Every finding on record at Villages Healthcare and Rehabilitation Center, The

Based on observation, interview, and record review, the facility failed to ensure that residents who require nephrostomy services receive such care consistent with professional standards of practice for 1 (Resident #2) of 3 residents reviewed for indwelling catheter care.Findings include: During an observation on 5/06/2026 at 2:30 PM, Resident #2 was sitting up in bed. There was a gauze pad with a transparent occlusive dressing covering her nephrostomy catheter insertion site on her right lower back. The dressing had a half-dollar sized area of bloody drainage and was dated 4/30/2026. (photographic evidence) During an interview on 5/06/2026 at 2:30 PM, Resident #2 stated that the last time she went to the hospital it had been because there was blood in her nephrostomy drainage bag and then the tube was pulled out. At the hospital they reinserted a nephrostomy tube. The dressing [over her nephrostomy catheter] had not been changed since she returned from the hospital. Review of Resident #2's admission Record documented an admission date of 4/14/2026 with medical diagnoses that included fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing; other artificial openings of urinary tract status; and local infection of the skin and subcutaneous tissue. Review of Resident #2's most recent MDS (Minimum Data Set) Admission/5-day Medicare Assessment, dated 4/20/2026, documented her BIMS (Brief Inventory of Mental Status) Score as 15 out of 15, which indicated she was cognitively intact. The assessment documented an indwelling catheter and an ostomy (nephrostomy - a thin, flexible tube [catheter] is inserted through the skin of the back directly into the kidney to drain urine into an external bag). Review of Resident #2's Physician Orders dated 4/15/2026, read, empty nephrostomy bag q shift.Review of Resident #2's Physician Orders dated 4/27/2026, read, cleanse with n/s [normal saline], pat area dry, apply bandage to nephrostomy site daily - every night shift and as needed. It was discontinued on 4/28/2026.Review of Resident #2's Physician Orders dated 4/28/2026, read, Consult f/u [follow up] with nephrology d/t [due to] nephrostomy.Review of Resident #2's Physician Orders dated 4/28/2026 read, cleanse with n/s, pat area dry, apply bandage to nephrostomy site daily - every night shift and as needed.Review of Resident #2's Physician Orders dated 4/30/2026 read, Send to ED [emergency department] for eval and treatment for hematuria - one time only for 1 day.Review of Resident #2's Physician Orders from 4/14/2026 through 4/27/2026 documented no orders for nephrostomy site care.Review of Resident #2's MAR/TAR (Medication Administration Record/Treatment Administration Record) from 4/14/2026 through 4/27/2026 documented no nephrostomy dressing changes. Review of Resident #2's MAR/TAR (Medication Administration Record/Treatment Administration Record) from 5/01/2026 through 5/05/2026 revealed documentation of daily nephrostomy dressing changes. Review of Resident #2's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/10/2026 documented in Section P - Patient Health Status that Resident #2 had an ostomy, a right nephrostomy. Review of Resident #2's Nursing admission assessment dated [DATE], in the Genitourinary section, documented that she did not have a catheter. There was no documentation in the admission Assessment regarding the presence of her nephrostomy. During an interview on 5/06/2026 at 5:17 PM, Physician #1 stated that the expectation was that the nurses would do skin and wound care and call the doctor to check on orders. It was the nurses' responsibility to provide care to the patients. The nurses did not do their due diligence. During an interview on 5/06/2026 at 5:22 PM, APRN (Advanced Practice Registered Nurse) #1 stated that typically there were protocols for catheter care. The expectation was for the nurses to follow the orders for nephrostomy care. There was a risk for infection when a nephrostomy dressing wasn't changed as ordered. Bacteria thrived in a moist, wet environment. During an interview on 5/06/2026 at 5:32 PM, Staff A, LPN (Licensed Practical Nurse) stated that she couldn't recall an order for a [nephrostomy] dressing change [for Resident #2]. She confirmed that she did not complete a dressing change on 5/03/2026. She believed she had to have checked it off accidentally. During an interview on 5/06/2026 at 5:37 PM, Staff B, LPN confirmed that he did not do a dressing change for [Resident #2's Name] on 5/05/2026. He might have inadvertently checked it [the nephrostomy dressing change] off. During an interview on 5/06/2026 at 6:15 PM, the DON (Director of Nursing) stated that the expectation was for the admitting nurse to contact [Resident #2's Name] physician for nephrostomy care orders and when orders were in place the expectation was for the nurses to follow those orders. During an interview on 5/07/2026 at 1:30 PM, Staff D, LPN stated that she remembered [Resident #2's Name]. She had checked off all the sections in the admission Assessment that applied to [Resident #2's Name]. She thought she had put the nephrostomy in the skin section. She confirmed that the nephrostomy should be documented in the admission Assessment. The expectation was that they should be doing dressing changes. She had notified the doctor and got the order to empty the [nephrostomy] bag. She should have gotten an order for nephrostomy dressing changes. Review of the policy and procedure titled, Indwelling Catheters, with the last review date of 1/29/2026 read, Policy: It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the residents that have the indication for use beyond 14 days. Procedure: 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site. Review of the policy and procedure titled, Wound Care, with the last review date of 1/29/2026 read, Policy: it will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 1. Pressure injury risk/skin integrity assessment/evaluation will be completed upon admission. 4. The admission evaluation may identify pre-existing signs prior to admission to the facility. 6. Wound care procedures and treatments should be performed according to physician orders. 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. 10. Document in the clinical record when treatments are performed.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection via indwelling urinary catheters for 1 of 3 residents, Resident #2, reviewed for urinary catheters.Findings Include: During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed. The Resident's urinary catheter collection bag was lying on the floor. Review of Resident #2's care plan dated 09/15/2025 read, Focus: Baseline Care Plan: Resident has a urinary catheter. Date initiated: 09/15/2025. Interventions: Resident has a urinary catheter in place and needs the following care: keep the bag below bladder level, cover the bag for dignity, give catheter care as ordered, report immediately if the catheter comes out, the resident seems to be in pain, the urine becomes dark or cloudy, or there is no urine to empty on your shift. During an interview on 12/11/2025 at 2:13 PM, the Director of Nursing stated, The foley bag should be hanging on the bed frame, off of the floor. Review of the policy and procedure titled, Indwelling Catheters issued: 04/01/2022 read, Policy: It will be the policy of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site. 10. Staff should ensure proper placement of the catheter tubing as to ensure that it is not kinked, pulling excessively, and allows for gravity drainage. If a resident does not wish to utilize proper placement of the catheter tubing and/or bag, his/her wishes should be maintained, and addressed in the plan of care.

Based on interview and record review, the facility failed to recognize, evaluate, and address the needs of residents, including but not limited to, residents at risk or already experiencing impaired nutrition, for 3 of 5 residents, Residents #1, #2, and #7, reviewed for nutrition and weight loss.Findings Include: 1) Review of Resident #1's medical record documented an admission date of 5/09/2025, with medical diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and unspecified severe protein-calorie malnutrition Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] documented under Section C - BIMS [Brief Interview for Mental Status] Score 09 = moderate cognitive impairment. Section K – Feeding tube; Proportion of total calories the resident received through parenteral or tube feeding – 51% or more. Review of Resident #1's Care Plan documented, Focus – The resident's nutrition is provided by non-oral methods. [Resident #1's name] Is at risk for complications associated with enteral feedings due to dx [diagnosis] of: dysphasia [impairment in the in producing, understanding, reading, or writing language] and esophageal cancer, has severe protein calorie nutrition receives enteral feedings to supplement PO [by mouth] intake to ensure nutritional and hydration needs are met. Goal - Resident will remain free from significant weight loss (5%/30 days, 10%/180 days) and maintain adequate hydration through the next review date. Interventions – Weights as ordered and as needed. Notify Physician of significant weight changes as needed. Routine Dietitian assessment. Review of Resident #1's Weight Summary documented dated 5/26/2025 130.0 pounds. There were no additional weights recorded in the record. Review of Resident #1's Nutritional Risk Evaluation dated 5/16/2025 read, Current Weight – [nothing documented]; Ideal Body Weight 128 – 156 lbs [pounds]; BMI [Body Mass Index] [nothing was documented]. Summary: 83 y.o [year old] male admitted NPO [nothing by mouth] on enteral feedings [receives nutrition through a gastrointestinal tube that is inserted in the stomach]. Will monitor PO intakes, TF [tube feed] tolerance and recommend to adjusted TF/supplement as needed. Review of Resident #1's physician's orders dated 05/09/2025 read, Nothing by mouth diet: Nothing by mouth texture, Nothing by mouth consistency. During an interview on 12/11/2025 at 4:45 PM the Director of Nursing (DON) stated, New admits get weighed, and the dietitian sees all new patients initially. She will follow residents with wounds and weight loss. We have an RD [Registered Dietitian] here 5 days a week. She sees all new patients within the first couple of days. We also have the Dietary Manager who sees the residents for their food preferences. For weights, we try to get them with the admission assessment or as soon as possible. Weights are obtained on an as needed basis or physician order. We don't have a set frequency when we get them. During an interview at 3:24 PM the RD stated, [Resident #1's name], I see there was no weight on admission. I did not bring it to anyone's attention. I go see them when they are admitted . I use an ideal weight range – when I saw him, I could tell that he was in the range. There again, anybody who was on a tube feeding, I need to see them monthly. When I go through the halls at feeding time, I see them, I talk to the nurses. From what I saw he was doing fine. Weights is a tool that I use. I don't feel that the weight is imperative. I believe the facility's policy is to weigh residents on admission, every week for 4 weeks, and then monthly, that is the standard. During an interview on 12/12/2025 at 4:04 PM the DON stated, Between nursing, the RD and the CDM [Certified Dietary Manager], we go over any issues in the morning meeting, and we go over orders. If something comes up, we let [the RD's name] know right then and there. If there's a low albumin, we'll let her know and put in an order. She [the RD] will follow up. If someone has a change in weight, if they are not liking what they are being offered or if they have a new wound, we let her know. It is up to me, the ADON, the UM [Unit Manager] or the nursing staff to obtain weights and notify the RD of concerns. Weights are obtained upon admission, monthly and PRN, just depending on if the doctor said more often. If it's not being done [obtaining weights] [name of the RD] gives us a list. We [the ADON and DON] go over the list with the nurses and assign someone to obtain the weights. A request was made for Resident #1's weights. None were provided. 2) Review of Resident #2's medical record documented the resident was admitted on [DATE] with a diagnosis of unspecified protein-calorie malnutrition. Review of Resident #2's weight documented the resident weighed 147 pounds on 09/16/2025. No weights were documented for October 2025 or November 2025. Dated 12/11/2025 the resident was documented as weighing 124.8 pounds, a 15% weight loss over three months. Review of Resident #2's Dietary Narrative Note dated 09/22/2025 read, 75 y/o [year old] male seen for new admission. On PO [oral] diet of NAS [no added sodium]/CCHO [consistent carbohydrate diet]/reg [regular]/thins with fair PO intakes. Per staff report patient is able to eat independently with set up help. No chewing or swallowing difficulties. BMI 19.9 in an acceptable range. Per documentation stage 2 pressure ulcer to R [right] buttocks. Recent labs noted with low PAB [prealbumin] level, low H&H [hemoglobin and hematocrit]. Meds include; Amlodipine, Carvedilol, Metformin, Terazosin, HTCZ [hydrochlorothiazide], Lisinopril, FeSO4 [iron sulfate], MV [multivitamin] w/ minerals, Vit [vitamin] B12, Atorvastatin, Hydralazine, Resident is at risk for altered nutrition d/t [due to] receives a therapeutic diet, has suboptimal PO intakes, DM2 [diabetes mellitus), CKD [chronic kidney disease], receives diuretics. Recommend to add 120ml [milliliter] house nutritional supplement for at risk for malnutrition and to meet increased calorie/protein needs. Will monitor and f/u [follow up] prn [as needed]. Review of Resident #2's physician order dated 09/22/2025 read, House Nutritional Supplement three times a day for at risk for malnutrition offer 120 ml [milliliters] TID [three times per day] and document percent consumed. Review of Resident #2's Medication Administration Records (MAR) for October 2025 and November 2025 revealed that there was no documentation of the daily percentage of the house supplement that was consumed by Resident #2. During an interview on 12/11/2025 at 11:25 AM Resident #2 stated, I have lost weight. I don't like the food that is served. Sometimes they bring me different food if I ask. I don't know how much weight I have lost. During an interview on 12/12/2025 on 3:24 PM, the Registered Dietician stated, When someone has a low BMI I look at them. I look at the residents when I go by. Communication here is really great, so the nurses or doctors will send me messages. For me, weights are a tool that I use, but it is not the most important tool that I use. I make sure skin is ok. I don't feel that weight is imperative. I do a weight range to estimate the ideal. I emailed [Director of Nursing's name] for the monthly weights today and let her know which ones weren't done. He [Resident #2] was on that list. She checked all of the weights. I go through the monthly weights. I just started here back in May. In November I sent her a list of residents with no November weights. When I went back, she told me they were done, and nothing triggered. If I don't do one little thing when I put in the order for supplements, the nurses don't have the option to document the percentages of the supplements consumed and I don't check the amount consumed unless there is weight loss. Review of Resident #2's admission MDS dated [DATE] under section C documented Resident #2's BIMS score as 15 = normal cognitive function with little to no impairment. Review of Resident #2's care plan dated 09/15/2025 read, Focus: [Resident #2's name] is at risk for an alteration in nutrition and/or hydration r/t [related to]: receives a therapeutic diet, has suboptimal PO [oral] intakes, DM2, CKD, receives diuretics. Date initiated: 09/22/2025. Interventions: Provide tray set up; assist as needed. Provide diet as ordered. Offer and provide alternate as needed. Honor food preferences, encourage adequate intake at meals. Keep fresh water at bedside. Encourage adequate fluid intake. Observe for s/sx [signs/symptoms] of dehydration, update for physician if noted. Supplements as ordered. Registered Dietician consult as needed. Administer medications as ordered; observe for effectiveness and for SE's [side effects]. Labs as ordered; report findings to physician. Provide cues/encouragement during meals. Allow adequate time to eat. Weights as ordered and as needed. Notify physician of significant weight changes if noted. 3) Review of Resident #7's medical diagnoses documented a diagnosis of unspecified protein-calorie malnutrition. Review of Resident #7's weight record documented dated 10/16/2025 130.9 pounds , 132.0 pounds on 10/17/2025, and 132.0 pounds on 10/21/2025. There were no weights documented for November 2025 or December 2025. Review of Resident #7's Dietary narrative note dated 10/23/2025 read, 89 y/o female seen for new admission. On PO diet of NAS/reg/thins with variable PO intakes. Per staff report resident is able to eat independently with set up help. No chewing or swallowing difficulties noted. BMI 22 within a healthy range. Resident c/o [complains of] diarrhea, no food intolerances/allergies, a probiotic has been started. Resident also agreeable to add 120 ml house supplement q [every] day. Per documentation LLE [left lower extremity] wound, no pressure areas noted. Recent labs noted with PAB 11. Meds include; isosorbide, metoprolol, famotidine, sertraline, mirabegron, melatonin, lactobacillus, vit B12, Cholecalciferol. Resident is at risk for altered nutrition d/t receives a therapeutic diet, has variable PO intakes, cancer dx [diagnosis]. Recommend to add 120 ml house nutritional supplement q day for at risk for malnutrition. Will monitor and f/u prn. Review of Resident #7's physician order dated 10/23/2025 read, House nutritional supplement one time a day for at risk for malnutrition offer 120 ml q day and document percent consumed. Review of Resident #7's MAR for October 2025, November 2025, and December 2025 did not document the daily percentage of the house supplement that was consumed by Resident #7. Review of Resident #7's care plan dated 10/16/2025 read, Focus: [Resident #7's name] is at risk for an alteration in nutrition and/or hydration r/t receives a therapeutic diet, has variable PO intakes, cancer dx [diagnosis]. Date initiated: 10/23/2025. Interventions: Provide tray set up; assist as needed. Provide diet as ordered. Offer and provide alternate as needed. Honor food preferences. Encourage adequate intake at meals. Keep fresh water at bedside. Encourage adequate fluid intake. Observe for sx/sx of dehydration; update physician if noted. Supplements as ordered. Registered Dietician consult as needed. Administer medications as ordered. Labs as ordered; report findings to physician. Allow adequate time to eat. Weights as ordered and as needed. Notify physician of significant weight changes if needed. During an interview on 12/12/2025 at 4:03 PM, the Director of Nursing stated, Between nursing and the Dietician and the CDM [Clinical Dietary Manager], we go over orders in the clinical morning meetings, and if something comes up, like a low pre albumin, I would let [Registered Dietician's name] know about the issue and to follow up on it. If someone has a changing weight, or they are not liking what they are being offered for food, or has a new wound, we will communicate that to [Registered Dietician's name], either myself, the nurses and staff, or ADON [Assistant Director of Nursing]. Residents should be weighed upon admission, monthly, and PRN, depending on if the doctor says to do it more often. [Registered Dietician's name] usually communicates with us via email or gives us a list of weights that are still needed, then the nursing staff go around and get the weights. A request was made for the weights for Residents #1, #2, and #7 and the percentage of the supplements consumed by Residents #2 and #7 for November and December, none were provided. During an interview on 12/12/2025 at 4:16 PM, the Director of Nursing stated, nurses should put the weights into [name of the electronic system], there was obviously a communication breakdown. A request was again made for the weights for Residents #1, #2, and #7, none were provided. Review of the policy and procedure titled Weights and Weight Loss, with an issue date of 4/01/2022 read, Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedure: New admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician. Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. Weights will be recorded. 3. The RD/DTR [Dietetic Technician] is to review all admission weight for possible intervention. 7. Monthly weights will be completed by the nursing department, unless otherwise indicated or ordered. 8. Weekly and daily weights may be obtained per RD or Physician orders in order to monitor clinical status of a resident requiring closer monitoring and intervention.

