Every finding on record at Whitney Center

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #77) reviewed for activities of daily living (ADL), the facility failed to provide care and services sufficient to ensure the resident was free from neglect and harm. The facility failed notify the physician when a rash developed and worsened, failed to apply an appropriate treatment, failed to complete ongoing accurate assessments of the area and instead erroneously documented that the skin was intact during which time the rash was worsening without treatment. Staff handed the ordered Nystatin powder to the resident for self-application without education or an assessment of the resident's ability to apply it and failed to ensure and document the Nystatin was being applied when necessary. The facility failed to ensure the physician assessed the area timely for appropriate treatment and subsequently, over the course of 4 weeks, the rash worsened without treatment, spread to both groins, under both breasts and in the abdominal folds, became itchy and painful, impaired the resident's ability to sleep and resulted in a strong sour musty odor emanating in and from the resident's room. Subsequent to surveyor inquiry, MD #1 assessed the area for the first time since the resident's admission and identified the rash as candida intertrigo (a superficial fungal skin fold infection caused by yeast (candida) which causes skin fold inflammation, maceration, burning, itching and a distinctive musty rancid odor due to fungal growth). Further, MD #1 documented the candida intertrigo rash on the left groin exhibited superficial skin desquamation (separation of the outer layer of the skin) which required oral and topical antifungal medications. The findings include: Resident #77 was admitted to the facility in May 2026 with diagnoses that included macular degeneration, and legal blindness. The physician's orders dated 5/5/26 directed to apply Nystatin Powder (an antifungal powder used to treat fungal skin conditions) 100000 unit/gm to the breasts, abdominal folds, and groin topically every 12 hours as needed for rash. The physician's orders also directed to complete weekly skin checks every Tuesday evening shift. The nursing admission assessment dated [DATE] identified Resident #77 was alert and oriented, required glasses and a magnifying glass for vision, and had no skin issues. The care plan dated 5/8/26 identified Resident #77 had an ADL performance deficit due to activity intolerance. Interventions included to provide Resident #77 assistance of 1 for showering, dressing, and personal hygiene, and complete weekly skin inspections to observe for redness, open areas, scratches, cuts, and bruises. A physician's order dated 5/18/26 directed to apply Hydrocortisone cream 1% (a topical steroidal cream for skin rash) to the lower anterior neck as needed. Weekly skin checks were completed on 5/5, 5/12, and 5/19/26 and identified no skin issues. RN #4 completed the 5/19/26 check. A physician's note dated 5/22/26, by MD #1, identified that Resident #77 reported the rash on the anterior neck was better but hydrocortisone ran out and the area was becoming itchy. Recommendations included discontinue Hydrocortisone cream for the neck and start Triamcinolone 0.01% (a topical steroidal cream for rash) twice daily for one week then daily for one week and then reevaluate. A physician's order dated 5/22/26 directed to discontinue Hydrocortisone cream and start Triamcinolone 0.01% (a topical steroidal cream for rash) for neck rash. Nurse's note dated 5/23/26 at 9:58 PM, by RN #7, identified Resident #77 complained of itchiness and redness to the left side of the abdominal fold with redness and excessive moisture observed. RN #7 cleansed and dried the abdominal fold and applied Hydrocortisone cream (the Hydrocortisone cream was for a neck rash and had been discontinued 5/22/26). The note also identified Nystatin powder was reordered and awaiting pharmacy delivery. There was no documentation the physician was notified of the redness and excessive moisture in the abdominal fold. Physician's notes dated 5/8, 5/18, 5/22, 5/29, and 6/8/26 by MD #1 identified no documentation or assessment of the skin or rash in the inguinal area, abdominal folds or under the breasts. Skin checks dated 6/2 and 6/9/26 identified no documentation of skin rash in the inguinal area or abdominal fold. The clinical record dated May and June 2026, including the MAR's failed to identify that Nystatin powder had been applied to the inguinal area or abdominal folds. Observation on 6/14/26 at 8:00 AM and 10:10 AM identified a strong sour musty odor emanating in and from the residents room. Resident #77 was in the room sleeping. Interview with Resident #77 on 6/15/26 at 12:05 PM identified he/she has had a rash in the left groin area for several weeks which had now progressed to both abdominal folds and under both breasts. Resident #77 identified he/she has had a rash in the past but prior to admission in May 2026, the rash had cleared. After admission, the rash returned to the left groin, and he/she first reported the rash to NA#2 on one of his/her shower days. NA# 2 had a nurse come and look at the rash while in the shower room, however, the nurse looked at it and left the shower room with no treatment offered or provided. Within 2 days, the same nurse gave Resident #77 a small bottle of white powder and told the resident it was for the rash and to use the powder on the rash. Resident #77 showed this surveyor the small plastic bottle on his/her bedside table which was labeled Nystatin Powder 100000 unit/gm 15 gm, which appeared full and was not labeled with Resident #77's name. Resident #77 identified the nurse just left the powder in his/her room and did not give any instructions on how often or when to apply the powder. Resident #77 identified that due to his/her blindness, he/she was unable to apply the powder independently because of the size of the bottle, inability to see the bottle opening, and being unable to see his/her groin area. Resident #77 identified that he/she could not recall any other treatment or assessments of the area by staff, and no facility staff had ever applied the powder to the area. Resident #77 identified that the rash has become significantly worse, spreading all the way across his/her abdomen, under the breasts and into the underarm areas. Resident #77 identified the rash is very itchy and painful, and he/she was very uncomfortable and having difficulty sleeping. Observations during this interview continued to identify a strong sour musty odor emanating in and from Resident #77's room. Observation of Resident #77 with the DNS on 6/15/26 at 12:10 PM identified a large beefy red area at Resident #77's left groin extending up into Resident #77's left abdomen and down to the top of the left thigh. During this observation, the previously identified sour musty odor was more pronounced when looking at the rash areas. Resident #77 gave the bottle of Nystatin powder to the DNS. Upon exiting Resident #77's room, the DNS identified that she also noted a sour musty odor from the room that worsened during the assessment of Resident #77's left groin area. The DNS identified the smell as yeast and believed it was from the skin rash. The DNS identified that the Nystatin powder was the same type and bottle ordered from the facility pharmacy and identified it should be applied by a licensed nurse, kept in the medication cart and not left at Resident #77's bedside. The clinical record failed to reflect Resident #77 had been assessed to self-administer medications and there was no physician's order to self-apply the Nystatin powder. A physician's note dated 6/15/26, by MD #1 subsequent to surveyor inquiry identified that prior to admission to the facility, Resident #77 had been struggling with candida intertrigo (a superficial fungal skin fold infection caused by yeast (candida) which causes skin fold inflammation, maceration, burning, itching and a distinctive musty rancid odor due to fungal growth). Previously, Resident #77 had been using Nystatin powder with intermittent improvement and worsening and now the left groin had become painful. The left groin was observed to have superficial skin desquamation (separation of the outer layer of the skin) with lesser rash at the right groin and under the bilateral breasts. The treatment plan included to discontinue Nystatin powder, start Ketoconazole 2% ointment (a topical antifungal medication used to treat candida intertrigo) to the affected areas twice daily for one week, and Diflucan 100 mg (an oral antifungal medication) daily for 5 days, and re-evaluate in one week. Interview with RN #4 (RN Supervisor) on 6/16/26 at 12:15 PM identified she was the regular nurse assigned to Resident #77 and was aware that Resident #77 had a rash in the left inguinal fold which had been red and open for several weeks but was unable to recall when the rash first appeared. RN #4 identified that Resident #77 had an order for Nystatin powder which had been applied on scheduled shower days (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). RN #4 identified the Nystatin powder was applied by the nurse aides (this is in conflict with the DNS interview that licensed staff apply the Nystatin powder) and kept in the treatment cart (this is in conflict with the resident interview and surveyor observation that the Nystatin powder was left at the resident's bedside). RN #4 identified the nurse aides would notify the nurse that the Nystatin powder had been applied, and the nurse would document the application in the MAR. RN #4 identified that she had been notified by multiple nurse aides over the past several weeks that the Nystatin powder had been applied, however, she could not recall the names of the nurse aides who applied the Nystatin powder (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). RN #4 identified she was not sure what the facility policy was regarding nurse aide applying Nystatin powder. Following a review of MAR's dated May and June 2026, which identified no documentation of Nystatin powder having been applied, RN #4 identified that NA #2 first notified her of Resident #77's left inguinal area rash during a scheduled shower, and that RN #4 assessed the area and applied Nystatin powder after the shower (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied, and the resident interview that the nurse came into the shower room to see the rash, but left and did not apply a treatment). RN #4 was unable to say why there was no documented skin assessment of the area on that shower day after NA #2 notified her of the rash, why she had not documented the application of Nystatin powder, or why she documented Resident #77 had no skin issues on 5/19/26. (Based on the nursing schedules and interview with DNS on 6/17/26 at 6:30 AM, RN #4 and NA #2 were assigned to Resident #77, on a scheduled shower day, on 5/15/26. Interview with NA #2 on 6/16/26 at 2:00 PM identified that she occasionally floated to Resident #77's unit and the first time she was assigned to Resident #77, she was assisting Resident #77 in the shower room during a scheduled shower day. NA #2 indicated NA #3 showed her a red rash in Resident #77's left groin and belly area. NA #2 notified RN #4 who assessed the area and left the room. NA #2 identified that since she was not regularly assigned to Resident #77, she did not have any information about the rash after that day. NA #2 identified that Nystatin powder is only applied by the nurse and that the medication is kept in the locked medication cart (this is in conflict with RN #4 who identified the Nystatin powder was applied by the nurse aides, Resident #77 interview that indicated no one applied the Nystatin powder and that it was left at the bedside, and surveyor observation of the Nystatin powder at the bedside). Interview with NA #3 on 6/17/26 at 11:27 AM identified she was aware that Resident #77 had a rash on his/her left groin area but could not recall when she first saw it. NA #3 also identified that Nystatin powder would never be applied by a nurse aide. NA #3 identified that on Resident #77's unit there were not regularly assigned nurse aides and that staff often rotated assignments. NA #3 identified Resident #77 did not have a regular nurse aide assigned to him/her. Interview with RN #7 on 6/17/26 at 3:15 PM identified that she was an agency nurse who provided care for Resident #77 on 5/23/26 during the 3:00 PM - 11:00 PM shift. RN #7 recalled Resident #77 reported having a red itchy area in the left groin and she noted on assessment a reddened area to the left groin and abdominal fold, which also had moisture. RN #7 indicated she cleaned and dried the area and attempted to locate the Nystatin powder however none was available. RN #7 identified she notified the RN Supervisor (this is in conflict with the nursing schedule for 5/23/26 which identified she, RN #7, was the RN Supervisor for the 3:00 PM - 11:00 PM shift) and used what was on hand which was Hydrocortisone cream (the Hydrocortisone cream had been discontinued and had been ordered for a neck rash). RN #7 identified she did not check the physician's order for the Hydrocortisone cream, did not document on the MAR the application of the Hydrocortisone cream, did not notify the physician of the rash, and believed she reported the rash to the 3:00 PM - 11:00 PM RN Supervisor (this is in conflict with the nursing schedule for 5/23/26 which identified she, RN #7, was the RN Supervisor for the 3:00 PM - 11:00 PM shift). RN #7 indicated she did not know the Hydrocortisone cream had been discontinued or that it was ordered for a neck rash. Interview with MD #1 on 6/17/26 at 4:02 PM identified Resident #77 came into the facility with an active left inguinal rash (this is in conflict with the admission assessment which identified Resident #77 had no skin issues) and had used Nystatin powder in the past for treatment. MD #1 identified that Resident #77 initially reported that topical Nystatin powder was working however the area worsened (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). MD #1 identified on her assessment on 6/15/26, (subsequent to surveyor inquiry), the left groin area appeared angry and inflamed. MD #1 recommended discontinuing the Nystatin powder, starting oral Diflucan and topical Ketoconazole. MD #1 identified she was not aware Resident #77 had been given and directed to self-apply. MD #1 identified Resident #77 was legally blind and had visual acuity issues. MD #1 identified that although the order for the Nystatin powder directed application every 12 hours as needed, it should have been applied regularly and was meant to be applied daily after personal hygiene or after showers. Following a review of MD #1's physical exam notes dated 5/8, 5/18, 5/22, 5/29, and 6/8/26, which failed to identify documentation of an active left groin or inguinal rash with use of Nystatin powder, MD #1 identified that Resident #77 had not brought up any issues related to the left inguinal or groin area at any of the visits. MD #1 identified that Nystatin powder had been pulled from Resident #77's previous medication history. MD #1 identified she had not noted any odor during any of her visits with Resident #77 that were consistent with candida intertrigo. MD #1 also identified she had not been notified of worsening rash in the left groin, left inguinal area or abdominal folds until the DNS notified her on 6/15/26. MD #1 identified that Hydrocortisone cream (applied by RN #7) would not be appropriate to use on candida intertrigo. MD #1 further identified that it would be up to the nursing staff to determine if Resident #77 was able to safely administer medications including applying Nystatin powder and that would have required a self-administration medication assessment. The facility policy on resident abuse directed it was the policy of the facility to ensure that each resident was treated with kindness, compassion, and in a dignified manner in accordance with all regulations and applicable laws. Abuse or mistreatment of any kind towards a resident was strictly prohibited and allegations of abuse by an individual towards a resident must be reported immediately and all allegations would be thoroughly investigated and acted upon according to the steps of this policy. The policy further directed that neglect was the failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. The policy further directed that any observation, suspicion, or belief that a resident had been abused, neglected, exploited, or abandoned should be immediately reported to the supervisor on duty, the administrator of health services, and or the DNS. The facility policy on resident rights directed that residents of the facility had the right to be treated with consideration, respect, and full recognition of their dignity and individuality in an environment that promoted maintenance or enhancement of their quality of life and privacy in treatment handing care for their personal needs. The policy also directed that residents had the right to be treated equally with other residents in receiving care and services and that the facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source for care.

