care. A Nursing note dated January 21, 2026, at 6:06 p.m. revealed Resident #50 was placed on oxygen via nasal cannula by hospice, and that the oxygen was ordered for comfort measures. A care plan focus initiated January 21, 2026, revealed Resident #50 had oxygen therapy due to ineffective gas exchange, with a goal to have no signs or symptoms of poor oxygen absorption through the review date. Interventions included to monitor for signs and symptoms of respiratory distress and report to physician as needed, including respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. A formal request was submitted to the facility on January 22, 2026, at 2:40 p.m. for all hospice records from start of care to present for Resident #50, including the hospice visit notes from January 19 and 21, 2026, which were not available in the EMR or a hospice binder or in medical records. The facility provided the hospice records, to include the hospice visit notes on January 23, 2026, at 8:40 A.M. Review of a Hospice Recert Summary Report dated January 22, 2026, revealed the following documentation which included hospice coordination notes, vital signs log, and physician orders: January 13, 2026: Resident #50's oxygen saturation was 93% on RA. January 15, 2026: Resident #50's oxygen saturation was at 90% on room air and oxygen was ordered for Resident #50. Despite the documentation that oxygen was ordered for Resident #50, there was no evidence of a physician order for oxygen. January 19, 2026: Resident #50's oxygen saturation was 87% on RA, and that the nurse attempted to apply oxygen via nasal cannula, however the oxygen concentrator was missing water, so staff was notified to fill the water, and then oxygen was applied to Resident #50 on 2L. There was no evidence of a physician order for oxygen. A physician order dated January 21, 2026 included to give oxygen via nasal cannula at 2L, may titrate between 2-4L to maintain oxygen saturation above 90%. Despite the documentation on January 19, 2026, that Resident #50 was hypoxic with oxygen saturation of 87%, there was no evidence in the clinical record or hospice documentation that a physician was notified of a change of condition or that change of condition monitoring was ordered. Additionally, there was no evidence of a physician order for oxygen until January 21, 2026. An observation was conducted on January 20, 2026, at 10:00 a.m. of Resident #50 laying in the bed in her room. Resident #50 had an oxygen concentrator next to her bed, which was turned on and set to 2L. The nasal cannula was not on the resident, and was draped over the top of the concentrator. The resident opened her eyes and stated she was very tired, and then closed her eyes, and was unable to answer further questions. Another observation was conducted on January 21, 2026, at 9:35 a.m. of Resident #50 laying in the bed in her room, with the oxygen concentrator turned on and set to 2L. The resident was wearing the nasal cannula in her nose. The resident was unable to open her eyes for more than a few seconds and could not answer questions. An interview was conducted on January 21, 2026, at 1:52 p.m. with a licensed practical nurse (LPN / Staff #45), who stated that Resident #50 was on hospice services and that she would know to look for any hospice orders or hospice care plans in the resident's hospice binder at the nurses' station. Staff #45 then looked for Resident #50's hospice binder at the nurses' station, then stated that Resident #50 did not have a hospice binder. Additionally, Staff #45 stated that a hospice nurse was just in the facility two days prior on January 19, 2026, and that anything that hospice ordered would be included in the orders in the electronic medical record (EMR). Staff #45 then reviewed Resident #50's clinical record and stated that there was no physician order for oxygen therapy, and no care plan for oxygen therapy. Resident #50 was then observed together in the resident's room with Staff #45, and Staff #45 stated that the resident was on oxygen and the dose was 2L, and that she believed a hospice staff who was just there earlier this morning had applied it. An interview was conducted on January 22, 2026, at 1:22 p.m. with the Assistant Director of Nursing (ADON / Staff #25) who stated that if a resident who previously was not on oxygen therapy had a change of condition to now require oxygen, then the provider should be notified right away and the resident would have a physician order for change of condition monitoring. Additionally, Staff #25 stated that if a resident was on oxygen therapy, then there would need to be a physician order. Staff #25 stated that if a resident was on oxygen therapy, then oxygen saturation would be monitored every shift to ensure the resident was maintaining oxygen saturation within normal limits. Staff #25 stated that if a resident were on oxygen therapy, then there would be a specific care plan for oxygen. The clinical record for Resident #50 was reviewed together and Staff #25 stated that the first oxygen order for Resident #50 was placed on January 21, 2026, for oxygen at 2L. Staff #25 stated that she could not determine from reviewing the clinical record why Resident #50 needed the oxygen because the clinical rationale and oxygen saturation monitoring were not documented in the clinical record. Staff #25 stated the clinical reason Resident #50 was on oxygen along with monitoring of the resident's oxygen saturation every shift should have been included in the resident's medical record. Staff #25 stated she could not locate any recent hospice notes and that the notes would be sent to the medical records director to be uploaded in the EMR. An interview was conducted with the medical records director (Staff #144) on January 22, 2026, at 1:42 p.m. who stated that she did not have any hospice notes for the visit on January 19, 2026, to present. A telephonic interview was conducted with the hospice clinical liaison RN (Staff #305) on January 22, 2026, at 1:58 p.m. Staff #305 stated that the hospice company communicates with the facility via documentation that is sent over via email to the medical records director every other week. Additionally, Staff #305 stated that for each of the hospice residents, there is a binder that is kept by the facility, where hospice staff will add notes regarding care and any updates on the residents. A telephonic interview was conducted with a hospice RN (Staff #301) on January 22, 2025, at 2:26 P.M, who stated that she was the nurse who visited Resident #50 on January 19, 2026, and that she took the resident's vital signs and noted that the resident was hypoxic, with oxygen saturation around 88-90%, and that the resident had an oxygen concentrator at bedside already upon Staff #301 entering the room. An interview was conducted with the Director of Nursing (DON / Staff #100) on January 23, 2026, at 8:21 a.m. who stated that the facility staff monitors long-term care resident's vital signs monthly and if there was a change of condition, then vital signs would be assessed every shift. Staff #100 also stated that if a resident were on oxygen therapy, then oxygen saturation would be assessed every shift and documented in the medical record. Additionally, for a change of condition, Staff #100 stated there would be a physician order placed for change of condition monitoring and a progress note in the medical record that included that the physician was notified of the change. Staff #100 stated that if a resident was administered oxygen, then there would be a physician order for the oxygen. Regarding Resident #50, the DON stated that she believed the resident was placed on oxygen by the hospice nurse the morning of January 21, 2026, and the physician order for oxygen was also placed that day. The DON stated that she believed the oxygen was for comfort measures and that she was not aware of any episodes of hypoxia for Resident #50. The clinical record was reviewed, and the DON stated that it was not in the clinical record that the provider was notified of any change of condition for Resident #50, but she assumed it was in the hospice nurse's notes that a provider was notified. Additionally, the DON stated after reviewing the medical record, that there was no oxygen saturation for Resident #50 documented from January 17, 2026, through January 21, 2026. The DON stated that if the clinical record did not accurately reflect a resident's current status or capture a change of condition, then the resident could have an adverse outcome. Review of the facility policy titled Documentation and Charting, dated July 2025, revealed it is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident. 6. The elements of quality medical nursing care. 7. A legal record that protects the resident, physician, nurse and the facility. 8. A source of all resident charges. Review of the facility policy titled Comprehensive Person-Centered Care Planning, revised June 2025, revealed it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment as indicated. The facility IDT includes, but is not limited to the following professionals: A. Attending Physician or Non-Physician Practitioner (NPP) designee involved in resident's care; B. Registered Nurse responsible for the resident; C. Nurse Aide responsible for the resident; D. Member of the Food and Nutrition services staff; E. To the extent practicable, resident and/or resident representative; F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.

Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure insulin was administered according to provider instruction for one resident (#5). This deficient practice could result in side effects leading to negative resident outcomes. The sample size was 5. The universe was 56. Findings include: Regarding Resident # 5 Resident # 5 was re-admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM) with chronic kidney disease, moderate protein-calorie malnutrition, generalized muscle weakness, and sequelae of cerebral infarction. A physician order dated April 9, 2025, revealed the resident was to receive 20 units of Insulin Glargine Solution one time a day for diabetes, unless the blood sugar was less than 110. The resident's Diabetes Mellitus- Insulin Injection care plan, revised on April 14, 2025, revealed the resident was noncompliant with his therapeutic diet, and was to have diabetes medication as ordered by the doctor. The resident's annual Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview Mental Status (BIMS) score of 14 indicating he was cognitively intact. The assessment indicated that the resident had an active diagnosis of DM, received a diabetic therapeutic diet while a resident, and required insulin therapy. Review of the Medication Administration Record (MAR) for January 2026, revealed that from January 1- 23, 2026, Insulin Glargine was administered on 5 occasions when the recorded blood sugars were less than 110. Review of the clinical record revealed no evidence of the provider authorizing the administration of Insulin Glargine to be administered when blood sugars were less than 110. An interview was conducted during a medication pass observation on January 22, 2026 at approximately 7:30 a.m. with Certified Medication Aide (CMA/Staff #77). The CMA stated that when a medication is ordered with parameters, staff are expected to follow the order as written. The CMA stated that administering medication outside of prescribed parameters can overmedicate a resident and may cause the resident to have an adverse effect, which has to immediately be reported to the charge nurse, and the doctor. An interview was conducted on January 23, 2026 at 8:15 a.m., with the Director of Nursing (DON/Staff #100). The DON stated insulin affects blood glucose levels by lowering blood sugar, not just in residents with diabetes, but in anyone that receives it. The DON continued, that when insulin is administered outside of prescribed parameters, it can cause hypoglycemia, which may result in serious adverse outcomes, including hospitalization. The DON stated that staff are expected to follow ordered parameters and to notify the provider when blood glucose values fall outside of those parameters. An interview was conducted with a Certified Nurse Assistant (CNA/Staff #68) on January 23, 2026, at 9:27 a.m. The CNA stated they are trained and responsible for performing finger-stick blood glucose monitoring. The CNA stated that low blood sugar may cause a resident to pass out or become delirious and that the nurse is immediately notified if blood glucose readings are below 60 or if the resident exhibits signs of hypoglycemia, such as cold, clammy skin or confusion. The CNA further stated that residents are positioned safely to prevent injury while nursing assistance is obtained and that provider orders are expected to be followed, as failure to follow orders may result in resident harm. An interview was conducted on January 23, 2026, at 10:05 a.m. with the Clinical Resource Nurse (Staff #99), who served as the Director of Nursing (DON)- by proxy, due to the unavailability of the presiding DON. The DON- by proxy reviewed the documentation and identified five occasions in which Insulin Glargine was administered when the resident's blood glucose level was below 110. The DON by proxy stated that the nurse responsible for administering the medication outside of the prescribed parameters was identified earlier that day and provided re education. The DON by proxy further stated that the expectation is for all medications to be administered in accordance with provider orders and that, upon review of Resident #5's documentation, this expectation was not met. The facility's Medication Administration Policy, reviewed in October 2025, revealed that when administering unit-dose medications, staff are required to obtain vital signs when indicated and to hold medications when parameters are not met. The policy further states that if there is any question regarding medication dosage, the medication should not be administered until clarification is obtained. The facility's Medication (Drug) Regimen Review (MRR) policy, reviewed April 2025, revealed the MRR includes identification of irregularities, medication-related errors, adverse consequences, and the use of unnecessary drugs.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further resident abuse. Findings include: -Resident #1 was admitted on [DATE] with diagnoses of dementia, non-displaced bimalleolar fracture of the lower right leg, alcohol abuse, and type 2 diabetes. The resident's bed assignment in the electronic health record (EHR) revealed that the resident was moved to a different bed in a different unit on September 21, 2024. A 5-day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident had no cognitive impairment. The progress note dated on October 1, 2024 included that resident #1 saw and attempted to slap resident #2 who then stood up from his chair and struck resident #1. Per the documentation, both residents swung at each other several times before resident #1 fell to the ground and sustained a laceration on the right forehead. It also indicated that staff attempted to intervene but were unsuccessful; and, both residents were separated, 911 was called and resident #1 was transported to the hospital for further evaluation. The hospital after visit summary dated October 1, 2024 revealed that resident #1 received sutures for his laceration. -Resident #2 was admitted on [DATE] with diagnoses of cellulitis of the right upper limb, alcohol dependence, and acquired absence of left leg below the knee. The admission MDS assessment dated [DATE] included BIMS score of 15 indicating the resident had no cognitive impairment. A progress note dated September 20, 2024 included that resident #2 was told by staff to lower the volume of his TV because his roommate (resident #1) reported that it was too loud. Per the documentation, resident #2 told staff that he was going to keep playing the TV at a loud volume until they moved his roommate (resident #1) out of his room. It also included that resident #2 was bothered by a situation that had occurred earlier in the day where his roommate (resident #1) had defecated on the floor of their shared room when on the way to the bathroom. The progress notes dated October 1, 2024 revealed that resident #2 was being escorted by two staff members due to being discharged to another facility. It also included that resident #2 had an altercation with another resident (#1) and that staff had attempted to intervene but were unsuccessful. Per the documentation, resident #2 told staff that he was defending himself because the other resident (#1) attacked him. The documentation also included that after the altercation with another resident (#1) was over, resident #2 was placed in an observation unit until the police department came to arrest him. An interview with central supply (staff #14) was conducted on October 3, 2024 at 1:49 p.m. The central supply staff stated that she and another staff (#8) were going down the main hallway when she saw resident #1 walking towards resident #2. She said that both residents then stopped and resident #1 had attempted to hit resident #2 but had missed. The central supply staff said that at this point, resident #2 stood up from his wheelchair and hit resident #1. She said that she placed her hand on the shoulder of resident #2 shoulder in an attempt to get him to sit down. She stated that once the altercation was over, a behavioral health technician (staff #8) sat with the resident in his room to ensure his safety; and later, she and staff #8 escorted resident #2 directly to another facility which was next door. In an interview with a Behavioral Health Tech. (BHT/staff #8) conducted on October 3, 2024 at 2:02 p.m., the BHT stated that he was going down the hallway and saw resident #1 standing up and was a little bit behind resident #2. The BHT said that resident #1 swung at resident #2 but had missed; and, resident #2 then stood up and punched resident #1. The BHT said that he and another staff (#8) attempted to separate both residents. He stated that after resident #1 fell to the ground, he and staff #8 were able to get resident #2 back into his wheelchair. An interview was conducted on October 3, 2024 at 2:13 p.m. with a Certified Nursing Assistant (CNA/staff #5) who stated that she was on her way into a resident's room when she heard resident #2 talking with other staff about a shower. Staff #5 indicated she then saw resident #1 slapped resident #2 who then stood up and hit resident #1. The CNA stated that she saw two other staff members (#14 and #8) attempted to separate both residents but resident #1 continued to go after resident #2. The CNA further stated that other nurses came to separate the two residents; and, she then went back to providing resident cares. During an interview with the Director of Nursing (DON/staff #11) conducted on October 3, 2024 at 2:19 p.m., the DON stated that since the incident on October 3, 2024 between residents #1 and #2, the facility had identified areas that could be improved upon such as additional de-escalation training for staff and implementing behavioral contractions. The DON said that the facility could have done a better job with establishing boundaries with new residents upon admission and the behavioral contracts outlines the expectations related to those boundaries. The DON said that both residents #1 and #2 had a history prior to the altercation as there was an issue when resident #1 was admitted on [DATE]. She stated that resident #2 was upset with resident #1 because resident #1 defecated on the floor of their shared room. The DON said that resident #1 was then moved to a different room because he felt threatened by resident #2. The DON said that staff ensures that both residents did not dine together, were not in activities together, and were not in the common areas together. The DON further stated that the two staff (#8 and #14) that escorted resident #2 on October 3, were not familiar with the resident's history with resident #1. The DON said that allowing residents who do not get along with each other cross paths with each other could result in one resident could provoke the other to have a negative reaction and it can cause an altercation to take place. The DON stated that the facility did not have any policy on de-escalation management with residents who are aggressive towards other residents. The facility policy on Resident Rights with last review date of June 2024 included that residents have a right to be free from physical abuse. A review of a policy on Abuse: Prevention of and Prohibition Against with revision date of November 2023, revealed that it is their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical, mental and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on clinical record review, interviews, and policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure that one resident (#1) received treatment and care in accordance with professional standards of practice by failing to call a provider and emergency services in a timely manner. The deficient practice has the potential of the resident suffering from a life-threatening medical event. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that include epilepsy, intractable, with status epilepticus, major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side. A review of a Minimum Data Set (MDS) assessment dated [DATE], indicated that resident #1 was unable to complete a Brief Interview for Mental Status (BIMS). Staff assessment revealed resident #1's cognitive skills for daily decision making was severely impaired. Review of the physician orders revealed resident was prescribed Levetiracetam (anticonvulsant), Lacosamide (anticonvulsant), and Divalproex Sodium (anticonvulsant). There were no orders for as needed seizure medication. A review of a care plan for seizure disorder revealed interventions that included seizure precautions: do not leave resident alone during a seizure, protect from injury. Other interventions included post seizure treatment: turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro checks. Review of the intake information submitted by the fire department to the SA complaint tracking system on July 18, 2024 revealed that the fire department arrived to the facility and saw resident #1 actively vomiting and unable to protect his own airway; however, the resident was left unattended. The information also included that nurse in charge of the resident (referring to staff #28) was sitting at a desk away from the patient and knew very little about the resident. Per documentation, the nurse (referring to staff #28) waited almost 2 hours to call 911 and did not have eyes on the patient when the fire department arrived. Further, the fire department alleged that the resident was never given any medications to stop the resident's active seizures. A review of progress note revealed that on July 18, 2024 at 6:02 AM, resident #1 was found laying on the ground next to the sliding door. The note indicated that staff initiated neurological checks and assessed the resident for injuries. The note did not give any indication of a seizure activity taking place. Further review of the progress note dated July 18, 2024 at 7:00 AM indicated it was a late entry and that the Nurse Practitioner (staff #102/NP) had ordered the resident to be sent to the emergency room for an evaluation related to the fall and due to the resident hitting his head. Review of the progress note dated July 18, 2024 at 7:43 AM stated that the physician and Director of Nursing (DON) were contacted at 6:15 AM with a request to call the facility back related to the resident's condition. The progress note dated July 18, 2024 at 9:37 AM indicated the resident had a seizure at 5:45 AM. It noted that the resident was taken to his room and the resident had intermittent seizure activity persisted with some emesis. It also stated that after receiving orders from the NP (staff #102) the resident was sent to the hospital at 8:02 AM. An telephone interview was conducted with Licensed Practical Nurse (staff #28/LPN) on July 23, 2024 at 10:37 AM. The LPN stated he was familiar with resident #1. The LPN indicated that sometime after 5:00 AM on July 18, 2024 another staff member had seen resident #1 on the floor. They had assessed the resident for injuries and implemented 15-minute neurological checks. The LPN also indicated that once the resident had been assessed, the resident wanted to remain in his wheelchair in the hallway. The LPN stated that at 5:45 AM resident #1 informed the LPN that he felt he was going to have a seizure and proceeded to have a seizure which lasted approximately 1 to 1 1/2 minutes long. The LPN indicated that resident #1 was brought back to the room and that seizure activity continued intermittently. The LPN indicated the LPN reached out to NP (staff #102) at 5:59 AM and then called 911 at 6:00 AM and the Emergency Medical Technicians (EMT) arrived at 7:00 AM. The LPN stated that when EMTs arrived at the facility the EMTstaff stated that the LPN waited too long to call the EMT and that the LPN should have called sooner. An interview was conducted with LPN (staff #61) on July 24, 2024 at 10:43 AM. The LPN stated that a resident having intermittent seizure would be considered a medical emergency. The LPN indicated that a provider's order was required before sending someone to the hospital, even in the event of a medical emergency. The LPN indicated that it was possible to call 911 and to be on the phone with a provider getting the order simultaneously. An interview was conducted with LPN (staff #54) on July 24, 2024 at 10:54 AM. The LPN stated that when a resident was having intermittent seizures that it was considered a medical emergency but as long as the resident was breathing, laying on their side and their head was being supported, they would call the provider and then 911. The LPN also stated calling 911 would have to be done quickly when a resident was having an active seizures. The LPN stated that per their clinincal training, it was not acceptable that it would take an hour to reach a provider to get an order. The LPN stated than an hour was too long and that they would call the provider right away using their own personal phone because the facility did not have a cell phone for staff to use. The LPN also stated they would call the provider, not text them. A telephone interview was conducted on July 23, 2024 at 1:29 PM with a NP (staff #102). The NP indicated she was familiar with resident #1. The NP stated that she had received a call from staff #28's private number at 6:20 AM on July 18, 2024 but she did not answer the phone because she did not know who it was. The NP also stated she received a call at 6:40 AM on July 18, 2024 from the Villa [NAME] phone number and at that time the order was given to send the resident to the hospital. A telephone interview was conducted with the complainant on July 23, 2024 at 1:34 PM. The complainant indicated that the call from the facility regarding a resident having a seizure came in on July 18, 2024 at 6:53 AM and the EMT responded at 6:54 AM. An interview was conducted with the Director of Nursing (staff #81/DON) on July 24, 2024 at 11:45 AM. The DON stated that when a situation was an emergency staff can call 911 first and then contact the provider after or direct another staff to call 911 while another staff was contacting the provider. The DON stated that a resident having intermittent seizures was considered a medical emergency if there was no medication in place. The DON stated the expectation was for staff to contact the provider immediately if a resident was having seizures and was in epileptic status, maybe a few minutes to ensure resident safety. The DON stated that staff #28 contacted the provider 15 minutes after resident #1 had a seizure. The DON stated that it was not an acceptable length of time between the seizure activity and calling a provider and the expectation was that staff call much sooner than 15 minutes. The DON indicated the risk of the delay in care could lead to the resident having brain damage, hypoxia, and the patient could suffer. A review of the facility policy titled Change of Condition Reporting last reviewed in June 2024 revealed, Licensed nurse will initiate appropriate first aid measures until emergency response personnel arrive on the scene.

Based on clinical record review, staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to provide care and services related to a peripherally inserted central catheter (PICC) line resulting in the hospitalization for one resident (#75). The deficient practice resulted in complications related to the PICC line not being removed. Findings include: -Resident #75 was admitted to the facility on [DATE] with diagnoses of urinary tract infection (UTI), weakness, pneumonia, hepatitis C, and hypertension. An antibiotic care plan, initiated March 14, 2024 revealed that resident #75 was on intravenous medications due to a diagnosis of complicated UTI. Goals for this care plan included will be free from complications through the review date, with a noted intervention that the facility staff will check the dressing at site daily, and monitor for any signs and symptoms of infection. A physician order dated March 15, 2024 noted ertapenem 1 gm (gram) (antibiotic) intravenously one time a day for complicated UTI. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. A review of progress notes revealed a provider's note dated March 21, 2024 that indicated patient had a PICC line and to continue treating patient with ertapenem. Further review of the progress notes revealed a nursing note dated March 22, 2024 indicating the resident was discharged to a boarding house at 3:00 p.m., signed his discharge, and was to follow up with his doctor and the pharmacy about his medications within the next week to two weeks. However, no mention of the PICC, or removal of the PICC was noted on discharge. An interview was conducted with a Licensed Practical Nurse (LPN/staff #100) on April 12, 2024 at 9:28 a.m. Staff #100 stated that he discharged the resident back in march, and that he vaguely remembered the resident. The LPN further stated that he was unaware of the PICC being present, and that he would have never discharged the resident if he knew a PICC line was present. An interview was conducted with the Director of Nursing (DON/staff #40) on April 12, 2024 at 10:51 a.m. who stated that the facility discharged the resident with a PICC and she just found out about it last night. The DON stated that the resident was now at the facility after being hospitalized for sepsis. The DON further stated that they were changing policy so that a full assessment was done on all residents when they discharge to identify PICC lines or anything else was noted in the chart. The DON further stated that her expectation was that full skin assessments were completed prior to discharge so this do not happen again. Review of information received from the SA complaint tracking system revealed that on April 2, 2024, a hospital physician reported the resident was discharged from the facility to the streets with PICC in place. The physician reported that the resident arrived to the emergency department with severe sepsis and bacteremia. The report revealed the resident had stated he was discharged to the streets with the PICC in place. The physician stated in the report that a hospital case manager called the facility to confirm that the resident was discharged to the streets with a PICC line in place with no plans for removal or follow-up; and, the resident had drug use history of methamphetamines sometimes intravenously. The physician reported that with the resident's history of polysubstance use disorder the situation could have been profoundly worse if patient had used PICC for drug use. A review of facility policy titled, Intravenous fluid and drug administration general policies revised in August of 2022, revealed that the nurse should monitor the patient for therapeutic response, recognize indications of untoward reactions, and implement nursing interventions as indicated, and that monitoring of patients should be ongoing.