Based on observation, interview, and record review, the facility failed to prevent the recurrence of pressure ulcers for 1 of 3 residents, Resident #2, reviewed for pressure ulcers.Findings include: During an observation on 12/11/2025 at 11:25 AM, Resident #2 was lying on his back in bed on an air mattress. The call device was within reach There was a foley catheter bag clipped to the right side of the bed. There was a wheelchair at the foot of the bed. During an interview on 12/11/2025 at 11:25 AM, Resident #2 stated, They haven't turned me since last night. I am getting a sore on my butt, and it hurts. During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed, in the same position that the surveyor observed him in at 11:25 AM. During an observation on 12/11/2025 at 2:18 PM, the DON (Director of Nursing) and the ADON (Assistant Director of Nursing) were observed wearing gowns and gloves, and repositioning Resident #2 in bed. Resident #2's lower back was bright red and there was a small open area on the left side of the sacrum. During an interview on 12/12/2025 at 5:19 PM, the Assistant Director of Nursing stated, Residents with wounds should be turned and repositioned every hour and as needed. Residents without wounds should be turned and repositioned every two hours and as needed. Review of Resident #2's care plan dated 09/15/2025 read, Focus: [Resident #2's name] is noted to have skin impairment as follows: pressure ulcer: to sacrum. Date initiated: 09/16/2025. Interventions: Monitor and treat for pain as indicated/ordered. Administer medications for wound healing as ordered; observe for effectiveness and for Se's [side effects]. Provide diet as ordered. Observe intake. Offer/provide alternatives as needed. Provide nutritional supplements as ordered to promote wound healing. Registered Dietician consult as needed. Pressure reducing mattress to bed. Turn and reposition to promote wound healing. Keep sheets clean, dry, and as wrinkle free as possible. Use proper positioning, transferring, and turning techniques to minimize friction. Perform wound treatments as ordered. Wound care physician services to follow. Observe wound for sx/sx [signs/symptoms] of infection and for significant decline; update physician if noted. Review of Resident #2's care plan dated 09/15/2025 read, Focus: [Resident #2's name] has a potential for skin impairment/pressure ulcer r/t [related to]: impaired mobility, incontinence of bowel, incontinence of bladder, hx [history] of pressure ulcers, fragile skin. Turn and reposition to promote offloading of pressure. Use proper positioning, transferring, and turning techniques to minimize friction, pressure reducing mattress to bed. Encourage and assist resident to float heels while in bed. Apply/remove foam boots to [NAME] [lower extremity] as ordered. Perform incontinence care prn [as needed] after each episode of incontinence. Perform skin treatments as ordered. Observe skin for sx/sx of skin breakdown/pressure ulcer if noted. Allow resident to make decisions re: daily cares; educate of unsafe choices as needed. Review of Resident #2's Healing Partners skin and wound note dated 12/08/2025 read, Reason for visit: new skin and wound consult on current resident. [Resident #2's name]. Wound care consulted today after nursing staff noted an open area on the sacrum. Patient was previously treated for a stage II pressure injury to the buttock. The patient was admitted to the facility on [DATE] following treatment at the hospital due to complaints of a recent fall that led to fracture of the right femur. Patient is at high risk for pressure ulcer formation related to decreased mobility, comorbidities, incontinence of stool. The resident is incontinent of bowel. Wound Assessment: Location: Sacrum: Primary Etiology: Pressure Ulcer/Injury. Stage/Severity: Stage 2. Assessment/plan: The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. Review of the policy and procedure titled, Wound Care issued 04/01/2022 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds, and the treatment of skin impairment. 8. Preventative measures, such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots, and use of positioning devices. Use of barrier creams may vary according to product and may be used following incontinent care for additional prevention, provided there is no clinical contraindication.

Based on interview and record review, the facility failed to ensure residents received post operative care per the physician's orders for 1 of 3 residents, Resident #1, reviewed for wound care. Findings include: Resident #1 was admitted to the facility on [DATE], with medical diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and Unspecified severe protein-calorie malnutrition. Review of Resident #1's physician's orders dated 5/12/2025 read, Day 5 post op [after surgery] clean right hip with hibiclens. Day 10 post op remove aquacel dressing [a dressing to absorb wound fluids]. Clean right hip surgical site with hibiclens [antiseptic skin cleanser] and 4 by 4s [a square medical bandage] remove staples and apply steri strips [sterile adhesive strips] for 2 wks [weeks].Review of Resident #1's TAR (Treatment Administration Record) for May 2025 did not contain documentation the physician's orders were followed for day 5 post op clean right hip with hibiclens, day 10 post op remove aquacel dressing clean right hip surgical site with hibiclens and 4 by 4s or to remove staples and apply steri strips in 2 wks.During an interview on 12/12/2025 at 10:08 AM, the Director of Nursing stated, The expectation is that all physician orders are to be followed or the physician should be notified. Resident #1's staples should have been removed on May 16th [2025]. Review of the policy and procedure titled, Wound Care, with an issue date of 4/01/2022 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care procedures and treatments should be performed according to physician orders. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care.

Based on observation, interview, and record review, the facility failed to ensure care was provided in a manner that maintains each residents' dignity for 1 of 7 residents, Resident #2, reviewed for personal clothing.Findings included: During an observation on 12/11/2025 at 11:25 AM, Resident #2 was lying on his back in bed on an air mattress. The call device was within reach. There was a foley catheter bag clipped to the right side of the bed. There was a wheelchair at the foot of the bed with a pair of pants and a shirt placed over the back of the wheelchair. The resident was wearing a hospital-style gown and had a white blanket over his legs. During an interview on 12/11/2025 at 11:25 AM, Resident #2 stated that he prefers to wear his personal clothing but was not given an option to get dressed this morning, stating, I think they don't want to get me dressed because of this catheter tube. During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed. Review of Resident #2 care plan dated 09/15/2025 read, Focus: Baseline care plan: Resident needs assist with ADLs [activities of daily living]. Date initiated: 09/15/2025. Interventions: Assist/provide ADL care and support as needed. During an interview on 12/12/2025 at 10:08 AM, the Director of Nursing stated that it is her expectation that all residents are provided assistance as needed to get up out of bed each morning, ADL [activities of daily living] care is provided, and residents are dressed in their own personal clothing, unless the resident prefers otherwise. Review of policy and procedure titled, ADL Care and Assistance issued 04/01/2022 read, Policy: It will be the policy of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. 3. Staff should be mindful to provide ADL care with dignity, privacy, and respect to the resident, unless otherwise indicated by the resident.

Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, specifically without adequate monitoring or adequate indications for use, in 1(Resident #1) out of 3 residents reviewed for unnecessary pain medications. Findings include:Review of Resident #152's physician order dated 9/19/2025 read, Oxycodone HCL oral tablet 5 mg [milligrams] give 1 tablet every 4 hours as needed for pain, for severe pain 7-10 for 3 days.Review of Resident #1's Medication Administration Record (MAR) for September 2025 documented that Oxycodone HCL tablet 5 mg was administered on 9/21/2025 at 2006 (8:06 PM) with a pain level of 3, on 9/22/2025 at 0946 (9:46 AM) for a pain level of 2, on 9/23/2025 at 0946 (9:46 AM) for a pain level of 6, on 9/24/2025 at 0930 (9:30 AM) for a pain level of 6, on 9/24/2025 at 1439 (2:39 PM) for a pain level of 6, on 9/25/2025 at 0900 (9:00 AM) for a pain level of 6, on 9/25/2025 at 2021 (8:21 PM) for a pain level of 4, on 9/26/2025 at 0936 (9:36 AM) for a pain level of 6, and at 2028 (8:28 PM) for a pain level of 3, on 9/28/2025 at 0436 (4:36 AM) for a pain level of 3, and at 0914 (9:14 AM) for a pain level of 6, and on 9/30/205 at 0920 (9:20 AM) for a pain level of 6.Review of Resident #1's October 2025 MAR documented Oxycodone HCL tablet 5 mg was administered on 10/1/2025 at 0922 (9:22 AM) for a pain level of 6, on 10/2/2025 at 0355 (3:55 AM) for a pain level of 2 and at 0920 (9:20 AM) for a pain level of 6, on 10/3/2025 at 0810 (8:10 AM) for a pain level of 6, on 10/5/2025 at 0845 (8:45 AM) for a pain level of 6, on 10/5/2025 at 0332 (3:32 AM) for a pain level of 3 and at 0832 (8:32 AM) for a pain level of 6.During an interview on 11/13/2025 at 12:40 PM Staff A, Licensed Practical Nurse (LPN) stated, I did administer the oxycodone. I did not see the parameters or that it was only for 3 days. I think she [Resident #1] asked to have that, so I gave it. I should have followed the orders. I did not follow them.During an interview on 11/13/2025 at 12:55 PM the Director of Nursing (DON) stated, I was not aware that she [Resident #1] was given her medication [oxycodone] outside the parameters or that the medication was only ordered for three days and she received it after those three days. We should have gotten another order for the medication to continue. The nurses should not have continued the oxycodone. They should not have administered it outside the parameters. If she specifically asked for it, they really should have gotten an order to administer it or get the parameters lowered or discontinued the parameters altogether.During an interview on 11/13/2025 at 3:35 PM Staff B, Registered Nurse (RN) stated, We should follow any orders that have parameters on them. If I gave it, then no, I did not follow the orders. I should have.Review of the policy and procedure titled Medication Administration with an issue date of 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure: 2. The Director of Nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications should be administered in a timely manner and in accordance with the physicians orders. Newly admitted residents may receive medications prior to delivery from the pharmacy by accessing the Emergency Drug Kit or other medication storage unit used for the purpose of storing medications when certain medications are not available.