Based on review of the clinical record, facility documentation, facility policy and interviews for 4 of 7 residents (Resident #40, 42, 97 and 71) reviewed for pressure ulcers, the facility failed to consistently conduct weekly skin assessments, consistently monitor and comprehensively document pressure ulcers, report changes to the physician, and used multiple different wound assessment forms making it confusing to track progress. Physicians relied on licensed staff verbal reporting of wound condition which led to insufficient oversight, inadequate re-evaluation and delay in treatment changes. Despite the facility being aware of quality deficiencies with pressure ulcer surveillance, assessment, documentation, and tracking, the facility failed to implement and sustain effective corrective actions. This resulted in the deterioration of Resident #40s pressure ulcer to the right heel and right gluteal region overtime resulting in actual harm which required hospitalization. Further, it resulted in the application of a treatment to Resident #71 which was not indicated for use on healed skin. The findings include: 1. Resident #40 was admitted to the facility in December 2025 with diagnoses that included contractures and a stage II pressure ulcer of the coccyx. The admission nursing assessment dated [DATE] identified Resident #40 had a stage II pressure ulcer of the coccyx, present on admission, with partial thickness skin loss, exposed dermis with no undermining/tunneling. (Key characteristics such as description, measurement, size and drainage were not documented) Review of the Physician's History and Physical (H & P) dated 12/30/25 failed to address the stage II pressure ulcer of the coccyx. Review of the December 2025 physician's orders failed to direct a treatment to the stage II pressure ulcer of the coccyx The admission MDS dated [DATE] identified Resident #40 had moderately impaired cognition, required one person assist with bed mobility and toileting, two person assist with transfers, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers or pressure ulcer treatments (this is in conflict with the admission nursing assessment that identified a stage II pressure ulcer on the coccyx). The care plan dated 1/19/26 identified Resident #40 had a pressure ulcer. Interventions included educating the resident and family about causative factors and preventative measures, encourage good nutrition and follow facility protocols for treatment of an injury. a. Coccyx pressure ulcer. Review of the admission and weekly skin assessments dated 12/30/25 through 3/22/26, 11 weeks, identified no documented skin checks or assessments of the stage II pressure ulcer for 6 of the 11 weeks. Further, none of the 6 of the assessments completed included measurements or description of the stage II pressure ulcer. Review of physician's progress notes dated 1/2/26 through 3/22/26, 8 notes, failed to include documentation of an evaluation of the stage II pressure ulcer or subsequent treatment orders. Physician's note dated 3/23/26 identified Resident #40 had a stage II wound at the top of the sacrococcygeal junction (top of the tail bone and bottom of vertebrae) that measured 2.5 cm in diameter. (This is the first measurement of the stage II pressure ulcer on the coccyx since admission [DATE], 11 weeks) Physician's order dated 3/23/26 directed to cleanse the wound with normal saline, apply skin barrier and foam dressing with skin prep to the peri-wound every shift. (This is the first treatment order in 11 weeks). Physician's note dated 3/27/26 identified wounds were present on the heels, glute (unspecified) and sacrum. The wounds were unable to be examined. Staff reported much less discharge from the right heel wound. A skin check dated 4/8/26 identified the stage II pressure ulcer of the coccyx measured 4.0 cm by 1.5 cm with seropurulent drainage (thin, cloudy, yellow-tan drainage) and surrounding edema with Moisture associated skin dermatitis (MASD) on the buttocks. (There was no documented notification to the physician for the MASD, no documented notification of the drainage and no new physician's order). A wound nursing note dated 4/8/26 identified the stage II pressure injury of the coccyx measured 6.0 by 4.0 cm with no drainage (this is in conflict with the skin assessment that identified the pressure ulcer measured 4.0 cm by 1.5 cm). Physician progress note dated 4/10/26 identified that staff report wounds are stable (this is in conflict with the skin assessment and wound note of 4/8/26 that showed a deterioration of the stage II on the coccyx). Physician progress note dated 4/15/26 failed to reflect documentation of the coccyx pressure ulcer or any changes. A skin check dated 4/17/26 identified the stage II pressure injury of the coccyx measured 6.5 cm x 3.0 cm with light exudate, 80 % slough (devitalized tissue) and MASD to the buttock region described as plateaued. There was no documented notification for the MASD. Physician progress note dated 4/20/26 (12 days after MASD was first identified) noted a stage 1 - 2 pressure ulcer to the coccyx with fungal dermatitis. Physician's order dated 4/20/26 directed to apply Nystatin to the left glute (buttock) followed by skin prep to the wound, complete blood count or CBC (measures blood components) and basic metabolic profile or BMP (measures chemistry of blood). Review of skin checks and nursing wound notes dated 4/22/26 through 5/29/26, 5 weeks, only one wound note included measurements of the coccyx pressure ulcer and indicated no changes with continued MASD. Physician progress notes dated 4/22/26 through 5/14/26, 3 weeks, did not include a re-evaluation of the coccyx wound or MASD. Physician progress note dated 5/15/26 identified perirectal incontinence dermatitis looks slightly improved with no re-revaluation of the stage 1 - 2 pressure ulcer. Resident #40 was transferred to the hospital for evaluation of (separate) wounds on 5/29/26. A hospital wound assessment dated [DATE] identified a stage II moist open pressure injury to the left ischial tuberosity that measured 4.0 cm by 4.0 cm. The area was cleansed with soap and water, skin prep applied and was dry and intact upon discharge on [DATE]. The facility failed to consistently and comprehensively monitor and treat a stage II coccyx pressure ulcer between 12/30/25 - 5/29/26. b. Right heel wound. A skin check dated 2/16/26 identified a newly popped blister to the right heel that measured 4.5 cm x 8 cm with partial thickness skin loss and exposed dermis. A wound nursing note dated 2/16/26 identified a new wound, described as a blister, to the right heel that measured 4.5 cm x 8.0 cm, no tunneling/undermining with scant serosanguineous (red/pink) drainage (the area was not staged). Physician's order dated 2/18/26 (2 days following the identification of the blister) directed to cleanse the right heel with normal saline, apply Medi honey followed by a foam dressing and heel protector cup every evening, wrap with Coban tape. Physician progress note dated 2/19/26 identified a new stage III pressure ulcer to the right foot (this is in conflict with the area which was noted as the right heel). The plan included keeping the area clean and dry, applying skin prep to the surrounding area and cover with a foam heel cup. Offload heels with blue boots and a foam wedge while in bed. A skin check dated 4/8/26 identified the right heel stage II pressure ulcer measured 5.5 cm x 3.5 cm with 60% slough and moderate purulent drainage (this is in conflict with the physician progress note of 2/19/26 which identified the area as a stage III pressure ulcer, further, there was no documented notification to the physician of the deterioration). A wound nurses note dated 4/8/26 identified improvement in the right heel (this is in conflict with the skin check dated 4/8/26 which documents a deterioration). Subsequent skin check on 4/17/26 identified the left heel as a stage II without thorough description. Skin checks dated 4/24/26, 5/8/26 and 5/15/26 omitted measurements despite documenting increasing slough, eschar, drainage and odor (there was no documented notification to the physician of the deterioration). There were no other documented wound notes 4/9/26 through 5/17/26, 5 weeks. A wound nurses note dated 5/18/26 identified the right heel as unstageable with a measurement of 7.0 cm x 3.5 cm with moderate purulent drainage, slough and maceration. The physician was notified. Physician progress notes dated 5/22/26 identified improvement to the right heel in the appearance of the wound after partial debridement. Physician progress note dated 5/29/26 identified there was a concern for the right ischial tuberosity wound and the right heel. Further, although the right heel improved in appearance, it now has exposed bone. Resident #40 was transferred to the hospital. Hospital podiatric surgical consult dated 5/29/26 identified no surgical intervention required. Resident #40 was to continue with offloading and turning schedule, treatment and followed as outpatient. Osteomyelitis was ruled out. c. Right gluteal region wound. Also referred to in the clinical record as the right ischial tuberosity and right hip. A skin check dated 3/18/26 identified there was no documented skin condition to the right gluteal region. Wound nurses note dated 3/22/26, 2 days later, identified a new stage II pressure injury to the right hip measuring 4.0 cm x 1.5 cm, no tunneling or undermining with a scant amount of serosanguineous drainage. Physician progress note dated 3/23/26 identified a new right gluteal pressure injury with mixed tissue and linear deep tissue injury (DTI). Physician's orders dated 3/23/26 directed to apply protective barrier cream to the right gluteal stage I (pressure ulcer) followed by foam dressing to the right gluteal region DTI. Weekly skin checks dated 3/25, 4/1, 4/8, 4/17/26 and 4/24/26 did not include documentation of the right gluteal pressure ulcer. A wound nursing note dated 4/8/26 identified the right gluteal pressure ulcer had worsened measuring 6.0 cm x 2.0 cm with yellow drainage, slough and surrounding erythema. The physician was notified. (No change in treatment noted). Review of the clinical record failed to identify wound assessments had been completed on 3/30/26, and 4/16/26 through 4/21/26. Review of physician progress notes dated 3/27, 4/10 and 4/15/26 did not include documentation of the right gluteal pressure ulcer. The physician progress note dated 4/10/26 identified relying on staff reports that the wound was stable. A skin check dated 5/8/26 identified the wound had significantly deteriorated to a stage IV pressure ulcer measuring 8.0 cm x 7.0 cm with increased size, odor, exudate, surrounding maceration and 90% eschar. Skin checks 5/15, 5/18 and 5/22/26 identified the presence of a pressure injury with no other defining characteristics. The clinical record failed to reflect documentation of wounds/pressure ulcers from 4/22/26 to 5/17/26 over 3 weeks. Physician progress notes dated 5/8/26 identified Resident #40 was referred to plastic surgery as the gluteal pressure ulcer, now newly described as the ischial tuberosity, was larger. Bedrest was ordered with breaks for meals and quick trips. The right gluteal wound was described as large and deep with necrotic tissue requiring debridement on 5/15/26. Physician's progress note dated 5/18/26 identified the wound looked better. Physician's progress note dated 5/22/26 identified the wound remained unstageable. Physician's progress note dated 5/29/26 identified Resident #40 was sent to the hospital for possible surgical evaluation as the wound was described as large and deep, malodorous with slough requiring care beyond that of a wound clinic (scheduled for 6/9/26). The clinical record identified the resident was transferred to the hospital on 5/29/26. Hospital Discharge summary dated [DATE] identified Resident #40 was admitted with a right gluteal ischial pressure ulcer with suspected osteomyelitis and superimposed infection which was debrided on 5/31/26. A CT scan and subsequent infectious disease consult identified the wound was representative of osteomyelitis. Resident #40 was treated with IV antibiotics and discharged with continued antibiotic therapy to complete a six-week course. Resident #40 was to continue with recommended treatment of kerlix and gauze, continued vitamin/supplementation and follow up with infectious disease as an outpatient. Interview with the DNS on 6/15/26 7:39 AM identified nursing staff were expected to complete weekly skin assessments. The DNS indicated after her review, for those residents with wounds, weekly wound monitoring was inconsistent and not comprehensive. The nurses were using different forms to document wounds. One of the forms was 52 pages and confusing to work with. In response, the DNS developed and implemented a new condensed wound tracking assessment form but identified some nurses were still using alternate wound forms. The DNS further identified new wounds should be assessed comprehensively on admission or when newly identified and weekly thereafter. The DNS identified wound management was a shared responsibility of the interdisciplinary team, however, she was responsible for oversight. The DNS indicated nursing staff were educated when it was identified that wound notes were not being completed consistently and comprehensively. The DNS was unable to provide documentation of the education, did not complete audits to determine compliance and was unable to explain how it would be determined if there was improvement in wound documentation. Interview with MD #1 on 6/15/26 at 10:55 AM identified she was the Medical Director and monitored wounds at the facility. MD #1 indicated she did not conduct formal wound rounds and relied on nursing staff to comprehensively assess wounds and report to her. MD #1 would evaluate wounds based on clinical findings and nursing reports. MD #1 identified she became concerned about inconsistent wound tracking in the preceding 4 - 6 weeks and discussed the matter with the DNS. As a result, MD #1 now reviews anyone with wounds or rashes on a weekly basis. MD #1 indicated that for any newly identified wound she would expect a call from nursing staff to obtain information or for nursing staff to notify the on-call physician during after-hours and not wait until she was on site. Resident #40 was immobile with contractures, was noncompliant with repositioning and preferred to stay up in his/her chair for extended periods to spend time off the unit which contributed to the development and progression of pressure injuries. The right ischial would was largely unstageable and difficult to determine its progression overtime until debrided so it is difficult to determine if it was unavoidable. The right heel was also unstageable and there was an early concern for osteomyelitis. An early medical workup of labs in did not indicate infection and an x-ray of the right heel, which presented with exposed bone once debrided was negative for osteomyelitis. Resident #40 was referred to plastic surgery for further recommendations for both wounds as the emergency contact wanted to avoid hospitalization. Resident #40 was unable to be seen by the plastic surgeon therefore was subsequently transferred to the hospital after conferring with the emergency contact. Resident #40 was diagnosed with osteomyelitis of the right ischial tuberosity and treated with IV antibiotics before returning to the facility. Subsequent interview with the DNS following further record review on 6/17/26 at 6:14 AM identified it is expected that skin assessments be conducted weekly on shower days by nursing staff. If an abnormal skin condition is identified, nursing staff are expected to implement a weekly wound monitoring form and perform a more comprehensive assessment. If the form was not initiated or completed in its entirety with a comprehensive assessment, there was no conclusive way to determine and report changes over time. Interview with RN #8 on 6/17/26 at 9:35 AM identified he was responsible for weekly skin assessments for residents on his assignment. RN #8 indicated that for newly identified skin conditions requiring a more comprehensive assessment, the form can be expanded to document additional characteristics. RN #8 did not indicate the newly developed wound nursing note form would be implemented for a newly identified skin condition. Subsequent interview with MD #1 on 6/18/26 at 8:43 AM regarding the right heel wound, identified that comprehensive weekly wound tracking was inconsistent in recent weeks. These concerns were discussed with the DNS with variable improvement. MD #1 further identified a combination of inconsistent wound monitoring and timely reporting of significant changes instead of notification of subtle changes that could have been addressed earlier and lack of continuity of assessments due to different nursing staff managing the wound resulted in harm to Resident #40 with subsequent hospitalization. 2. Resident #42 was admitted to the facility in July 2025 with diagnoses that included myelodysplastic syndrome (abnormal blood cells that do not function properly), neoplasm of the colon and Alzheimer's disease. The quarterly MDS dated [DATE] identified Resident #42 was independent with bed mobility, transfers, and toileting, ambulated with the assistance of a walker, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The care plan dated 2/10/26 identified Resident #42 had the potential for developing a pressure ulcer and ADL deficit. Interventions included educating the resident and resident representative about the causes of pressure injuries, follow protocols for prevention and treatment of skin breakdown, provide a skin inspection and report changes to the nurse. A skin check dated 4/17/26 did not identify any abnormal skin conditions. A podiatry consult dated 4/22/26 identified the resident representative expressed concern regarding a red and inflamed area on the residents left ankle. Resident #42 was observed to have a pre-ulcerative site on the left lateral malleolus (ankle). Recommendations included thick heel protectors to prevent ulceration. The facility nurse took a verbal order from the physician. A nurses note dated 4/22/26 identified the (community) podiatrist notified the facility of redness to the left malleolus. Skin prep was to be applied twice daily and heel floats to be worn in the evening. The resident representative was present and notified of the new orders. Physician's order dated 4/22/26 directed skin prep to the left malleolus twice daily. Physician's progress note dated 4/24/26 identified Resident #42 was diagnosed with a new pressure ulcer of the left ankle by the podiatrist during routine care. Resident #42 complained of pain in the left foot where it was noted the left malleolar area had a central opening, stage II approximately 2.0 mm. No drainage or signs of infection. Heel floats were ordered as a protective measure. Review of the weekly skin checks and wound notes 4/30/26 through 5/18/26 did not include the presence of or any monitoring or tracking of the stage II pressure ulcer on the left malleolus. Interview with the DNS on 6/15/26 at 7:39 AM identified nursing staff were expected to complete weekly skin assessments. The DNS indicated for those residents with wounds, weekly wound monitoring was inconsistent and not comprehensive. The nurses were using different forms, one was 52 pages, and confusing to work with. In response, the DNS developed and implemented a new condensed wound tracking assessment form but noted some nurses were still using alternate wound forms. The DNS further identified new wounds should be assessed comprehensively on admission or when newly identified and monitored weekly thereafter. The DNS further identified wound management practices was a shared responsibility of the interdisciplinary team, however, she was responsible for oversight. The DNS indicated nursing staff were educated when it was identified wound notes were not being completed consistently and comprehensively. However, the DNS was unable to provide documentation of the education, did not complete audits to determine compliance and was unable to explain how it would be determined if there was improvement in the deficient practice. Observation on 6/17/26 at 6:30 AM identified the left malleolus was scabbed with no surrounding erythema. Review of the Skin Assessment policy dated 2022 directed that staff shall notify the physician when any resident is identified with a skin integrity concern. A description of the area is provided to the physician and orders obtained for wound care. The nurse shall document the wound orders in the medical record and responsible party notified. Wound care will be completed as ordered until a new treatment is received or the wound is healed. Weekly documentation of the wound will be performed until healed. Review of the Wound Management Program dated 8/2018 directed that all wounds will be monitored by the interdisciplinary team and current standards of practice. All residents will be assessed for skin integrity on admission using a skin tool. Skin integrity will be observed daily by the nurse aide, weekly by a licensed nurse. Any breach in skin integrity will be documented and monitored weekly until healed. All new wounds will be reported directly to the supervisor. The National Pressure Injury Advisory Panel (NPUAP) identifies wound assessments should include location, length, width, depth, wound bed characteristics (granulation, slough, eschar), Exudate/drainage amount and type, undermining/tunneling, condition of surrounding peri wound, signs of infection and pain [NPIAP International Guideline for Prevention and Treatment of Pressure Injuries, 2025]. 3. Resident #97 was admitted to the facility in January 2024 with diagnoses that included Alzheimer's disease and sacral pressure ulcer. The quarterly MDS dated [DATE] identified Resident #97 had moderately impaired cognition, was dependent on staff with personal hygiene, toileting and rolling left and right in bed. Additionally, Resident #97 was frequently incontinent of bladder, always incontinent of bowel, and had a stage 4 coccyx pressure ulcer on admission. The care plan dated 12/4/25 identified Resident #97 had impairment of the skin integrity and was readmitted with a stage 4 coccyx pressure ulcer. Interventions included use of an air mattress and treatment as ordered. The physician progress note dated 1/16/26 identified Resident #97's wound was not healing. The note indicated there were no reports of the wound getting worse; however, the prognosis remained poor. The physician progress note dated 2/20/26 identified Resident #97's sacral pressure injury had diminished in size. Resident #97 remained at high risk for recurrent skin integrity issues related to poor mobility, double incontinence, and resistance to repositioning. The physician progress note dated 4/24/26 identified Resident #97's sacral wound remained open with a depth of 0.8 cm, measuring 1.5 cm at the 5 o'clock position and 2 cm at the 12 o'clock position. The wound was noted to have grayish-brown drainage with an unpleasant odor. Resident #97 continued to decline slowly but appeared comfortable. The physician's order dated 6/1/26 (original order date 12/17/24) directed to perform weekly skin checks every Friday evening shift. The physician's order dated 6/1/26 (original order date 1/5/26) directed to place the resident on an air mattress while in bed, ensure the mattress was set and maintained according to manufacturer guidelines, and check mattress function and inflation every shift. The physician's order dated 6/1/26 (original order date 3/13/25) directed: Coccyx wound: Apply gauze soaked with Dakins 0.25% solution to wound bed for 10 minutes, pat dry. Apply skin prep to peri wound. Pack wound with Aquacel Ag rope using a continuous strip. Cover with Bordered foam dressing. Change daily and as needed every day shift. The clinical record failed to reflect documentation that weekly wound measurements were completed on 9/3/25, 9/10/25, 10/1/25, 10/8/25, 10/15/25, 10/22/25, 11/12/25, 11/19/25, 11/26/25, 12/3/25, 12/10/25, 12/17/25, 12/24/25, 12/31/25, 1/7/26, 1/14/26, 1/21/26, 1/28/26, 2/4/26, 2/11/26, 2/25/26, 3/4/26, 3/18/26, 4/1/26, 4/29/26, 5/6/26, 5/13/26, 5/20/26, 5/27/26, and 6/3/26. The clinical record failed to reflect documentation that weekly skin checks were completed on 9/5/25, 9/19/25, 10/3/25, 10/10/25, 11/7/25, 11/21/25, 12/5/25, 12/26/25, 1/2/26, 1/9/26, 2/27/26, 4/24/26, 5/1/26, 5/8/26, 5/29/26, and 6/12/26. The nurse's note dated 6/10/26 at 1:13 PM identified Resident #97 had a healing stage 3 pressure ulcer to the coccyx. The coccyx wound assessment measured 1 cm x 1 cm x 1 cm. No undermining, tunneling, drainage, odor or signs or symptoms of infection noted. The peri-wound area was intact with rolled edges. Wound care was provided as ordered and pressure-relieving/offloading interventions were continued. Interview and clinical record review with the DNS on 6/18/26 at 6:30 AM identified she was unable to provide documentation demonstrating weekly skin checks and weekly assessments including description and measurements had been completed consistently and was not aware that licensed nurses had not consistently completed weekly skin checks or weekly wound measurements as required. The DNS indicated licensed nurses are required to complete weekly skin checks on schedule shower days and to complete weekly wound assessments including description and measurements on Wednesdays. The DNS indicated it is the responsibility of the licensed nurse to complete and document these assessments in the clinical record. The DNS indicated she will be reviewing the facility's wound care program and providing education to the nursing staff. The DNS indicated that the facility does not have a designated nurse to do weekly wound monitoring. Interview with MD #1 on 6/18/26 at 9:00 AM identified she was not aware that licensed nurses had not consistently completed weekly skin checks or weekly wound assessments including description and measurements. MD #1 indicated licensed nurses are to complete weekly skin check and weekly wound assessments including description and measurements in accordance with facility policy. MD #1 indicated the licensed nurses are required to notify her when a wound deteriorates and she would assess the wound and review the treatment orders. Review of the facility skin checks policy identified skin checks will be completed weekly and as needed, on resident's shower day or on a day/time they prefer. The skin checks will be documented in the medical record. Review of the facility skin assessment policy identified all residents shall have a skin assessment weekly by a licensed nurse. If an area of concern is noted the licensed nurse shall notify the physician. A description of the area is given to the physician. The physician will address the concern by giving the licensed nurse orders for wound care. The nurse shall document the wound care orders in the [NAME]