Based on staff and resident interviews, clinical record review, facility records and facility policy, the facility failed to ensure that three residents (#2, 6, 8) were provided catheter related care as ordered. Failure to ensure that a physician's orders are implemented and failure to ensure care was provided can lead to increased risk of and late detection for urinary tract infections (UTIs) and other adverse effects. Findings include: Resident #6 was admitted on [DATE] with diagnoses of paraplegia, and neuromuscular dysfunction of the bladder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] included that this resident was cognitively intact, and that this resident was dependent for toileting hygiene. This assessment included that this resident had an indwelling catheter. A care plan initiated 6/26/23 included that this resident had an indwelling catheter #16/10 milliliter (mL) for a diagnosis of paraplegic neurogenic bladder and was at risk for frequent UTIs. Interventions included to change catheter bag and tubing as ordered and to provide catheter care by cleansing the catheter with soap and water and patting dry every shift. A Physician's order dated 11/3/2023 included catheter care - cleanse with soap and water and pat dry every shift. A Physician's order dated 11/3/2023 included indwelling urinary catheter care: Empty drainage bag every shift and as needed (prn). Report changes in urine amount, color, sedimentation, odor every shift. However, review of the clinical record for catheter care revealed that December of 2023 was missing 4 opportunities for catheter care and November of 2023 was missing 7 opportunities for catheter care. Review of the clinical record for emptying the drainage bag revealed that December of 2023 was missing 4 opportunities for emptying and November of 2023 was missing 7 opportunities for emptying. Review of this resident's clinical record for 1/10/24, 1/25/24, and 2/15/24 included recommendations by providers to implement a Urinary Analysis (UA). However, these orders were not transcribed into the electronic Medication Administration Record (eMAR) or the electronic Treatment Administration Record (eTAR) and documentation was not found to support that a UA was provided for any of the above dates. Resident #2 was admitted on [DATE] with diagnoses that include bladder neck obstruction, obstructive and reflux uropathy, muscle weakness and altered mental status. An Annual MDS assessment dated [DATE] included that this resident was severely cognitively impaired, and that this resident required substantial/maximal assistance with toileting hygiene. This assessment included that this resident had an indwelling catheter. A care plan initiated 02/27/2023 included that this resident had an indwelling foley catheter due to bladder neck obstruction 16 french/ 10 ml with an intervention of catheter care - cleanse with soap and water and pat dry every shift. A physician's order dated 11/21/2023 included indwelling urinary catheter care: Empty drainage bag every shift and prn. Report changes in urine amount, color, sedimentation, odor every shift. A physician's order dated 11/21/2023 included catheter care - cleanse with soap and water and pat dry every shift. However, review of the clinical record for catheter care revealed that February 2024 was missing 1 opportunity, January 2024 was missing 2 opportunities, and December of 2023 was missing 9 opportunities. Review of the clinical record for emptying the drainage bag revealed that January 2024 was missing 3 opportunities, December 2023 was missing 9 opportunities, and November 2023 was missing 9 opportunities. Resident #8 was admitted with diagnoses of neuromuscular dysfunction of the bladder, need for assistance with personal care, and muscle weakness. A discharge assessment - return anticipated MDS dated [DATE] included that this resident required substantial/maximal assistance for personal hygiene. This assessment included that this resident has an indwelling catheter. A care plan dated 2/6/23 included that this resident had an indwelling Suprapubic Catheter for diagnoses of neurogenic bladder and a stage 4 pressure injury and had a potential for recurring Urinary Tract Infection (UTI). This care plan included interventions of Indwelling urinary catheter care: Empty drainage bag every shift and prn and to provide suprapubic catheter care every shift. A physician's order dated 2/7/2023 included catheter care - cleanse with soap and water and pat dry every shift. A physician's order dated 2/7/2023 included indwelling urinary catheter care: Empty drainage bag every shift and prn. Report changes in urine amount, color, sedimentation, odor every shift. However, review of the clinical record for catheter care revealed that November 2023 was missing 3 opportunities, December 2023 was missing 8 opportunities, and January 2024 was missing 4 opportunities. Review of the clinical record for emptying the drainage bag revealed that 11/23 was missing 2 opportunities, 12/23 was missing 8 opportunities, and 1/24 was missing 3 opportunities An interview was conducted on 2/16/24 at 10:39 AM with resident #6 who said that about once a month he had to change his own catheter. He said that he had asked a nurse to change it for 3 days in a row and that the nurse said that there was not an order in the computer. He said that on the 4th day it leaked because the facility was understaffed and did not empty it. He said that a hospitality aid told him that they were understaffed so she was emptying catheters. An interview was conducted on 2/16/2024 at 11:02 PM with resident #9 who said that staff change his foley and take care of it because if they don't it overflows. He said that it overflowed a few times. An interview was conducted on 2/16/24 at 1:14 PM with a Certified Nursing Assistant (CNA/staff #7) who said that the CNAs perform catheter care. She said she had never seen a nurse perform catheter care. She said that catheter care is not performed every shift but that she tries to do so and that she will clean the catheter if it looks gunky. An interview was conducted on 2/16/24 at 2:58 PM with a CNA (staff #23) who said that staffing today was pretty good, we'll get everything done, but that a lot of the time there is not enough time to get everything done for the residents. An interview was conducted on 2/16/24 at 1:32 PM with a Licensed Practical Nurse (LPN/staff #43) who said that catheter care can be recorded as a nurse note or in the MAR TAR. This nurse said that catheters are normally changed once a month unless the Doctor orders it sooner or if complications arise. This nurse said that if care was not recorded it was not provided and that this nurse never saw a note or was aware of a request for a UA. An interview was conducted on 2/16/23 at 3:02 PM with an LPN (staff #31) who said that catheter care should be provided daily and that the nurse charts on the catheter care. This nurse said that if there is a blank in the record that means it was not charted on and if it was not charted was not done. This nurse said that catheters are changed as needed and as ordered. She said that usually the doctor will notify the nurses of new orders. An interview was conducted on 2/16/24 at 3:21 PM with the Director of Nursing (DON/staff #14) who reviewed the residents' record and said the resident should have had a monthly UA and did not. She said that her expectations are that the orders are transcribed and read back by the nurse and implemented. She said that it did not happen in this case. She said that her expectation for catheter care was that facility policy was daily, as needed or as the physician's order states. She said that her expectation is that catheter care is charted in the Medication Administration Record or Treatment Administration Record and that it did not meet her expectations that those opportunities were missed. A policy/procedure titled Catheter Drainage Bag reviewed 12/23 included to document all appropriate information in medical record. A policy/procedure titled Physician Orders reviewed 8/23 included that it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care and that medication, treatment or related procedure orders are transcribed in the eMAR, eTAR accordingly.

Based on clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#34) had a PASARR (Pre-admission Screening and Resident Review) Level I completed. Findings include: Resident #34 was admitted [DATE], with diagnoses that included Major Depressive disorder, and anxiety disorder. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the clinical record did not find a PASARR level I. An interview was conducted with the social worker (staff #54) on September 14, 2023 at 11:25 AM who said that all residents have a level I PASARR and that she was not sure what the timing was for completion of the Level I. She said that this resident did not have a Level I. An interview was conducted with the Director Of Nursing (DON/staff #19) on September 15, 2023 at 11:40 AM who said that Level 1 PASARRs should be done when the resident comes to the facility. She said that this resident's PASARR was not performed in a timely manner and that the facility does have a quality improvement plan in place for PASARRs.

Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 54. The deficient practice has the potential to negatively affect resident care. Findings include: Review of the facility staff schedules which included staff call offs, revealed that in February 2023, there were 3 dates with no RN on duty for 8 consecutive hours. Review of the staff schedules which included staff call offs for July 2023, revealed 3 days with no RN on duty for 8 consecutive hours. An interview was conducted on September 15, 2023 at 11:00 AM, with the Director of Nursing (DON/staff #98). She stated that the facility follows their facility assessment, which would include 8 hours of RN coverage a day. She further stated that they missed the 8-hour requirement on those months. She further stated that she is in the facility Monday through Friday and as needed for call offs that are done through the staffing coordinator. Review of the facility Staffing policy titled 'Sufficient staff revealed that it is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of acre and considering the number, acuity, and diagnosis of the facility's resident population in accordance with the facility assessment.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one sampled resident's (#41) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care. Findings include: Resident #41 was admitted on [DATE] with diagnosis including Wernicke's encephalopathy, chronic obstructive pulmonary disease, major depressive disorder, unspecified psychosis, chronic respiratory failure, heart failure, and paroxysmal atrial fibrillation. The resident was transferred to the emergency department on May 7, 2023 for breathing difficulty and hypertension, per Tucson Medical Center (TMC) emergency department triage notes. TMC summary notes indicated decreased breath sounds, wheezing and rales present. Resident #41 was then returned home to Villa [NAME] on May 11, 2023. A review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 5, indicating severe cognitive impairment. The TMC summary progress notes revealed that resident #41 was confused, the morning post admission, and could not provide much history or context as to why she had been admitted . A review of the physician's orders in the electronic health record revealed no evidence of hospital transfer orders; however, the electronic health record revealed that the resident was admitted to TMC on May 7, 2023 and was then readmitted to Villa [NAME] on May 11, 2023. An interview with the Director of Nursing (DON, clinical resource, staff #19) was conducted on September 14, 2023 at 11:49 a.m. The DON stated that you need an order for essentially everything and the expectation is that there should be an order for the resident to be transferred to the hospital; however, the DON reviewed resident #41's electronic health record and stated that there is no evidence that there was an order in the record. The DON stated that without an order, there would be a risk of staff not following physician's orders. A review of the facility's admission, transfer and discharge policy, with a review date of October of 2022, revealed that a resident's physician shall document if the transfer or discharge is necessary because the safety of the resident is endangered due to the clinical or behavioral status of the resident. However, the electronic medical record revealed no evidence of the aforementioned documentation.

Based on clinical record review, observations, resident and staff interviews, and review of facility policy and procedure, the facility failed to follow physician's orders prior to the administration of oxygen for one resident residents (#41). Findings include: Resident #41 was admitted on [DATE] with diagnosis including Wernicke's encephalopathy, chronic obstructive pulmonary disease, anxiety, major depressive disorder, unspecified psychosis, chronic respiratory failure, heart failure, and paroxysmal atrial fibrillation. Resident #41 was then transferred to Tucson Medical Center (TMC) for breathing difficulties and hypertension on May 7, 2023 and then readmitted to the facility on [DATE]. A review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 5, indicating severe cognitive impairment. The MDS, section 'O', further revealed no evidence that resident was on oxygen prior to admission or on oxygen while a resident at Villa [NAME]. A review of the physician orders on May 22, 2023 revealed an order for oxygen via nasal route, but did not indicate any parameters. A review of the physician's orders on September 12, 2023 revealed that an order for oxygen at 2 liters per minute, as needed to keep oxygen saturation at 89% or greater, dated September 12, 2023 had been added to the electronic health record. A review of the progress note dated July 27, 2023, revealed that the assessment plan for resident #41 contained her diagnosis of COPD and chronic respiratory failure and included the plan to continue on Prednisone, Trelegy and Albuterol as needed. An observation on September 11, 2023 at 9:00 AM, revealed that resident #41 was on 7 liters of oxygen. A subsequent observation for resident #41 was conducted on September 11, 2023 at 10:05 AM. The resident was still observed to be on 7 liters of oxygen. No marked distress was observed. An interview was conducted telephonically on September 11, 2023 at 11:41 AM, with the daughter of resident #41. The daughter stated that the resident is supposed to be on oxygen and had been on oxygen prior to admission. An interview was conducted with staff #59 (ADON and functioning as RN on the unit) on September 12, 2023 at 10:14 AM, Staff #59 stated oxygen is a medication for which an order is required. Staff#59 further stated that an order for oxygen was in place for resident #41, but not for a titration up to 7 liters. He stated that the oxygen should not have been set at 7 liters for resident #41. He stated that the risk for oxygen set above parameters could cause a lot of damage and could cause oxygen poisoning. An interview was conducted with staff # 19 (DON) on September 13, 2023 at 9:50 AM. Staff #19 stated that the expectation for staff is to follow physician's orders regarding respiratory care. She stated that the risk could include services and treatments not being received as ordered which could impact their health. A review of the physician orders policy with a review date of August 2022 revealed that orders for medication need to include the following: name and strength of the drug, quantity and specific duration of therapy, dosage and frequency of administration, route of administration and reason or problem for which it was given. However, the physician orders were incomplete and not followed as written. A review of the oxygen policy with a review by date on July, 2023 revealed a resident's clinical record will include that oxygen is to be administered, when and often, type of device for administration utilized, charting and documentation related to oxygen use, oxygen concentrator storage in the resident's room while in use and removal thereof when not in use as well as storage for e-tanks. However, MDS charting revealed that oxygen was not in use.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#114) or their representative have the ability to request, refuse, or discontinue treatment. The census was 57. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #114 was initially admitted into the facility on [DATE], hospitalized on [DATE], and readmitted to the facility on [DATE] with diagnoses that included aneurysm of the ascending aorta, without rupture, unspecified sequelae of cerebral infarction (complications resulting from a stroke), aphasia following cerebral infarction (communication disorder resulting from a stroke), and muscle weakness. Review of the clinical record revealed Durable Power of Attorney (POA) was signed on June 14, 2016 by resident #114. This POA also includes the ability to make healthcare decisions on behalf of resident #114. Review of the clinical record revealed the [discharge] Minimum Data Set (MDS) dated [DATE] revealed staff assessed the resident as cognitively severely impaired and never/rarely made decisions related to daily decision making. Review of the current orders revealed resident #114 is on the following psychotropic medications: Sertraline (anti-depressant), Oxcarbazepine (mood stabilizer), and Hydroxyzine (anti-anxiety). Review of the clinical record indicated there was a verbal consent for the use of psychotropic medications (Seroquel and Sertraline, both of which are anti-depressants). However, the form did not have a date indicating when verbal consent was received and it did not identify who provided the verbal consent. An interview was conducted with the resident's representative on September 14,2023 at 10:09 AM, via phone. The resident representative stated they never gave verbal or written consent for psychotropic medications for resident #114. Review of the clinical record revealed that as of September 14, 2023 10:34 AM there was no documentation in the progress notes or nurses' notes indicating verbal consent was received from the resident or the resident's representative. An interview was conducted with the Registered Nurse (RN #44) on September 14, 2023 at 11:39 AM. RN #44 stated she had been working at facility for about a year. RN #44 indicated resident #114 has a hard time expressing themselves due to a stroke but she believed resident #114 understood what was being communicated to her. RN #44 acknowledged that all residents should have signed consents for psychotropic medications upon admission. After reviewing the resident's clinical record, RN #44 was able to find verbal consent form for Seroquel but could not find it for Hydroxyzine and Oxcarbazepine. An interview was conducted with the Assistant Director of Nursing (ADON #59) on September 14, 2023 at 12:10 PM, the ADON stated that they believed the resident was capable of making their own decisions regarding medical care and they did not have a current diagnosis that supports the inability to make their own decisions. The ADON indicated he asked the resident for verbal consent to administer psychotropic medications and also received verbal consent from the Resident Representative as well. The ADON indicated that the second staff signature was a Registered Nurse (staff #17) and they should have documented receiving the verbal consents in the resident's clinical record. The ADON also acknowledged that there was a verbal consent form in the resident's clinical record for one of their current psychotropic medications and not the other two. The ADON indicated he did not know where the consent forms for Hydroxyzine or Oxcarbazepine were or if they were completed. An interview was conducted with Certified Nursing Assistant (CNA #85) on September 14, 2023 at 12:54 PM with CNA #85 indicated she was aware the resident was at the facility because they had a stroke and the resident does not verbalize needs well. CNA #85 indicated that communication is done via close-ended questions and gestures to ensure needs are met. On September 14, 2023 at 1:27 PM, Acting Director of Nursing (ADON #19) provided a copy of resident #114 undated verbal consent form. ADON #19 acknowledged the consent form was not completed in it's entirely and stated she started a QAPI review to address the gap. An interview was conducted with the Administrator (ADM) on September 15, 2023 at 8:31 AM. The ADM stated that he could not recall specific language in the policy around the rights of a Resident Representative or what happens when a resident cannot make their own decisions. After reviewing the Resident's Rights policy, he acknowledged there was no language in the policy that outlines the rights of the Resident Representatives.