Based on interview and record review, the facility failed to notify the provider for 1 of 3 residents, Resident #2, reviewed for change in condition and transfer. Findings include:Review of the nursing progress note for Resident #2 dated 6/30/2025 at 11:16 PM read, Pt's [patient's] wife requested pt. to return to hospital and called 911 for pt. to be transported. Unaware until paramedics arrived. When asked why, pt's wife wouldn't give a reason.Review of the medical record for Resident #2 did not provide for documentation of the resident's physician being notified when Resident #2 was transported to or returned from the hospital on [DATE].During an interview on 07/15/2025 at 4:06 PM, the Assistant Director of Nursing (ADON) stated, If a resident is transferred to the hospital, the nurse should inform the doctor and the DON [Director of Nursing], and document that the provider was notified. When a Resident returns from the hospital, the expectation is for the nurse to obtain vital signs, perform a skin check, complete a physical assessment, check whether there are new orders, and notify the doctor.During an interview on 07/15/2025 at 5:20 PM, Staff B, Registered Nurse (RN) stated, Shortly after [Resident #2's name] arrived at the facility, [Resident #2's name] wife decided we weren't taking good care of him. She called 911 and he went with EMS [emergency medical services] around 7:30 PM. He was only in the facility for around 30 minutes. [Staff A, LPN's name] is a brand-new nurse and may not have known to call the doctor. The procedure that is followed when a resident returns from the hospital is to obtain vital signs, document that the resident has returned, and notify the doctor.During an interview on 07/16/2025 at 5:00 PM, Staff A, Licensed Practical Nurse (LPN) stated, I didn't call the doctor when [Resident #2's name] left. I called [the previous Director of Nursing's name]. He [Resident #2] got back around 10:45 PM. I asked [Staff C, LPN's name] or [Staff B, RN's name] what I should do, and they told me he was taken out of the system. His wife asked not to be bothered. I was new, I asked, and I didn't know what to do.During an interview on 07/16/2025 at 5:21 PM, Staff C, LPN stated, [Staff A, LPN's name] informed me that [Resident #2's name] wife called EMS. I told her that she needs to call the DON.During an interview on 07/17/2025 at 12:53 PM, the Director of Nursing (DON) stated, If the resident or family member calls EMS, the nurse should try to speak to EMS to find out where the resident is going, notify the doctor, notify the family, and document the change in condition and the notifications. When a resident returns, it is my expectation that the nurse will assess the resident, call the doctor, call the family, check for new orders, put any new orders into the computer, and document a skin assessment.During an interview on 07/17/2025 at 3:05 PM, Physician #1 stated, I do not recall being notified that [Resident #2's name] went to the hospital. I do expect to be notified when residents go to the hospital and return from the hospital.Review of the policy and procedure titled, Change in Condition Issued date: 4/1/2022, read, Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. Procedure: 1. Observe resident during routine care and during monthly/quarterly/annual assessment periods to identify significant changes in physical or mental conditions, orientation, change in vital signs, weights, etc. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director.

Based on observation, interview, and policy review, the facility failed to prevent the possible spread of infection by failing to ensure staff performed hand hygiene during medication administration for 2 of 2 residents, Residents #11 and #12, reviewed for medication administration. Findings include:During an observation on 07/16/2025 at 09:00 AM Staff E, Licensed Practical Nurse (LPN) entered Resident #11's room, did not complete hand hygiene, and used an automatic blood pressure cuff on Resident #11's right wrist and obtained the blood pressure reading. Staff E, LPN exited the resident's room, did not perform hand hygiene, walked back to the medication cart, and placed five tablets and one capsule (oral medications) into a medication cup. Staff E, LPN entered Resident #11's room, did not perform hand hygiene and handed Resident #11 the medication cup. Resident #11 proceeded to take the medications orally with water. Staff E, LPN exited Resident #11's room, did not perform hand hygiene, walked back to the medication cart in the hallway, and placed a new medication cup on top of the medication cart. Staff E, LPN stated that he was going to check the blood pressure of another resident and picked up the blood pressure cuff and preceded to a different resident's room.During an interview on 07/16/2025 at 09:10 AM, Staff E, LPN confirmed that he did not perform hand hygiene before or after administering medications to Resident #11. Staff E, LPN stated, I should have cleaned my hands.During an observation on 07/16/2025 at 08:51 AM, Staff D, LPN placed four tablets and one capsule (oral medications) into a medication cup. Staff D, LPN proceeded to enter Resident #12's room, did not perform hand hygiene, handed the medication cup to Resident #12. Resident #12 preceded to take the pills and dropped one pill on her shirt. Staff D, LPN picked up the pill with her bare hand and placed it back into the medication cup. Resident #12 took the remaining pills.During an interview on 07/16/2025 at 08:57 AM, Staff D, LPN confirmed that she did not perform hand hygiene upon entering the resident's room, picked up the pill from Resident #12's shirt without wearing gloves, and placed it back into the medication cup. Staff D, LPN stated, I should have worn gloves to pick up the pill.During an interview on 07/16/2025 at 10:10 AM, the Director of Nursing (DON) stated that her expectation is that nurses are to complete hand hygiene before and after administering medications, and when hands are visibly soiled. The DON stated that when a pill is dropped, the nurse is to pick up the pill using a gloved hand, dispose of the pill, and obtain a new pill for the resident.During an interview on 07/16/2025 at 11:00 AM Staff F, LPN the Unit Manager stated he expects the nurses to perform hand hygiene before and after administering medications to residents. Should a resident drop a pill on themselves or on the floor, if the resident picks up the pill themselves, and takes it, that is the resident's right, however, if the resident does not pick up the pill, the nurse should wear gloves to pick up the pill, dispose of it, and get the resident a new pill.Review of the policy and procedure titled, Medication Administration Issued 4/1/2022, read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless clinically indicated or necessitated by other circumstances, such as lack of availability of medication or refusals of medication by the resident. Procedure: 11. Established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications.Review of the policy and procedure titled, Infection Prevention and Control Program Revised 11/28/2022, read, Policy: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Procedure: It is the standard that this facility's Infection Prevention and Control program (IPCP), is based upon information from the Facility Assessment and follows national standards to prevent, recognize, and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program includes: h. The hand hygiene guidelines to be followed by staff involved in direct resident contact. Surveillance/Monitoring: h. Safeguards against exposure to a potential source of infection. i. Uses appropriate hand hygiene prior to and after all guidelines. n. Ensures that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on observation, interviews, and record reviews, the facility failed to ensure proper hydration for 1 of 3 residents, Resident # 363. Findings include During an observation on 05/05/25 at 11:14 AM Resident #363 was sitting in a wheelchair at his bedside table that had a breakfast tray on it. The resident ate approximately 75% of a bowl of cheerios with milk. Review of Resident #363's physician order dated 4/2/25 read, Sodium Chloride Intravenous Solution 0.45 % (Sodium Chloride) Use 50 ml/hr [milliliters an hour] intravenously [IV] one time a day every Tuesday, Thursday, Sunday for AKI (Acute Kidney Injury), dehydration. 50 ml/hr for a total of 500 milliliters only three days a week. During an interview on 05/06/25 at 12:13 PM, Staff C, LPN (Licensed Practical Nurse) stated A nurse with the last name [Staff D's last name] was on last night, the patient [Resident #363] was not hooked up to any IV fluids when I saw him and gave him meds this morning at around 09:30 AM. Sometimes the night nurses start the IV fluids earlier than ordered so that it will finish by the time the patient is ready to get out of bed in the morning. During an interview on 05/06/25 at 01:26 PM, Staff C, LPN stated the resident often refuses meals, He is not a big drinker or eater. That's why we have to give him supplements and IV fluids. During an observation on 05/06/2025 at 1:26 PM, Staff C administered 120 ml (milliliter) of MedPass 2.0 supplement, (a fortified nutritional shake designed to provide extra calories and protein) to Resident #363. During an observation on 05/06/25 at 1:37 PM Resident #363 was sitting in a wheelchair in his room eating a pudding cup. Resident #363 was not observed to have IV fluids being administered. During an interview on 05/06/25 at 1:37 PM, Resident #363 stated he told the staff he did not want a tray or any food for lunch, and that he does not feel like eating. The resident was unable to recall whether he received IV fluids this morning or last night. During an interview on 05/06/25 at 02:43 PM Staff B, Unit Manager stated that 1/2 normal saline bag was not administered to the patient [Resident #363] last night by [Staff D's name]. Review of Resident #363's care plan read, (Resident #363's name) is at risk for complications r/t [related to] receiving IV therapy. Currently has midline to left upper arm. Is receiving IV fluids for the treatment of: Decrease fluid [Resident #363's name] is at risk for an alteration in nutrition and/or hydration r/t; AKF [Acute Kidney Failure], has had significant weight loss, has variable PO [oral] intakes, receives diuretics. Date Initiated: 02/15/2025. Review of the MAR (electronic medication administration record) read, Sodium Chloride Intravenous Solution 0.45% (Sodium Chloride) Use 50 ml/hr intravenously one time a day every Tuesday, Thursday, Sunday for AKI, dehydration 50 ml/hr for a total of 500 ml only three days a week, Start Date 04/03/2025. The administration time was documented at 0600 [6:00 AM]. Review of the MAR dated 05/06/2025 documented Sodium Chloride Intravenous Solution was administered, per the documented initials, by Staff D. Review of the policy and procedure titled, P&P Medication Administration issued 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure: 3. Medications should be administered in a timely manner and in accordance with the physician's orders. Review of the policy and procedure titled, P&P Nutrition and Hydration Assistance, issued 4/1/2022 read, Policy: It will be the policy that this facility will provide the level of assistance required to the residents while maintaining their highest practical level of function and personal preferences.

Based on observation, record review, and interview, the facility failed to administer enteral nutrition for 1 of 3 residents, Resident #92, and fluids as ordered for hydration and water flushes as order by the physician. Findings include: During an observation of Resident #92 on 5/5/25 at 10:12 AM the feeding pump was set at 45 milliliter/hour (ml/hr) administering Glucerna 1.5 and 30 ml/hr H2O (water) flush. During an observation of Resident #92 on 5/5/25 at 2:35 PM the feeding pump was set at 45 ml/hr administering Glucerna 1.5 and 30 ml/hr H2O flush. (Photographic evidence obtained) During an observation of Resident #92 on 5/6/25 at 8:36 AM the feeding pump was set at 45 ml/hr administering Glucerna 1.5 and 30 ml/hr H2O flush. During an observation of Resident #92 on 5/6/25 at 12:06 PM the feeding pump was set at 45 ml/hr administering Glucerna 1.5 and 30 ml/hr H2O flush. Review of Resident #92's physician order dated 3/25/25 read, Glucerna 1.5 at 60 ml/hr via pump 24 hrs [24 hours/continuous] and H2O at 55 ml/hr via pump 24 hrs. Review of Resident #92's Nutrition Risk Evaluation dated 3/25/25 read, Resident at nutritional risk related to medical conditions. History of metabolic encephalopathy, diabetes. Has feeding tube. Receiving Glucerna 1.5 at 60 ml/hr daily to achieve adult requirements of 20 kcal/kg [kilocalories per kilogram] and protein needs of 1.0-1.2 g/kg [gram/kilogram] daily. Current weight 247 lbs. [pounds] and 70 inches for a Body Mass Index (BMI): 35.4 (obesity). Nursing staff provides care as ordered by Physician team. Review of Resident #92's dietary progress note dated 4/22/25 by the Dietitian read, RD [Registered Dietitian] monthly TF [tube feed] review weight at 239 lbs., no significant weight changes, BMI 34.3 indicative of obesity. Using adjusted obesity weight of 184 lbs. to calculate estimated nutritional needs. On TF of Glucerna 1.5 at 60ml/hr x 24 hrs with 55 ml/hr of H2O x 24 hrs. Resident is at risk for malnutrition due to NPO [nothing by mouth] on enteral feedings due to dysphagia, obesity, DM [diabetes mellitus], CVA [cerebral vascular accident]. TF provides 100% estimated nutritional needs. Recommend to continue with current nutritional plan of care. During review of Resident #92's weights on 2/24/25, the resident weighed 247 lbs. On 4/10/25, the resident weighed 239 pounds which is a -3.24 % weight loss. During an interview on 5/06/25 at 1:21 PM Staff A, Licensed Practical Nurse (LPN) verified the feeding pump setting, the pump is running at 45 ml/hr with 30 ml/hr flush. Staff A, LPN went to her computer and stated [Resident #92's name] should be on 60 ml/hr with 55 ml/hr of water, the order date is 3/25/25. I have to go by doctor orders. I don't know who changed that setting. During an interview on 5/06/25 at 1:51 PM Staff B, Unit Manager/LPN stated [Staff A's name], did not ask me anything regarding [Resident #92's name] and I am not aware of any changes from the dietitian/nutritionist. You are supposed to check the setting is correct and if you are not sure get clarification from the doctor or Unit Manager. During an observation on 5/6/25 at 2:52 PM with the Director of Nursing (DON) of Resident #92's room showed the feeding pump was set at 60 ml/hr, however the water flush continued to be set at 30 ml/hr. During an interview on 5/6/25 at 2:53 PM the DON stated, The expectation is for the nurse to follow the doctors' orders. When the staff fix the setting it should have been done correctly according to the doctors orders. Review of the policy and procedure titled, P & P Enteral Tube Feeding issued: 1/1/2022 read, Policy: It will be the policy of this facility to provide nourishment to the resident who is unable to obtain adequate nourishment orally via use of enteral tube feeding. Procedure: 1. Verify/obtain physician's order for enteral feeding. Be certain that the order for the enteral feeding tube specifies such as rate, amount, times of administration and any specific orders related to stopping/holding tube feeding.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 2 of 4 residents, Resident #36 and #363, reviewed for oxygen therapy. Findings Include: 1) During an observation on 05/05/25 at 09:55 AM, Resident #36 was observed lying in bed wearing nasal cannula (NC) with oxygen being administered at 3 liters/minute (l/min). There was no date on the oxygen tubing. Review of the electronic medication administration record (MAR) read, Change, date oxygen tubing and bag weekly every Thursday midnight shift every night shift every 7 day(s) Wash concentrator air filters with soap and water weekly on Thursday midnight shift, be sure oxygen in use sign is on the door. Start Date 05/03/2025. 2) During an observation on 05/05/25 at 11:26 AM Resident #363 was observed lying in bed, holding the oxygen nasal cannula tubing in his hands. The oxygen concentrator was administering oxygen at 4 liters/minute, and the oxygen tubing was not dated. During an observation on 05/06/25 at 02:14 PM Resident #363 was sitting in a wheelchair wearing a nasal cannula with oxygen being administered at 4 liters/min. There is no date on the oxygen tubing. Review the physician's order for Resident #363 read, Change, date oxygen tubing and bag weekly every Thursday midnight shift. During an interview on 05/08/25 at 09:50 AM, the Director of Nursing stated that the nurses are expected to change, label and date the oxygen tubing every seven days on Thursdays. Review of the policy and procedure titled P&P Oxygen Administration issued on 4/1/2022 read, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff, but is only required to have tubing dated appropriately demonstrating that the tubing was changed.