Based on review of the clinical record, facility documentation, facility policy and interview for 4 of 5 residents (Resident #42, 29, 77, 18 and 21) reviewed for skin conditions, the facility failed to complete weekly skin assessments and wound assessments. The findings include: 1. Resident #42 was admitted to the facility in July 2025 with diagnoses that included myelodysplastic syndrome (abnormal blood cells that do not function properly), neoplasm of the colon and Alzheimer's disease. The quarterly MDS dated [DATE] identified Resident #42 was independent with bed mobility, transfers, toileting, ambulated with the assistance of a walker, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. The care plan dated 2/10/26 identified Resident #42 had the potential for developing a pressure ulcer and ADL deficit. Interventions included educating the resident and responsible party about the causes of pressure injuries, follow protocols for prevention and treatment of skin breakdown, provide a skin inspection and report changes to the nurse. Physician progress note dated 3/23/26 identified Resident #42 was observed with dry skin on his/her bottom, described as potentially mildly itchy. The plan included starting with A&D ointment with consideration for a topical antifungal if the condition worsens or fails to improve. Physician orders dated 3/23/26 directed A&D topical ointment to left buttocks/gluteal cleft (affected area dry skin) two times daily until resolved. Physician progress note dated 4/10/26 identified Resident #42 recalled previously having itchy skin but was reporting that it felt better. A&D cream was used for the dry area on the bottom with good effect. The skin was warm and dry with appropriate turgor and color. Skin Check dated 5/7/26 did not identify any abnormal skin conditions. Skin Check dated 5/14/26 was not completed. Physician's order dated 5/18/26 directed to apply Ketoconazole External Cream 2 % to left buttocks topically daily and Hydrocortisone Cream 2.5 % apply to left buttocks topically daily for a rash. The clinical record did not include a documented assessment for the left buttock. Skin condition dated 5/21/26 identified a rash on the left buttock of unspecified size. Resident #42 was seen by the physician and new orders were placed for Ketoconazole (medicated ointment used to treat fungal skin conditions and hydrocortisone cream (used to treat inflammatory skin conditions). Physician progress note dated 5/22/26 identified Resident #42 had a new rash on the buttock region and was responding to the prescribed antifungal cream. Interview with Person #1 on 6/15/26 at 9:00 AM identified a large rash was observed on the buttock region while assisting Resident #42 in the bathroom. Person #1 further identified he/she was concerned as the rash appeared that it had been present for some time. Resident #42 was subsequently received a dermatology consultation and was prescribed medications for treatment. Interview with MD #1, the Medical Director identified the presence of a fungal rash can appear over the course of a few days. Resident #42 had a large rash to the buttock region. Previously, Resident #42 was observed to have dry skin that had cleared. Resident #42 subsequently developed a large rash to the left buttock and ordered ketoconazole prior to being seen by dermatology. Interview with the DNS on 6/15/26 at 1:56 PM identified nursing staff were expected to conduct weekly skin check assessments and report any abnormal findings. The DNS further identified she was first notified of the skin rash by Person #1. Resident #42 was prescribed ketoconazole once identified. Review of the facility policy for the Wound Management Program dated 8/2018 directed that all wounds will be monitored by the interdisciplinary team and current standards of practice. All residents will be assessed for skin integrity on admission using a skin tool. Skin integrity will be observed daily by the nurse aide, weekly by a licensed nurse. Any breach in skin integrity will be documented and monitored weekly until healed. All new wounds will be reported directly to the supervisor. 2. Review of a hospital discharge assessment note dated 5/22/26 identified Resident #29 had skin issues which included right lower leg cellulitis and a right buttock wound. The note directed to reposition every 2 hours for the right buttock and treatments to the right lower leg. Resident #29 was admitted to the facility in May 2026 with diagnoses that included cellulitis of the right lower limb and venous insufficiency. The nursing admission assessment dated [DATE] failed to reflect an assessment or documentation of the right buttock wound, which was identified in the 5/22/26 hospital discharge assessment or the wounds to the right lower leg. two lower leg wounds located on the right medial calf and right shin, related to venous stasis. Further review of the admission assessment failed to identify an assessment of the wounds including appearance or measurements. Physician's order dated 5/22/26 directed skin checks weekly but failed to direct offloading of both lower extremities or the right buttock wound. A 5/23/26 Braden Scale assessment identified Resident #29 was at risk to develop pressure ulcers. A physician's note dated 5/23/26 identified Resident #29 was seen for the admission history and physical. The note identified Resident #29 had a history a foot ulcers as well as venous ulcers, was seen by podiatry following hospital admission and was found to have venous stasis dermatitis with maggots present upon exam. Vascular surgery was consulted during hospitalization due to a right great toe wound with drainage which was attributed to venous disease. Exam identified that Resident #29 had right lower extremity dressing in place that appeared clean, dry and intact, a right discolored/darkened toenail, and redness at the sacrum that was slow to blanche. The treatment plan for the right buttock wound included offloading every 2 hours; betadine and a dry sterile dressing to the right hallux daily per podiatry and can apply a mildly compressive ace bandage from the forefoot up to the tibial tuberosity for assistance with edema control daily. Resident #29 to have both extremities offloaded while in bed at all times. Review of the clinical record failed to reflect physician's orders for offloading of the right buttock or lower extremities or treatment for the redness at the sacrum. The care plan dated 5/23/26 identified cellulitis of the right lower extremity. Interventions included weekly treatment documentation to include measurement of each area of skin cellulitis including width, length, color, exudate, and any other notable changes or observations. The care plan failed to include interventions related for the right buttock wound or redness at the sacrum. The admission MDS dated [DATE] identified Resident # 29 had intact cognition, was always incontinent of bowel and bladder and required substantial assistance from staff with bathing and transfers and was dependent on staff assistance with toileting. Additionally, the MDS identified Resident #29 was at risk to develop pressure ulcers, had no pressure ulcers upon admission, and had 2 venous wounds upon admission. A weekly skin check note dated 5/29/26 identified the resident had venous wounds at the right shin and right medial calf present since admission but failed to note the right buttock wound or redness at the sacrum. A hyperbaric wound clinic note dated 6/2/26 identified Resident #29 had right lower extremity cellulitis. Exam identified an open wound on the right lateral leg that measured 7.5 cm x 8.0 cm x 0.1 cm with small to moderate serosanguinous drainage, a red wound base, open irregular borders, and moist drainage noted on the dressing. The exam also identified a wound at the right medial ankle which measured 0.6 cm x 0.6 cm x 0.2 cm that had scant serosanguinous drainage, a red wound base, open edges, and moist drainage noted on the dressing. The treatment plan identified to cleanse and soak the right leg and right plantar foot with Vashe solution, apply Aquacel AG f/b gauze, wrap with kerlix and Coban from the base of the toes to the crease of the knee and change every other day, and return to the clinic in two weeks. The note also directed that Resident #29 was referred to Podiatry for the foot callus with an appointment scheduled on 6/8/26. A 6/5/26 nursing weekly skin check note failed to reflect the right buttock wound or redness at the sacrum. A podiatry clinic note dated 6/9/26 identified Resident #29 had a stage III pressure injury at the right sub 5th metatarsal head of the right foot that appeared stable with granular tissue and fibrotic borders. The treatment plan identified to continue facility dressing changes every two days, offload the right foot and avoid pressure, footboard in wheelchair, foot placement to promote healing, and follow up with podiatry in three weeks to reassess closing and healing. A physician's order dated 6/9/26 directed treatment of the stage III pressure ulcer of the right foot, sub 5th metatarsal head to include Aquacel AG and compression wrap with kerlix and Coban, change every 2 days and offload the heels every shift. A 6/13/26 weekly skin check failed to reflect the newly identified stage III pressure ulcer at the right sub 5th metatarsal head of the right foot, the right buttock wound or redness at the sacrum. The note failed to identify any documentation of the wound appearance or measurements for each leg wound. Subsequent to surveyor inquiry, a weekly skin assessment completed on 6/15/26 at 11:56 AM identified Resident #29 had a stage III right plantar foot pressure injury at the sub 5th metatarsal head and a small stable scab at the left lateral lower leg. The assessment failed to document wound appearance or measurement for each leg wound. A hyperbaric wound clinic note dated 6/16/26 identified the wound at the plantar aspect of the 5th metatarsal of the right foot as closed and resurfaced, Resident #29 had right lower extremity cellulitis, the right lateral leg measured 2 cm x 2.5 cm x 0.1 cm with small serosanguinous drainage, a red scabbed wound base, open borders, and dried drainage noted on the dressing. Interview with the DNS on 6/17/26 at 2:00 PM identified she had been made aware of multiple issues related to pressure ulcer, wound, and skin assessments and wound monitoring during the survey. The DNS identified that she was not aware of the right buttock wound or redness at the sacrum upon the residents admission and was not aware that weekly wound assessments and full body skin assessments had not been completed. The DNS identified that it was the policy of the facility to complete weekly skin assessments by the licensed nurse and that the nurse aides did a visual check of the resident's skin daily during care. The DNS identified that if the nurse aide identified a skin issue, he/she would notify the licensed nurse who would complete an assessment of the area and if the issue was confirmed, the nurse would notify the physician for treatment orders. The DNS identified weekly skin assessments were per the physician's order and were to be documented in a skilled nursing assessment in their entirety including wound appearance and measurements as well as any newly identified skin concerns. The DNS also identified nursing staff were expected to observe and document any issues with bony prominences including the sacrum. The DNS was unable to identify why interventions including offloading of the buttocks and bilateral heels had not been implemented and were typically directed by the physician's orders. Interview with MD #1 on 6/17/26 at 4:02 PM identified that she was not aware of the right buttock wound or redness at the sacrum identified on admission. MD #1 also identified that while podiatry identified that Resident #29 had a newly identified stage III pressure ulcer at the right sub 5th metatarsal head of the right foot following callus removal, she would disagree as the wound did not appear to be caused by pressure. MD #1 identified she would have expected the nursing staff to follow the facility policy regarding skin assessments and pressure injury prevention. MD #1 failed to identify why there were no orders or subsequent assessments of Resident #29's right buttock or sacrum that were identified in the physician's exam note 5/23/26, or why orders to offload Resident #29's lower extremities, per the hospital documentation on 5/22/26 and 5/23/26 admission note, were not placed until 6/9/26 (18 days after admission) following the identification of the stage III pressure injury. The facility policy on skin assessments directed that all residents should have a skin assessment weekly by a licensed nurse. The policy further directed if the licensed nurse identified any resident with skin integrity concern, the licensed nurse would notify the MD. A description of the area would be given to the MD, and the MD would address the concern by giving the licensed nurse orders for wound care. The nurse would document the wound care orders in the electronic medical record. The family/POA would be notified of the change in skin integrity. Wound care would be completed as ordered until new treatment ordered was received or until healed. Weekly documentation of the wound would be performed until healed. The facility policy on weekly skin checks directed that skin checks would be completed weekly and as needed, on the resident shower day, or on a date and time that they preferred. The policy also directed that these skin checks would be documented in the medical record The facility policy on the wound management program directed that all wounds, regardless of origin, would be monitored throughout the facility, and managed using current standards of practice. Whenever possible, interventions would be identified with the goal to prevent tissue damage and/or infection. The policy further directed that all residents would be assessed for skin integrity upon admission using the skin tool in the electronic medical record. All residents would have their skin integrity observed daily by the nurse aide. All residents would have their skin integrity observed by nursing at least weekly. Any breach in skin integrity would be documented and monitored on the skin tool in the electronic medical record and done weekly until healed. The policy also directed that interventions and treatments would reduce or eliminate underlying contributing factors and that wound care would be directed by the MD order. 3. Resident #77 was admitted to the facility in May 2026 with diagnoses that included chronic kidney disease, macular degeneration, and legal blindness. The physician's orders dated 5/5/26 directed to apply Nystatin Powder (an antifungal powder used to treat fungal skin conditions) 100000 unit/GM to the breasts, abdominal folds, and groin topically every 12 hours as needed for rash. The physician's orders also directed to complete weekly skin checks every Tuesday evening shift. The nursing admission assessment dated [DATE] identified Resident #77 was alert and oriented, was occasionally incontinent of bladder, required glasses and a magnifying glass for vision, required a wheelchair and walker for mobility, and had no skin issues. The care plan dated 5/8/26 identified Resident #77 had an ADL performance deficit due to activity intolerance. Interventions included that Resident #77 required assist of 1 for showering, dressing, and personal hygiene, and required weekly skin inspections to observe for redness, open areas, scratches, cuts, and bruises. A physician's note dated 5/8/26 by MD #1 identified Resident #77 was seen for an admission history and physical and identified Resident #77 was legally blind related to macular degeneration. The physician's note failed to identify issues related to a skin rash or skin problems at Resident #77's inguinal area. Review of a BIMS assessment dated [DATE] identified Resident #77 had intact cognition. A physician's order dated 5/18/26 directed to apply Hydrocortisone cream 1 % (a topical steroidal cream for skin rash) to the lower anterior [NAME] as needed. Further review of the clinical record identified an order end date of 5/22/26. Review of the clinical record identified that Resident #77 had weekly skin checks completed on 5/5, 5/12, and 5/19/26. Further review of the clinical record identified the skin check on 5/19/26 was completed by RN #4 and identified Resident #77 had no skin issues. A physician's note dated 5/22/26 by MD #1 identified that Resident #77 reported the rash on the anterior neck was better but Hydrocortisone ran out and that Resident #77 felt the area was becoming itchy. The note further identified that the anterior neck rash had improved with less redness and no drainage. The note further identified assessment findings which included a subacute cough, environmental allergies, skin rash, and bilateral leg edema. The treatment plan included discontinue hydrocortisone cream for the rash on the neck and start triamcinolone 0.01% (a topical steroidal cream for rash) twice daily for one week then daily for one week and then reevaluate. Further review of the 5/22/26 physician's note failed to identify documentation related to a skin rash or skin problems at Resident #77's inguinal area. The nurse's note dated 5/23/26 at 9:58 PM by RN #7 identified that Resident #77 complained of itchiness and redness to the left side of the abdominal fold. The note further identified redness was observed with excessive moisture. The note further identified RN #7 cleansed and dried the abdominal fold and applied Hydrocortisone cream. The note also identified Nystatin powder was reordered and awaiting pharmacy. Review of the clinical record failed to identify an active physician's order for Hydrocortisone cream for Resident #77 on 5/23/26. Further review of the clinical record also failed to identify any documentation that the physician was notified regarding Resident #77's rash on or after 5/23/26. Review of the clinical record identified that Resident #77 had weekly skin checks completed on 6/2 and 6/9/26. Further review of the clinical record identified all skin checks and failed to identify any skin issues for Resident #77. Review of the clinical record failed to identify documentation that Nystatin powder was administered to Resident #77 for the months of May or June 2026. Observations on 6/14/26 at 8:00 AM and 10:10 AM identified a strong sour musty odor emanating from Resident #77's open doorway. Resident #77 was observed sleeping during these observations. Follow up observation and interview with Resident #77 on 6/15/26 at 12:05 PM identified he/she had a rash on his/her left groin area for several weeks which had now progressed to the bilateral abdominal folds and under both breasts. Resident #77 identified that he/she had an ongoing issue with a yeast rash in the folds of his/her abdomen, breasts and underarms over several years, however prior to admission to the facility on 5/5/26, the rash had cleared. Resident #77 identified that following admission, the rash began to return to his/her left groin area. Resident #77 identified that she first discussed the rash with NA #2 on one of his/her shower days but could not recall when. Resident #77 identified that NA #2 then had a nurse come and look at the rash, and after the nurse looked at it, the nurse left the shower room, and no treatment was offered or provided. Resident #77 identified that the following day, or possibly the day after, the same nurse provided Resident #77 a small bottle of white powder and directed that the bottle was for Resident #77 to use the powder on the rash. Resident #77 then picked up a small plastic bottle on his/her bedside table which was labeled Nystatin Powder 100000 unit/GM 15 GM. Observation identified the bottle appeared full and had no resident label identifying it was for Resident #77. Resident #77 identified the nurse just left the powder in his/ her room and had not given any instructions on how often or when to administer the powder, and due to his/her blindness, he/she was unable to apply the powder independently due to the size of the bottle, being unable to see the bottle opening, and being unable to see his/her groin area to apply the powder. Resident #77 identified that he/she could not recall any additional treatment or