Based on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one section (O) of a Minimum Data Set (MDS) assessment for one sampled resident (#41) included that the resident is on oxygen. The deficient practice could result in residents not receiving the required care and services for an oxygen dependent resident. Findings include: Resident #41 was admitted on [DATE] with diagnosis including Wernicke's encephalopathy, chronic obstructive pulmonary disease, anxiety, major depressive disorder, unspecified psychosis, chronic respiratory failure, heart failure, and paroxysmal atrial fibrillation. Resident #41 was then transferred to Tucson Medical Center (TMC) for breathing difficulties and hypertension on May 7, 2023 and then readmitted to the facility on [DATE]. A review of the quarterly MDS (minimum data set) dated July 20, 2023 revealed that section 'O' special treatments, procedures and programs contained no evidence that resident #41 was on oxygen prior to admission to the facility or currently while at the facility. The MDS further revealed that the resident had a BIMS (brief interview of mental status) score of 5, indicating severe cognitive impairment. A review of the physician orders revealed oxygen orders dated May 25, 2022 for resident #41 and revised orders dated September 12, 2023, noting oxygen at 2 liters per minute as needed to keep saturation greater than 89 percent as needed for chronic obstructive pulmonary disease. A review of the care plan dated July 20, 2023 revealed that oxygen was care planned for resident #41. A review of the physician progress notes dated July 27, 2023 revealed no shortness of breath, coughing or wheezing. The notes further revealed under the assessment / plan section that the resident has chronic respiratory failure and that as of May 22, 2023 resident #41 receives oxygen via nasal cannula. An observation on September 11, 2023 at 10:05 a.m. revealed that the resident was on 7 liters of oxygen. An interview was conducted the ADON (staff #59), who was functioning as the nurse on the unit, on September 12, 2023 at 10:14 a.m. The ADON reviewed the electronic medical record and was able to locate orders for oxygen, but was unable to locate the oxygen on the most recent MDS. An interview was conducted with the MDS coordinator (staff #30) on September 12, 2023 at 1:17 p.m. The MDS coordinator stated that if in use, oxygen should always be indicated in section 'O' on the MDS. The MDS coordinator pulled up the MDS for resident #41, in the electronic health record, and stated that there was no indication of oxygen in the resident's MDS. She stated that this was an error. The MDS coordinator stated that the risk of not having oxygen noted in the MDS resulted in an inaccurate electronic health record and that the resident's information would be inaccurately conveyed. An interview was conducted with the administrator (staff #78) on September 13, 2023 at 7:13 a.m. The administrator stated that his expectation is that the MDS is completed accurately and timely. The administrator reviewed resident #41's MDS and stated that oxygen was not selected as having been received prior to or during the stay at the facility. He stated that the risk for not having oxygen noted on resident #41's MDS would not accurately reflect all that the facility had done for the resident and could result in information potentially not being accurately shared with staff. A review of the oxygen administration policy dated July, 2023 revealed that the resident's clinical record will include that oxygen is to be administered, when and how it is to be administered, type of device utilized, special procedures or treatments to be administered as well as any charting and documentation as related to oxygen use.

Based on observations, clinical record review, resident interview, staff interviews, and review of facility policies, the facility failed to ensure that one resident (#37) received adequate supervision to prevent medication accidents and that one resident (#41) received neurological checks after an unwitnessed fall. The deficient practices could result in resident #37 sustaining medication accident-related injuries and life-threatening injuries for resident #41. Findings include: Resident #37 was admitted on [DATE] with diagnosis including paraplegia, pressure ulcer of the sacral region, major depressive disorder, anxiety disorder, opioid dependence-in remission, pain, and end stage renal disease. A review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. A review of the physician orders revealed no evidence of an order for the self-administration of antifungal creams or wound cleanser. A review of the care plan dated July 19, 2023 revealed no notation that the resident is able to self-administer medications. A review of the assessment section of the electronic health record revealed no evidence that the resident had been assessed for medication self-administration. An observation was conducted for resident #37 on September 11, 2023 at 10:12 a.m. Phytoplex antifungal ointment as well as Inzo antifungal cream and equos wound cleanser were observed, in plain view, on the resident's bedside table. During the same observation, the resident had initiated the call light, as he was experiencing pain. The assistant director of nursing entered the room, asked what level of pain the resident was experiencing and the resident reported he was at a '10' pain level. Continued observation at this time revealed no evidence of the medication being removed or the resident questioned about the medication on his bedside table. An observation was conducted on September 12, 2023 at 10:22 AM. The resident was not observed in his room; however, both antifungal medications and wound cleanser were still observed on the bedside table. An interview was conducted on September 12, 2023 at 10:22 AM with staff #27 (RNA-restorative nursing assistant). The RNA stated that the resident had been admitted to the hospital earlier this morning. An interview was conducted with staff #85 (CNA) on September 12, 2023 at 10:30 AM, Staff #85 stated that anything a patient is in need of, to include pills, tablets, topicals or SVN treatments constitute medications. She stated that if a resident needs a medication, they have to go through the nurse. She stated that the resident would tell the nurse and if an order for the medication was not present, then the nurse would contact the provider to review the request. She stated that residents are not allowed to administer their own medications under any circumstances. She stated that if medications are found in a resident's room, she would notify the nurse and try to figure out how long the medications had been there. Staff #85, then stated that the medications would be removed and disposed of. An interview was conducted with staff #59 (ADON) on September 12, 2023 at 10:55 AM, Staff #59 stated that medications include both prescribed and over the counter treatments. He stated that if a resident requests a medication that had not been ordered, he would call the doctor to obtain an order. He stated that residents are not allowed to self-administer medications at this facility, unless it is during training, prior to going home, and then only supervised. He stated that medications should not be at a resident's bedside table. He stated that if he observes medications at bedside, he removes them, puts the resident's name on them and locks them up. Staff #59 stated that the risk could include other residents, such as roommates, accidentally taking the medications. An interview was conducted with staff #19 (DON) on September 13, 2023 at 9:48 AM, Staff #19 stated that the expectation is that medications should not be at a resident's bedside table. She stated that if a resident request medication self-administration, then an assessment is conducted and an order from the physician is obtained. Staff #19 stated if medications are found at bedside, the medications are removed. However, if medications are missed by staff, she stated then additionally staff would be re-educated. She stated that the risk would be the difficulty to monitor the frequency of medication administration and other people could be wandering around and take the medication. A review of the self-administration of medication policy with a review date of May, 2023 revealed that residents can self-administer medications only, once they have been evaluated for cognitive, visual and physical ability by the interdisciplinary team (consisting of the medical director or primary physician, director of nursing or representative and social services), the candidacy for self-administration is then noted to be reflected in the resident chart, the resident will be educated and nursing will conduct ongoing monitoring. However, no evidence of an assessment was noted in the chart for resident #37. ________________ Resident #41 was admitted on [DATE] with diagnosis including Wernicke's encephalopathy, chronic obstructive pulmonary disease, anxiety, major depressive disorder, unspecified psychosis, chronic respiratory failure, heart failure, and paroxysmal atrial fibrillation. Resident #41 was then transferred to Tucson Medical Center (TMC) for breathing difficulties and hypertension on May 7, 2023 and then readmitted to the facility on [DATE]. A review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 5, indicating severe cognitive impairment. A review of the care plan revealed a focus area for falls initiated on July 20, 2023, due to confusion, noting gait and balance problems as well as poor awareness of safety needs. A further review of the care plan revealed that the resident had slipped out of her wheelchair on May 18, 2023 with no reported injury and on June 12, 2023 was found on the mat next to her bed. The care plan and associated interventions were noted as updated and no subsequent concerns for interventions were observed. However, a subsequent review of the electronic health record revealed no evidence that the unwitnessed fall on June 12, 2023 had the proper neurological checks conducted subsequent to the fall. An interview was conducted on September 12, 2023 at 10:30 a.m. with staff #85 (CNA). Staff #85 stated that post falls, residents are assessed for injuries, staff try to find out what and how the fall occurred, the nurse would be notified, vitals would be taken and documented in the electronic health record. She stated that vitals were always taken after a resident has fallen and reported that health related issues could be missed if they were not taken. An interview was conducted on September 14, 2023 at 8:30 a.m. with staff # 44 (LPN). Staff #44 stated that after falls, residents are assessed for injuries, staff help them get up as appropriate, take the resident's vitals and conduct neurological checks if an unwitnessed fall has occurred. Staff would then notify the family and continue with charting the 'neurochecks' for the next 72 hours. She stated that the neurological checks are recorded on a 'hardcopy' document and then given to the medical records department, who then file the neurological checks. She stated that she is unsure if the medical records department uploads them to the electronic health record. Copies of the neurological checks for resident #41 were requested on September 14, 2023 at 8:AM. The Director of Nursing stated that the facility was unable to locate the neurological checks for the unwitnessed fall of resident #41. An interview was conducted on September 14, 2023 at 11:47 AM, with the Director of Nursing, staff #19. Staff #19 stated that neurological checks should be completed for all unwitnessed falls. She stated that the CNA's complete the hardcopy form, which is on a clipboard. She stated that this form is then given to the nurses and subsequent to the documentation time frame indicated for neurological checks is then provided to vital records for storage. She stated that she had been unable to locate the neurological checks and was unsure where they had gotten lost. She stated that the risk to the resident would be that staff would be unaware of a change in neurological condition which could be an indicator for other health related issues. A review of the fall management system policy with a review date of May, 2023 revealed that a physical assessment and or evaluation will be completed by a licensed nurse and documented in the nursing progress notes; however, the policy did not address the documentation of neurologic 47954 Based on clinical record reviews, staff interviews, facility documentation, facility policy, and national standards, the facility failed to ensure oxygen cylinders were stored safely in accordance with professional standards. This deficient practice could result in life-threatening injuries. Findings include: -Resident #15 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, chronic kidney disease stage 4, hypertension, congestive heart failure, gout, contracture of the right hand and peripheral vascular disease. A change of condition Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A falls care plan revised July 28, 2023 revealed that resident #15 has a potential for a fall occurrence related to gait balance problems and a history of several falls. Goals for this care plan will be free of falls through the review date, with a noted intervention that the facility will provide a safe environment with floors free of spills and/or clutter. A vision care plan revised August 7, 2022 revealed resident #15 had decreased visual acuity. The goals for this care plan included Maintaining optimal quality of life by visual function, with a noted intervention of keep room well lit and free from clutter. However, one oxygen cylinder was found in the resident's room unsecured on the floor, without a carrier device, which could result in life-threatening injuries related to an oxygen cylinder fire or explosion. A physician's order dated September 12, 2023 noted Oxygen at 2 liters, via nasal cannula and may titrate to maintain oxygen saturation greater than 90% every day and night for congestive heart failure. An observation was made on September 11, 2023 at 10:15 AM, of one oxygen cylinder stored standing up on the floor, without a carrier device. The oxygen cylinder was observed to be full. An observation was made on September 11, 2023 at 10:39 AM, of a staff member in the room providing services, however the oxygen cylinder remained on the floor until the staff members exit. A repeat observation was made on September 11, 2023 at 11:50 AM, where the oxygen cylinder were still present. An interview was conducted with a Certified Nursing Assistant (CNA staff/#80) on September 11, 2023 at 1:06 PM. Staff #80 stated that they have training every month, and that the leaders make sure their training is complete. Staff #80 also stated that oxygen bottles are only stored in oxygen storage, or in the wheeled carriers. Staff #80 stated that oxygen bottles should never be stored on the floor or laying down. An interview was conducted with The Maintenance director (staff #99) and the Environmental service director (staff #93) on September 11, 2023 at 1:53 PM. Staff #93 stated that staff get monthly and annual in-services related to training. Staff #93 also stated that oxygen bottles are not supposed to be used or stored on the floor and that a carrier device must be used to transport oxygen cylinders. Staff #93 and staff #99 conducted an observation of room [ROOM NUMBER], during this interview, with staff #93 acknowledging the presence of the free-standing oxygen cylinder without a carrier device and stating that bottle is not supposed to be there, we will get it right now. An interview was conducted with the Director of Nursing (DON staff #89). The DON stated that Oxygen storage is part of annual training but also done on hire. The DON stated that the training does include the use of carrier devices. The DON stated that oxygen should never be stored on the floor and must always be in a carrier and secured. The DON further stated that she can appreciate the risks involved with storage an oxygen cylinder on the ground. The DON further stated her expectation is that the staff follow facility policy. A review of facility policy titled 'Oxygen Administration' revealed that Oxygen tanks will be kept in holders on wheelchairs, or in carriers for ambulatory residents, and that Oxygen tanks will be stored in the oxygen room, full tanks in the designated area, and empty tanks in the designated area. An Occupational Safety and Health Administration (OSHA) website titled Compressed Gas and Equipment' revealed Hazards associated with compressed gasses include oxygen displacement, fires, explosions, and toxic gas exposures, as well as the physical hazards associated with high pressure systems. Special storage, use, and handling precautions are necessary in order to control these hazards.