Based on observations, interviews, and record review, the facility failed to maintain the kitchen equipment in a clean and sanitary manner for 3 of 4 nourishment rooms. Findings Include: During an observation on 5/5/25 beginning at 9:28 AM with the Assistant Dietary Manager showed at 9:54 AM in the 500 Hall nourishment room, there were brown and red splattered substances on the interior base of the freezer. There was an orange sticky substance splattered on the inside walls of the microwave. At 10:03 in the 200 Hall nourishment room, there was a brown splattered substance on the back wall of the refrigerator, there was food build up on the microwave oven plate and opaque splatters on the exterior front glass of the microwave oven, at 10:15 AM in the 100 Hall nourishment room, there was a brown splattered substance on the lower refrigerator drawers, and a brown built up sticky substance on the interior base of the freezer. During an interview on 5/5/25 at 10:20 AM the Assistant Dietary Manager stated, The nutrition rooms should be cleaned daily. I usually do rounds in the morning to make sure the cooks have cleaned them, but I haven't gotten to them this morning. Review of the policy and procedure titled P&P Kitchen Sanitation, with an issue date of 4/1/22 and a revision date of 10/1/23 read, Procedure: 1. Kitchens: kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.

Based on observations, interviews, and record reviews, the facility failed to maintain complete and accurately documented medical records for 2 of 5 residents, Residents #365 and #363, reviewed for medication administration and unnecessary medications. Findings include: Review of Resident #365's physician order read, Metoprolol 25 mg [milligrams] PO [oral] BID [twice daily], 0.5 tablet [1/2 tablet]. Hold for SBP [systolic blood pressure] less than 110, HR [heart rate] below 60 BPM [beats per minute]. Review of Resident #365's Medication Administration Record (MAR) for May 2025 did not provide for documentation of the resident's heart rate or blood pressure as ordered prior to administering metoprolol to Resident #365 on 5/1/2025 at 8:00 AM, 5/2/2025 at 8:00 AM, 5/2/2025 at 9:00 PM, 5/3/2025 at 8:00 AM, 5/4/2025 at 8:00 AM, 5/4/2025 at 9:00 PM, 5/6/2025 at 8:00 AM, and 5/7/2025 at 8:00 AM. During an interview on 05/06/25 at 01:28 PM Staff C, Licensed Practical Nurse (LPN) stated The CNA [Certified Nursing Assistant] gives me the vital signs and I check them before giving medications. Sometimes I will wait and put all the blood pressures in last, so I will put 'NA' [not applicable] in the meantime as a place holder. During an interview on 05/07/25 at 12:06 PM Staff B, Unit Manager stated, I expect the nurses to document the blood pressure and heart rate prior to giving cardiac medications, such as metoprolol. Nurses should not document 'NA' in place of vital signs on the MAR. During an interview on 05/07/25 at 12:10 PM the Director of Nursing (DON), stated, The nurses should document the vital signs on the MAR. Review of physician order for Resident #363 dated 4/2/25 read, Sodium Chloride Intravenous Solution 0.45 % [Sodium Chloride] Use 50 ml/hr [milliliters/hour ] intravenously one time a day every Tuesday, Thursday, Sunday for AKI [acute kidney injury], dehydration. 50 ml/hr for a total of 500 ml only three days a week. During an observation on 05/06/25 at 01:37 PM Resident #363 was observed at lunch time eating a pudding cup in his room. IV (intravenous) fluids were not observed being administered. Review of MAR (electronic medication administration record) read, Sodium Chloride Intravenous Solution 0.45% (Sodium Chloride) Use 50 ml/hr intravenously one time a day every Tuesday, Thursday, Sunday for AKI, dehydration 50 ml/hr for a total of 500 ml only three days a week, Start Date 04/03/2025. The administration time was documented at 0600 [6:00 AM]. Review of the MAR dated 05/06/2025 documented Sodium Chloride Intravenous Solution was administered, per the documented initials, by Staff D. During an interview on 05/06/25 at 12:13 PM Staff C, LPN stated, A nurse with the last name [Staff D's last name] was on last night. The patient [Resident #363] was not hooked up to any IV fluids when I saw him and gave him meds this morning at around 0930 [9:30 AM]. Sometimes the night nurses start the IV fluids earlier than ordered so that it will finish by the time the patient is ready to get out of bed in the morning. During an interview on 05/06/25 at 02:43 PM Staff B, Unit Manager stated, The 0.45% normal saline bag was not hung last night by Registered Nurse, Staff D. Review of the policy and procedure titled P&P Medication Administration issue date, 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure: 3. Medications should be administered in a timely manner and in accordance with the physician's orders. Review of Policy and Procedure titled, P&P Charting and Documentation issued, 4/1/2022 reads, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on observations, interviews, and record reviews, the facility failed to prevent the possible spread of infection by failing to adhere to posted infection control signage and standards of practice, failing to maintain hand hygiene during medication administration, failing to maintain hand hygiene during wound care, and failing to handle and store tube feeding products per the manufacturer's recommendations. (Photographic evidence obtained) Findings include: 1) During an observation on 5/6/25 at 10:02 AM the door to Resident #61's room had a sign posted for Enhanced Barrier Precautions that read, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting. Devise care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Upon entering Resident #61's room a blue disposable gown was observed hanging inside the room. Review of Resident #61's, medical record documented the resident was admitted on [DATE] with a diagnosis of Clostridium Difficile (C-Diff - a bacterium that can cause severe diarrhea and inflammation of the colon) and placed on contact precautions at that time. Resident #61 completed antibiotic treatment for C-Diff and was no longer symptomatic. Resident #61 went to a higher level of care for an unrelated surgical procedure on 4/11/25 to the left hand. Resident #61 returned to facility with a surgical wound to the left wrist. Review of Resident #61's physician order dated 3/13/25 read: Contact Precautions for C. Difficile bacterium in stool. The order dated 3/13/25 was discontinued on 5/7/25. An order dated 5/7/25 read, Resident requires Enhanced Barrier precautions due to wound. During an observation on 5/6/25 at 12:17 PM of Resident #61's room, a Certified Nursing Assistance (CNA) entered the room; then entered the resident's bathroom to provide care. The CNA was wearing gloves; no other personal protective equipment was donned. During an observation on 5/6/25 at 12:40 PM of Resident #61's room, a disposable blue gown was hanging inside on the back of the door. During an interview on 5/6/25 at 2:01 PM Staff C, Licensed Practical Nurse (LPN) stated I do not know why the gown is hanging in [Resident #65's name] room, it was there when I got here this morning. During an interview on 5/6/25 at 2:52 PM the Director of Nursing (DON) stated, That gown should not be there, it is disposable, that is strange. During an interview on 5/7/25 at 8:36 AM Resident #61 stated, The staff does not wear gowns when they are with me, they haven't in a long time. 2) During an observation on 5/7/25 beginning at approximately 9:17 AM of medication administration Resident #166 was observed to request a pain pill from Staff F, LPN. The pain medication was not available in the medication cart for the resident. Staff F, LPN contacted the pharmacy via phone to receive an authorization code to retrieve the requested pain medication from the Pyxis machine (an automated medication dispensing cabinet for the dispensing of medications). At approximately 9:42 AM Staff F, LPN started toward the 200 unit via a secured corridor, the secured corridor required a pass key to enter. While walking through the corridor the laundry and kitchen rooms were passed. Upon exiting the secured corridor Staff F, LPN requested the assistance of another nurse to retrieve the pain medication from the Pyxis machine. Staff F, LPN entered the code on the Pyxis screen with her bare index finger. The other nurse did the same sequence, and the pain medication was retrieved. Staff F, LPN went through the 200 unit via the secured corridor. Upon exiting the secured corridor Staff F, LPN went directly to the Resident #166's room, did not perform hand hygiene and administered the pain medication to Resident #166. During an interview on 5/7/25 at approximately 9:56 AM Staff F, LPN stated, I should have sanitized my hands before giving the resident their pain medication. During an interview on 5/7/25 at 11:35 AM the Director of Nursing stated, That should not have happened [not performing hand hygiene prior to the medication administration.] Review of the policy and procedure titled, P & P Medication Administration issued on 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. 11. Established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) must be followed during the administration of medications. 3) During an observation on 05/07/25 at 10:35 AM Staff E, CNA (Certified Nursing Assistant) was providing assistance for Resident #56 in the bathroom. Staff E was not wearing personal protective equipment of a gown when assisting the resident in the bathroom. During an observation on 05/07/25 at 10:36 AM there was an Enhanced Barrier Precautions (EBP) Sign posted on Resident #56's door. During an interview on 05/07/25 at 10:38 AM Staff E, CNA stated, I didn't have to wear a gown when taking [Resident 56's name] to the bathroom. Not that I know of. They didn't tell me nothing about that. Review of the physician order dated 3/19/25 for Resident #56 read, Requires enhanced barrier precautions R/T [related to] G-tube [gastric tube]. During an interview on 05/07/25 at 11:35 AM the Director of Nursing (DON) stated, The expectation is for staff to wear gloves and a gown when toileting residents that are on enhanced barrier precautions. We go over enhanced barrier precautions and the need for gowning every week during our town hall meetings. Review of the policy and procedure titled, P & P Enhanced Barrier Precautions issued on 4/1/2024 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. 4. For residents for whom EBP (Enhanced Barrier Precautions) are indicated, EBP is employed when performing the following High-contact resident cars activities. a. Dressing, b. Bathing, c. Transferring, d. Providing Hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Devise care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. h. Wound Care: any skin opening requiring a dressing. 4) During an observation on 05/05/25 at 10:17 AM, Resident #366 was lying in bed with his eyes closed. A Jevity 1.5 tube feeding bottle was on the table below the television. The Jevity 1.5 bottle was approximately one third full and the bottle was not dated. During an observation on 05/07/25 at 08:18 AM of Resident #366's room it showed there was a bottle of Jevity 1.5 tube feeding on the table in the room. The Jevity 1.5 tube feed bottle was approximately one half full, was not dated, and there was no cap on the bottle. During an interview on 05/07/25 at 08:20 AM Staff B, Unit Manager stated, The tube feeding bottles should be dated and timed. Review of the physician order for Resident #366 dated 4/10/25, read, Jevity 1.5 Bolus Feed 237 ml (milliliters) every 4 hours, 137 ml free water flush with each bolus feed. Review of the [NAME] Nutrition recommendations for Jevity 1.5 for bolus feeding read, Storage and Handling: After Opening: Once opened, the formula should be covered, refrigerated, and used within 48 hours. Review of the policy and procedure titled, P&P Enteral Tube Feeding issued on 1/1/2022 read, Policy: It will be the policy of this facility to provide nourishment to the resident who is unable to obtain adequate nourishment orally via use of the enteral tube feeding. Procedure: 9. For residents receiving enteral tube feeding with the use of a pump or via gravity infusion - Replace infusion sets every 24 hours for open tube systems or 48 hours for closed tube feed systems or per manufacturer's guidelines. 5) During an observation on 05/08/2025 beginning at 8:30 AM of the Wound Care Nurse and the Assistant Director of Nursing (ADON) performing wound care for Resident #316 a wound dressing was not observed on the wound. Resident #316 stated it was just removed since she knew she was going to have the wound dressing changed. The ADON cleansed the wound bed with sterile water and gauze. The ADON did not remove her gloves, perform hand hygiene, don a clean pair of gloves, and applied physician ordered ointment to the wound and covered the wound with the clean wound dressing. During an interview on 05/08/2025 at 8:42 AM the ADON stated, I should have changed my gloves and sanitized my hands after I cleaned the wound. 51447

Based on observation, interview, and record review, the facility failed to ensure food items were properly labeled or discarded upon expiration, failed to ensure test strips were not expired, and failed to ensure the kitchen environment and equipment were kept clean (Photographic evidence obtained). Findings include: During observation on [DATE] at 9:15 AM while conducting a walk-through tour of the kitchen with the Certified Dietary Manager (CDM), there were pooling of water in the dish room, dirty towels were placed under the juice containers, and test strips expired on [DATE] were being used for the pot and pan sink. During an interview on [DATE] at 9:35 AM, the CDM confirmed the water leak in the dish room, a leak under the juice machine, and the expired test strips being used to check the sanitation. During an observation on [DATE] at 7:30AM while conducting follow-up tour of the kitchen with the CDM, there were a buildup of a black and grey substance on the wall behind the dish machine and a small bucket full of water, and numerous dirty towels/rags under the juice machine. In the dry storage room, there were fourteen bags of hot cereal creamy wheat farina with an expiration date of [DATE], two ,d+[DATE] bags of a food product with no identifying label, and one box of buttermilk biscuit mix with an expiration date of [DATE]. The mixer had numerous stains and dark brown and cream-colored food particles or debris inside, on the top and sides of the mixer. During an interview on [DATE] at 8:28 AM, the CDM confirmed the presence of a black/grey substance on the wall behind the dish machine, numerous food particles on the top and sides of the mixer. The CDM confirmed that there were products without a label and identified the product as coconut and the expired biscuit mix and farina. The CDM stated that the products should be labeled according to the policy and that all products should be monitored for expiration dates. The CDM stated the dish machine and the juice machine had a leak. Review of the facility policy and procedures titled Kitchen Sanitation last reviewed on [DATE] read, Policy: It will be the policy of the facility that the food service area and equipment shall be maintained in a clean and sanitary manner. Procedure . 14. The Food Services/ Dietary Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Review of the facility policy and procedures titled Refrigerated Storage last reviewed on [DATE] read, Procedure . 4. Dietary staff will label, date, and monitor refrigerated food, including, but not limited to leftovers to ensure use by use-by dates, or frozen (when applicable) or discarded. Review of the facility policy and procedures titled Refrigerated Storage last reviewed on [DATE] read, Policy: Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent foodborne illness and minimize bacterial growth. Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment. Procedure . 3. Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule- or as visually necessary. These are then wiped down with sanitizer solution (bleach at 100 parts per million).