assessments of the area by any nursing staff, and no facility staff had ever applied the powder to the area for him/her. Resident #77 also identified that since the initial time the rash was looked at by NA #2 and the nurse, the rash had become significantly worse spreading all the way across his/her abdomen, under the breasts and into the underarm areas, was very itchy and painful, and that he/she was very uncomfortable and having difficulty sleeping due to the rash continuing to worsen. Observations during this interview continued to identify a strong sour musty odor emanating from Resident #77's room. Observation of Resident #77 and interview with the DNS on 6/15/26 at 12:10 PM identified a large beefy red area at Resident #77's left groin area and extending up into Resident #77's left abdomen and down to the top of Resident #77's left thigh. During this observation, the previously identified sour musty odor was more pronounced during the observation of Resident #77's skin area with the DNS. Resident #77 also provided the bottle of Nystatin powder to the DNS, who took the bottle from Resident #77 and identified she would come back with MD #1 to assess Resident #77 later in the afternoon. Upon exiting Resident #77's room, the DNS identified that she also noted a sour musty odor from the room that worsened during the assessment of Resident #77's left groin area. The DNS identified the smell as yeast and identified she believed it was from Resident #77's skin rash. The DNS identified that the Nystatin powder was the same type and bottle ordered from the facility pharmacy and that it was supposed to be administered by a licensed nurse from the medication cart and not left at Resident #77's bedside. Review of the clinical record failed to identify assessments related to self-administration of medication for Resident #77. Further review of the clinical record failed to identify any physicians order related to self-administration of nystatin powder for Resident #77. A physician's note dated 6/15/26 by MD #1 identified that Resident #77 had been struggling with candida intertrigo (a superficial fungal skin fold infection caused by yeast (candida) which causes skin fold inflammation, maceration, burning, itching and a distinctive musty rancid odor due to fungal growth) prior to admission to the facility. The note further identified that Resident #77 had been using Nystatin powder with intermittent improvement and worsening and now the left groin had become painful. The note identified that the left groin was observed to have superficial skin desquamation (separation of the outer layer of the skin) at the left groin, with lesser rash at the right groin and under the bilateral breasts. The note identified the treatment plan included an escalation of treatment which in included to discontinue Nystatin powder; start Ketoconazole 2% ointment (a topical antifungal medication used to treat candida intertrigo) to the affected areas twice daily for one week, and Diflucan 100 mg (an oral antifungal medication) daily for 5 days, and re-evaluate in one week. Interview with RN #4 (RN supervisor) on 6/16/26 at 12:15 PM identified she had been the regular nurse assigned to care for Resident #77 and was aware that Resident #77 had a rash at the left inguinal fold which had been red and open for several weeks. RN #4 identified she was unable to recall when the rash first appeared. RN #4 identified that Resident #77 had an order for Nystatin powder which had been applied on Resident #77's scheduled shower days (Monday and Friday on the 7:00 AM to 3:00 PM shift) but that the powder was applied by the nurse aide staff and kept in the treatment cart, not the medication cart. RN #4 identified that the nurse aides would notify the nursing staff that the powder was applied and then the nurse would document the medication administration on the MAR, and that she had been notified by multiple nurse aide staff over the past several weeks regarding Nystatin administration. RN #4 identified she was not sure what the facility policy was regarding nurse aide administration of prescribed medications. Following a review of MAR records for May and June 2026 which identified no documentation of Nystatin powder being administered for Resident #77, RN #4 then identified that NA #2 first notified her of Resident #77's rash during a scheduled shower day, and that RN #4 assessed the area and applied Nystatin powder to the area following Resident #77's shower. Following review of the 77's clinical record which failed to identify any documentation regarding this, RN #4 identified she was unable to identify why she had not documented Resident #77's skin assessment during his/her shower day with NA #2, why she had not documented any administration of Nystatin powder by her or any other staff members in May or June, why she documented Resident #77 had no skin issues on 5/19/26, or why she had not documented any assessments of Resident #77's left inguinal fold rash, which she identified had been present for several weeks and was red and open. Interview with NA #2 on 6/16/26 at 2:00 PM identified that she was not the regular nurse aide assigned to Resident #77, but she occasionally would float to Resident #77's unit and assist with resident care. NA #2 identified that the first time she was assigned to Resident #77's unit, she was assisting Resident #77 in the shower room during a scheduled shower day. NA #3 identified Resident #77 reported a red rash at the left groin and belly area and showed it to NA #2, who then notified RN #4. NA #2 identified RN #4, who assessed the area and then left the room. NA #2 identified that since she was not regularly assigned to Resident #77, she was not sure what happened after that regarding the rash. NA #2 also identified that Nystatin powder was only applied by the nurse assigned to Resident #77 and that the medication was kept in the locked medication cart, and that nurse aides would not have access to the medication. Interview with RN #7 on 6/17/26 at 3:15 PM identified that she was an agency nurse who provided care for Resident #77 on 5/23/26 on the 3:00 PM – 11:00 PM shift. RN #7 identified that she recalled Resident #77 reported having a red itchy area at the left groin and she noted on assessment a reddened area to the left groin and abdominal fold. RN #7 also identified that the area also had moisture and she cleaned and dried the area. RN #7 then attempted to locate Nystatin powder within the medication cart, however there was none available. RN #7 then identified notified the RN supervisor and that she used what was on hand which was Hydrocortisone cream. RN #7 identified she did not check the physician's order regarding the Hydrocortisone cream, did not document on the MAR regarding use of the Hydrocortisone cream, did not notify the physician, and believed she reported the skin issue the 3:00 PM – 11:00 PM RN supervisor as well as to next shift however she was not 100% sure. RN #7 identified she was not aware that there was not an active order for Hydrocortisone cream or that it had been previously ordered for an anterior neck rash. Review of the nursing schedule for 5/23/26 identified RN #7 was the RN supervisor for the 3:00 PM – 11:00 PM shift. Interview with MD #1 on 6/17/26 at 4:02 PM identified that Resident #77 came into the facility with an active left inguinal rash and had used Nystatin powder in the past for treatment. MD #1 identified that Resident #77 initially reported that topical Nystatin powder was working however the area worsened. MD #1 identified on her assessment on 6/15/26, subsequent to surveyor inquiry to the DNS, she noted assessment of Resident #77's left groin area appeared angry and inflamed. MD #1 identified her treatment plan included discontinuing Nystatin, starting oral Diflucan and topical Ketoconazole. MD #1 also identified that she was not aware that Resident #77 had been given the Nystatin powder or that any nursing staff had directed Resident #77 to self-administer the Nystatin powder and identified Resident #77 was legally blind and had visual acuity issues. MD #1 also identified that while the Nystatin powder orders were every 12 hours as needed, the powder should have been applied regularly and was meant to be applied daily after personal hygiene or after showers. Following a review of MD #1's physical exam notes on 5/8, 5/18, 5/22, 5/29, and 6/8/26, which failed to identify documentation related to an active left groin or inguinal rash with use of Nystatin powder, MD #1 then identified that Resident #77 had not brought up any issues related to the left inguinal or groin area at any of these visits. MD #1 identified that Nystatin powder had been pulled from Resident #77 previous medication history and MD #1 further identified that Resident #77 had reported complaints related to diarrhea and stasis dermatitis of the bilateral lower legs at most of his/her visits. MD #1 also identified most of her conversations at each visit with Resident #77 focused on changing cardiology providers. MD #1 identified she had not noted any odor during any of her visits with Resident #77 that were consistent with candida intertrigo. MD #1 also identified she had not been notified of any issues related to the left groin or left inguinal area by any nursing staff until the DNS notified her on 6/15/26. MD #1 also identified that the Nystatin powder was ordered specifically for candida intertrigo also identified that Hydrocortisone cream would not be appropriate to use on this type of skin issue. MD #1 further identified that it would be up to the nursing staff to determine if Resident #77 was able to safely administer medications to him/herself including Nystatin powder and that would have required a self-administration medication assessment. Although requested, the facility failed to provide a policy on medication administration. The facility policy on skin assessments directed that all residents should have a skin assessment weekly by a licensed nurse. The policy further directed if the licensed nurse identified any resident with skin integrity concern, the licensed nurse would notify the MD. A description of the area would be given to the MD and the MD would address the concern by giving the licensed nurse orders for wound care period the nurse would document the wound care orders in the electronic medical record. The family/POA would be notified of the change in skin integrity. Wound care would be completed as ordered until new treatment ordered was received or until healed. Weekly documentation of the wound would be performed until healed. The facility policy on weekly skin checks directed that skin checks would be completed weekly and as needed, on the resident shower day, or on a date and time that they preferred. The policy also directed that these skin checks would be documented in the medical record The fa

Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #21, 40 and 96) reviewed for nutrition the facility failed to monitor weights and document in the clinical record in accordance with physician orders. The findings include: 1. Resident #21 was admitted to the facility in August 2023 with diagnoses that included Alzheimer's disease and congestive heart failure. The quarterly MDS dated [DATE] identified Resident #21 was moderately cognitively impaired and required set up assist with eating. Physician orders dated 1/5/26 directed to obtain vital signs and weights every 15 days. Nutritional assessment dated [DATE] identified Resident #21weight was stable at 126 lbs. with no significant weight changes in the past 30, 90, 180 days. The resident receives 120ml house supplement daily for weight maintenance. No new nutrition recommendations at this time. The care plan dated 1/5/26 identified Resident #21 had a nutritional care plan in place with interventions that included to monitor for signs of dysphagia (difficulty swallowing), provide supplements as ordered and weight at the same time of day and record as ordered. Social service care plan note dated 1/14/26 identified appetite and possible weight loss discussed. Diet adjusted to chopped meats. Review of the weight log dated 1/21/26, and 5/11/26 identified Resident #21 had a weight loss of 14 lbs. or 9.52% loss in less than four months. The weight log further noted weights were obtained monthly and not every 15 days per physician's order. Interview and clinical record review with the Dietitian on 6/18/26 10:18 AM she routinely completes a nutritional assessment quarterly or as needed. Resident #21 had been experiencing weight loss over time and developed a pressure injury thereby increasing protein needs. Resident #21 received supplementation, was particular as to what he/she will accept, appetite was variable and he/she may even refuse weights. The Dietitian indicated that while a monthly weight was sufficient for Resident #21, obtaining weights as prescribed was inconsistent. There had been discussions with leadership about the need for improved weight monitoring in the past. However, the practice remained inconsistent. Interview with the DNS on 6/18/26 at 10:40 AM identified the nurse aide was responsible for obtaining weights per physician's order. The nurse evaluates any discrepancies. The DNS acknowledged there had been an ongoing problem with obtaining weights according to physician orders and that nurse aides should be consistent and document any refusals. A review of the facility policy for Weights directed weights to be obtained on admission, weekly for four weeks then monthly unless otherwise ordered by the physician. 2. Resident #40 was admitted to the facility in December 2025 with diagnoses that included hypertensive heart and chronic kidney disease, with heart failure. The admission MDS dated [DATE] identified Resident #40 had moderately impaired cognition, required supervision or touching assistance with eating, had no swallowing disorder, and did not have a 5% or more weight loss in the last month or 10% or more weight loss in the last 6 months. The care plan dated 1/19/26 identified Resident #40 had a nutrition focused care plan, with interventions that included completing weights as ordered. A physician's order dated 12/31/25 through 1/28/26 directed to complete a weight every week for 4 weeks, on admission. Review of the clinical record 12/31/25 through 1/30/26 identified the following weights: 1/5/26 - 209.2 lbs. 1/10/26 - 206 lbs. 1/12/26 - 182.7 lbs. (weight loss of 12.7% in 7 days). 1/18/26 - 185.4 lbs. 1/20/26 - 184.4 lbs. 1/30/26 - 182.2 lbs. A physician's order dated 1/6/26 through 3/2/26 directed to complete a weight every other day, on the day shift. Review of the clinical record dated 1/6/26 through 3/2/26 failed to identify weights were completed on the following days: 1/6, 1/8, 1/22, 1/26, 1/28, 2/3, 2/5, 2/7, 2/9, 2/11, 2/13, 2/15, 2/21, 2/23, 2/25, 2/27, and 3/1/26. A physician's order dated 3/3/26 through 6/2/26 directed to complete a weight every other day, on day shift, every Monday, Wednesday, and Friday. Review of the clinical record dated 3/3/26 through 6/2/26 failed to identify weights were completed on the following days: 3/2, 3/4, 3/6, 3/13, 3/16, 3/20, 3/23, 3/25, 3/27, 3/30, 4/1, 4/3, 4/6, 4/8, 4/10, 4/13, 4/15, 4/17, 4/20, 4/29, 5/4, 5/8, 5/11, 5/15, 5/18, 5/20, 5/22, and 5/25/26. Review of the Weights and Vitals Summary identified Resident #40 weighed 166.6 lbs. on 5/27/26, an 18.7% weight loss from 1/5/26. Interview with MD #1 on 6/18/26 at 8:20 AM identified that she was aware that Resident #40 had been losing weight and that the recommendations made by the Dietitian during the nutritional consults had been implemented, as well as monitoring lab work. MD #1 indicated that she was Resident #40's PCP; he/she had been her patient since before his/her admission to the facility, and that Resident #40 had been on a declining trajectory prior to admission, which was part of the reason for his/her long-term care stay. MD #1 further indicated that the order for every other day weight monitoring was not for the purpose of nutritional monitoring, but due to Resident #40's edema and history of heart failure, but that she would expect the weights to be completed per the physician's order and that more frequent weight monitoring would have identified a weight loss sooner. Interview with the Registered Dietitian (RD #1) on 6/18/26 at 10:00 AM identified that Resident #40 had some strange weights back in January, when he/she was admitted to the facility. RD #1 indicated that she had used the hospital weight for a baseline weight on 1/6/26 and that she believed it was an outlier, and the subsequent readings in the 180s were accurate weights. RD #1 indicated that if the facility's admission weight was not in the clinical record when she was completing her consult, then she would attempt to obtain a weight, if feasible, to ensure accurate weight reporting. RD #1 indicated that sometimes admission weights, reweights, and weights per the physician's orders were not always captured, in which case she would weigh the resident herself, if feasible. Interview with the DNS on 6/18/26 at 10:52 AM identified that routine weight monitoring for long term care residents was completed monthly unless an order otherwise was put in by the doctor. The DNS indicated that the nurse aides typically obtain the weights, but the nurses were responsible to ensure the weights were completed per the physician's order. The Weights policy directs that resident weights will be monitored regularly unless otherwise ordered by the attending physician. If a resident presents with a significant unplanned loss the following will be done: the resident will be reweighed to validate the variance, the attending physician will be notified of the weight loss, the dietitian will be notified of the weight loss, and the care plan will be updated with the appropriate interventions as needed. 3. Resident #96 was admitted to the facility October 2024 with diagnoses that included vascular dementia, diabetes, dysphagia, and gastrostomy. The care plan dated 2/12/25 identified Resident #96 as requiring a feeding tube related to dysphagia and failure to thrive. Interventions included administering feeding tube per physician's order, discontinuing feeding tube per resident request, and maintaining the head of bed elevated at 45 degrees during tube feeding and 30 minutes following administration. The annual MDS dated [DATE] identified Resident #96 had severely impaired cognition and required supervision or touching assistance with eating. The physician's order dated 11/8/25 through 6/1/26 directed to obtain weight every two weeks. Review of the clinical record failed to reflect documentation of weights had been obtained every 2 weeks per the order. The physician's progress note dated 10/2/25 through 6/15/26 failed to reflect documentation regarding resident weights. The medication administration record (MAR) dated 11/11/25 through 6/18/26 failed to reflect documentation that weights were obtained every two weeks and documented as ordered. Review of the nurse's note dated 11/11/25 through 6/18/26 failed to reflect documentation that weights had been obtained every two weeks in accordance with the physician's order. The care plan dated 4/27/26 identified Resident #96 would maintain tolerance to diet and feeding tube. Interventions included obtaining weights as ordered and providing the prescribed diet and feeding tube as ordered. The quarterly nutrition assessment dated [DATE] at 12:53 PM identified Resident #96 weighed 137.6 lbs. on 4/11/26. Resident #96 received a regular ground diet with thin liquids and was dependent on enteral nutrition for 100% of nutrition and hydration needs. Resident #96 indicated he/she does not eat anything here as he/she does not like the food and had a poor appetite, consumed only bites of food and tea, and remained at risk due to being underweight and having limited mobility. The quarterly nutrition assessment failed to reflect documentation regarding weight were not being obtained every two weeks as ordered and documented in the clinical record. The physician's order dated 6/1/26 directed to provide a regular diet, ground texture and thin liquid consistency. The order further directed administration of Glucerna 1.5 Cal at 80 ml/hr via feeding tube every shift. Feeding tube on at 8:00 PM, Off at 9:00 AM related to dysphagia. Review of the weights summary dated 6/16/26 identified the following weights were documented: 11/10/25 - 139.8 lbs. (no second weight documented for verification). 3/5/26 - 139.8 lbs. (no second weight documented for verification). 4/11/26 - 137.6 lbs. (no second weight documented for verification). Further clinical record review failed to reflect documentation of weights for December 2025, January 2026, February 2026, and May 2026 through June 18, 2026. Interview and clinical record review with the DNS on 6/18/26 at 8:30 AM identified she was not aware Resident #96's weights were not being obtained every two weeks as ordered and documented in the clinical record. The DNS indicated the clinical record lacked documentation that weights were obtained as ordered. The DNS indicated the nursing staff were responsible for ensuring weights were obtained and documented in the resident clinical record. Interview with LPN #3 on 6/18/26 at 8:52 AM identified he was not aware of Resident #96's weights had not been obtained and documented in the clinical record. LPN #3 indicated he had obtained Resident #96 weight sometimes, and he had forgotten to document the weights in the resident clinical record. LPN #3 indicated there was no designated area in the MAR for documenting resident weights. LPN #3 indicated the nurse aides were responsible for obtaining and documenting resident weights in the clinical record. Interview with RN #11 on 6/18/26 at 8:56 AM identified she was not aware Resident #96's weights had not been obtained and documented in the clinical record. RN #11 indicated the nurse aides were responsible for obtaining and documenting resident weights in the clinical record. Interview with MD #1 on 6/18/26 at 9:02 AM identified she was not aware Resident #96's weights had not been obtained and documented in the clinical record until the survey. MD #1 indicated the nursing staff were responsible for obtaining and documenting resident weights in accordance with physician's orders. MD #1 indicated the expectation was that licensed nurses follow the physician orders related to resident weights. MD #1 indicated the clinical record identified weights were not obtained as ordered. Interview and clinical record review with RN #6 (RN Supervisor) on 6/18/26 at 9:38 AM identified she was not aware Resident #96's weights had not been obtained and documented in the clinical record. RN #6 indicated the nurse aides were responsible for obtaining and documenting resident weights in the clinical record. RN #6 indicated there was no designated area in the MAR for documenting resident weights. Interview and clinical record review with the Dietitian on 6/18/26 at 10:28 AM identified she was aware that Resident #96's weights had not been obtained and documented in the clinical record. The Dietitian indicated the nursing staff were responsible for obtaining and documenting resident weights in accordance with physician's orders. Subsequent to surveyor inquiry regarding Resident #96's weight monitoring, the resident was weighed on 6/18/26. Review of the facility weights policy identified it is the policy of the facility that resident weights will be monitored regularly unless otherwise ordered by the attending physician. Weights are taken on all residents on admission, weekly for 4 weeks and then monthly unless there is a change in condition.