Based on observation, clinical record reviews, resident and staff interviews and policy review, the facility failed to ensure pain management was provided to two residents (#37 and #115) consistent with professional standards of practice and the resident's goals and preferences. Findings include: Resident #115 was admitted on [DATE] with diagnoses that included cellulitis of the left lower limb and acute osteomyelitis of the right femur. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The assessment included the resident received scheduled pain medication and as needed pain medication and that she occasionally reported her pain level at a 7 which interfered with day to day activities and sleep. The assessment also included that the resident received opioid medication 5 of 7 days reviewed. A review of the care plan revealed the resident had acute and chronic pain related to osteomyelitis with interventions of follow pain scale to medicate as ordered. This document also included the resident was admitted with bilateral lower extremity wounds red without drainage and right ankle with a fluid filled blister with intervention of administering antibiotics as ordered, to monitor and document wound including size, depth and margins and to document progress in wound healing on an ongoing basis, and to notify physician as indicated A review of the physician's orders revealed the following orders: - WOUND CARE: Bilateral Lower Extremities LEGS/FEET Cleanse with wound wash. Pat dry. Cover ulcers with Xeroform, wrap with Kerlix, secure with Ace wrap. Dressing change 3X/week and PRN for drainage or soiling. every night shift every Tue, Thu, Sat for WOUND CARE DRAINAGE/SOILING. - Oxycodone HCl Oral Tablet 5 MG (analgesic) Give 2 tablet by mouth every 4 hours as needed for pain 1-10. During an observation conducted on September 15, 2023 at 8:44 AM, the resident asked a Licensed Practical Nurse (LPN/staff #2) who was performing wound care for pain medication. This resident expressed pain multiple times during wound care and the nurse said that it was not yet time for her pain medication. However, this LPN did not contact the physician prior to the wound care or postpone the wound care until the resident could be medicated for pain. An interview was conducted after this observation with this LPN (staff #2) who said that she would talk to the physician about scheduling a medication for prior to wound care as she had pain especially with her right leg. She said that the resident had her as needed pain medication given at 5:53 AM, for a pain of 7/10 and could not have another dose yet as it was scheduled for every 4 hours. During an interview conducted with the Director of Nursing (DON/staff #19) on September 15, 2023 at 11:40 AM, the DON said that the staff should ask if the resident is in pain before performing wound care and the staff should treat the pain accordingly. She said that it did not meet her expectations that this resident did not receive pain medication before receiving wound care. 47911 Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#37) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for the resident. Findings include: Resident #37 was admitted on [DATE] with diagnosis including paraplegia, pressure ulcer of the sacral region, chronic pain syndrome, unspecified pain, major depressive disorder, anxiety disorder, opioid dependence-in remission, pain, psychoactive substance abuse-uncomplicated and end stage renal disease. A review of the MDS (minimum data set) assessment for resident #37, dated July 19, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. A review of the care plan dated July 13, 2023 revealed that the resident is prescribed opioid medications for pain and that the medication is to be administered as prescribed. A review of the physician orders for resident #37 dated July 14, 2023, revealed that staff are to monitor the resident for pain every shift and medicate as needed per physician's order. A review of the MAR (medication administration record) for August and September 2023 revealed that pain levels were being monitored with resident #37. A further review of the MAR revealed that oxycodone was ordered for pain levels ranging from 6 to a 10 on the pain scale; however, the administration record revealed that oxycodone had been administered outside of the ordered parameters on 4 separate occasions to include: August 4, 2023 at 12:48 PM: Oxycodone administered for a pain level of 2 August 20, 2023 at 2:19 AM: Oxycodone administered for a pain level of 4 August 22, 2023 at 6:45 AM: Oxycodone administered for a pain level of 0 August 24, 2023 at 9:57 AM and 2:07 PM: Oxycodone administered for a pain level of 0 September 3, 2023: Oxycodone administered for a pain level of 5 The MAR further revealed that resident #37 was noted to have experienced a pain level of 9 on August 8, 2023 and was given Tylenol, which had been ordered for pain levels up to 5. An interview was conducted with resident #37 on September 11, 2023 at 10:12 AM. The resident stated that his pain was not controlled well. He stated that he was unable to participate in therapy due to pain levels. An interview was conducted with staff #59 (ADON) on September 13, 2023 at 10:31 AM. Staff #59 stated that his expectation is that medications are to be administered accurately as per physician's orders. Staff #59 reviewed the MAR for resident #37 and stated that oxycodone should not have been administered at a 5 or below and that for pain exceeding a level 6 Tylenol should not have been administered. An interview was conducted with staff #19 (DON) on September 13, 2023 at 11:13 AM. Staff #19 stated that medications are to be administered accurately as per physician orders. Staff # stated that when determining whether or not to administer pain medications, nursing staff are to assess the resident's pain level and administer medications in compliance with the physician's orders utilizing the designated pain scale in the order. She stated that the designated pain with a '0' level was probably a documentation error. Staff #19 stated that the risk for administering medication outside of parameters can include a resident's pain level not being well-controlled as well as pain medication not being administered as ordered. A review of the facility's pain management policy with a review date of September, 2022 revealed that the physician should be consulted for additional interventions id pain is not relieved by currently ordered treatment modalities and comfort measures. A review of the medication administration policy with a review date of May, 2023 revealed that a resident's orders are to be reviewed prior to dose administration and that medication administration is the be documented.

Based on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure that a resident's wound care was conducted in accordance with current standards for 1 resident (115). Findings include: Resident #115 was admitted on [DATE] with diagnoses that included cellulitis of the left lower limb and acute osteomyelitis of the right femur. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The assessment included the resident had 2 venous and arterial ulcers. A review of the care plan revealed the resident was admitted with bilateral lower extremity wounds red without drainage and right ankle with a fluid filled blister with intervention of administering antibiotics as ordered, to monitor and document wound including size, depth and margins and to document progress in wound healing on an ongoing basis, and to notify physician as indicated. A review of the physician's orders revealed the following orders: - WOUND CARE: Bilateral Lower Extremity, LEGS/FEET Cleanse with wound wash. Pat dry. Cover ulcers with Xeroform, wrap with Kerlix, secure with Ace wrap. Dressing change 3X/week and PRN for drainage or soiling. every night shift every Tue, Thu, Sat for WOUND CARE DRAINAGE/SOILING A wound care observation for resident #115 was conducted September 15, 2023 at 8:44 AM, with a Licensed Practical Nurse (LPN/staff #2). During the wound care observation, the nurse was observed not to wash or sanitize her hands after touching the resident's feet then removing the resident's socks then removing her dressings, between removing the dressings and cleaning the wounds, and between dressing different wounds, An interview was conducted 9/15/23 at 9:18 AM, with this LPN (staff #2). During the interview both nurses stated that they were supposed to wash their hands between removing a dressing, prior to starting a dressing and after finishing a dressing, and between wounds. She said that she missed times to perform hand washing. During an interview conducted with the Director of Nursing (DON/staff #19) on September 15, 2023 at 11:40 AM, the DON said the staff should knock on door, wash hands or perform hand hygiene, go to the resident and obtain consent and ask if they are in pain, place supplies on a barrier, remove the dressing with gloves, clean and measure the wound, then wash hands before going to next wound. Then the nurse should follow physician orders, take off gloves and perform hand hygiene. She said that she had trained this nurse on what to do but that this LPN was not wound certified. A policy titled Complex Wound Management reviewed 7/2023 revealed that all treatments involving breaks in the skin require clean technique, unless otherwise ordered by the physician. A Centers for Disease Control Hand Hygiene Guidance revealed that The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. This document included that healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, and after contact with blood, body fluids, or contaminated surfaces.

Based on observations, resident and staff interviews and facility policy review, the facility failed to ensure a sanitary, clean and homelike environment was provided for three sampled residents (#14, #55 and #56). Findings include: -Resident #14 was readmitted on [DATE] with diagnosis including Parkinson's disease, schizoaffective disorder-bipolar type, hypertension, major depressive disorder and need for assistance with personal care. A review of the MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, indicating the resident was cognitively intact. -Resident #55 was admitted on [DATE] with diagnoses of Parkinson's disease, bipolar disorder, hypertension, anxiety and morbid obesity. A review of the MDS assessment dated [DATE] revealed a BIMS score of 15, indicating that the resident was cognitively intact. The clinical record revealed that resident #55 was discharged on [DATE]. -Resident #56 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), hypertension, and adjustment disorder with mixed anxiety and depressed Mood. The MDS assessment dated [DATE] revealed a BIMS score 14 indicating the resident was cognitively intact. The clinical record revealed that resident #56 was discharged on [DATE] The pest control company activity log from November 2022 through May 2023 revealed mice as pest problem on the following dates and locations: -November 21, 2022 - social service room; -November 26, 2022 - 200-unit resident room; -December 12, 2022 - 300-unit nurse station; -December 21, 2022 - activity room; -January 16, 2023 - resident rooms; -January 22, 2023 - nurses station, 200-unit, 300-unit, break-room; -January 28, 2023 - 300-unit shower room; -February 10, 2023 - 300-unit nurses' station; -March 22, 2023 - 200 unit; -April 6, 2023 - rooms, gym, dining room, offices; and, -May 24, 2023 - office. An interview with the resident #14 was attempted on May 24, 2023 at 12:00 p.m., but was unsuccessful as the resident was not available in his room. An interview was with a random female resident conducted on May 24, 2023 at 12:10 p.m. The resident stated the facility had mice and there were droppings all over her room and in the drawer of her bedside table. She stated that roaches come out and scurry across the floor at night; and that, she last observed a mouse in her room on May 23, 2023. The female resident further stated that she had reported the problem to the nursing staff about a month ago; however, she had not received any updates on what the facility was doing to address the problem. An observation was conducted during the interview and revealed mouse droppings in the drawer of the resident's night-table. The resident stated that these had been in her drawer for about a week. There were also mouse droppings behind the shower chair in the attached bathroom and between the bed and night-table of the resident's roommate. An interview was conducted with the restorative nurse assistant (RNA/staff #68) on May 24, 2023 at 12:20 p.m. The RNA stated that an exterminator comes to the facility on ce a week and or when issues were reported or observed. An interview with the maintenance staff (staff #69) and the housekeeping supervisor (staff #93) was conducted on May 24, 2023. The housekeeping supervisor stated that she had observed mouse droppings in the random female resident's night-table drawer. The maintenance stated that the droppings found behind the shower chair and between the bed and night-table of the random resident and her roommate were mouse droppings. Staff #69 stated that the mice had been an issue for at least the past four and a half months; however, he stated that the he feels the issue has improved. The housekeeping supervisor stated that there was a concern for the number of items some residents may have in their drawers; however, the random female resident only had papers in her drawer and no evidence of food related items. The facility's policy on Pest Control revised on May, 2022 revealed that the facility will utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment. The facility policy on Homelike Environment included that it is their policy to provide a homelike environment. A review of the facility policy on Housekeeping Services included that it is their policy to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites.