Based on record review and interview, the facility failed to conduct a comprehensive assessment in a timely manner for 1 of 5 residents reviewed for unnecessary medications, Resident #146. Findings include: Review of Resident #146's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included infection and inflammatory reaction due to indwelling urethral catheter, presence of urogenital implants, parkinsonism, Alzheimer's disease, unspecified mood disorder and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #146's Minimum Data Set (MDS) records revealed the resident's admission MDS assessment was not completed. During an interview on 2/14/2024 at 12:16 PM, Minimum Data Set Coordinator 1 confirmed that Resident #146's admission minimum data set assessment was due on 1/16/2024 and that the assessment had not been completed timely. Review of the facility policy and procedures titled MDS Transmission last reviewed on 1/24/2024, showed the policy read, Transmittal Requirements: Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS [Centers for Medicaid and Medicare] System, including the following: (i) Admission assessment.

Based on observation, record review, and interview, the facility failed to ensure PICC (Peripherally Inserted Central Catheter) line dressing was changed for 1 of 1 resident with PICC line, Resident #69. Findings include: During an observation on 2/12/2024 at 10:20 AM, Resident #69 had a PICC line in his right arm. The PICC line was covered with a dressing dated 2/1/24 and the clear covering was cracked and peeling at the upper left edge. During an interview on 2/12/2024 at 10:20 AM, Resident #69 stated, No one has come in to change my dressing for over a week. Review of Resident #69's physician order dated 1/24/2024 read, Change dressing 24 hours post PICC line insertion, then every week and PRN [as needed]. If gauze is used dressing must be changed every 24 hours as need . Start Date: 01/24/2024. During an interview on 2/14/2024 at 9:20 AM, Staff B, Licensed Practical Nurse (LPN), stated, His dressing is compromised and should have been changed when the nurse flushed his line. During an interview on 2/14/2024 at 9:30 AM, the Director of Nursing stated, The dressing is compromised. My expectation is that it should have been changed. The Director of Nursing confirmed the date on the bandage read, 2/1/2024. Review of the facility policy and procedures titled PICC IV [Intravenous] Line issued on 4/1/2022 read, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal law . Dressing Changes: Sterile dressing change using transparent dressing is performed: 24 hours post-insertion or upon admission if not dated upon admission, at least weekly, If the integrity of the dressing has become compromised (wet, loose, or soiled).

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and maintain kitchen equipment in a clean and sanitary condition in the main kitchen and 4 of 4 neighborhood kitchens, potentially affecting all 114 residents, and the facility failed to serve food in accordance with professional standards for food service safety in 1 of 2 neighborhoods observed. Findings include: 1. During the initial tour with the Food Services Manager on 9/6/2022 beginning at 9:09 AM, the following were observed: a) Chopped ham and carrots in the walk-in refrigerator that were not labeled or dated, b) Raw frozen hamburger patties open to the air in the freezer, with the plastic covering not closed over the meat, c) A plate containing a pureed meal that was unlabeled and undated in the two door cooks cooler, d) A hotel pan of French fries and a sandwich between two disposable plates that was unlabeled and undated in the [CONDITION(S)] refrigerator, e) a buildup of a black substance inside the door of the oven and the oven deck, f) a brown sticky substance at the top of the point of the triangular shaped opener on the table mounted can opener, g) The fryer was observed covered with baking pans. On removal of the baking pan on the left fryer, the oil was observed to have a film on top of the oil and crumbs on the shelf in the front of the fryer. There were drips of an oily substance down the side of the fryer. During an interview on 9/6/2022 at the time of initial tour, the Food Services Manager confirmed all concerns identified during the tour. 2. During breakfast food service on 9/7/2022 beginning at 9:10 AM with the Food Services Manager, the following were observed: a) Staff C, Community Chef, carried a hotel pan containing link sausages. Staff C inverted the hotel pan and dropped the sausage links into another hotel pan that was on the steam table. He then moved the sausage around in the pan on the steam table with the same gloved hand that carried the hotel pan to the steam table, b) Staff C put two slices of bacon on a plate that had a large dried green colored stain in the center of the dish. Staff C noticed debris on the plate, dumped the bacon slices back into the pan of bacon on the steam table, and put the dirty plate in the dirty dish bin. He then served that bacon on another plate, c) Staff C served oatmeal into 3 large white bowls that had visible dark colored debris in the eating surface and rims of the bowls. The bowls of oatmeal were served to residents, d) Staff C picked up two slices of pancakes with tongs and laid them on the flat surface in front of steam table, put on a glove on one hand and chopped the pancake into small pieces and put the pieces of pancake on the plate with the gloved hand. The surface in front of the steam table had been used for plates, utensils, box of alcohol swabs and thermometer and had not been sanitized or cleaned prior to placing food on the surface, e) Staff C picked up two slices of pancakes with tongs and laid them on the flat surface in front of steam table, put on a glove on one hand and chopped the pancake into small pieces and put the pieces of pancake on the plate with the gloved hand. Staff C then picked up two link sausages with tongs and put them on the flat surface in front of the steam table and chopped the sausages into small pieces and add them to the plate. During an interview on 9/7/2022 at 9:30 AM, the Food Services Manager confirmed that food should not be touched with a gloved hand that has touched other surfaces, the bacon slices should not have been put back on the steam table once it came into contact with the soiled plate, the oatmeal was served in dishes that had dark debris in the eating area of the bowl and rims and that food should not be cut up on the surface in front of the steam table as the surface is not a clean surface to place food to cut. He stated it is not normal to cut food up on the steam table this way. 3. During a tour of the neighborhood kitchens with the Food Services Manager on 9/8/2022 beginning at 7:38 AM, the following were observed: a) Neighborhood 100: The stove had grease on handles of stove and had black substances on the oven deck, b) Neighborhood 400: There were two Styrofoam containers labeled with resident names but without dates in the refrigerator, c) Neighborhood 500: The microwave had yellow greasy substances on the inside of the microwave. The stove had grease on handles of the stove and had black substances on the oven deck. Cheese and butter were open to air in the refrigerator and hot dogs were unwrapped in the freezer. The refrigerator had brown and yellow debris on the shelves and bottom of the refrigerator, d) Neighborhood 200: The oven had black substances on the oven decks. During an interview on 9/8/2022 at 8:30 AM, the Food Services Manager confirmed all concerns identified on the tour of the neighborhood kitchens. He stated there were no cleaning schedules or documentation of cleaning being completed on all food service equipment in the main kitchen or the neighborhood kitchens at this time. Review of the policy and procedure titled, Sanitation, revised in December 2008, and last reviewed on 1/22/22 reads, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free of breaks, corrosion, open seams, cracks and chipped areas that may affect their use and proper cleaning. 3. All equipment food contact surfaces and utensils shall be washed to remove and completely loosen soils by using the manual or mechanical means necessary and sanitizing using hot water and or chemical sanitizing solutions . 7. Cutting boards (acrylic or hardwood) will be washed and sanitized between uses . 11. For fixed equipment or utensils that do not fit in the dish washing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures . 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the policy and procedure titled, Food Preparation and Service, revised in November 2010, and last reviewed on 1/22/22 reads, Policy Statement. Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. Food Service/Distribution . 6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single use items and shall be discarded after each use.

Based on observation, interview, and record review, the facility failed to ensure that the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 3 of 6 medication carts reviewed, and the medications were not left unattended in the resident rooms. Findings include: During an observation of Medication Cart #1 on 9/6/2022 at 9:06 AM with Staff E, Licensed Practical Nurse (LPN), there were one opened [MEDICATION(S)] insulin pen with no opened or expiration dates, and one unopened [MEDICATION(S)] insulin pen with the pharmacy instructions to refrigerate until opened. During an interview on 9/6/2022 at 9:10 AM, Staff E, LPN, stated, All insulin should be refrigerated if they aren't opened and have the date they were opened on them. During an observation of Medication Cart #2 on 9/6/2022 at 9:18 AM with Staff F, LPN, there were one bottle of [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, one opened bottle of [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, one opened bottle of [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, one opened bottle of [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, one opened bottle of [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, two insulin [MEDICATION(S)] pens with no opened or expiration dates, one [MEDICATION(S)] insulin pen with no opened or expiration dates, one [MEDICATION(S)] insulin pen with no opened or expiration dates, and one unopened [MEDICATION(S)] with the pharmacy instructions to refrigerate until opened. During an interview on 9/6/2022 at 9:20 AM, Staff F, LPN, stated, All eye drops and insulin should have been dated. I don't know why they aren't. During an observation of Medication Cart #3 on 9/6/2022 at 9:25 AM with Staff G, LPN, there were one [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, one [MEDICATION(S)] ophthalmic solution with no opened or expiration dates, and one [MEDICATION(S)] ophthalmic solution with no opened or expiration dates. During an interview on 9/6/2022 at 9:32 AM, Staff G, LPN, stated, All the eye drops should be dated when they are opened. 2. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/6/2022 at 9:55 AM, Resident #8 was sitting in his room eating breakfast. On his table, there was a bottle of [MEDICATION(S)] Solution 22.3-6.8 MG/ML ([MEDICATION(S)] HCI-[MEDICATION(S)] Mal) with box next to the bottle. During an interview on 9/6/2022 at 9:55 AM, Resident #8 stated his nurse would administer the drops for him. During an interview on 9/9/2022 at 8:49 AM, Staff J, Licensed Practical Nurse (LPN), stated, Resident #8 had orders for [MEDICATION(S)] Solution 22.3-6.8 MGM/L ([MEDICATION(S)] HCI-[MEDICATION(S)] Mal) but it should be administered by the nurse. Resident #8 has no order to self-administer. He should not have had that in his room. During an interview on 9/9/2022 at 8:51 AM, Staff K, LPN, stated Resident #8 had no orders to self-administer medication and she might had left the medication behind in the resident room. 3. During an observation on 9/7/2022 at 9:52 AM, there was a medication cup containing several pills on the resident's overbed table with the breakfast tray in Resident 92's room. During an interview on 9/7/2022 at 9:53 AM, Resident #92 stated, I am slow going this morning, haven't gotten around to taking them yet. The nurse just left them there for me to take. During an interview on 9/7/2022 at 10:00 AM, Staff A, LPN, stated, That was my mistake. I should not have left the medication. During an interview on 9/7/2022 at 10:21 AM, Staff B, Unit 4 Manager, stated, It is not normal for nurse to leave medication at bedside unattended. Review of the policy and procedure titled Storage of Medications with an effective date of 9/2018, and last approval date of 1/22/2022, reads, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is only accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures. I. General Guidance . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists . II. Temperature . 4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit (2 degree Celsius) and 46 degrees Fahrenheit (8 degrees Celsius) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator that is attached to the inside of the refrigerator in accordance with state regulations and facility policy . III. Expiration Dating (Beyond-Use Dating): 1. Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing . 3. Certain medications or package types, such as IV solutions, multidose injectable vials, ophthalmics, [MEDICATION(S)] tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency . 4 . b. Drugs dispensed in the manufacturer's original container will carry the manufacturer's original expiration date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached and unless the medication is . ii. An ophthalmic medication; iii, An item for which the manufacturer has specified a usable duration and open. 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulation/ guidelines require different dating . 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