Based on observation, review of facility documentation, facility policy, and interviews for 2 of 2 medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed. The findings include:a. Observation on 6/15/26 between 7:30 AM - 7:55 AM of the East Rock medication cart with RN #8 (RN Supervisor) identified the following.Review of the East Rock controlled drug change of shift audit sheets dated February 2026 through June 14, 2026, identified missing signatures on multiple dates and shifts. February 2026 was missing 21 signatures.March 2026 was missing 14 signatures.April 2026 was missing 26 signatures.May 2026 was missing 33 signatures.June 1, 2026, through June 14, 2026 was missing 11 signatures. Interview with RN #8 on 6/15/26 at 7:52 AM identified he was not aware that the nurses were not signing the controlled drug change of shift audit sheets. RN #8 indicated it was the responsibility of all the nurses to sign the controlled drug change of shift audit sheets at the beginning of the shift and at the end of each shift when the controlled substance count is completed. b. Observation on 6/15/26 between 7:55 AM - 8:00 AM of the [NAME] Rock medication cart with RN #8 and LPN #3 identified the following.Review of the [NAME] Rock controlled drug change of shift audit sheets November 2025 through June 14, 2026 identified missing signatures on multiple dates and shifts. November 2025 was missing 21 signatures.December 2025 was missing 12 signatures.January 2026 was missing 38 signatures.February 2026 was missing 34 signatures.March 2026 was missing 19 signatures.April 2026 was missing 35 signatures.May 2026 was missing 23 signatures.June 1, 2026 through June 14, 2026 was missing 11 signatures. Interview with LPN #3 on 6/15/26 at 7:59 AM identified he was not aware that nurses were not signing the controlled drug change of shift audit sheets. LPN #3 indicated it was the responsibility of all the nurses to sign the controlled drug change of shift audit sheets at the beginning of the shift and at the end of each shift when the controlled substance count is completed. Interview with the [NAME] President of Health and Wellbeing on 6/15/26 at 9:12 AM identified she was not aware of the missing signatures on the controlled drug change of shift audit sheets. The [NAME] President of Health and Wellbeing indicated the expectation is that the licensed nurses will count the narcotics at change of each shift and sign the controlled drug change of shift audit sheets after completing the count.Interview with the DNS on 6/15/26 at 9:30 AM identified she was not aware of the missing signatures on the controlled drug change of shift audit sheets. The DNS indicated the expectation of the facility is that the on-coming and out-going licensed nurse count the controlled substances during each shift change and sign the controlled drug change of shift audit sheets. The DNS indicated an in-service will be given to the licensed nurses regarding the importance of signing the controlled drug change of shift audit sheets.Interview with MD #1 on 6/18/26 at 9:04 AM identified she was not aware of the missing signatures on the controlled drug change of shift audit sheets. MD #1 indicated the expectation of the facility is that the on-coming and out-going licensed nurse count the controlled substances during each shift change and sign the controlled drug change of shift audit sheets. Review of the controlled substances policy identified the purpose is to establish procedures for the safe procurement, storage, administration, documentation, inventory, and disposal of controlled substances within the facility. This policy is designed to ensure compliance with federal and state regulations, promote resident safety, and prevent diversion, loss, or misuse of controlled substances. Shift-to-shift counts > A complete count of all controlled substances shall be conducted at every nursing shift change. Two licensed staff members shall verify counts and sign the controlled substances record. Any discrepancy shall be investigated immediately and reported according to facility procedures.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to consistently record the dishwashers final rinse temperature according to facility policy. The findings include: Observation on 6/14/26 at 8:44 AM with the Chef Manager in the kitchen identified the June 2026 dish machine temperature record had missing dishwasher temperatures for the breakfast meals 6/4/26 through 6/10/26, 7 days, and for the lunch meal on 6/10/26.Interview with the Chef Manager on 6/14/26 at 8:44 AM identified he was not aware of the missing dishwasher temperatures 6/4/26 through 6/10/26 and for lunch on 6/10/26. The Chef Manager confirmed the identified temperature recordings had not been documented. The Chef Manager indicated the assigned dietary aide is responsible for documenting the dish machine temperatures at each meal. The Chef Manager indicated the dishwasher wash temperature should be maintained between 150 degrees Fahrenheit and 165 degrees Fahrenheit and the final rinse temperature should reach 180 degrees Fahrenheit.Interview with the Quality Venue Opener on 6/14/26 at 9:00 AM identified she was not aware of the missing dishwasher temperatures for breakfast on 6/4/26 through 6/10/26 and for lunch on 6/10/26. The Quality Venue Opener indicated the assigned dietary aide is responsible for documenting the dish machine temperatures at each meal. Interview with the [NAME] President of Health and Wellbeing on 6/14/26 at 9:10 AM identified she was not aware of the missing dishwasher temperatures for breakfast on 6/4/26 through 6/10/26 and for lunch on 6/10/26. The [NAME] President of Health and Wellbeing indicated she will meet with the kitchen staff regarding documenting dishwasher temperatures.Review of the dishwashing procedures policy identified the purpose is to establish standardized dishwashing procedures that ensure all dishes, utensils, and food-contact equipment are properly cleaned and sanitized in accordance with food safety regulations. Adhering to these procedures helps prevent cross-contamination, maintains sanitary conditions, protects the health and safety of residents and team members, and ensures compliance with health department and organizational standards. Record the final rinse temperature.

Based on review of facility documentation, the QAPI plan, and interviews, the facility failed to develop and implement policies and procedures for data collection systems, feedback, monitoring, analysis, and action, including adverse event monitoring and developing and implementing action plans. The findings include: Review of the QAPI Plan (requested during entrance conference) dated 1/2/26 directed that the purpose of the Quality Assurance and Performance Improvement (QAPI) Program was to establish a systematic, organization wide approach to monitoring, evaluating, and improving the quality of care, quality of life, safety, and services provided to residents. The QAPI Leadership Structure included the Administrator, Clinical Director, and the Director of Nursing, and the plan directed the following responsibilities: ensuring the implementation of the QAPI plan, providing necessary resources, and reporting outcomes to leadership. The QAPI plan failed to identify procedures for data collection systems, feedback, monitoring, and data analysis and failed to identify a mechanism to develop and implement action plans including measuring the success of actions and tracking performance. The QAPI plan further identified Performance Improvement Project (PIP) #1 was falls, with a goal to reduce falls with injury by 15% within 12 months. Review of the Medical Staff/Quality Assurance Meeting minutes dated 2/20/26 and 5/15/26 failed to identify data analysis and performance tracking for PIP #1. Review of the 11/21/25 and 2/20/26 Medical Staff/Quality Assurance Meeting sign in failed to identify the facility's Administrator was in attendance. Review of facility documentation dated 5/15/26 failed to identify the facility's Administrator was in attendance at the QA meeting. Interview with the Administrator on 6/18/26 at 11:32 AM identified that the DNS was not available to attend the QAPI task, as she was finishing up other areas of the survey. The Administrator indicated that the facility holds a hybrid meeting of Medical Staff and QAPI, quarterly, and that the facility's current QAPI program was in need of developing a more comprehensive plan for feedback, monitoring, data analysis, and performance tracking; his plan would be to separate the Medical Staff and QAPI meetings to ensure a more intensive focus on the quality assurance piece. The Administrator identified that the facility currently had falls as a performance improvement project, but he was not able to answer questions regarding specific details, as the [NAME] President of Health and Wellbeing was overseeing the project, and she was unavailable to attend the QAPI task. The Administrator indicated that he did not regularly attend the quarterly Medical Staff and QAPI meetings due to scheduling conflicts but moving forward he would ensure that the QAPI meetings would be scheduled on days that he could be in attendance, as he should be attending. The Administrator identified that he was not aware of the concerns, in particular about wounds and weight monitoring, that were identified by the survey team and he was not sure if the [NAME] President of Health and Wellbeing was aware. Although requested, a QAPI policy was not provided. Please cross reference F684, F686 and F692.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #77) reviewed for activities of daily living, the facility failed to ensure the residents dignity was maintained when appropriate assessment and treatment to a fungal rash was not done over the course of several weeks which led to the rash worsening that produced a strong sour musty odor in and emanating from the residents room. The findings include:Resident #77 was admitted to the facility in May 2026 with diagnoses that included chronic kidney disease, macular degeneration, and legal blindness. The physician's orders dated 5/5/26 directed to apply Nystatin Powder (an antifungal powder used to treat fungal skin conditions) 100000 unit/gm to the breasts, abdominal folds, and groin topically every 12 hours as needed for rash. The physician's orders also directed to complete weekly skin checks every Tuesday evening shift. The nursing admission assessment dated [DATE] identified Resident #77 was alert and oriented, required glasses and a magnifying glass for vision, and had no skin issues.The care plan dated 5/8/26 identified Resident #77 had an ADL performance deficit due to activity intolerance. Interventions included to provide Resident #77 assistance of 1 for showering, dressing, and personal hygiene, and complete weekly skin inspections to observe for redness, open areas, scratches, cuts, and bruises.A physician's note dated 5/18/26 by MD #1 identified Resident #77 an itchy rash to the lower anterior neck since 5/15/26. Recommendation included to apply Hydrocortisone cream topically. A physician's order dated 5/18/26 directed to apply Hydrocortisone cream 1% (a topical steroidal cream for skin rash) to the lower anterior neck as needed. Review of the clinical record identified that Resident #77 had weekly skin checks completed on 5/5, 5/12, and 5/19/26. Further review of the clinical record identified the skin check on 5/19/26 was completed by RN #4 and identified Resident #77 had no skin issues. A physician's note dated 5/22/26, by MD #1, identified that Resident #77 reported the rash on the anterior neck was better but hydrocortisone ran out and the area was becoming itchy. Recommendations included discontinue Hydrocortisone cream for the neck and start Triamcinolone 0.01% (a topical steroidal cream for rash) twice daily for one week then daily for one week and then reevaluate. A physician's order dated 5/22/26 directed to discontinue Hydrocortisone cream.The nurse's note dated 5/23/26 at 9:58 PM, by RN #7, identified that Resident #77 complained of itchiness and redness to the left side of the abdominal fold with redness and excessive moisture observed. RN #7 cleansed and dried the abdominal fold and applied Hydrocortisone cream (The Hydrocortisone cream was for a neck rash and had been discontinued 5/22/26). The note also identified Nystatin powder was reordered and awaiting pharmacy delivery.Review of the clinical record failed to identify the physician had been notified about Resident #77's complaint of itchiness and redness to the left side of the abdominal fold with redness and excessive moisture. Review of physician's notes dated 5/8/26, 5/18/26 5/22/26, 5/29/26 and 6/8/26 by MD #1 identified no documentation or assessment of the skin or rash in the inguinal area, abdominal folds or under the breasts. Review of skin checks dated 6/2/26 and 6/9/26 identified no documentation of skin rash or skin problems in the inguinal area or abdominal fold. Review of the clinical record dated May and June 2026, including the MAR's failed to identify that Nystatin powder had been applied to the inguinal area or abdominal folds. Observation on 6/14/26 at 8:00 AM and 10:10 AM identified there was a strong sour musty odor emanating in and from the residents room. Resident #77 was in the room sleeping. Interview with Resident #77 on 6/15/26 at 12:05 PM identified he/she has had a rash in the left groin area for several weeks which had now progressed to the both abdominal folds and under both breasts. Resident #77 identified that in the past he/she had a yeast rash in the folds of the abdomen, under the breasts and underarms, however, prior to admission to the facility in May 2026, the rash had cleared. Resident #77 identified that after admission, the rash began to return to the left groin area, and he/she first reported the rash to NA#2 on one of his/her shower days. NA# 2 had a nurse come and look at the rash while he/she was in the shower room, however, the nurse looked at it and left the shower room with no treatment offered or provided. Within 2 days, the same nurse gave Resident #77 a small bottle of white powder and told the resident it was for the rash and to use the powder on the rash. Resident #77 showed this surveyor the small plastic bottle on his/her bedside table which was labeled Nystatin Powder 100000 unit/gm 15 gm. The bottle appeared full and was not labeled with Resident #77's name. Resident #77 identified the nurse just left the powder in his/her room and did not given any instructions on how often or when to apply the powder. Resident #77 identified that due to his/her blindness, he/she was unable to apply the powder independently because of the size of the bottle, inability to see the bottle opening, and being unable to see his/her groin area. Resident #77 identified that he/she could not recall any other treatment or assessments of the area by staff, and no facility staff had ever applied the powder to the area. Resident #77 also identified that when the rash first developed it has become significantly worse, spreading all the way across his/her abdomen, under the breasts and into the underarm areas. Resident #77 identified the rash is very itchy and painful, and he/she was very uncomfortable and having difficulty sleeping because the rash continues to worsen. Observations during this interview continued to identify a strong sour musty odor emanating in and from Resident #77's room.Observation of Resident #77 with the DNS on 6/15/26 at 12:10 PM identified a large beefy red area at Resident #77's left groin and extending up into Resident #77's left abdomen and down to the top of the left thigh. During this observation, the previously identified sour musty odor was more pronounced when looking at the rash areas. Resident #77 gave the bottle of Nystatin powder to the DNS. Upon exiting Resident #77's room, the DNS identified that she also noted a sour musty odor from the room that worsened during the assessment of Resident #77's left groin area. The DNS identified the smell as yeast and believed it was from the skin rash. The DNS identified that the Nystatin powder was the same type and bottle ordered from the facility pharmacy and identified it should be applied by a licensed nurse, kept in the medication cart and not left at Resident #77's bedside. The clinical record failed to reflect Resident #77 had been assessed to self-administer medications and there was no physician's order to self-apply the Nystatin powder.A physician's note dated 6/15/26, by MD #1, subsequent to surveyor inquiry, identified that prior to admission to the facility, Resident #77 had been struggling with candida intertrigo (a superficial fungal skin fold infection caused by yeast (candida) which causes skin fold inflammation, maceration, burning, itching and a distinctive musty rancid odor due to fungal growth). Previously, Resident #77 had been using Nystatin powder with intermittent improvement and worsening and now the left groin had become painful. The left groin was observed to have superficial skin desquamation (separation of the outer layer of the skin) at the left groin, with lesser rash at the right groin and under the bilateral breasts. The treatment plan included an escalation of treatment to discontinue Nystatin powder, start Ketoconazole 2% ointment (a topical antifungal medication used to treat candida intertrigo) to the affected areas twice daily for one week, and Diflucan 100 mg (an oral antifungal medication) daily for 5 days, and re-evaluate in one week. Interview with RN #4 (RN Supervisor) on 6/16/26 at 12:15 PM identified she had been the regular nurse assigned to care for Resident #77 and was aware that Resident #77 had a rash at the left inguinal fold which had been red and open for several weeks. RN #4 was unable to recall when the rash first appeared. RN #4 identified that Resident #77 had an order for Nystatin powder which had been applied on scheduled shower days (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). RN #4 identified the Nystatin powder was applied by the nurse aides (this is in conflict with the DNS interview that licensed staff apply the Nystatin powder) and kept in the treatment cart (this is in conflict with the resident interview and surveyor observation that the Nystatin powder was left at the resident's bedside). RN #4 identified that the nurse aides would notify the nurse that the Nystatin powder had been applied, and the nurse would document the application in the MAR. RN #4 identified that she had been notified by multiple nurse aides over the past several weeks that the Nystatin powder had been applied, however, she could not recall the names of the nurse aides who applied the Nystatin powder (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). RN #4 identified she was not sure what the facility policy was regarding nurse aide application of Nystatin powder. Following a review of MAR's dated May and June 2026, which identified no documentation of Nystatin powder having been applied, RN #4 identified that NA #2 first notified her of Resident #77's left inguinal area during a scheduled shower day, and that RN #4 assessed the area and applied Nystatin powder to the area following Resident #77's shower (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied, and the resident interview that the nurse came into the shower room to see the rash, but left and did not apply a treatment). RN #4 was unable to say why there was no documented skin assessment during his/her shower day with NA #2, why she had not documented the application of Nystatin powder, or why she documented Resident #77 had no skin issues on 5/19/26.Interview with NA #2 on 6/16/26 at 2:00 PM identified that she was not the regular nurse aide assigned to Resident #77, but she occasionally would float to Resident #77's unit and assist with resident care. NA #2 identified that the first time she was assigned to Resident #77, she was assisting Resident #77 in the shower room during a scheduled shower day. NA #3 identified Resident #77 reported a red rash at the left groin and belly area and showed it to NA #2, who then notified RN #4. NA #2 identified RN #4 assessed the area and left the room. NA #2 identified that since she was not regularly assigned to Resident #77, she was not sure what happened after that regarding the rash. NA #2 also identified that Nystatin powder is only applied by the nurse assigned to Resident #77, that the medication was kept in the locked medication cart, and that nurse aides would not have access to the medication (this is in conflict with RN #4 identified the Nystatin powder was applied by the nurse aides, Resident #77 who indicated no one applied the Nystatin powder and that it was left at the bedside, and surveyor observation of the Nystatin powder at the bedside).Review of nursing schedules and interview with DNS on 6/17/26 at 6:30 AM identified RN #4 and NA #2 were assigned to Resident #77, on a scheduled shower day, on 5/15/26 (Friday).Interview with NA #3 on 6/17/26 at 11:27 AM identified she was aware that Resident #77 had a rash on his/her left groin area but could not recall when she first saw it. NA #3 also identified that Nystatin powder would never be applied by a nurse aide. NA #3 identified that on Resident #77's unit there were not regularly assigned nurse aides and that staff often rotated assignments on that unit. NA #3 identified Resident #77 did not have a regular nurse aide assigned to him/her.Interview with RN #7 on 6/17/26 at 3:15 PM identified that she was an agency nurse who provided care for Resident #77 on 5/23/26 during the 3:00 PM - 11:00 PM shift. RN #7 identified that she recalled Resident #77 reported having a red itchy area at the left groin and she noted on assessment a reddened area to the left groin and abdominal fold. RN #7 also identified that the area also had moisture and she cleaned and dried the area. RN #7 attempted to locate the Nystatin powder in the medication cart, however there was none available. RN #7 identified she notified the RN Supervisor (this is in conflict with the nursing schedule for 5/23/26 which identified she, RN #7, was the RN Supervisor for the 3:00 PM - 11:00 PM shift) and used what was on hand which was Hydrocortisone cream (the Hydrocortisone cream had been discontinued). RN #7 identified she did not check the physician's order regarding the Hydrocortisone cream, did not document on the MAR the application of the Hydrocortisone cream, did not notify the physician of the rash, and believed she reported the skin issue to the 3:00 PM - 11:00 PM RN Supervisor (this is in conflict with the nursing schedule for 5/23/26 which identified she, RN #7, was the RN Supervisor for the 3:00 PM - 11:00 PM shift) as well as to the next shift, however she was not sure. RN #7 identified that she was not aware that there was not an active order for Hydrocortisone cream or that it had been previously ordered for an anterior neck rash. Interview with MD #1 on 6/17/26 at 4:02 PM identified that Resident #77 came into the facility with an active left inguinal rash (this is in conflict with the admission assessment which identified Resident #77 had no skin issues) and had used Nystatin powder in the past for treatment. MD #1 identified that Resident #77 initially reported that topical Nystatin powder was working however the area worsened (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). MD #1 identified on her assessment on 6/15/26, (subsequent to surveyor inquiry), she noted the left groin area appeared angry and inflamed. MD #1 identified she recommended discontinuing the Nystatin powder, starting oral Diflucan and topical Ketoconazole. MD #1 also identified that she was not aware that Resident #77 had been given the Nystatin powder or that nursing staff had directed Resident #77 to self-administer the Nystatin powder. MD #1 identified Resident #77 was legally blind and had visual acuity issues. MD #1 also identified that although the Nystatin powder orders directed application every 12 hours as needed, it should have been applied regularly and was meant to be applied daily after personal hygiene or after showers. Following a review of MD #1's physical exam notes on 5/8, 5/18, 5/22, 5/29, and 6/8/26, which failed to identify documentation of an active left groin or inguinal rash with use of Nystatin powder, MD #1 then identified that Resident #77 had not brought up any issues related to the left inguinal or groin area at any of the visits. MD #1 identified that Nystatin powder had been pulled from Resident #77's previous medication history. MD #1 identified she had not noted any odor during any of her visits with Resident #77 that were consistent with candida intertrigo. MD #1 also identified she had not been notified of any issues related to the left groin or left inguinal area by any nursing staff until the DNS notified her on 6/15/26. MD #1 also identified that the Nystatin powder was ordered specifically for candida intertrigo that the Hydrocortisone cream would not be appropriate to use on this type of skin issue. MD #1 further identified that it would be up to the nursing staff to determine if Resident #77 was able to safely administer medications to him/herself including Nystatin powder and that would have required a self-administration medication assessment. The facility policy on resident rights directed that residents of the facility had the right to be treated with consideration, respect, and full recognition of their dignity and individuality in an environment that promoted maintenance or enhancement of their quality of life and privacy in treatment handing care for their personal needs. The policy also directed that residents had the right to be treated equally with other residents in receiving care and services and that the facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source for care.