Based on clinical record reviews, observations, staff interviews, and review of facility policies, the facility failed to ensure that care and services were provided to prevent the development and/or deterioration of pressure ulcers for two residents (#57 and 88). Findings include: -Resident #57 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission nursing note dated June 12, 2015, did not include documented evidence that a pressure ulcer was present. A nursing admission assessment dated [DATE], included that the resident required extensive to total assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. This assessment also included that the resident had a sacral wound, however, the stage, measurements, or a complete description of the wound bed and surrounding tissue were not included. On June 13, 2015, a treatment order was obtained to administer [MEDICATION NAME] spray to the sacral wound three times a day. However, the June 2015 TAR (Treatment Administration Record) documentation included that the prescribed treatment had not been administered until June 16, 2015, three days after it was ordered. In addition, the treatment was not administered three times a day as ordered, from June 17 through 30. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was at risk for pressure ulcer development and had a stage 3 pressure ulcer. However, further review of the clinical record revealed there was no assessment of the pressure ulcer, which included any measurements or a description of the wound bed, from the time of admission through June 24. A NP (Nurse Practitioner) wound care note dated June 25, 2015, which was 13 days after admission to the facility, was the first documentation of a thorough assessment of a pressure ulcer. The documentation included the resident had a stage 3 pressure ulcer on the coccyx, which measured 2 by 3.5 cm (centimeters) and the wound bed was 80% red with 20% eschar and had serosanguinous drainage present. The above wound assessment also included that the resident had decreased mobility and oral intake, increased confusion/dementia, and that the resident had additional breakdown. The newly identified areas of skin impairment were as follows: -Right ankle-SDTI (Suspected Deep Tissue Injury) stage 4, which measured 1 by 1 cm. -Left Heel-SDTI, which measured 4.5 by 5.5 cm. According to this same NP wound assessment from June 25, podus boots to off load and protect the heel/foot were prescribed. Further review of the June 2015 TAR, revealed the order for the podus boots, however; there was no documented evidence that the podus boots had been applied, nor were there any treatment orders for the right ankle and left heel pressure ulcers. The next wound assessments were not completed until seven days later. The NP wound care note dated July 2, 2015 included the following: -Coccyx: Stage 2 blisters, which measured 4.5 by 7 by 0.2 cm. (now a combination of three wounds). The wound bed was red, with a scant amount of serosanguinous drainage present. -Right ankle: Stage 4 with an opened area that measured 3 by 2 cm, with a red wound bed. -Left heel: DTI (Deep Tissue Injury)/stage 4, which measured 5.5 by 7.5 cm, with 100% eschar now present. According to the July 2015 TAR, the following treatments were prescribed: -Coccyx: [MEDICATION NAME] to the coccyx with each brief change was ordered on July 3, 2015. However, the TAR documentation included that the [MEDICATION NAME] was only applied on July 4, and was not applied from July 5 through 16. -Coccyx: [MEDICATION NAME] to coccyx three times a day and as needed was ordered on July 17, 2015. This treatment was not consistently administered three times a day, as ordered from July 17 through 31. -Left heel: Paint left heel with [MEDICATION NAME], leave open to the air for 10 minutes and then place a clean sock on, twice a day. This order was dated July 10, however; the TAR documentation showed that the treatment had only been administered once a day, on multiple days. A nursing weekly wound review note dated July 9, 2015, included that a pressure ulcer was present on the left heel, which measured 6 by 6.5 cm. Per this note, this pressure ulcer was present on admission, however, according to the NP note (from June 25), the pressure ulcer to the left heel was not identified until June 25. In addition, the documentation on the nursing weekly wound note included that the pressure ulcer was a stage 1. However, the documentation also included that eschar was present, which according to the pressure ulcer staging guidelines, the presence of slough and/or eschar would be classified as an unstageable pressure ulcer and not a stage 1. Furthermore, the pressure ulcer had previously been identified by the NP on July 2, 2015, as a DTI/Stage 4 pressure ulcer. In addition, the above nursing weekly wound review documentation did not address the previously identified stage 4 pressure ulcer on the resident's right ankle. The next assessments of the resident's pressure ulcers were not completed until eight days later on July 10, 2015 per the NP wound care note, which included the following: -Coccyx: Stage 2, which measured 5 by 5 cm with 2 areas combining. The wound bed was red with serosanguinous drainage present. -Right ankle: SDTI/stage 4, which measured 1.5 by 2.0 cm and the wound bed was now 100% eschar. -Left heel: SDTI/stage 4. No measurements were included on this assessment. The wound bed had 100% hard eschar present. The NP wound care note dated July 16, 2015, included the following: -Coccyx: Stage 2, which measured 4 by 4.5 cm. However, the documentation included that the pressure ulcer would now be counted as a stage 1 due to the lower half having resurfaced. Right ankle: Unstageable, which measured 1.2 by 2.5 by 0.2 cm. The pressure ulcer had 90% eschar present which was debrided, and then revealed the wound bed was 90% slough. -Left heel: Unstageable, which measured 4.5 by 4 cm. The wound bed had 100% dry eschar present. In addition, the above NP wound care note included the following treatments dated July 17: -Right ankle: off load, apply Santyl and a foam dressing and skin prep three times a week. -Left heel: keep dry, paint with [MEDICATION NAME] every shift, off load, and heel protectors. Review of the nursing weekly wound review also dated July 16, 2015, did not include the stage of the right ankle pressure ulcer, but did include that granulation tissue, and a small amount of serous drainage was present. However, this documentation was not reflective of the NP wound care note and assessment on the same day, which identified that the pressure ulcer on the resident's right ankle was unstageable. A pressure ulcer care plan was developed on July 16, 2015, and identified that the resident had a stage 2 on the coccyx and a stage 1 on the left heel. The care plan did not accurately reflect that the resident had an unstageable pressure ulcer to the left heel. Another pressure ulcer care plan was developed on July 22, 2015, which identified that an unstageable pressure ulcer was present on the resident's right ankle. The interventions included to provide pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin while in bed. During the survey on July 22, 2015 at 10:00 a.m., an observation was conducted of the resident's bed and a pressure relieving/reducing mattress was not in place. Further review of the clinical record revealed there was no documentation that preventative measures such as a pressure relieving/reducing mattress was in place, prior to or after the development of multiple pressure ulcers. An interview was conducted on July 22, 2015, with a LPN (Licensed Practical Nurse), who agreed that a pressure ulcer relieving/reducing mattress had not been provided. A second interview was conducted on July 23, 2015, with a LPN. Following a review of the June and July 2015 TAR documentation, the LPN stated that the TARs were incomplete and did not include consistent documentation that all of the prescribed treatments had been administered. In regards to the care plans, the LPN stated that the pressure ulcer care plan was inaccurate and had not been revised to reflect the current stage of the left heel pressure ulcer. The LPN also stated that a pressure relieving/reducing mattress should have been provided. A facility policy titled, Charting and Documentation included that All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy also included the following: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record. 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided .c. The assessment data and/or any unusual findings obtained during the procedure/treatment. A facility policy titled, Support Surface Guidelines included The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The policy also included the following: 1. Redistributing support surfaces are to provide comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. 5. Selecting a mattress for the resident based on pressure ulcer risk is both cost-effective and clinically appropriate. In addition, the policy included: 1. Any individual at risk for developing pressure ulcers should be placed on a redistributing support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. 6. Monitor for other pressure ulcer risk factors and provide interventions as indicated. A facility policy titled, Pressure Ulcers/Skin Breakdown, included the following: 2 .the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, staging, length, width and depth, presence of exudate or necrotic tissue. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. Another facility policy titled, Pressure Ulcer Treatment included The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The policy also included that the pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the current status of the pressure ulcer(s). b. Current support surfaces. c. Pressure ulcer care. The policy further noted that the following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, and presence of drainage. The policy also provided the definitions of each stage of a pressure ulcer as follows: -SDTI: purple or maroon localized area of discoloration intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. -Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. -Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. -Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. -Stage 4: Full thickness loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. -Unstageable: Full thickness tissue loss which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. -Resident #88 was admitted to the facility on [DATE] and readmitted to the facility March 3, 2014, with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE], revealed the resident was cognitively intact. In Section G., the resident was assessed to require extensive assist with bed mobility, and was totally dependent with transfers and personal hygiene. Per the MDS, the resident was always incontinent of bowel and bladder. A Braden Scale dated June 28, 2015, assessed the resident to be at low risk for pressure ulcer development. Review of the care plan for activities of daily living (ADL) revealed the resident required extensive to total assist of 1 to 2 persons with ADLS. A Weekly Skin Check dated July 19, 2015, documented the presence of old scar tissue to the right and left gluteal fold and that skin was intact but fragile, and there were a few scratched areas that were superficial. Review of the MAR for June and July 2015, revealed that barrier cream was being applied to the gluteal folds every shift (three times daily). During an interview with the resident conducted on July 21, 2015 at 10:30 a.m., it was noted that the room smelled of urine. The resident stated that the night shift was short staffed and that no one had time to change him, so he waited for day shift. He stated that he was wet through to the sheets. An interview was conducted on July 22, 2015 at 2:05 p.m., with the certified nursing assistant (CNA), who was taking of the resident on July 21, 2015. The CNA stated that the resident was more wet than normal yesterday, when she came on duty and she changed him right away. The CNA stated that the resident wears briefs. During a second interview with resident #88 on July 23, 2015 at 9 a.m., the resident stated that his bottom was sore and that he had not been changed in a while. This information was relayed to the LPN at 9:15 a.m. The nurse then checked the resident and stated that the resident has a re-occurring pressure ulcer. Review of the nurse's note dated July 23, 2015 revealed the resident reported that his bottom hurt. Upon inspection it was noted that the resident had five small superficial areas of pink skin with white tissue surrounding the area, over old scar tissue. An observation of the resident's buttock area was conducted with the wound physician on July 23, 2015 at 10:05 a.m. At this time, the physician stated that the resident had an unstageable pressure ulcer to the left gluteal fold, which measured 2 cm by 3 cm, with no depth, and granulation tissue was present, with no exudate. According to the initial wound review dated July 23, 2015, the resident had a new onset of an unstageable pressure ulcer to the left gluteal fold, which measured 2 by 3, with no depth. Per the assessment, granulation tissue was present, there was no exudate, wound edges were attached, and skin surrounding the wound was fragile. Wound treatment changes were recommended. An interview with the DON was conducted on July 23, 2015 at 10:45 a.m., who stated that her expectations would be that every resident would be checked every 2 hours for wet briefs or restroom checks and repositioning. A review of the facility policy for Pressure Ulcer Risk Assessment included that the purpose was to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy included that pressure ulcers are usually formed when a resident remains in the same position for extended period of time causing increased pressure or a decrease of circulation to the area, which destroys the tissues. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. perspiration, feces, and /or urine). Staff will perform routine skin inspections (with daily care). The policy further stated that pressure ulcers are a serious skin condition for residents.