Based on interview, clinical record review, and policy and procedure review, the facility failed to notify the physician following a change in condition for 1 (Resident #1) of 3 sampled residents. Finding included: Review of the facility's Policy and Procedure titled Change of Condition Process, last reviewed [DATE] reads: Intent: The purpose of this policy is to ensure the facility promptly informs the resident, consults the residents physician and notify, consistent with his or her authority, residents representative when there is a change requiring notification. Procedure: The facility must inform the resident, consult with the resident's physician and/or notify the residents family member or legal representative when there is a change requiring such notification. Situations requiring notification include: 2. A significant change in the residents physical mental or psychosocial status that is a deterioration in health, mental psychosocial status in either life threatening conditions or clinical complications. This may include: 1. Life threatening conditions or 2. Clinical complications. 1. A need to alter treatment significantly, that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. This may include: 1. A decision to transfer or discharge the resident from the facility. 2. Discontinuing a treatment or changing a medication due to a) adverse consequences or b) acute condition. 3. Upon the identification of a change in condition in a resident, the nurse will complete an evaluation in the resident status and document the findings on the SBAR (Situation, Background, Assessment, Recommendation) Change of Condition in the resident's electronic medical record. Review of the clinical record for Resident #1 revealed an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#1 revealed the order dated [DATE] at 9:31 AM for nephrology consult related to BUN (blood urea nitrogen) and creatinine; the order dated [DATE] at 12:19 PM for nephrology consult related to acute [MEDICAL CONDITION], Saccharomyces Bloulardii capsule 250 mg (milligrams), give one capsule by mouth two times a day for [MEDICATION NAME] for 14 days, and [MEDICATION NAME] Solution Reconstituted 1 GM (gram), use 1 gram intravenously one time a day for leukocytosis (high white blood cell count) for 7 days; and the order dated [DATE] at 2:38 PM to send to ER (emergency room ) for further evaluation related to hydro[DIAGNOSES REDACTED] (a condition that typically occurs when a kidney swells due to urine failing to properly drain from the kidney to the bladder). Review of the physician's orders [REDACTED].#1 revealed the order dated [DATE] at 7:15 PM to insert a midline (peripheral venous access device); the order dated [DATE] at 10:42 PM for Sodium Chloride Solution 0.9%, use 125 ml/hr (milliliters per hour) intravenously every shift for hydration; and the order dated [DATE] at 10:44 PM for Stat (Latin for urgent or rush) CBC (Complete Blood Count), BMP (Basic Metabolic Panel) at 5:00 AM. Review of the physician progress notes [REDACTED]. Pt (Patient) today evaluated requested by nurse due to abnormal labs. BUN-99 (61), Creat (Creatinine) 4.2 (2.6), WBC (White Blood Cell) 16.3 (6.7), INR (International Normalized Ratio: how long it takes blood to form a clot) 7.2 ([MEDICATION NAME] on hold). At evaluation patient is alert, c/o (complaining of abdominal pain), at PE (Physical Exam) there is abdominal mild distention, possible due to bladder distention. Pt has a meatal stenosis (abnormal narrowing of the urethral opening), urologist consulted last week, and is pending for dilation. Abdominal ultrasound ordered stat report: Conclusion: Marked urinary bladder distention resulting in mild right hydro[DIAGNOSES REDACTED]. Electronically signed by (the Medical Doctor's signature) on [DATE]. A Foley Cath (catheter) was placed by nurse and urine started to drain with clamping every 400 cc (cubic centimeter). Nephrologist was consulted to evaluate Pt for AKI (Acute Kidney Injury) on CKD ([MEDICAL CONDITION]). He evaluated Pt and discussed case by phone and decide to send Pt to ER (emergency room ). Send Pt to ER for AKI. Review of the weights and vitals summary in the clinical record for Resident #1 revealed blood pressure (BP) documented on [DATE] at 2:33 AM as ,[DATE] mmHg (millimeter of mercury). Warnings section read: Diastolic Low of 60 exceeded. Systolic Low of 90 exceeded. Blood pressures were documented as ,[DATE] mmHg on [DATE] at 9:54 PM and ,[DATE] mmHg on [DATE] at 10:12 AM. Review of the [DATE] Medication Administration Record for Resident #1 revealed an order dated [DATE] at 6:25 PM: Vital signs every shift. On [DATE], blood pressure was documented as ,[DATE] by (Staff D's name), Licensed Practical Nurse (LPN). Review of the clinical record for Resident #1 revealed no documentation of review of condition by Staff D, LPN related to the low blood pressure, no SBAR (Situation, Background, Assessment, Recommendation) Change in Condition documentation, and no notification of the Attending Physician of low blood pressure of ,[DATE]. During an interview with the Attending Physician on [DATE] at 10:57 AM, she stated: I gave the order for (Resident #1's name) to be discharged on [DATE] to the emergency room for evaluation of his hydro[DIAGNOSES REDACTED] found on ultrasound. He was having difficulty passing urine and required a catheter to empty his bladder. We placed a catheter on [DATE] and I consulted a nephrologist. We spoke on the phone on [DATE] sometime in the afternoon and decided that he should be transferred to the emergency room and I called the nurse and gave orders to transport the resident to the Emergency Department (ED) for evaluation. That is the last call that I received from the facility or the nephrologist on [DATE]. Early on [DATE], the facility called me and told me that the resident had abnormal labs worse than on the 19th. I was very upset because I thought that he was already in the hospital. I was not called to discontinue the order to transfer to the hospital and I would not expect that a consultant would discontinue my order to transfer without calling me and discussing the need to discontinue that order. I was never informed of any changes in the resident's condition. No one called me to let me know that the resident had a low blood pressure in the 80's. I would have sent the patient immediately. I expect that all staff will notify me immediately whenever there is a change in a resident's condition so they can get prompt attention. I expect that any drop-in blood pressure below 90 systolic would be rechecked and reported immediately. During a follow-up telephone interview with the Attending Physician on [DATE] at 7:35 AM, she stated: I was at the facility until about 5:30 PM seeing (Resident #1's name) and other residents. I was there when they placed a Foley catheter. I did not tell the facility staff to discontinue the transfer, but I believe that I instructed them to hold the transfer until I spoke with (the Nephrologist's name). I did speak with him and we agreed the resident should be transferred to the hospital and I gave the telephone order. I think this was a miscommunication and (the Nephrologist name) and I should have communicated our plans. It is my expectation that staff call me to clarify any orders or for any orders that they are unable to carry out. I also expect that staff will notify me immediately when a patient has a change in condition. Had I been called at 2:30 in the morning I would have sent the patient to the emergency department immediately. During a telephone interview with the Nephrologist on [DATE] at 11:42 AM, he stated: I was called on consult for (Resident #1's name). I spoke to the (Attending Physician's name) over the telephone regarding his acute [MEDICAL CONDITION] and ultrasound results. We may have spoken about hospitalization and transfer to the ED related to his meatal stenosis and renal ultrasound results of [MEDICAL CONDITION] and hydro[DIAGNOSES REDACTED]. I saw the patient later that evening about 7 PM or so. I thought he was dry and needed fluids. (The Administrator's name) assured me that they could administer those at the nursing home, so I ordered a midline and an IV (Intravenous) bolus of normal saline and then a continuous IV of normal saline at 125 ml/hr (milliliter/hour). The resident was confused but I was told that was his usual state of health. He was awake and alert when I examined him. I ordered a normal saline fluid bolus and to get repeat labs later that evening and if they were not improved to transfer the patient to the hospital. I was not called during the rest of the evening or night about the patient. I was not aware that the labs were not completed until early in the morning and was not notified of any blood pressure drop into the 80's systolic. If I had been called, I would have transferred the patient to the ED immediately for evaluation given he had a supratherapeutic INR (International Normalized Ratio, a laboratory measurement of how long it takes blood to form a clot) and new leukocytosis and worsening [MEDICAL CONDITION]. I did not know when I saw the patient that he was ordered to transfer to the hospital by (the Attending Physician's name) and I did not discontinue that order. As a consultant if I changed any orders I would have spoken to the attending before I did, so they are aware of my findings, and why I chose to change something. I expect that the staff call me when I have requested labs and they cannot be gotten. If my patients have any change in their conditions, I would expect that the nurses do a full assessment of the patient when they find that a patient is hypotensive, recheck the blood pressure and notify the attending or myself immediately. During a follow-up telephone interview with the Nephrologist on [DATE] at 9:13 AM, he stated: I was not notified that his blood pressure dropped, I would have advised the staff to call (the Attending Physician's name) and transfer the resident. I feel the resident was stable when I left the facility and did not know that there was an order to transfer and I think that his hydro[DIAGNOSES REDACTED] would have improved with emptying his bladder. I know that he had an elevated INR and his [MEDICATION NAME] was being held. I do believe that a delay of hours with that low a blood pressure will affect many organs including the kidneys. During consults I will review the medication administration record, the patient's history and physical, the patient's laboratory data, I speak with the nurses and will speak with the physician who called the consult to me. I did not call (the Attending Physician's name) after I saw the patient, I really should have but I had spoken to her earlier and didn't think to call her after I saw the patient. During a telephone interview with the facility Medical Director on [DATE] at 3:50 PM, he stated: As Medical Director, I am responsible for attending monthly meetings related to quality improvement, patient safety and am involved in staff education and training for the facility nurses. I usually attend in person, but with the COVID-19 (Coronavirus Disease 2019) crisis, we have been meeting via telephone conference. As a physician, I would expect to be called immediately with any changes in a resident's condition. A blood pressure of ,[DATE] should be rechecked. The resident should be assessed from head to toe for any other changes and if accurate, an immediate call should be placed to the attending physician for further orders. All physician orders [REDACTED]. I would expect the facility to send a resident to the emergency department if there was an order to do so. During an interview with Staff C, Registered Nurse (RN), on [DATE] at 11:15 AM, she stated: I did get orders on (Resident #1's name) on [DATE] to transfer him to the emergency room at about 2:30 PM in the afternoon after we informed the doctor of the retroperitoneal ultrasound results. I called (the Attending Physician's name) and took the verbal order to transfer based on the ultrasound results. I am not sure what happened or why we did not transfer the resident per the orders. The next morning when I came in the resident was still here and I called (the Attending Physician's name) to get the order to send him to the emergency room based on his abnormal morning labs. I did not assess the patient and was not aware that his blood pressure was low. During an interview with Staff H, Licensed Practical Nurse (LPN), on [DATE] at 1:15 PM, she stated: I was the nurse caring for (Resident #1's name) on the evening of [DATE]. I started my shift at 3:00 PM, I was not given in report that there was an order to transfer (Resident #1's name) to the hospital. The resident had a Foley catheter and the nephrologist came in that evening to see the resident. No one told me that there was an order and I did not look at the start of the shift for any orders and any incomplete orders, usually the nurse will tell me in report. When (the Nephrologist's name) came in, I wrote orders to place a midline, start a fluid bolus and after the bolus start NS (normal saline) at 125 ml/hr. I called (the Nephrologist's name) to let him know that I didn't have the midline in, and I wrote an order to do stat labs at 5:00 AM and discontinued the order for labs after fluid bolus at about 10:45 PM. When I ended my shift, (Resident #1's name) did not have a low blood pressure. I think his blood pressure was in the 140's systolic that evening. I did talk with (the Nephrologist's name) when he came in about 6:30 PM or 7 PM that evening. He let me know that he thought the resident needed IV fluids and a line was placed. He wanted to get repeat labs after the fluid bolus to see if his kidney function improved after getting the fluids and after the Foley was placed. When the nurse couldn't get the midline in for several hours (she had two others to do before his), I called (the Nephrologist's name) back to let him know. When I cannot get an order done, I am supposed to let the doctor know. So, I couldn't do the fluid bolus until the midline was in and I couldn't get any repeat labs after the bolus, so he told me to get the labs stat at 5 AM. I am supposed to call the doctors with any change in condition for a resident. Changes of condition are like a fever, a fall, high or low blood pressures, high or low Accuchecks, confusion, anything that is a change from normal for the resident. I don't do any type of a chart review with the outgoing or oncoming nurses. The night nurses usually do 24-hour checks. During a telephone interview with Staff D, Licensed Practical Nurse (LPN) on [DATE] at 6:19 PM, she stated: I was the nurse taking care of (Resident #1's name) the morning he was transferred to the hospital. I saw but didn't really notice the blood pressure and I can't really tell you what time that I saw it. I think that I was the person who documented his vital signs. Usually the aide will give me a paper with all the vital signs and I will put them in the computer. Usually the aide will tell you of any abnormal blood pressures or temperatures but that night the aide did not. I float on every unit, so I don't always work with the aide that was on that night. I did not check to see what his normal blood pressure was, if I had checked and knew that it was in the 140's earlier, I would have called the doctor. Many residents have low blood pressures at night, so I just wasn't concerned. I should have checked to see what the earlier blood pressure trends were. I would have rechecked the residents blood pressure and called the doctor. I did not check on the resident and don't know what time I knew that was the blood pressure. I really should have followed up that blood pressure and I did not check and typically redo the blood pressures when they are that low. It is policy to call the doctor for any changes in residents' condition. I did not call until the abnormal labs came back. I did not repeat the resident's vital signs for the transfer to the hospital. I really should have done a new set of vital signs. During an interview with the Director of Nursing (DON) on [DATE] at 4:15 PM, she stated: I was not aware that (Resident #1's name) had an order to transfer to the hospital that was not discontinued or carried out. It is my expectation that all physician orders [REDACTED]. I was not aware that (Resident #1's name) had a low blood pressure in the middle of the night that was not followed up on. There does not appear to be any other blood pressure documented and it was documented on the MAR (Medication Administration Record) by the nurse taking care of him that night. So, I have to assume that the nurse was aware of the low blood pressure at some point within the night because she documented this in her MAR. I would expect that all staff that see a blood pressure in the 80's would do a recheck immediately and because he had received fluid bolus for being dry/dehydrated and started on fluids. I would expect that to be considered by the nurse caring for the resident and acted on by calling the doctor immediately to notify them. I did not look into this after we found out he expired in the ED. I was not aware that the previous order to discharge the patient to the ED for evaluation was present and that it had not been discontinued. A consulting physician can discontinue an attending physicians' orders. The nephrologist came to see (Resident #1's name) that evening and ordered IV fluids, a midline and to recheck labs later that evening. I really cannot tell you why the resident wasn't transferred or why there isn't an order to have the resident stay here. We are expected to follow all doctor's orders as they are written and if they cannot be followed, we are expected to notify the doctor. (The Attending Physician's name) was not notified that the order was not carried out, there are no notes or orders indicating that she was notified. I don't know if the nephrologist spoke to (the Attending Physician's name) about keeping the resident here. I think that a blood pressure in the 80s is a change of condition that must be followed up on and reported so treatment can begin immediately. This should have been assessed and treated and it seems like it wasn't. During a follow-up interview with the DON on [DATE] at 1:34 PM, she stated: My expectation is that the doctors communicate with each other when they make changes. The nursing staff should be passing on incomplete orders and incoming nurses look up new orders. If there is a pending order, staff should contact physicians to clarify the orders in case there was a change. Right now, night shift confirms all orders. When the night shift nurse came on duty that night, she should have called the physician to clarify the order. The night nurse that documented the low blood pressure, should have assessed the resident and called the physician. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:15 PM, she stated: I was not aware that (Resident #1's name) had a drop in his blood pressure during the night. I wasn't aware that (Resident #1's name) did not get any follow-up vital signs or assessment. It is my expectation that all staff notify the doctor with any changes in condition. All staff should fill out a change of condition whenever they call with changes. The nurse should have called the doctor and rechecked the blood pressure and temperature. During an interview with the Administrator on [DATE] at 4:45 PM, she stated, I was not aware that (Resident #1's name) had a low blood pressure in the middle of the night. I was not aware that the staff did not call the attending physician. I was not aware that the staff did not do a follow-up assessment after getting a low blood pressure. During a follow-up interview with the Administrator on [DATE] at 1:32 PM, she stated: I expect nursing staff to communicate changes in report, to clarify any incomplete physician orders [REDACTED]. Consultants and attending doctors should communicate clearly so there is no confusion for the nursing staff. Review of the receiving hospital's records revealed: Service Date/Time: [DATE], 08:57 EDT (Eastern Daylight Time). Emergency Documentation: History of Present Illness: 88-y/o (year old) male presents to the ED from The Villages Rehab for evaluation of altered mentation compared to his baseline, duration unclear. Patient was sent here by his rehab facility for abnormal labs and evaluation of a Foley that is not draining properly. According to report, the patient is currently at a rehab facility s/p (status [REDACTED]. Patient's Foley catheter was placed about ,[DATE] days ago and had approximately 1700 mL of urine drained before it started to malfunction. Vitals & Measurements: Gastrointestinal: soft, distended abdomen, bowel sounds distant, tenderness to lower abdomen, Foley catheter with dark bloody urine in early portion. Disposition: Time: 1029 (10:29 AM). Decision to dispo: deceased . Condition at disposition: deceased . Assessment/Plan: 1. deceased . 2. [MEDICAL CONDITION]. 3. [MEDICAL CONDITION] with septic shock ([MEDICAL CONDITION] is when the infection is severe enough to affect the function of your organs, such as the heart, brain, and kidneys. Septic shock is when you experience a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death. 4. Gross hematuria (when a person can see the blood in his or her urine). 5. History of closed distal fibula fracture.