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #77) reviewed for activities of daily living, the facility failed to ensure that a resident with significant visual impairment was assessed to self-administer medications prior to being given Nystatin powder to self apply, which was left unsecured at the bedside, and prior to obtaining an order from the physician to self administer Lactaid. The findings include: Resident #77 was admitted to the facility in May 2026 with diagnoses that included chronic kidney disease, macular degeneration, and legal blindness.The nursing admission assessment dated [DATE] identified Resident #77 was alert and oriented, was occasionally incontinent of bladder, required glasses and a magnifying glass for vision, required a wheelchair and walker for mobility, and had no skin issues.The physician's order dated 5/5/26 directed to apply Nystatin Powder (an antifungal powder used to treat fungal skin conditions) 100,000 unit/GM to the breasts, abdominal folds, and groin topically every 12 hours as needed for rash. The physician's orders also directed to complete weekly skin checks every Tuesday evening shift. Further, administer Lactaid tablet 3000 units (an over the counter medication used to treat lactose intolerance) 2 tablets by mouth twice daily for lactose intolerance. May leave at bedside for self-administration.Review of the clinical record failed to identify documentation that an assessment to self-administer medications had been completed. The care plan dated 5/8/26 identified Resident #77 had an ADL performance deficit due to activity intolerance. Interventions included that Resident #77 required the assistance of 1 for showering, dressing, and personal hygiene, and required weekly skin inspections to observe for redness, open areas, scratches, cuts, and bruises. The care plan failed to reflect self-administration of medications.A physician's note dated 5/8/26 by MD #1 identified Resident #77 was seen for an admission history and physical and identified Resident #77 was legally blind related to macular degeneration and that Resident #77 was able to take Lactaid on his/her own. The note also identified Resident #77 denied any active issues, and on physical exam, Resident #77's skin had chronic skin changes to the bilateral legs, a thickened skin patch behind the left medial malleolus, and the soles of the feet were rough and darkened, which Resident #77 reported was from walking barefoot. The note also identified no open areas to the skin. Review of a BIMS assessment dated [DATE] identified Resident #77 had intact cognition.Review of the clinical record identified that Resident #77 had weekly skin checks completed on 5/5, 5/12, and 5/19/26. The skin check on 5/19/26 was completed by RN #4 and identified Resident #77 had no skin issues. The nurse's note dated 5/23/26 at 9:58 PM by RN #7 identified that Resident #77 complained of itchiness and redness to the left side of the abdominal fold. The note further identified redness was observed with excessive moisture and that RN #7 cleansed and dried the abdominal fold and applied hydrocortisone cream. The note also identified Nystatin powder was reordered and awaiting pharmacy.Review of the clinical record identified that Resident #77 had weekly skin checks completed on 6/2 and 6/9/26. Further review of the clinical record identified all skin checks and failed to identify any skin issues for Resident #77.Review of the clinical record failed to identify that Nystatin powder had been applied during the months of May or June 2026.On 6/14/26 at 8:00 AM and 10:10 AM there was a strong sour musty odor emanating from Resident #77's open doorway. Resident #77 was observed sleeping during these observations. Interview with Resident #77 on 6/15/26 at 12:05 PM identified he/she has had a rash on the left groin area for several weeks which had now progressed to the abdominal folds and under both breasts. Resident #77 identified that he/she had an ongoing issue with a yeast rash in the folds of his/her abdomen, breasts and underarms over several years, however prior to admission to the facility in May 2026, the rash had cleared. Resident #77 identified that following admission, the rash began to return to the left groin area. Resident #77 identified that he/she first discussed the rash with NA #2 on one of the shower days but could not recall when. Resident #77 identified that NA #2 had a nurse come and look at the rash, and after the nurse looked at it, the nurse left the shower room, and no treatment was offered or provided. Resident #77 identified that the following day, or possibly the day after, the same nurse gave Resident #77 a small bottle of white powder and told Resident #77 the powder was for the rash. Resident #77 picked up a small plastic bottle on his/her bedside table which was labeled Nystatin Powder 100000 unit/GM 15 GM. Observation identified the bottle appeared full and had no resident label identifying it was for Resident #77. Resident #77 identified the nurse just left the powder in his/ her room and had not given any instructions on how often or when to administer the powder, and due to his/her blindness, he/she was unable to apply the powder independently due to the size of the bottle, being unable to see the bottle opening, and being unable to see his/her groin area to apply the powder. Resident #77 identified that he/she could not recall any additional treatment or assessments of the area by any nursing staff, and no facility staff had ever applied the powder to the area for him/her. Resident #77 also identified that since the initial time the rash was looked at by NA #2 and the nurse, the rash had become significantly worse spreading all the way across the abdomen, under the breasts and into the underarm areas, was very itchy and painful, and that he/she was very uncomfortable and having difficulty sleeping due to the rash continuing to worsen. During this interview the strong sour musty odor was smelt and was emanating from Resident #77's room.Observation of Resident #77's rash areas with the DNS on 6/15/26 at 12:10 PM identified a large beefy red area at Resident #77's left groin extending up into Resident #77's left abdomen and down to the top of Resident #77's left thigh. During this observation, the previously identified sour musty odor was more pronounced. Resident #77 also provided the bottle of Nystatin powder to the DNS, who took the bottle from Resident #77 and identified she would come back with MD #1 to assess Resident #77 later in the afternoon. Upon exiting Resident #77's room, the DNS identified that she also noted a sour musty odor from the room that worsened during the assessment of Resident #77's left groin area. The DNS identified the smell as yeast and identified she believed it was from Resident #77's skin rash. The DNS identified that the Nystatin powder was the same type and bottle ordered from the facility pharmacy and that it should have been administered by a licensed nurse from the medication cart and not left at Resident #77's bedside. A physician's note dated 6/15/26 by MD #1 identified that Resident #77 had been struggling with candida intertrigo (a superficial fungal skin fold infection caused by yeast (candida) which causes skin fold inflammation, maceration, burning, itching and a distinctive musty rancid odor due to fungal growth) prior to admission to the facility. The note further identified that Resident #77 had been using Nystatin powder with intermittent improvement and worsening and now the left groin had become painful. The note identified that the left groin was observed to have superficial skin desquamation (separation of the outer layer of the skin) at the left groin, with lesser rash at the right groin and under the bilateral breasts. The note identified the treatment plan included an escalation of treatment which in included to discontinue Nystatin powder; start Ketoconazole 2% ointment (a topical antifungal medication used to treat candida intertrigo) to the affected areas twice daily for one week, and Diflucan 100 mg (an oral antifungal medication) daily for 5 days, and re-evaluate in one week. Interview with RN #4 (RN supervisor) on 6/16/26 at 12:15 PM identified she had been the regular nurse assigned to care for Resident #77 and was aware that Resident #77 had a rash at the left inguinal fold which had been red and open for several weeks. RN #4 identified she was unable to recall when the rash first appeared. RN #4 identified that Resident #77 had an order for nystatin powder which had been applied on Resident #77's scheduled shower days (Monday and Friday on the 7:00 AM to 3:00 PM shift) but that the powder was applied by the nurse aide and kept in the treatment cart, not the medication cart (this is in conflict with the interview with Resident #77 who said staff had not applied the powder). RN #4 identified that the nurse aides would notify the nursing staff that the powder was applied and then the nurse would document the medication administration on the MAR, and that she had been notified by multiple nurse aides over the past several weeks regarding nystatin application. RN #4 identified she was not sure what the facility policy was regarding nurse aide administration of prescribed medications. Following a review of MAR records for May and June 2026 there was no documentation of Nystatin powder being applied. RN #4 then identified that NA #2 first notified her of Resident #77's rash during a scheduled shower day, and that RN #4 assessed the area and applied nystatin powder to the area following Resident #77's shower. Following review of the 77's clinical record which failed to identify any documentation regarding the application of Nystatin powder by RN #4. RN #4 identified she was unable to say why she had not documented Resident #77's sin assessment during his/her shower day with NA #2, why she had not documented any application of Nystatin powder in May or June 2026, why she documented Resident #77 had no skin issues on 5/19/26, or why she had not documented the left inguinal fold rash, which she identified had been present for several weeks and was red and open.Interview with NA #2 on 6/16/26 at 2 PM identified that she was not the regular nurse aide assigned to Resident #77, but she occasionally would float to Resident #77's unit and assist with resident care. NA #2 identified that the first time she was assigned to Resident #77's unit, she was assisting Resident #77 in the shower room during a scheduled shower day. NA #3 identified Resident #77 reported a red rash at the left groin and belly area and showed it to NA #2, who then notified RN #4. NA #2 identified RN #4 assessed the area and then left the room. NA #2 identified that since she was not regularly assigned to Resident #77, she was not sure what happened after that regarding the rash. Review of nursing schedules for 5/15/26 - 5/17/26 and interview with DNS on 6/17/26 at 6:30 identified upon her review of the nursing schedules, census, Resident #77's admission and shower days, RN #4 and NA #2's daily assignments, the first day NA #2 would have been assigned to Resident #77 with RN #4 also working on a scheduled shower day for Resident #77 would have been 5/15/26 (Friday). Further review of the nursing schedules for 5/16/26 identified RN #4 was assigned to Resident #77 on the 7:00 AM - 3:00 PM shift and on 5/17/26 RN #4 was assigned to Resident #77 on both the 7:00 AM - 3:00 PM shift and 3:00 PM - 11:00 PM shift.Interview with RN #8 on 6/17/26 at 11:07 AM identified that he was sometimes assigned as the nurse for Resident #77. RN #8 identified that when Resident #77 first came to the facility on 5/5/26 he noted that there was an odor coming from her belongings which she brought from her prior facility. RN #8 identified that the odor had now dissipated but he would at times smell an odor coming from Resident #77 that smelt musty which he attributed to Resident #77 refusing showers at times. RN #8 identified he was not aware of any issues related to candida intertrigo for Resident #77.Interview with Housekeeper #1 on 6/17/26 at 11:15 AM identified that she had noted a strong foul odor in Resident #77's room. Housekeeper #1 identified that Resident # 77 had a lot of belongings within the room and at times was incontinent of urine. Housekeeper #1 identified she wasn't sure if the smell was related to Resident #77 or his/her belongings, but Housekeeper #1 had noted the odor for several weeks.Interview with RN #7 on 6/17/26 at 3:15 PM identified that she was an agency nurse who provided care for Resident #77 on 5/23/26 on the 3:00 PM - 11:00 PM shift. RN #7 identified that she recalled Resident #77 reported having a red itchy area at the left groin and she noted on assessment a reddened area to the left groin and abdominal fold. RN #7 also identified that the area also had moisture and she cleaned and dried the area. RN #7 then attempted to locate Nystatin powder within the medication cart, however there was none available. RN #7 identified she notified the RN supervisor and that she used what was on hand which was hydrocortisone cream. RN #7 identified she did not check the physician's order regarding the hydrocortisone cream, did not document on the MAR regarding use of the hydrocortisone cream, did not notify the physician, and believed she reported the skin issue the 3:00 PM - 11:00 PM RN supervisor as well as to next shift. RN #7 identified she was not aware that there was not an active order for hydrocortisone cream or that it had been previously ordered for an anterior neck rash. Interview with MD #1 on 6/17/26 at 4:02 PM identified that Resident #77 came into the facility with an active left inguinal rash and had used Nystatin powder in the past for treatment. MD #1 identified that Resident #77 initially reported that topical Nystatin powder was working however the area worsened. MD #1 identified on assessment 6/15/26, subsequent to surveyor inquiry to the DNS, she noted the left groin area appeared angry and inflamed. MD #1 identified her treatment plan included discontinuing Nystatin, starting oral Diflucan and topical ketoconazole. MD #1 also identified that she was not aware that Resident #77 had been given the Nystatin powder or that nursing staff had directed Resident #77 to self-administer the Nystatin powder and identified Resident #77 was legally blind and had visual acuity issues. MD #1 also identified that while the Nystatin powder orders were every 12 hours as needed, the powder should have been applied regularly and was meant to be applied daily after personal hygiene or after showers. Following a review of MD #1's physical exam notes on 5/8, 5/18, 5/22, 5/29, and 6/8/26, which failed to identify documentation related to an active left groin or inguinal rash with use of Nystatin powder, MD #1 identified that Resident #77 had not brought up any issues related to the left inguinal or groin area at any of these visits. MD #1 identified that Nystatin powder had been pulled from Resident #77 previous medication history and MD #1 further identified that Resident #77 had reported complaints related to diarrhea and stasis dermatitis of the bilateral lower legs at most of his/her visits. MD #1 also identified most of her conversations at each visit with Resident #77 focused on changing cardiology providers. MD #1 identified she had not noted any odor during any of her visits with Resident #77 that were consistent with candida intertrigo. MD #1 also identified she had not been notified of any issues related to the left groin or left inguinal area by any nursing staff until the DNS notified her on 6/15/26. MD #1 also identified that the nystatin powder was ordered specifically for candida intertrigo also identified that hydrocortisone cream would not be appropriate to use on this type of skin issue. MD #1 further identified that it would be up to the nursing staff to determine if Resident #77 was able to safely administer medications to him/herself including nystatin powder and that would have required a self-administration medication assessment. Although requested, the facility failed to provide a policy on medication administration.The facility policy on self-administration of medication directed the facility was to allow residents the right to self-administer medications and treatment subject to the approval of the interdisciplinary team and the MD. The policy further directed that on admission, the resident and or the responsible party would be informed if the resident wished to administer his or her own medications and treatments the following would occur:The resident would be assessed for the capability to self-administer.If the resident was assessed to be incapable, the nurse would sign and date the self-administration form checking that the resident was incapable of self-administering medication treatment. If the resident was assessed as being capable the resident must sign the self-administration form. This would then be included in the resident's plan of care.A physician's order must be obtained for the self-administration indicating the specific medication and treatments to be self-administered by the resident.Nursing was responsible for recording on the MAR the medications that were given. In order to do this the nurse should inquire at the end of each shift to determine if routine and or PRN medications were taken and document the resident's response on the MAR prior to the next care plan review and on an annual basis the nurse should check for the proper storage and correct count of the medications to ascertain the continued ability of the resident to self-administer his her own medications.The policy also directed that the privilege to self-administer medications could be revoked:By the interdisciplinary team if they determined for any reason it was unsafe.The resident refused or forgot to notify the nursing staff that medications were or were not taken.The resident did not safely store medications.When the amount of medications was audited and it was determined that the resident was not taking the medications as ordered.The facility policy on storage and expiration dating of medications and biologicals directed that the facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #67, 77, and 91) reviewed for advance directives, the facility failed to ensure that advance directive choices were reviewed and confirmed with the resident (Resident #67 and 91); and failed to ensure that, following a signed advanced directive change in code status, the physician's order and clinical record reflected the resident's (Resident #77) wishes and for 1 of 2 residents (Resident #89) reviewed for death, the facility failed to ensure a signed advance directive was completed following admission to the facility. The findings include: 1. Resident #67 was admitted to the facility in [DATE] with diagnoses that included idiopathic gout, chronic kidney disease, and hypertension. A nursing admission assessment dated [DATE] identified Resident #67 was alert and oriented, was continent of bowel and incontinent bladder and required assistance with standing due to poor balance. Review of the clinical record failed to identify an advance directive care plan. Review of the physician's orders failed to identify an advance directives or resuscitation status for Resident #67. Review of the clinical record failed to identify documentation that advance directive choices were reviewed and confirmed with Resident #67. Review of the clinical record and interview with the DNS on [DATE] at 11:30 AM identified there was an issue with advanced directives for Resident #67. The DNS identified she would look into the matter. Review of the clinical record for Resident #67 on 6/15, 6/16, and [DATE] failed to identify any documentation related to advance directive choices. 