Based on clinical record reviews, observations, staff interviews, review of hospital documentation and policy, the facility failed to ensure that two resident's (#99 and #133) were free of significant medication errors. Findings include: -Resident #99 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan for End Stage [MEDICAL CONDITION] related to [MEDICAL TREATMENT] dated April 3, 2015, included as an intervention to administer medications as ordered. A physician's order dated May 26, 2015, included for [MEDICATION NAME] Sodium ([MEDICATION NAME]/anticonvulsant/epileptic [MEDICAL CONDITION] medication) 200 milligram (mg) by mouth, three times daily. Another physician's order dated May 27, 2015, included for [MEDICAL TREATMENT] three times a week on Tuesday, Thursday and Saturday. According to the Medication Administration Record [REDACTED]. Review of a nursing progress note dated June 2, 2015, revealed the resident had a [MEDICAL CONDITION] at 4:05 a.m., which lasted approximately 30 seconds. The note included that vital signs were stable and will continue to assess and monitor. Review of the June 2015 MAR indicated [REDACTED]. The code written on the MAR for each day that the medication was not administered was the number 11, which indicated the resident was out of the facility at [MEDICAL TREATMENT]. Review of the July 2015 MAR indicated [REDACTED]. Again, the documentation included that the resident was out of the facility at [MEDICAL TREATMENT]. Review of the clinical record did not reveal any documentation for June and July 2015, that the physician was notified that the resident did not receive the anti-[MEDICAL CONDITION] medication on the mornings when the resident went to [MEDICAL TREATMENT], nor were there any orders to hold the [MEDICATION NAME]. There was also no documentation of a [MEDICATION NAME] level that was done from admission through July 11, 2015. A nursing progress note dated July 11, 2015, documented the [MEDICAL TREATMENT] center notified the facility that the resident had a [MEDICAL CONDITION] during her treatment and was taken by ambulance to the emergency room (ER). According to the hospital ER documentation dated July 11, 2015, the resident went to [MEDICAL TREATMENT] at 5:00 a.m. and was dialyzed until about 7:00 a.m., when she started having some [MEDICAL CONDITION] activity and became unresponsive. The documentation included that the resident's anti-[MEDICAL CONDITION] medication blood level was found to be subtherapeutic and she was given one gram (1,000 mg) of the anti-[MEDICAL CONDITION] medication intravenously and was then discharged back to the facility. A interview was conducted with a pharmacist on July 23, 2015, who stated that this anti-[MEDICAL CONDITION] medication is not cleared from the blood during [MEDICAL TREATMENT]. On July 23, 2015 at 12:30 p.m., a licensed practical nurse (LPN) was asked if it was important to notify the physician when medication was not administered three times a day as ordered because the resident was out of the building for [MEDICAL TREATMENT], and replied No, I don't think it is important. The Director of Nursing (DON) was interviewed on July 23, 2015 at 1:00 p.m., who confirmed that per their policy, if a medication is held, the physician is notified and must order the hold. -Resident #133 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a medication pass observation on July 22, 2015 at 8:00 a.m., a registered nurse (RN) administered resident #133 the following medications: [REDACTED]. However, review of the physician's orders and the July 2015 Medication Administration Record [REDACTED]. Review of the clinical record revealed that resident #133's blood pressure fluctuated between 120/70 to 160/90 over a one month period (June 23- July 22, 2015). An interview was conducted on July 22, 2015 at 8:40 a.m., with the registered nurse who stated she had missed those doses. An interview was conducted with the Director of Nursing on July 22, 2015 at 9:00 a.m., who stated that she would expect the nurse to give the correct amount of medication and that the nurse is responsible to ensure the right medication, the right dose, right resident, right time, and the right route are followed. Review of the facility policy regarding, Medication Administration revealed that medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administering before giving the medications.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#2) was transferred in a safe manner to prevent a fall, which resulted in a humerus fracture. The sample size was three. Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE], revealed that the resident was totally dependent on staff for transfers and required the physical assistance of two for transfers. A review of the resident's clinical record did not reveal a care plan regarding how the resident should be transferred by staff. Progress Notes dated August 24, 2013 documented "Resident was being transferred left upper arm scraped causing 1 centimeter skin tear." A review of a facility incident report dated August 24, 2013 documented "Resident was being transferred from bed to chair small skin tear to left upper arm was caused...CNA (certified nursing assistant) was transferring resident, upper left arm slid on device causing a 1 centimeter skin tear...CNA who was responsible for the transfer did so without assistance. She was given transfer policy which she signed..." Progress Notes dated August 28, 2013 documented "Resident having excessive pain. Medicated with good effects." Progress Notes dated August 28, 2013 documented "...resident is still complaining of pain but is unable to rate her pain or say where it is. As needed pain medication has been given but patient continues to yell out in pain..." A review of the facility incident report dated August 30, 2013 documented, "This writer was informed by a CNA that patient has a new bruise on her left upper chest and under her left armpit. When I assess patient she was screaming in pain when I tried to lift her arm to look. When asked what happened she replied 'I don't know.' She verbalized 'I don't know and I don't remember but it hurts'...She cared for the resident herself and knows how combative she is. CNA instructed to always have 2 staff present during any transfer." Progress Notes dated August 30, 2013 documented "X-ray came back and shows an acute fracture of the proximal left humerus..." Review of a statement in staff member #1's (CNA) personnel file documented "...(Resident #2) was assisted to the floor by (staff member #1) who was attempting to get the patient out of bed using the PAL (a sit to stand mechanical lift) by herself. The patient sustained a skin tear as a result of the transfer. (Another CNA) asked (staff member #1) why she did not wait for help as all the other staff were in the dining room as it was policy to have two people operate the PAL. Also (Resident #2) is a Hoyer (sling) lift (transfer)." Staff member #1 was terminated. Review of a Reportable Event Record/Report dated September 10, 2013, revealed documentation that during the transfer, the resident "ended up on (CNA's name) lap, is the most likely cause of the fractured shoulder..." An interview was conducted with staff member #1 on November 12, 2013. Staff member #1 stated that she attempted to get the resident out of bed with a sit to stand lift. Staff member #1 stated that she held the resident by the waist and put her on the floor gently. Staff member #1 stated that she used the sit to stand lift by herself and that she should have used the Hoyer lift to transfer the resident. Staff member #1 stated that the resident's clinical record would have directed her on how to transfer the resident but that she did not check the clinical record. An interview was conducted with the DON (Director of Nursing) on November 13, 2013. The DON stated that at the time of the resident's injury, the Point of Care (CNA computerized charting) did not designate how the resident should have been transferred. The DON stated that the CNA was new to the facility and should have asked how to transfer the resident. The DON further stated that at the time of the resident's injury, there was not a care plan to direct staff on how to transfer the resident. The DON stated that a transfer care plan should have been developed. The facility's policy regarding Transfers documented to provide residents with "safe transfers...Stand-Lift: Requires 2 staff members assistance until the resident has demonstrated the ability to transfer with minimal assistance."

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident's (#3) grab bar on his bed was secured to prevent a fall which resulted in serious injury. The sample size was three. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a Daily Skilled Nurse's Note dated September 24, 2011, which revealed the resident required a one person physical assist for physical functioning. The resident's clinical record revealed an ADL (activities of daily living) care plan dated September 30, 2011. An intervention documented was "Staff provides total assist of 1-2 with bed/chair mobility and transfers..." The resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident required a one person physical assist for bed mobility. The resident's clinical record revealed Nurse's Notes dated November 23, 2011, which documented "...when this writer came back into room, resident was on the floor with CNA's (certified nursing assistants) by his side, this writer asked, 'what happened that he is on the floor?' CNA stated I was cleaning him up, when I turned him, he rolled off the bed by accident...resident transferred to...emergency room ..." A review of hospital documentation revealed a History and Physical dated November 24, 2011 which documented "Per his wife he was being changed and cleaned up when the support railing in his bed broke and he fell to the floor." A further review of hospital documentation dated November 24, 2011 revealed the resident sustained [REDACTED]. An interview was conducted on July 31, 2012 with the CNA who cared for the resident when he fell from his bed on November 23, 2011. The CNA stated that while she provided incontinent care for the resident, the resident held on to the grab bar on his bed. The CNA stated that when she took one hand off the resident to obtain a wipe, the grab bar fell off the bed and the resident fell to the floor. The CNA stated that the grab bar was attached to a piece of board. The CNA stated that the board was not attached to the bed but rested between the mattress and the bed frame. An interview was conducted on July 31, 2012 with the LPN (licensed practical nurse) who cared for the resident when he fell from his bed on November 23, 2011. The LPN stated that the CNA did not realize that the grab bar was not secure. The LPN stated that the CNA did not realize that the grab bar was going to fall off the resident's bed when she turned him. The LPN stated that grab bar was attached to a piece of plywood approximately 10 x 15 inches. The LPN stated that the plywood was not attached to the bed but slid under the mattress. The LPN stated "I was really surprised" when she saw the grab bar. An interview was conducted with the DON (director of nursing) on July 31, 2012. The DON stated that the grab bar was attached to a piece of wood approximately a foot wide that was placed under the resident's mattress. The DON stated that when the resident rolled over in bed, the entire grab bar and piece of wood slid out from under the bed and the resident fell to the floor. The DON stated that the resident normally had a recliner next to his bed but that the recliner was not in the room at the time the resident fell from his bed. An interview was conducted with the maintenance director on July 31, 2012. The maintenance director stated that he did not know how this type of rail was placed on the resident's bed. The maintenance director stated that the rest of the grab bars in the facility are screwed onto the bed frame with a screw and locking nut. The maintenance director further stated that preventative maintenance is not done for the grab bars as the locking nut will not allow the grab bar to become loose. Another interview was conducted with the DON on August 1, 2012. The DON stated that grab bars on resident beds are not routinely inspected as the facility has never had a problem before. A review of the facility's policy Resident Safety documented "All staff is responsible for reporting any equipment problems to the maintenance department, if it is an unsafe piece of equipment is should be removed from service immediately."