Based on interview, clinical record review, and policy and procedure review, the facility failed to ensure a resident was free from neglect by not following the physician's orders [REDACTED].#1) of 3 sampled residents. Findings include: Review of facility's the Policy and Procedure titled Freedom from Abuse, Neglect, and Exploitation, last reviewed [DATE] read: Intent. The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Definitions. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility's Policy and Procedure titled Change of Condition Process, last reviewed [DATE] reads: Intent: The purpose of this policy is to ensure the facility promptly informs the resident, consults the residents physician and notify, consistent with his or her authority, residents representative when there is a change requiring notification. Procedure: The facility must inform the resident, consult with the resident's physician and/or notify the residents family member or legal representative when there is a change requiring such notification. Situations requiring notification include: 2. A significant change in the residents physical mental or psychosocial status that is a deterioration in health, mental psychosocial status in either life threatening conditions or clinical complications. This may include: 1. Life threatening conditions or 2. Clinical complications. 1. A need to alter treatment significantly, that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. This may include: 1. A decision to transfer or discharge the resident from the facility. 2. Discontinuing a treatment or changing a medication due to a) adverse consequences or b) acute condition. 3. Upon the identification of a change in condition in a resident, the nurse will complete an evaluation in the resident status and document the findings on the SBAR (Situation, Background, Assessment, Recommendation) Change of Condition in the resident's electronic medical record. Review of the clinical record for Resident #1 revealed an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#1 revealed the order dated [DATE] at 9:31 AM for nephrology consult related to BUN (blood urea nitrogen) and creatinine; the order dated [DATE] at 12:19 PM for nephrology consult related to acute [MEDICAL CONDITION], Saccharomyces Bloulardii capsule 250 mg (milligrams), give one capsule by mouth two times a day for [MEDICATION NAME] for 14 days, and [MEDICATION NAME] Solution Reconstituted 1 GM (gram), use 1 gram intravenously one time a day for leukocytosis (high white blood cell count) for 7 days; and the order dated [DATE] at 2:38 PM to send to ER (emergency room ) for further evaluation related to hydro[DIAGNOSES REDACTED] (a condition that typically occurs when a kidney swells due to urine failing to properly drain from the kidney to the bladder). Review of the physician's orders [REDACTED].#1 revealed the order dated [DATE] at 7:15 PM to insert a midline (peripheral venous access device); the order dated [DATE] at 10:42 PM for Sodium Chloride Solution 0.9%, use 125 ml/hr (milliliters per hour) intravenously every shift for hydration; and the order dated [DATE] at 10:44 PM for Stat (Latin for urgent or rush) CBC (Complete Blood Count), BMP (Basic Metabolic Panel) at 5:00 AM. Review of the physician progress notes [REDACTED]. Pt (Patient) today evaluated requested by nurse due to abnormal labs. BUN-99 (61), Creat (Creatinine) 4.2 (2.6), WBC (White Blood Cell) 16.3 (6.7), INR (International Normalized Ratio: how long it takes blood to form a clot) 7.2 ([MEDICATION NAME] on hold). At evaluation patient is alert, c/o (complaining of abdominal pain), at PE (Physical Exam) there is abdominal mild distention, possible due to bladder distention. Pt has a meatal stenosis (abnormal narrowing of the urethral opening), urologist consulted last week, and is pending for dilation. Abdominal ultrasound ordered stat report: Conclusion: Marked urinary bladder distention resulting in mild right hydro[DIAGNOSES REDACTED]. Electronically signed by (the Medical Doctor's signature) on [DATE]. A Foley Cath (catheter) was placed by nurse and urine started to drain with clamping every 400 cc (cubic centimeter). Nephrologist was consulted to evaluate Pt for AKI (Acute Kidney Injury) on CKD ([MEDICAL CONDITION]). He evaluated Pt and discussed case by phone and decide to send Pt to ER (emergency room ). Send Pt to ER for AKI. Review of the weights and vitals summary in the clinical record for Resident #1 revealed blood pressure (BP) documented on [DATE] at 2:33 AM as ,[DATE] mmHg (millimeter of mercury). Warnings section read: Diastolic Low of 60 exceeded. Systolic Low of 90 exceeded. Blood pressures were documented as ,[DATE] mmHg on [DATE] at 9:54 PM and ,[DATE] mmHg on [DATE] at 10:12 AM. Review of the [DATE] Medication Administration Record for Resident #1 revealed an order dated [DATE] at 6:25 PM: Vital signs every shift. On [DATE], blood pressure was documented as ,[DATE] by (Staff D's name), Licensed Practical Nurse (LPN). Review of the clinical record for Resident #1 revealed no documentation of review of condition by Staff D, LPN related to the low blood pressure, no SBAR (Situation, Background, Assessment, Recommendation) Change in Condition documentation, and no notification of the Attending Physician of low blood pressure of ,[DATE]. During an interview with the Attending Physician on [DATE] at 10:57 AM, she stated: I gave the order for (Resident #1's name) to be discharged on [DATE] to the emergency room for evaluation of his hydro[DIAGNOSES REDACTED] found on ultrasound. He was having difficulty passing urine and required a catheter to empty his bladder. We placed a catheter on [DATE] and I consulted a nephrologist. We spoke on the phone on [DATE] sometime in the afternoon and decided that he should be transferred to the emergency room and I called the nurse and gave orders to transport the resident to the Emergency Department (ED) for evaluation. That is the last call that I received from the facility or the nephrologist on [DATE]. Early on [DATE], the facility called me and told me that the resident had abnormal labs worse than on the 19th. I was very upset because I thought that he was already in the hospital. I was not called to discontinue the order to transfer to the hospital and I would not expect that a consultant would discontinue my order to transfer without calling me and discussing the need to discontinue that order. I was never informed of any changes in the resident's condition. No one called me to let me know that the resident had a low blood pressure in the 80's. I would have sent the patient immediately. I expect that all staff will notify me immediately whenever there is a change in a resident's condition so they can get prompt attention. I expect that any drop-in blood pressure below 90 systolic would be rechecked and reported immediately. During a follow-up telephone interview with the Attending Physician on [DATE] at 7:35 AM, she stated: I was at the facility until about 5:30 PM seeing (Resident #1's name) and other residents. I was there when they placed a Foley catheter. I did not tell the facility staff to discontinue the transfer, but I believe that I instructed them to hold the transfer until I spoke with (the Nephrologist's name). I did speak with him and we agreed the resident should be transferred to the hospital and I gave the telephone order. I think this was a miscommunication and (the Nephrologist name) and I should have communicated our plans. It is my expectation that staff call me to clarify any orders or for any orders that they are unable to carry out. I also expect that staff will notify me immediately when a patient has a change in condition. Had I been called at 2:30 in the morning I would have sent the patient to the emergency department immediately. During a telephone interview with the Nephrologist on [DATE] at 11:42 AM, he stated: I was called on consult for (Resident #1's name). I spoke to the (Attending Physician's name) over the telephone regarding his acute [MEDICAL CONDITION] and ultrasound results. We may have spoken about hospitalization and transfer to the ED related to his meatal stenosis and renal ultrasound results of [MEDICAL CONDITION] and hydro[DIAGNOSES REDACTED]. I saw the patient later that evening about 7 PM or so. I thought he was dry and needed fluids. (The Administrator's name) assured me that they could administer those at the nursing home, so I ordered a midline and an IV (Intravenous) bolus of normal saline and then a continuous IV of normal saline at 125 ml/hr (milliliter/hour). The resident was confused but I was told that was his usual state of health. He was awake and alert when I examined him. I ordered a normal saline fluid bolus and to get repeat labs later that evening and if they were not improved to transfer the patient to the hospital. I was not called during the rest of the evening or night about the patient. I was not aware that the labs were not completed until early in the morning and was not notified of any blood pressure drop into the 80's systolic. If I had been called, I would have transferred the patient to the ED immediately for evaluation given he had a supratherapeutic INR (International Normalized Ratio, a laboratory measurement of how long it takes blood to form a clot) and new leukocytosis and worsening [MEDICAL CONDITION]. I did not know when I saw the patient that he was ordered to transfer to the hospital by (the Attending Physician's name) and I did not discontinue that order. As a consultant if I changed any orders I would have spoken to the attending before I did, so they are aware of my findings, and why I chose to change something. I expect that the staff call me when I have requested labs and they cannot be gotten. If my patients have any change in their conditions, I would expect that the nurses do a full assessment of the patient when they find that a patient is hypotensive, recheck the blood pressure and notify the attending or myself immediately. During a follow-up telephone interview with the Nephrologist on [DATE] at 9:13 AM, he stated: I was not notified that his blood pressure dropped, I would have advised the staff to call (the Attending Physician's name) and transfer the resident. I feel the resident was stable when I left the facility and did not know that there was an order to transfer and I think that his hydro[DIAGNOSES REDACTED] would have improved with emptying his bladder. I know that he had an elevated INR and his [MEDICATION NAME] was being held. I do believe that a delay of hours with that low a blood pressure will affect many organs including the kidneys. During consults I will review the medication administration record, the patient's history and physical, the patient's laboratory data, I speak with the nurses and will speak with the physician who called the consult to me. I did not call (the Attending Physician's name) after I saw the patient, I really should have but I had spoken to her earlier and didn't think to call her after I saw the patient. During an interview with Staff C, Registered Nurse (RN), on [DATE] at 11:15 AM, she stated: I did get orders on (Resident #1's name) on [DATE] to transfer him to the emergency room at about 2:30 PM in the afternoon after we informed the doctor of the retroperitoneal ultrasound results. I called (the Attending Physician's name) and took the verbal order to transfer based on the ultrasound results. I am not sure what happened or why we did not transfer the resident per the orders. The next morning when I came in the resident was still here and I called (the Attending Physician's name) to get the order to send him to the emergency room based on his abnormal morning labs. I did not assess the patient and was not aware that his blood pressure was low. During an interview with Staff H, Licensed Practical Nurse (LPN), on [DATE] at 1:15 PM, she stated: I was the nurse caring for (Resident #1's name) on the evening of [DATE]. I started my shift at 3:00 PM, I was not given in report that there was an order to transfer (Resident #1's name) to the hospital. The resident had a Foley catheter and the nephrologist came in that evening to see the resident. No one told me that there was an order and I did not look at the start of the shift for any orders and any incomplete orders, usually the nurse will tell me in report. When (the Nephrologist's name) came in, I wrote orders to place a midline, start a fluid bolus and after the bolus start NS (normal saline) at 125 ml/hr. I called (the Nephrologist's name) to let him know that I didn't have the midline in, and I wrote an order to do stat labs at 5:00 AM and discontinued the order for labs after fluid bolus at about 10:45 PM. When I ended my shift, (Resident #1's name) did not have a low blood pressure. I think his blood pressure was in the 140's systolic that evening. I did talk with (the Nephrologist's name) when he came in about 6:30 PM or 7 PM that evening. He let me know that he thought the resident needed IV fluids and a line was placed. He wanted to get repeat labs after the fluid bolus to see if his kidney function improved after getting the fluids and after the Foley was placed. When the nurse couldn't get the midline in for several hours (she had two others to do before his), I called (the Nephrologist's name) back to let him know. When I cannot get an order done, I am supposed to let the doctor know. So, I couldn't do the fluid bolus until the midline was in and I couldn't get any repeat labs after the bolus, so he told me to get the labs stat at 5 AM. I am supposed to call the doctors with any change in condition for a resident. Changes of condition are like a fever, a fall, high or low blood pressures, high or low Accuchecks, confusion, anything that is a change from normal for the resident. I don't do any type of a chart review with the outgoing or oncoming nurses. The night nurses usually do 24-hour checks. During a telephone interview with Staff D, Licensed Practical Nurse (LPN) on [DATE] at 6:19 PM, she stated: I was the nurse taking care of (Resident #1's name) the morning he was transferred to the hospital. I saw but didn't really notice the blood pressure and I can't really tell you what time that I saw it. I think that I was the person who documented his vital signs. Usually the aide will give me a paper with all the vital signs and I will put them in the computer. Usually the aide will tell you of any abnormal blood pressures or temperatures but that night the aide did not. I float on every unit, so I don't always work with the aide that was on that night. I did not check to see what his normal blood pressure was, if I had checked and knew that it was in the 140's earlier, I would have called the doctor. Many residents have low blood pressures at night, so I just wasn't concerned. I should have checked to see what the earlier blood pressure trends were. I would have rechecked the residents blood pressure and called the doctor. I did not check on the resident and don't know what time I knew that was the blood pressure. I really should have followed up that blood pressure and I did not check and typically redo the blood pressures when they are that low. It is policy to call the doctor for any changes in residents' condition. I did not call until the abnormal labs came back. I did not repeat the resident's vital signs for the transfer to the hospital. I really should have done a new set of vital signs. That night I think I had two TPNs (Total [MEDICATION NAME] Nutrition) running and tube feedings, and dementia patients in the halls. I was in the resident's room because his IV (Intravenous) bolus was done at shift start and I was checking to hang the new bag and was having trouble with the IV pump malfunctioning. I couldn't fix the problem and we did not have another pump to change it out. So, I finally had to take it off the pump and do it the old-fashioned way of free flowing by counting the drops per minute. The IV was not infusing by the pump because it had an air in line error. I really should have followed up that blood pressure and I did not check. Typically, I redo the blood pressures when they are that low. It is policy to call the doctor for any changes in residents' condition. I did not call until the abnormal labs came back. I did not repeat the resident's vital signs for the transfer to the hospital, I really should have done a new set of vital signs. I have received training on changes in condition and the expectations. I wish I had done that earlier. During an interview with the Director of Nursing (DON) on [DATE] at 4:15 PM, she stated: I was not aware that (Resident #1's name) had an order to transfer to the hospital that was not discontinued or carried out. It is my expectation that all physician orders [REDACTED]. I was not aware that (Resident #1's name) had a low blood pressure in the middle of the night that was not followed up on. There does not appear to be any other blood pressure documented and it was documented on the MAR (Medication Administration Record) by the nurse taking care of him that night. So, I have to assume that the nurse was aware of the low blood pressure at some point within the night because she documented this in her MAR. I would expect that all staff that see a blood pressure in the 80's would do a recheck immediately and because he had received fluid bolus for being dry/dehydrated and started on fluids. I would expect that to be considered by the nurse caring for the resident and acted on by calling the doctor immediately to notify them. I did not look into this after we found out he expired in the ED. I was not aware that the previous order to discharge the patient to the ED for evaluation was present and that it had not been discontinued. A consulting physician can discontinue an attending physicians' orders. The nephrologist came to see (Resident #1's name) that evening and ordered IV fluids, a midline and to recheck labs later that evening. I really cannot tell you why the resident wasn't transferred or why there isn't an order to have the resident stay here. We are expected to follow all doctor's orders as they are written and if they cannot be followed, we are expected to notify the doctor. (The Attending Physician's name) was not notified that the order was not carried out, there are no notes or orders indicating that she was notified. I don't know if the nephrologist spoke to (the Attending Physician's name) about keeping the resident here. I think that a blood pressure in the 80s is a change of condition that must be followed up on and reported so treatment can begin immediately. This should have been assessed and treated and it seems like it wasn't. During a follow-up interview with the DON on [DATE] at 1:34 PM, she stated: My expectation is that the doctors communicate with each other when they make changes. The nursing staff should be passing on incomplete orders and incoming nurses look up new orders. If there is a pending order, staff should contact physicians to clarify the orders in case there was a change. Right now, night shift confirms all orders. When the night shift nurse came on duty that night, she should have called the physician to clarify the order. The night nurse that documented the low blood pressure, should have assessed the resident and called the physician. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:15 PM, she stated: I was here and placed the catheter in (Resident #1's name). (The Attending Physician's name) was here in the building and she knew we got the catheter in the resident. I did know that there was an order for [REDACTED]. I'm not sure why he didn't go. (The Attending Physician's name) did not give me any order to hold the transfer or any indication that the transfer should be delayed until (the Nephrologist's name) got in. I'm not sure honestly, so much has been happening with getting everyone tested for coronavirus and now retesting residents and staff. There was testing going on [DATE] and we did know that (Resident #1's name) died in the emergency room . I was not aware that (Resident #1's name) had a drop in his blood pressure during the night. I wasn't aware that (Resident #1's name) did not get any follow-up vital signs or assessment. It is my expectation that all staff notify the doctor with any changes in condition. All staff should fill out a change of condition whenever they call with changes. The nurse should have called the doctor and rechecked the blood pressure and temperature. During an interview with the Administrator on [DATE] at 4:45 PM, she stated: We did not investigate (Resident #1's name) and his transfer to the hospital. I was aware that he died in the emergency department. We had facility staff tested for COVID-19, we did not look at this. Then we found out that a staff member tested positive and we did the [MEDICATION NAME] for residents for the Department of Health and had those residents tested and now have seven positive non-symptomatic residents. We were busy with all that and this was not looked at. I did ask the ADON to look into it, but with everything going on we just haven't had the time. I did speak with the doctors about the hospital transfer orders. (The Attending Physician's name) held the transfer until (the Nephrologist's name) evaluated the resident. I don't know if they were communicating. I was not aware that (Resident #1's name) had a low blood pressure in the middle of the night. I was not aware that the staff did not call the attending physician. I was not aware that the staff did not do a follow-up assessment after getting a low blood pressure. We did not report this as we were not aware that it had occurred until this complaint survey. His needs were being met here. Review of the receiving hospital's records revealed: Service Date/Time: [DATE], 08:57 EDT (Eastern Daylight Time). Emergency Documentation: History of Present Illness: 88-y/o (year old) male presents to the ED from The Villages Rehab for evaluation of altered mentation compared to his baseline, duration unclear. Patient was sent here by his rehab facility for abnormal labs and evaluation of a Foley that is not draining properly. According to report, the patient is currently at a rehab facility s/p (status [REDACTED]. Patient's Foley catheter was placed about ,[DATE] days ago and had approximately 1700 mL of urine drained before it started to malfunction. Vitals & Measurements: Gastrointestinal: soft, distended abdomen, bowel sounds distant, tenderness to lower abdomen, Foley catheter with dark bloody urine in early portion. Disposition: Time: 1029 (10:29 AM). Decision to dispo: deceased . Condition at disposition: deceased . Assessment/Plan: 1. deceased . 2. [MEDICAL CONDITION]. 3. [MEDICAL CONDITION] with septic shock ([MEDICAL CONDITION] is when the infection is severe enough to affect the function of your organs, such as the heart, brain, and kidneys. Septic shock is when you experience a significant drop in blood pressure that can lead to respiratory or heart failure, stroke, failure of other organs, and death. 4. Gross hematuria (when a person can see the blood in his or her urine). 5. History of closed distal fibula fracture.