2. Resident #77 was admitted to the facility in [DATE] with diagnoses that included chronic kidney disease, macular degeneration, and legal blindness. The physician's orders dated [DATE] directed Resident #77 was a full code. The nursing admission assessment dated [DATE] identified Resident #77 was alert and oriented, was occasionally incontinent of bladder, required glasses and a magnifying glass for vision, required a wheelchair and walker for mobility, and had no skin issues. Review of the clinical record failed to identify a care plan related to advance directive choices. Review of a BIMS assessment dated [DATE] identified Resident #77 had intact cognition. A signed advance directive form, signed by Resident #77's resident representative and dated [DATE], directed Resident #77 elected DNR (do not resuscitate) as a resuscitation status. The form was also signed and dated by MD #1 on the same date. Review of the clinical record and interview with the DNS on [DATE] at 11:30 AM identified there was an issue with the physician's order for full code and signed advance directive for DNR. The DNS identified she would look into the matter. Review of the clinical record on 6/15, 6/16, and [DATE] identified that the physician's order for full code for Resident #77 remained active. 3. Resident #91 was admitted to the facility in [DATE] with diagnoses that included prostate cancer, hypotension, and sleep disorder A nursing admission assessment dated [DATE] identified Resident #91 was alert and oriented, was continent of bowel and bladder and required use of a walker for ambulation. Review of the clinical record failed to identify a care plan related to Resident 91's advance directive choices. A physician's order dated [DATE] directed for DNR/DNI (do not resuscitate/do not intubate). Review of the clinical record failed to identify any documentation that advance directive choices were reviewed and confirmed with Resident #91. Review of the clinical record and interview with the DNS on [DATE] at 11:30 AM identified there was an issue with the physician's order for DNR/DNI without a signed advance directive in Resident #91's clinical records. The DNS identified she would look into the matter. Review of the clinical record for Resident #91 on 6/15, 6/16, and [DATE] failed to identify any documentation related to advanced directive choices. Interview with the DNS on [DATE] at 2:00 PM identified she was aware there were issues with physician's orders conflicting with advance directives or no advanced directives on file with orders for DNR for multiple residents at the facility, including Resident #67, Resident #77, and Resident #91. The DNS identified that during admission, the advance directive would often be pulled from the transfer or admission paperwork, however it was the policy to review all advance directive choices with residents within 48 hours of admission, and that the physician's order should reflect the resident's advanced directive choices. Subsequent to surveyor inquiry and following the interview with the DNS on [DATE] at 2:00 PM the facility provided a signed DNR/DNI advance directive form for Resident #67 dated [DATE] (13 days after admission). Review of the form failed to identify a physician's signature. Subsequent to surveyor inquiry and following the interview with the DNS on [DATE] at 2:00 PM, the facility provided a signed DNR/DNI advance directive form for Resident #91. Review of the form identified a physician's signature with the date [DATE] (2 days prior). The facility policy on advance directives directed that it was the policy of the facility that all residents would have documented advance directives in their medical record. The policy further directed that whenever any interdisciplinary team member had a conversation with a resident who was cognitively intact and their own decision maker regarding advance directives which included DNR, comfort measures, hospitalization, appointment, etc., the conversation was to be documented. The policy also directed the attending physician would write an order for the residents code status based on the resident's wishes and the attending physician would update the written code status orders on a regular basis. The policy also directed that appropriate code status paperwork would be placed in the advance directive section of the medical record and the residents code status would be reviewed at every resident care plan meaning to ensure all information was accurate and current period the policy further directed that appropriate advance directive paperwork would accompany the resident whenever they left the facility. 4. The Inter-Agency Referral Report dated [DATE] identified Resident #89 as DNR/MOLST (Do Not Resuscitate/Medical Orders for Life-Sustaining Treatment) (for reference only, not a legal order) with a received date of [DATE]. Resident #89 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and a fracture of an unspecified part of the neck of the right femur. Review of the clinical record failed to identify a signed advance directive. A physician's order dated [DATE] directed Do Not Resuscitate. The Nursing admission assessment dated [DATE] identified Resident #89 was confused and had impaired decision-making ability. The physician's note dated [DATE] identified that Resident #89's code status was not in the hospital's electronic clinical record, and the facility would need to confirm the code status with the POA, as Resident 89 had dementia, was delirious, and was unable to make his/her own decision, at this time. The care plan dated [DATE] failed to identify advance directive choices. The physician's note dated [DATE] (8 days following admission) identified a call was received from the facility RN with notification that Resident #89 was noted to have an oxygen saturation of 79% on room air, febrile-102 degrees F, dyspneic, and placed on oxygen. The RN called the POA who requested that Resident #89 be kept comfortable at the facility including hospice, if recommended, and declined transfer to the hospital. As needed morphine was ordered for air hunger/pain given the patient's discomfort, will have primary team assessed today. The Certificate of Death dated [DATE] identified Resident #89 expired on [DATE] at 8:00 AM. Interview with RN # 2 on [DATE] at 6:45 AM identified that Resident #89 was admitted with a diagnosis of failure to thrive and on [DATE] around 6:00 AM the resident had a sudden decline; she and the nurse aide had been checking on Resident #89 routinely through the night and around 6:00 AM, the nurse aide reported to her that Resident #89 was having difficulty breathing and was warm. RN #2 indicated that she assessed Resident #89 and noted him/her to be febrile and in respiratory distress. RN #2 further indicated that she placed Resident #89 on supplemental oxygen, called the on-call medical provider, and the POA, who confirmed that he/she did not want Resident #89 transferred to the hospital but to keep him/her comfortable at the facility. Clinical record review with the DNS on [DATE] at 9:09 AM identified a DNR order but no signed advanced directive. Interview with the DNS on [DATE] at 9:09 AM identified that when a resident that is not cognitively capable of decision making gets admitted to the facility, initially the facility would go by the hospital records for code status, but the expectation would be that the POA would be called, with a second nurse as a witness, to confirm code status or if the POA came in to visit the code status documentation would have been completed. The DNS indicated that she was not aware that Resident #89 did not have a signed advance directive in place, but that she would expect it to have been completed within a week of his/her admission. The Advance Directive policy directs that all residents have documented advance directives in their medical record.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #42) reviewed for care planning, the facility failed to notify the resident representative when blood was noted in the ostomy bag and failed to notify the physician of one of two incidents when Resident #42 left the nursing unit unaccompanied and failed to notify the resident representative of two incidents when the resident left the nursing unit unaccompanied. For 1 of 3 residents (Resident #77) reviewed for activities of daily living (ADL), the facility failed to notify the physician, for over 4 weeks, after the resident developed a fungal rash in the skin folds that worsened and became itchy and painful, impaired the residents ability to sleep and resulted in a strong sour musty odor emanating in and from the residents room. For 1 of 6 residents (Resident #18) reviewed for pressure ulcer, the facility failed to notify the physician and the resident representative of changes in skin status. The findings include: 1. Resident #42 was admitted to the facility in July 2025 with diagnoses that included Alzheimer's disease. The quarterly MDS dated [DATE] identified Resident #42 required one person assistance with transfers, ambulated with the assistance of one using a walker or wheelchair and did not exhibit wandering behaviors. a. Notification of blood in the ostomy bag. The care plan dated 10/15/25 identified Resident #42 had impaired cognition and a new ileostomy (opening in the abdomen to allow waste to exit the body, bypassing the colon, rectum, and anus). Interventions included providing ileostomy care every shift and check the ostomy every two hours while awake. Physician progress note dated 3/10/26 identified the preceding weekend, Resident #42 was observed to have a onetime occurrence of blood in the stool with delayed notification to the resident representative. Electronic communication dated 3/11/26 from Person #2 to the DNS identified he/she was made aware earlier the same day that sometime over the preceding weekend (3-4 days earlier) that Resident #42 had the presence of blood in the collection bag. The physician was notified by Person #2 he/she would be evaluating Resident #42 and pass along any outcome. The physician and family were to be notified of any change in condition. Person #2 indicated the concern will be investigated to determine what steps were taken once identified. Review of the clinical record dated 3/8/26 through 3/11/26 did not include a documented assessment related to blood in the collection bag or subsequent notifications. Social service care plan meeting notes dated 4/7/26 identified a report of blood in ostomy several weeks prior. Resident #42 to follow up with ostomy clinic requested. Interview with MD #1, the Medical Director on 6/15/26 at 11:18 AM identified Resident #42 had a onetime report of blood in the ostomy bag. The bleeding did not continue, and labs were obtained which remained consistent with goals of care. MD #1 indicated the resident representatives were very involved with Resident #42's care and should have been notified of the new finding. Interview with RN #4 on 6/15/26 at 12:08 AM identified she was made aware, but she was unable to recall who notified her, that there was blood in Resident #42's collection bag and later inquired about it when the resident representative came in for a visit. The resident representative indicated they were not previously notified of the change of condition. Interview with the DNS on 6/15/26 at 2:15 PM identified the resident representative should have been notified when staff saw blood in the ostomy bag and the finding should have been documented in the clinical record. b. Elopement. An Elopement Risk Screening dated 10/3/25 identified Resident #42 was not at risk for elopement. The care plan dated 10/15/25 identified Resident #42 had impaired cognition and was at risk for falls. Interventions included anticipating needs, providing assistance with a walker to the North living room where Resident #40 enjoys playing cards with his/her friends, and ensure friends are present before leaving the resident. Elopement Risk Screen dated 1/9/26 identified Resident #42 was at risk for elopement. Review of the care plan failed to reflect interventions to address the elopement risk. Still images (extracted from facility video surveillance) dated 3/9/26 identified at 4:23 PM showed Resident #42 walking with a walker and as a visitor was entering, the resident exited out of the health center unaccompanied. At 4:25 PM, Resident #42 was observed walking towards the restaurant/pub area unattended. At 4:26 PM, Resident #42 was observed in the restaurant/ pub area sitting with a staff member. At 4:33 PM Resident #42 was observed being escorted away from the area by another staff member. A wandering device was subsequently implemented following the 3/9/26 incident. Electronic communication dated 3/11/26 from Person #2 to the DNS identified he/she was made aware of an incident involving Resident #42 leaving the health center with his/her walker to the pub unaccompanied by anyone and was not signed out and the health center staff were unaware of his/her absence. Resident #42 went to the pub. A staff member observed Resident #42 in the pub and escorted him/her back to the health center. It was further noted that an incident occurred a few months earlier that Resident #42 left the health center and went to the lobby unaccompanied. A wandering device was discussed at the time, and the decision was made not to implement yet. The two incidents presented a safety concern, and a request was made for an immediate and thorough investigation into the two incidents. A request for findings and steps taken to prevent a reoccurrence was requested for each incident. A review of the clinical record and facility documentation dated 11/1/25 through 3/11/26 identified no documentation of either incident or physician notification or reportable event form. Interview with MD #1, the Medical Director on 6/15/26 at 11:18 AM identified it was a concern that Resident #42 left the nursing unit and no one was aware, but less of a concern because he/she did not leave the facility and was not hurt. MD #1 was notified when Resident #42 left the nursing unit unaccompanied on 3/9/26 but was not notified of the first incident. Review of the Change of Condition policy directed upon a change of condition of a resident, licensed staff shall notify the physician. Direction will be given to the nurse regarding physician orders. The nurse shall document any new orders in the electronic medical record and write a note of physician notification. The resident representative shall be notified of the change of condition with a corresponding note. 2. Resident #77 was admitted to the facility in May 2026 with diagnoses that included chronic kidney disease, macular degeneration, and legal blindness. The physician's orders dated 5/5/26 directed to apply Nystatin Powder (an antifungal powder used to treat fungal skin conditions) 100000 unit/gm to the breasts, abdominal folds, and groin topically every 12 hours as needed for rash. The physician's orders also directed to complete weekly skin checks every Tuesday evening shift. The nursing admission assessment dated [DATE] identified Resident #77 was alert and oriented, required glasses and a magnifying glass for vision, and had no skin issues. The care plan dated 5/8/26 identified Resident #77 had an ADL performance deficit due to activity intolerance. Interventions included to provide Resident #77 assistance of 1 for showering, dressing, and personal hygiene, and complete weekly skin inspections to observe for redness, open areas, scratches, cuts, and bruises. A physician's note dated 5/18/26 by MD #1 identified Resident #77 an itchy rash to the lower anterior neck since 5/15/26. Recommendation included to apply Hydrocortisone cream topically. A physician's order dated 5/18/26 directed to apply Hydrocortisone cream 1% (a topical steroidal cream for skin rash) to the lower anterior neck as needed. Review of the clinical record identified that Resident #77 had weekly skin checks completed on 5/5, 5/12, and 5/19/26. Further review of the clinical record identified the skin check on 5/19/26 was completed by RN #4 and identified Resident #77 had no skin issues. A physician's note dated 5/22/26, by MD #1, identified that Resident #77 reported the rash on the anterior neck was better but hydrocortisone ran out and the area was becoming itchy. Recommendations included discontinue Hydrocortisone cream for the neck and start Triamcinolone 0.01% (a topical steroidal cream for rash) twice daily for one week then daily for one week and then reevaluate. A physician's order dated 5/22/26 directed to discontinue Hydrocortisone cream. The nurse's note dated 5/23/26 at 9:58 PM, by RN #7, identified that Resident #77 complained of itchiness and redness to the left side of the abdominal fold with redness and excessive moisture observed. RN #7 cleansed and dried the abdominal fold and applied Hydrocortisone cream (The Hydrocortisone cream was for a neck rash and had been discontinued 5/22/26). The note also identified Nystatin powder was reordered and awaiting pharmacy delivery. Review of the clinical record failed to identify the physician had been notified about Resident #77's complaint of itchiness and redness to the left side of the abdominal fold with redness and excessive moisture. Review of physician's notes dated 5/8/26, 5/18/26 5/22/26, 5/29/26 and 6/8/26 by MD #1 identified no documentation or assessment of the skin or rash in the inguinal area, abdominal folds or under the breasts. Review of skin checks dated 6/2/26 and 6/9/26 identified no documentation of skin rash or skin problems in the inguinal area or abdominal fold. Review of the clinical record dated May and June 2026, including the MAR's failed to identify that Nystatin powder had been applied to the inguinal area or abdominal folds. Observation on 6/14/26 at 8:00 AM and 10:10 AM identified there was a strong sour musty odor emanating in and from the residents room. Resident #77 was in the room sleeping. Interview with Resident #77 on 6/15/26 at 12:05 PM identified he/she has had a rash in the left groin area for several weeks which had now progressed to the both abdominal folds and under both breasts. Resident #77 identified that in the past he/she had a yeast rash in the folds of the abdomen, under the breasts and underarms, however, prior to admission to the facility in May 2026, the rash had cleared. Resident #77 identified that after admission, the rash began to return to the left groin area, and he/she first reported the rash to NA#2 on one of his/her shower days. NA# 2 had a nurse come and look at the rash while he/she was in the shower room, however, the nurse looked at it and left the shower room with no treatment offered or provided. Within 2 days, the same nurse gave Resident #77 a small bottle of white powder and told the resident it was for the rash and to use the powder on the rash. Resident #77 showed this surveyor the small plastic bottle on his/her bedside table which was labeled Nystatin Powder 100000 unit/gm 15 gm. The bottle appeared full and was not labeled with Resident #77's name. Resident #77 identified the nurse just left the powder in his/her room and did not given any instructions on how often or when to apply the powder. Resident #77 identified that due to his/her blindness, he/she was unable to apply the powder independently because of the size of the bottle, inability to see the bottle opening, and being unable to see his/her groin area. Resident #77 identified that he/she could not recall any other treatment or assessments of the area by staff, and no facility staff had ever applied the powder to the area. Resident #77 also identified that when the rash first developed it has become significantly worse, spreading all the way across his/her abdomen, under the breasts and into the underarm areas. Resident #77 identified the rash is very itchy and painful, and he/she was very uncomfortable and having difficulty sleeping because the rash continues to worsen. Observations during this interview continued to identify a strong sour musty odor emanating in and from Resident #77's room. Observation of Resident #77 with the DNS on 6/15/26 at 12:10 PM identified a large beefy red area at Resident #77's left groin and extending up into Resident #77's left abdomen and down to the top of the left thigh. During this observation, the previously identified sour musty odor was more pronounced when looking at the rash areas. Resident #77 gave the bottle of Nystatin powder to the DNS. Upon exiting Resident #77's room, the DNS identified that she also noted a sour musty odor from the room that worsened during the assessment of Resident #77's left groin area. The DNS identified the smell as yeast and believed it was from the skin rash. The DNS identified that the Nystatin powder was the same type and bottle ordered from the facility pharmacy and identified it should be applied by a licensed nurse, kept in the medication cart and not left at Resident #77's bedside. The clinical record failed to reflect Resident #77 had been assessed to self-administer medications and there was no physician's order to self-apply the Nystatin powder. A physician's note dated 6/15/26, by MD #1, subsequent to surveyor inquiry, identified that prior to admission to the facility, Resident #77 had been struggling with candida intertrigo (a superficial fungal skin fold infection caused by yeast (candida) which causes skin fold inflammation, maceration, burning, itching and a distinctive musty rancid odor due to fungal growth). Previously, Resident #77 had been using Nystatin powder with intermittent improvement and worsening and now the left groin had become painful. The left groin was observed to have superficial skin desquamation (separation of the outer layer of the skin) at the left groin, with lesser rash at the right groin and under the bilateral breasts. The treatment plan included an escalation of treatment to discontinue Nystatin powder, start Ketoconazole 2% ointment (a topical antifungal medication used to treat candida intertrigo) to the affected areas twice daily for one week, and Diflucan 100 mg (an oral antifungal medication) daily for 5 days, and re-evaluate in one week. Interview with RN #4 (RN Supervisor) on 6/16/26 at 12:15 PM identified she had been the regular nurse assigned to care for Resident #77 and was aware that Resident #77 had a rash at the left inguinal fold which had been red and open for several weeks. RN #4 was unable to recall when the rash first appeared. RN #4 identified that Resident #77 had an order for Nystatin powder which had been applied on scheduled shower days (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). RN #4 identified the Nystatin powder was applied by the nurse aides (this is in conflict with the DNS interview that licensed staff apply the Nystatin powder) and kept in the treatment cart (this is in conflict with the resident interview and surveyor observation that the Nystatin powder was left at the resident's bedside). RN #4 identified that the nurse aides would notify the nurse that the Nystatin powder had been applied, and the nurse would document the application in the MAR. RN #4 identified that she had been notified by multiple nurse aides over the past several weeks that the Nystatin powder had been applied, however, she could not recall the names of the nurse aides who applied the Nystatin powder (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). RN #4 identified she was not sure what the facility policy was regarding nurse aide application of Nystatin powder. Following a review of MAR's dated May and June 2026, which identified no documentation of Nystatin powder having