Based on clinical record review, observations, staff and resident interviews, review of the National Pressure Ulcer Advisory Panel (NPUAP), and review of facility policy and documentation, the facility failed to ensure that four residents (#s 97, 17, 88, and 31), who entered the facility without pressure sores, were adequately monitored to prevent facility acquired pressure ulcers. Three of the five residents had unstageable pressure ulcers which resulted in substandard quality of care. One (#97), of the four residents, developed two pressure ulcers; one that was identified as unstageable and the second was identified with black, necrotic tissue. The facility also failed to provide preventative measures for the development of pressure ulcers for one resident (#42). The expanded sample size was five. Findings include: -Resident #17 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Licensed Practical Nurse's (LPN) note dated June 18, 2010, documented that the resident's skin was intact. Continued review of the clinical record revealed a LPN's note dated June 21, 2010, that documented the resident's heels were red. A treatment order was obtained on this same date and documented to provide the resident with continuous heel care. There was no direction identified on this form on what care the resident was to receive to prevent the development of pressure ulcers. Additional review of the clinical record revealed a physician's orders [REDACTED]. A nutritional assessment dated [DATE], revealed that the resident was at high risk for pressure ulcers, dehydration, and [MEDICAL CONDITION]/weight loss. It was further documented that the resident's oral intake was 32 percent and it was recommended for the resident to receive 2 Cal four ounces (oz) three times a day. A significant change MDS (Minimum Data Set) assessment dated [DATE], documented that the resident had short and long term memory problems and was moderately impaired of cognitive skills for daily decision making. The MDS also documented that the resident was totally dependent for bathing, dressing, and toilet use. The resident had no pressure ulcers at this time. The resident received preventative or protective foot care as well. Section V. of the MDS Resident Assessment Protocol Summary (RAPS) triggered the resident for pressure ulcers and directed staff to create a care plan. Continued review of the clinical record revealed a physician's orders [REDACTED]. There were no further dietary recommendations until September 1, 2010. Review of the care plan for skin integrity dated June 30, 2010, failed to contain specific individual interventions to prevent the development of pressure ulcers. The only intervention identified was for the licensed nurse to do weekly skin checks. A review of the weekly skin checks revealed assessments for June 27, and July 4, 11, 17, 2010, that documented there were no open areas. There were no further weekly skin checks documented as completed until August 9, 24 days later. On this date the form documented that there were no open areas. On August 15, 2010, the weekly skin check documented that the left heel had eschar. A review of the Weekly Wound Care assessments conducted by the LPN revealed the following: August 2, it stated that the left heel was black with eschar tissue. There were no measurements identified on this document. Under comments it was noted that there was eschar tissue. The interdisciplinary notes measured the left heel pressure ulcer 4 x 3.5 cm. August 9, the pressure ulcer had remained unchanged and was still necrotic black. There were no measurements identified on this document. Under comments it was noted that there was eschar tissue. There were no measurements identified on this form. August 11, the pressure ulcer on the left heel was changed to a stage 2, with measurements of 4 x 3 x .25. Under comments it was noted that there was eschar tissue. August 16, the weekly wound care document identified that the resident's left heel was a Stage 2 and was necrotic black. There were no measurements identified on this form. Under comments it was noted that there was eschar tissue. The interdisciplinary notes measure the wound with 3.5 x 3 x .24 and the LPN wrote the wound was stage 2 with thin eschar scab remaining. Finally, on August 23, 2010, the weekly wound care document identified that the resident's pressure ulcer was necrotic black. Under comments it was noted that there was eschar tissue. The interdisciplinary notes on this same date measured the wound at 2 x 1. The facility was unable to provide Braden scales for this resident. Review of the care plan revealed the care plan was not revised to include the care of this specific pressure ulcer until August 17, 2010. The problem identified that the resident had an unstagable pressure ulcer to the left heel. The interventions were for nursing to measure the wounds weekly. There were no other preventative measures documented on the care plan. During an observation of the left heel pressure ulcer treatment on September 1, 2010 at 9:55 a.m., the wound was observed to be black with the surrounding tissue deep red to brown in color. The black part of the wound was measured to be 2 x 2.5 cm by the LPN and there was some white area also observed to which the LPN stated was slough. On September 1, 2010 at 10:50 a.m., an interview was conducted with a Certified Nursing Assistant (CNA). She stated that the resident shower days were Tuesdays and Fridays and that she had showered the resident frequently. The CNA further stated the area on the left heel started out as a very small bruise which was reported to the nurse. She also stated she did not know how the bruise was acquired, but it kept getting larger. During an interview conducted on September 1, 2010 at 1:00 p.m., the LPN stated that heel care meant the heels were looked at and whatever else the physician ordered. She stated this resident had boots ordered, so they were applied. The boots, she stated, could be the pink footies that the resident was wearing because they are soft and protected the heels. She also stated that the pressure ulcer was a stage 2 a couple of times because there was no eschar tissue. During another interview on September 2, 2010 at 10:35 a.m., the same LPN stated her training for wounds was an eight contact hour class that was a one day training. She also stated that the weekly skin assessments was a head to toe assessment and with this resident's condition, the heels needed to be checked. A telephone interview was conducted with the dietician on September 2, 2010 at 11:50 a.m. The dietician stated that the nurses typically let the dietary manager know about wounds, and within 72 hours the dietary manager should do another assessment and put interventions into place such as the proper amount of protein. She further stated she remembered this resident had poor oral intake, but it was the dietary manager that attended the weekly NAR (Nutrition At Risk) meetings. During an interview conducted on September 2, 2010 at 2:15 p.m., another CNA stated that this resident's feet were crackly at first and that the nurse would put lotion on her heels every evening. She further stated that the area on the left heel first started out as a small discolored area and that she did not have to report it to the nurse because the nurse already knew about it. An interview was conducted on September 2, 2010 at 3:30 p.m., with another LPN. This nurse stated the left heel pressure ulcer started out as a spot and was sure she documented such. She further stated skin prep had been initiated by another nurse who thought the heels looked mushy. The LPN stated the skin prep would have been done with the heel care. During an interview conducted with the Assistant Director of Nursing (ADON) who was also the MDS staff person and a LPN, she stated on September 2, 2010 at 8:10 a.m., that she was responsible for updating the care plans. The MDS coordinator was interviewed again on September 3, 2010. The staff member stated the nurses were responsible to look at the skin and to complete the weekly skin checks. She stated she was unable to find any more weekly skin check assessments for this resident. She further stated if a CNA had reported a small area and the area was not opened, it would need to be investigated to find out what caused the area and then act upon the cause so that the area could be resolved. She also stated the resident's nutritional status would be reviewed. If the area was open, she stated in addition the physician would be notified for orders and dietary would be notified immediately and the laboratory test results would be reviewed. The ADON stated the nurses would be expected to document this information and then communicate the information to each other. She further stated she did not know if the physicians looked at wounds during their rounds, but a Nurse Practitioner had looked at wounds. She also stated if the wound did not appear to be improving within a week, the physician should be notified. -Resident 97 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. This was a closed record review. An initial nursing assessment was conducted on April 6, 2010. The nursing assessment documented that the resident was to receive a Braden scale weekly times four weeks. This same assessment identified the resident to be a mild risk for the development of pressure ulcers and scored a 16. The interventions identified were manage friction and shear, manage moisture, manage nutrition. Review of the treatment sheet for the month of April documented that the resident received a weekly Braden scale but there was no evidence to show what the resident scored and any associated risk factors or interventions as a result of these assessments. This document also failed to identify any preventative measures for the development of pressure ulcers. The resident's initial MDS assessment dated [DATE], recorded that the resident had no pressure ulcers. The MDS identified that the resident required extensive assistance from staff for activities of daily living. Section V. RAPS of the MDS documented that the resident triggered for being at risk for the development of pressure ulcers and directed staff to proceed with a care plan. The care plan was opened on April 22, 2010. The care plan determined that the resident had the potential for skin integrity alteration. The goal was to have no skin breakdown for the next 90 days. The interventions were to monitor and report any changes in skin and the nurse was to conduct weekly skin assessments. From April 6 through June 9, 2010, the facility was unable to provide the weekly skin checks. The facility was also unable to provide May's treatment sheet. On May 5, 2010, a Braden scale was done and identified the resident to be mild risk for the development of pressure ulcers. The interventions were to manage moisture and to manage nutrition. There was no mention of preventative measures of the resident's heels. Issues related to the right heel pressure ulcer: On June 9, 2010, the interdisciplinary notes documented that nursing identified an open blister on the resident's right heel and then obtained an order for [REDACTED]. On June 10, 2010, the interdisciplinary notes from nursing documented that the resident had a right intact heel blister which measured 3.5 by 4.5 by 0 and a new order was obtained for allergen to be administered every three days. A hand written care plan dated June 10, 2010, documented that the resident had a blister to the right heel and the goal was to have it resolve within 90 days. The approaches included to do treatment and dressing changes as ordered and to measure wound progress on a weekly basis. There was no mention of the resident to wear heel boots continuously. Nursing documented on June 13, 2010, that the resident's right heel blister "popped" open. On June 16, 2010, nursing documented that a dressing, to right heel, was done as ordered. The area now showed two blistered areas 3 by 3 by 0 "...eschar with red skin unopened blister middle area shows 2x2x0 unbroken blister, no drainage, no c/o pain or tenderness in area, also noted 1x1x0 eschar area non blister ro R (right) foot covered with cushion to protect whole area wrapped with Kling..." There was no mention in the care plan of this change in the resident's condition. On June 18 it was ordered to provide the resident with heel care. There was no mention which heel needed the care. Under the section that said direction there was nothing mentioned. A Braden scale was completed on this date and stated that the resident was at moderate risk for the development of pressure sores. The interventions identified were to manage friction and shear, manage moisture, manage nutrition, and protect heels. On June 21, the nurse documented that a right heel dressing change was done and now the resident had deep tissue injury noted. The area could not be staged since eschar tissue scab remained. The entry continued, "...middle of wound red skin present remains unopened @ this time, provider had seen wound same orders remain..." The care plan was not updated until July 1, 2010, and identified that the resident had an unstageable pressure ulcer but did not identify if the pressure ulcer was on the right or the left heel. This care plan did not address specific nursing interventions for the care and management of this pressure ulcer. July 7, 2010, the nurse documented that the resident had a dressing change and remained with the same measurements of hard eschar scab noted with no redness. There was no further documentation on the condition of the right heel from July 7 through 27, 2010. A Weekly Wound Care document dated July 27, 2010, noted that the resident had a right pressure ulcer that was necrotic and measured 2.50 cm by 2.50 cm and had identified that the area was "declining". No staging was identified. On August 6, 2010, the nurse documented that the resident's right heel had a dressing change and there was a foul odor noted, with eschar and the heel was soft and mushy. Again, the care plan was not updated to reflect a change in the resident's condition. A second entry dated August 9, 2010, on the Weekly Wound Care sheet identified that the right heel had a pressure ulcer that was necrotic black and measured 2.00 cm by 2.00 cm. On August 12, 2010, the resident was sent to a local hospital for wound evaluation and care. Issues related to the left heel pressure ulcer: Even though a care plan was initialed opened on April 22, and updated on June 10 and July 1, 2010, there was no mention of the pressure ulcer that existed on the left heel. A document entitled Weekly Wound Care dated June 18, 2010, noted that the resident had a pressure ulcer on the left heel that was necrotic and black and there was eschar present. The measurements were 3.00 cm by 3.00 cm. It was documented as improved under progress section. There was no stage identified. There was no care plan that addressed this change in the condition of the resident. The interdisciplinary notes dated June 19, nursing documented that there was a dressing change to heel wound and the entry stated that it was difficult for the nurse to fully assess since the resident was unable to follow directions and was unable to bend her knee and turn side to side. The entry stated, "...From what was visualized black necrotic tissue..." This entry did not document whether the area was on the right or the left heel. There were no measurements regarding the pressure ulcer and no stage identified. On June 21, 2010, the Weekly Wound Care form documented that the resident had a pressure ulcer on her left heel that was necrotic, black, and had eschar. There was no stage identified. The measurements were 4.00 cm by 4.50 cm and under the progress section it was documented as improved. Of note, on June 28, 30, and July 1, 2010, the nurse documented in the interdisciplinary notes that the left heel had an intact dressing and that the area remained same with eschar and hard covering. On July 2, the nurse documented that the "...deep tissue wound remains on left ankle..." On July 8, 2010, it was documented on the Weekly Wound Care that the resident had a left heel pressure ulcer that was necrotic, black and had eschar present. There was no stage identified. The measurements were 4.00 cm by 4.50 cm. It was documented that the cite had improved even though it had remained unchanged. The Weekly Wound Care dated July 14, 2010, stated that the resident again had a left heel pressure ulcer that was necrotic, black, and eschar was present. There was no stage identified and the measurements for the area was 4.00 cm by 4.50 cm. Nursing identified that the area had improved although the wound remained unchanged from June 21 and on July 8. -Resident # 31 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident was assessed on February 28, 2010, as low risk for development of pressure ulcers using the Braden Scale. The resident scored 16. Review of the annual MDS assessment dated [DATE], revealed the resident was cognitively impaired only in new situations and had no memory problems. She required extensive assistance for all activities of daily living, except eating. She was continent of bowel and usually continent of bladder. The resident had no pressure ulcers at this time. Section V. RAPS of the MDS assessment triggered the resident for pressure ulcers and directed staff to proceed with a care plan. Review of the dietary notes dated March 30, 2010, showed the resident's skin was intact. An revised care plan dated April 13, 2010, identified that the resident had a potential for altered skin integrity. The goal was to keep the resident from skin alteration for the next 90 days. The interventions included for staff to assist the resident to reposition at regular intervals, keep heels floated while in bed and nursing to conduct weekly skin checks. There was no evidence that weekly skin assessments were done from April 1 through August 12, 2010. Review of the nurse's notes revealed on August 12, 2010, a 2 cm by 2 cm wound was found on the resident's left heel which had possible eschar. The care plan was updated on August 16, 2010, and showed an identified problem of an unstageable ulcer to the left heel with a goal of the ulcer to be resolved over the next ninety days. Interventions included treatment and dressing changes as ordered, measure wound progress weekly and heel protector when in bed. Review of the nurse's documentation in the interdisciplinary notes dated August 16, 2010 of 1.5 cm by 2.5 cm of eschar scabbed tissue. On August 23 the nurse documented wound care to left heel was done as ordered and eschar scab was present and measured 0.5 cm by 0.5 cm. On September 1, 2010 the nurse documented the wound now measured 0.25 cm by 0.5 cm by 0.25 cm. On September 2, 2010, wound care was observed. The area was measured by the nurse to be 0.25 cm in width, 0.25 cm in depth and 0.5 cm in length. The skin in the center was brown with 2 cm circular edges which were pink and non- blanchable. There was no drainage or odor. On September 2, 2010, an interview was conducted with the resident's LPN. The LPN identified the wound as a stage 2 pressure ulcer which she said had improved despite the documentation of eschar present. The LPN was positive the weekly skin assessments were being done and these were given to the DON (Director of Nurses). An interview was conducted with the ADON (Assistant Director of Nurses) on September 2, 2010, and she was unable to provide the resident's weekly skin assessments. -Resident 88 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's significant MDS assessment dated [DATE], identified that the resident needed limited assistance from staff for activities of daily living. One stage 2 pressure ulcer was identified. It was also noted that there was to be a pressure relieving device while in bed. Section V. of the RAPS documented that the resident had triggered for pressure ulcers and referred staff to create a care plan. A nutritional care plan was documented as reviewed in March 2010, June 2010, and August 2010. There was no mention that the resident had a pressure ulcer. The care plan failed to show that the issue was defied and treatment was altered to meet the nutritional needs of the resident. On June 10, 2010, the care plan stated that the resident continued to have a stage two pressure ulcer located on the resident's left ankle and that the resident was seen to pick at her wound. The interventions documented that staff would assist the resident to float heels in bed and to keep any pressure and/or friction of her feet/ankles. An interview was conducted with the resident on September 2, 2010. The resident did say that she had a pressure ulcer on her left ankle. The resident proceeded to pull her sock down to expose the area. There was a Band-Aid that covered the cite. The resident stated that she liked to sleep with her left foot/ankle crossed over her right foot/ankle. She said that there were times in which the pressure ulcer was painful. The resident said that she did not sleep with a foot boot or pillow to prevent the area from coming close together. She said that staff have not offered her that in several months. An interview was conducted with a CNA who cared for the resident during the day shift. This interview took place on September 2, 2010. The CNA stated that she used to offer the resident a pillow, but that the resident would refuse. When asked if the resident goes to bed during the day and the CNA said that she does not and does not offer her a pillow since the resident's feet hang over the edge of the recliner. When asked if the resident crossed her left foot over her right foot, the CNA said that resident did. An interview was conducted with the CNA who provided the resident care during the evening shift. When the CNA was asked if she provided foot boots, floated heels, or pillows for the resident when the resident was in bed, the CNA said that she did not. -Resident #42 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment June 26, 2010, documented that the resident had mild cognitive impairment with no memory problems. The resident required extensive assistance by the staff for her activities of daily living. The resident had no pressure ulcers. A revised care plan dated June 29, 2010, identified the resident had the potential for alteration in skin integrity related to immobility and incontinence. There was only one intervention that addressed skin and that was to assist resident with pericare after toileting or incontinence. Review of the initial nursing assessment dated [DATE], documented the resident's skin as warm, dry and intact except for a skin tear on the left elbow. The Braden scale scored her at 12 high risk for development of pressure ulcers. The care plan was not updated to reflect that the resident was at high risk for the development of pressure ulcers. The facility was unable to provide any documented preventative measures to prevent the development of pressure ulcers from April to August 2010. An interview was conducted on September 2, 2010 with the ADON. The ADON confirmed that she was unable to find the weekly skin checks in the DON's office. The facility's policies and procedures were reviewed and documented the following: "...A pressure ulcer risk assessment, the Braden scale, will be completed upon admission, for the first 4 weeks of admission and with each additional assessment; quarterly, annually, and with significant change..." The policies continued: "...Review the resident's care plan to assess for any special needs of the resident...Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys tissues...Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs of irritation or breakdown...Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated...Nurses will conduct skin assessments at least weekly to identify changes..." Per the NPUAP and the prevention of pressure ulcers stated, "...Perform a head to toe skin assessment at least daily, especially checking pressure points such as...heels...Identify and correct factors compromising protein/calorie intake consistent with overall goals of care...Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other...Use devices that eliminate pressure on the heels...Implement pressure ulcer prevention educational programs...Include mechanisms to evaluate program effectiveness in preventing pressure ulcers..." .