Based on interview and record review the facility failed to ensure fall prevention safety measures were implemented to prevent falls for 1 resident (Resident #1) of 4 sampled residents resulting Resident #1 sustaining a fall at the facility, transfer to the hospital and subsequent [DIAGNOSES REDACTED]. Findings: Record review of the facility training document titled STEPS FOR SAFE TRANSFER FROM STRETCHER TO BED (Undated) revealed the facility standard of practice: 1. Ensure patient is positioned on sheet slider. 2. Ensure bed and stretcher is at the same and proper height. Ensure bed is locked. (test bed by attempting to push to make sure it is locked) Check and make sure that the stretcher is locked. (test by attempting to move) 3. Ensure all lines are moved and clear from being pulled out. (Example: oxygen lines, Foley catheter, wound vac, etcetera). 4. Make sure that we are aware of any precautions/bracing for the neck, legs and arms. (Have person support the braced area). When transferring be aware of pressure sores, fragile skin and shearing of skin during transfer. 5. Instruct patient that they are not to assist with the transfer for safety. 6. Must have a minimum of 2 people to transfer patients. When needed for larger patients get more help to ensure a safe transfer. NEVER attempt to transfer alone or without adequate help to ensure the safety of the patient and staff. 7. Once transferred from the stretcher ensure patient is positioned and safety in bed. During interview on 09/13/2019 at 10:03 AM, Staff B (Certified Nursing Assistant/Transport Staff) stated the facility always required 2 staff members to assist with transport of a resident. She stated that it definitely required 2 staff members to transfer a resident from a stretcher to a bed. She stated that staff assisting with resident transfers were required to ensure the locks on the resident's bed were locked. During interview on 09/13/2019 at 10:16 AM, Staff C (Certified Nursing Assistant/Transport Staff) stated the facility required that 2 to 3 staff assist when transferring a resident from a stretcher to a bed. She stated that it was important to make sure the wheels on the bed were locked before attempting to transfer a resident from a stretcher to a bed and emphasized resident safety was a high priority during transfer. During interview on 09/13/2019 at 12:43 PM, Staff I (Physical Therapy Assistant/Resident Transfer Trainer) stated that all resident transfers required a minimum of 2 staff to assist with the transfer. She stated that a staff member should never attempt to transfer a resident alone. Record review of a facility Nursing Home Federal Reporting 5 Day Report (Date of Incident: 08/07/2019) revealed Resident #1 fell when Staff A (Certified Nursing Assistant/Transport Staff) transferred him from a stretcher to a bed and hit his head on the metal part of the bed. The report documented Resident #1 fell as a result of the bed not being locked. The Federal Report documented that an allegation of neglect had been substantiated by the facility. Record review of the emergency services Patient Care Report (Run Number ) revealed Resident #1 was transferred from the facility to the hospital on [DATE] at 19:43 following a fall. The emergency services Patient Care Report identified Resident #1's chief complaint as an acute traumatic event that resulted in pain in the occipital region of his head and lower back pain. The emergency services Patient Care Report documented Resident #1 was in pain and grimaced with palpitation of his head and back. The emergency services Patient Care Report documented Resident #1 reported pain in his head and spinal area and stated that it had felt like a baseball hitting him at 90 miles an hour. The emergency services Patient Care Report documented Resident #1 reported he was a little foggy after the incident and had warned the staff member about his weight. The emergency services Patient Care Report documented that the staff member did not head his warning about his weight, and he fell . Record review of the hospital emergency documentation record reveal Resident #1 arrived at the hospital on [DATE] at 19:58. The hospital emergency documentation record revealed Resident #1 had been received at the hospital with designated urgent acuity and was diagnosed as suffering from closed injury of the head, closed traumatic subdural hemorrhage, fall from hospital gurney, and [MEDICATION NAME] adverse reaction. Record review of the hospital emergency documentation record revealed Resident #1 revealed the emergency room physician issued statim radiology orders that Resident #1 undergo computed tomography scans of the abdomen and pelvis without contrast related to trauma, of the brain/head without contrast related to trauma, of the C-spine without contrast related to neck trauma and of the chest without contrast related to trauma. The hospital emergency documentation record documented the results of Resident #1's computed tomography scan of the brain/head without contrast as IMPRESSION: TWO NEW ACUTE APPEARING RIGHT SUBDURAL HEMORRHAGES ABUTTING ANTERIORSAGITTAL FALX, REPORTED TO PHYSICIAN AT 22:00 HOURS ON 8/07/19; WHO REPORTED THAT PATIENT TODAY DROPPED WHILE BEING TRANSFERRED FROM ASTRETCHER TO A BED. Record review of the hospital emergency documentation record revealed Resident #1 was transferred from the emergency department to another hospital (physician's orders [REDACTED]. The hospital emergency documentation record reported Requires specialty care as the reason for Resident #1's transfer to another hospital. Record review of facility training records revealed documentation Staff A had successfully completed training related to transferring a resident on 12/26/2018. During interview on 09/13/2019 at 12:48 PM, Staff A stated that the bed moved when she was transferring Resident #1 from a stretcher to the bed. She stated that even though she had received training to always use 2 people and ensure the bed wheels were locked during resident transfers, she had attempted to transfer Resident #1 alone without assistance from another staff member. She stated that it seemed like the bed was locked before she attempted to transfer Resident #1 without the assistance of another staff member. During interview on 09/13/2019 beginning at 12:10 PM, the facility Director of Nursing stated that Resident #1 required hospital emergency room evaluation and treatment after he fell during transfer on 08/07/2019. She confirmed that Staff A had not ensured the bed was locked prior to attempting to transfer Resident #1 from a stretcher to a bed. She confirmed that Staff A had attempted to transfer Resident #1 from a stretcher to a bed contrary to the facility transfer safety techniques in which Staff A had been trained. During an interview on 10/08/2019 at 3:18 PM via telephone with Resident #1's spouse, when asked regarding her husband's fall she stated, He did not fall, they caused that fall. They transferred him, they had to call EMS because he hit his head. I heard his head hit the ground, because they did not secure the bed or the gurney. That was the end result, he was on the ground. EMS transferred him to the hospital.