been applied, RN #4 identified that NA #2 first notified her of Resident #77's left inguinal area during a scheduled shower day, and that RN #4 assessed the area and applied Nystatin powder to the area following Resident #77's shower (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied, and the resident interview that the nurse came into the shower room to see the rash, but left and did not apply a treatment). RN #4 was unable to say why there was no documented skin assessment during his/her shower day with NA #2, why she had not documented the application of Nystatin powder, or why she documented Resident #77 had no skin issues on 5/19/26. Interview with NA #2 on 6/16/26 at 2:00 PM identified that she was not the regular nurse aide assigned to Resident #77, but she occasionally would float to Resident #77's unit and assist with resident care. NA #2 identified that the first time she was assigned to Resident #77, she was assisting Resident #77 in the shower room during a scheduled shower day. NA #3 identified Resident #77 reported a red rash at the left groin and belly area and showed it to NA #2, who then notified RN #4. NA #2 identified RN #4 assessed the area and left the room. NA #2 identified that since she was not regularly assigned to Resident #77, she was not sure what happened after that regarding the rash. NA #2 also identified that Nystatin powder is only applied by the nurse assigned to Resident #77, that the medication was kept in the locked medication cart, and that nurse aides would not have access to the medication (this is in conflict with RN #4 identified the Nystatin powder was applied by the nurse aides, Resident #77 who indicated no one applied the Nystatin powder and that it was left at the bedside, and surveyor observation of the Nystatin powder at the bedside). Review of nursing schedules and interview with DNS on 6/17/26 at 6:30 AM identified RN #4 and NA #2 were assigned to Resident #77, on a scheduled shower day, on 5/15/26 (Friday). Interview with NA #3 on 6/17/26 at 11:27 AM identified she was aware that Resident #77 had a rash on his/her left groin area but could not recall when she first saw it. NA #3 also identified that Nystatin powder would never be applied by a nurse aide. NA #3 identified that on Resident #77's unit there were not regularly assigned nurse aides and that staff often rotated assignments on that unit. NA #3 identified Resident #77 did not have a regular nurse aide assigned to him/her. Interview with RN #7 on 6/17/26 at 3:15 PM identified that she was an agency nurse who provided care for Resident #77 on 5/23/26 during the 3:00 PM – 11:00 PM shift. RN #7 identified that she recalled Resident #77 reported having a red itchy area at the left groin and she noted on assessment a reddened area to the left groin and abdominal fold. RN #7 also identified that the area also had moisture and she cleaned and dried the area. RN #7 attempted to locate the Nystatin powder in the medication cart, however there was none available. RN #7 identified she notified the RN Supervisor (this is in conflict with the nursing schedule for 5/23/26 which identified she, RN #7, was the RN Supervisor for the 3:00 PM – 11:00 PM shift) and used what was on hand which was Hydrocortisone cream (the Hydrocortisone cream had been discontinued). RN #7 identified she did not check the physician's order regarding the Hydrocortisone cream, did not document on the MAR the application of the Hydrocortisone cream, did not notify the physician of the rash, and believed she reported the skin issue to the 3:00 PM – 11:00 PM RN Supervisor (this is in conflict with the nursing schedule for 5/23/26 which identified she, RN #7, was the RN Supervisor for the 3:00 PM – 11:00 PM shift) as well as to the next shift, however she was not sure. RN #7 identified that she was not aware that there was not an active order for Hydrocortisone cream or that it had been previously ordered for an anterior neck rash. Interview with MD #1 on 6/17/26 at 4:02 PM identified that Resident #77 came into the facility with an active left inguinal rash (this is in conflict with the admission assessment which identified Resident #77 had no skin issues) and had used Nystatin powder in the past for treatment. MD #1 identified that Resident #77 initially reported that topical Nystatin powder was working however the area worsened (this is in conflict with the clinical record and resident interview that identified the Nystatin had never been applied). MD #1 identified on her assessment on 6/15/26, (subsequent to surveyor inquiry), she noted the left groin area appeared angry and inflamed. MD #1 identified she recommended discontinuing the Nystatin powder, starting oral Diflucan and topical Ketoconazole. MD #1 also identified that she was not aware that Resident #77 had been given the Nystatin powder or that nursing staff had directed Resident #77 to self-administer the Nystatin powder. MD #1 identified Resident #77 was legally blind and had visual acuity issues. MD #1 also identified that although the Nystatin powder orders directed application every 12 hours as needed, it should have been applied regularly and was meant to be applied daily after personal hygiene or after showers. Following a review of MD #1's physical exam notes on 5/8, 5/18, 5/22, 5/29, and 6/8/26, which failed to identify documentation of an active left groin or inguinal rash with use of Nystatin powder, MD #1 then identified that Resident #77 had not brought up any issues related to the left inguinal or groin area at any of the visits. MD #1 identified that Nystatin powder had been pulled from Resident #77's previous medication history. MD #1 identified she had not noted any odor during any of her visits with Resident #77 that were consistent with candida intertrigo. MD #1 also identified she had not been notified of any issues related to the left groin or left inguinal area by any nursing staff until the DNS notified her on 6/15/26. MD #1 also identified that the Nystatin powder was ordered specifically for candida intertrigo that the Hydrocortisone cream would not be appropriate to use on this type of skin issue. MD #1 further identified that it would be up to the nursing staff to determine if Resident #77 was able to safely administer medications to him/herself including Nystatin powder and that would have required a self-administration medication assessment. The facility policy on change of condition directed that the licensed nursing staff would document any change of condition in the electronic medical record. The policy further directed that upon a change of condition of a resident, licensed staff would notify the physician. Direction would be given to the nurse regarding MD orders. The nurse would document any new orders in the electronic medical record as well as write a note of MD notification. The responsible party/POA would also be notified of the change with a corresponding note. The facility policy on skin assessments directed that all residents should have a skin assessment weekly by a licensed nurse. The policy further directed if the licensed nurse identified any resident with skin integrity concern, the licensed nurse would notify the MD. A description of the area would be given to the MD and the MD would address the concern by giving the licensed nurse orders for wound care period the nurse would document the wound care orders in the electronic medical record. The family/POA would be notified of the change in skin integrity. Wound care would be completed as ordered until new treatment ordered was received or until healed. Weekly documentation of the wound would be performed until healed. 3. Resident #18 was admitted to the facility in December 2025 with diagnoses that included Parkinson's disease, anemia, and urinary incontinence. The care plan dated 12/18/25 identified Resident #18 had an Activities of Daily Living (ADL) self-care performance deficit related to Parkinson's disease. Interventions included staff to perform personal hygiene and oral care. Weekly skin inspection for redness, open areas, bruising, and reporting any changes to the nurse. The quarterly MDS dated [DATE] identified Resident #18 had severely impaired cognition and was dependent on staff with personal hygiene, toileting hygiene, and rolling left and right in bed. Additionally, Resident #18 was frequently incontinent of bladder and bowel, and had a stage 2 pressure ulcer on admission. The Braden scale dated 3/16/26 identified Resident #18 was at risk for pressure ulcers. A skin check note dated 4/14/26 identified Moisture Associated Skin Damage (MASD) and Incontinence Associated Dermatitis (IAD) on the coccyx area which measured 5.0 cm x 5.0 cm. Treatment of Zinc Oxide cream applied to the affected area. The physician's note dated 4/20/26 identified Resident #18 has a stable stage II pressure injury to coccyx area. The wound had previously resolved but reopened in March 2026. Nursing reports indicated the pressure injury remains stable with no significant change in condition. Resident #18 is incontinent of bladder and bowel and remains at risk for impaired skin integrity due to mostly bed-bound status and malnutrition. Treatment includes Desitin barrier cream to coccyx area. Pressure-relieving interventions include repositioning and offloading of the coccyx area by positioning the resident on the side except during meals. The physician's order dated 6/1/26 directed to perform weekly skin checks every Wednesday on the day shift, administer Ensure 237 ml two times a day for weight and wound healing, place the resident on an air mattress, monitor functioning every shift and place a Roho cushion in the wheelchair. Further, apply [NAME] External Cream 13% (Zinc Oxide) to gluteus topically every shift for MASD (Moisture Associated Skin Damage). The skin check note dated 6/4/26 at 2:37 PM identified skin assessment to the coccyx area identified as MASD and IAD with measurement 5.0 cm x 5.0 cm. Review of the skin check form dated 6/11/26 identified Moisture Associated Skin Damage (MASD) and Incontinence Associated Dermatitis (IAD) to the coccyx. Review of the clinical record and nurse's note dated 12/15/25 through 6/17/26 failed to reflect consistent documentation of weekly skin checks in accordance with facility policy, physician's order, and professional standards of practice. The clinical record failed to reflect documentation that weekly skin checks were completed on 12/29/25, 1/5/26, 1/26/26, 2/2/26, 2/9/26, 3/9/26, 4/20/26, 4/27/26, 5/4/26, and 5/11/26. Review of the nurse's note dated 4/7/26 through 6/17/26 failed to reflect documentation that the resident representative had been notified of new skin impairments on 4/7/26, 4/14/26, 6/4/26, and 6/15/26. Review of the physician's note dated 4/20/26 through 6/15/26 failed to reflect that the resident representative had been notified of the new skin impairments on 4/7/26, 4/14/26, 6/4/26, and 6/15/26. Subsequent to surveyor inquiry on 6/15/26 at 2:39 PM, MD #2 was present and performed an assessment and measurement of the coccyx area. The assessment findings included a non-blanchable reddened area to the coccyx measuring 3.0 cm x 10.0 cm with macerated skin present. Additional findings included a dark red area to the right lateral ankle measuring 2 cm in circumference and a reddened area to the right heel measuring 1.4 cm x 1.0 cm, identified as a Stage I pressure injury. The resident's representative was to be notified of the newly identified skin impairments. Interview and clinical record review with the DNS on 6/18/26 at 6:30 AM identified she was not aware that licensed nurses had not notified Resident #18's representative of the newly identified skin impairments. The DNS indicated the facility failed to ensure the resident's representative was notified of newly identified skin impairments for Resident #18. The DNS indicated the licensed nurses are responsible for notifying the resident and the resident representative of any change in condition. Interview with MD #1 on 6/18/26 at 9:00 AM identified she was not aware that licensed nurses had not notified Resident #18's representative of the newly identified skin impairments. MD #1 indicated the licensed nurses are responsible for notifying the resident and the resident representative of any change in condition. Review of the facility change in condition policy identified licensed nursing staff will document any changes in condition in the electronic medical record. Upon change in condition of a resident, licensed staff shall notify the physician. Directions will be given to the nurse regarding physician's orders. The nurse shall document any new orders in the electronic medical record as well as write a note of physician notification. Responsible party and Power of Attorney shall be notified of the change with corresponding note.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #42) reviewed for care planning, the facility failed to revise the care plan in a timely manner after identifying the resident was at risk for elopement who subsequently left the nursing unit unaccompanied. The findings include:Resident #42 was admitted to the facility in July 2025 with diagnoses that included Alzheimer's disease.The quarterly MDS dated [DATE] identified Resident #42 ambulated with the assistance of one using a walker or wheelchair and did not exhibit wandering behaviors.Elopement Risk Screening dated 10/3/25 identified Resident #42 was not at risk for elopement.The care plan dated 10/15/25 identified Resident #42 had impaired cognition and was at risk for falls. Interventions included anticipating needs and provide assistance with a walker to the North living room where Resident #40 enjoys playing cards with his/her friends, ensure friends are present before leaving the resident.Elopement Risk Screen dated 1/9/26 identified Resident #42 was at risk for elopement. (The care plan did not include interventions to address the elopement risk).Still images (extracted from video surveillance) dated 3/9/26 identified at 4:23 PM identified Resident #42 was ambulating with a walker and exited out of the health center unaccompanied as a visitor was entering. At 4:25 PM, Resident #42 was observed walking towards the restaurant/pub area unattended. At 4:26 PM, Resident was observed in the restaurant/pub area sitting with a staff member. At 4:33 PM Resident #42 was observed being escorted away from the area by another staff member. Electronic communication dated 3/11/26 from Person #2 to the DNS identified he/she was made aware of incident involving Resident #42 leaving the health center with his/her walker to the pub unaccompanied by anyone and was not signed out and the health center staff were unaware of his/her absence. Resident #42 went to the pub. A staff member observed Resident #42 in the pub and escorted him/her back to the health center. It was further noted that an incident occurred a few months earlier where Resident #42 left the health center and went to the lobby unaccompanied. A wandering device was discussed at the time, and the decision was made not to implement one yet. The care plan dated 4/20/26 (72 days after the first alleged incident and 42 days after the second incident where Resident #42 left the health center unaccompanied) was revised to include a pattern of wandering, intervene as appropriate and ensure a wandering device was in place, secured to the rolling walker.Subsequent to the 2nd elopement on 3/9/26 a wandering device was implemented. Interview with the DNS on 6/15/26 at 1:56 PM identified Resident #42 exited the health center into the adjoining pub on two separate occasions and was not safe to be leaving the unit unaccompanied. The DNS could not recall the details of the first incident but acknowledged it was referenced in the electronic communication from Person #2 to the DNS. The second incident occurred on 3/9/26 where Resident #42 had left the unit unattended. Video surveillance identified Resident #42 was gone for a short while before being escorted by staff back to the unit. Each incident was not documented or investigated and aside from the two-hour routine resident checks already in place, no interventions were put in place to mitigate future attempts to leave the unit unattended until after the second incident where a wandering device was implemented. Although requested, a policy for care planning was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #42) reviewed for accidents, the facility failed to provide adequate supervision and thoroughly investigate an elopement, to prevent reoccurrence, after the resident left the nursing unit unaccompanied. Subsequently, inconsistent staff accounts, lack of documentation and failure to implement interventions resulted in a second elopement from the nursing unit after the resident told staff he/she was leaving. The findings include: Resident #42 was admitted to the facility in July 2025 with diagnoses that included Alzheimer's disease.The quarterly MDS dated [DATE] identified Resident #42 required one person assist with bed mobility, transfers, ambulated with the assistance of one using a walker or wheelchair and did not exhibit wandering behaviors.Elopement Risk Screening dated 10/3/25 identified Resident #42 was not at risk for elopement.The care plan dated 10/15/25 identified Resident #42 had impaired cognition and was at risk for falls. Interventions included anticipating needs and providing assistance with a walker to the North living room where Resident #40 enjoys playing cards with his/her friends, ensure friends are present before leaving the resident.Elopement Risk Screen dated 1/9/26 identified Resident #42 was at risk for elopement. (The care plan did not include interventions to address the elopement risk).Still images (extracted from video surveillance) dated 3/9/26 identified at 4:23 PM, Resident #42 was ambulating with a walker and exited out of the health center unaccompanied as a visitor was entering.At 4:25 PM, Resident #42 was observed walking towards the restaurant/pub area unattended.At 4:26 PM, Resident #42 was observed in the restaurant/pub area sitting with a staff member.At 4:33 PM Resident #42 was observed being escorted away from the area by another staff member. Electronic communication dated 3/11/26 from Person #2 to the DNS identified he/she was made aware of incident involving Resident #42 leaving the health center with his/her walker to the pub unaccompanied by anyone, was not signed out and the health center and staff were unaware of his/her absence. Resident #42 went to the pub. A staff member observed Resident #42 in the pub and escorted him/her back to the health center. It was further noted that an incident occurred a few months earlier where Resident #42 left the health center and went to the lobby unaccompanied. A wandering device was discussed at the time of the first incident, and the decision was made not to implement one yet.A review of the clinical record and facility documentation dated 11/1/25 through 3/11/26 did not include documentation of either incident or physician notification and a reportable event form was not completed.A wandering device was subsequently implemented following the 3/9/26 incident.Interview with Person #2 on 6/15/26 at 9:00 AM identified Resident #42 had left the health center unattended on two separate occasions with no notification by the facility when each incident occurred. The first incident occurred on 12/10/25 where Resident #42 left the health center. The incident was reported anonymously. The second incident occurred on 3/9/26 where again Resident #42 left the health center unattended and was located in the pub by a staff member and was escorted back to the unit. The DNS was contacted on 3/11/26 to discuss the concern. The DNS responded, updating Person #2 that video surveillance was reviewed that identified Resident #42 exited the health center at 4:24 PM and went to the pub. Resident #42 was observed sitting with an employee at the pub. At 4:32 PM a staff member from the health center arrived and assisted Resident #42 back to the health center. And that this information was provided only subsequent to Person #2's inquiry.Interview with the DNS on 6/15/26 at 1:56 PM identified Resident #42 exited the health center into the adjoining pub on two separate occasions and was not safe to be leaving the unit unaccompanied. The DNS could not recall the details of the first incident but acknowledged it was referenced in the electronic communication from Person #2 to the DNS. The second incident occurred on 3/9/26 when Resident #42 had left the unit unattended. Video surveillance identified Resident #42 was gone for a short while before being escorted by staff back to the unit. Each incident was not documented or investigated and except from the two-hour routine resident checks already in place, no interventions were put in place to mitigate future attempts to leave the unit unattended until after the second incident where a wandering device was implemented. Interview with the facility Receptionist on 6/16/26 at 12:24 PM identified she was provided a list of residents who reside at the health center but did not include a list or photographs of those residents who were restricted from leaving the health center unaccompanied. Daily receptionist schedule confirmed as 8:00 AM until 4:00 PM. Interview with NA #6 on 6/16/26 at 1:53 PM identified she was working during the 3:00 PM to 11:00 PM shift on 3/9/26 but could not recall if she was the assigned nurse aide for Resident #42. NA #6 recalled it was around change of shift when she was assisting another resident with ambulating past the nurse's station. NA #6 observed Resident #42 ambulating with his/her walker in the hall and turn the corner heading towards the exit of the health center. NA#6 asked where Resident #42 was going. Resident #42 responded he/she was going to the restaurant/pub. NA #6 observed that RN #8 and Administrative Assistant were also at the nurse's station at the time and laughed when Resident #42 made the comment he/she was leaving the area. NA #6 responded, (oh yeah) and took no further action as she was assisting another resident and could not leave them. Additionally, NA #6 felt that the statement was overheard by the charge nurse, who laughed in response and better suited to address the situation and had direct visualization of the exit doors. A short time later, NA #6 observed Resident #42 was not in his/her room. Recalling the earlier statement, NA #6 immediately left the health center and located Resident #42 in the adjoining restaurant/pub sitting with another employee having a drink. NA #6 escorted Resident #42 back to the health center and offered reminders that he/she should not leave the unit unattended. NA #6 further identified that she had heard that Resident #42 left the unit unaccompanied on a previous occasion but had no details. NA #6 indicated no one spoke with her about the events that led up to Resident #42 leaving the unit unaccompanied on the second occasion. Interview with RN #8 on 6/17/26 at 7:16 AM identified he was the assigned charge nurse during the 7:00 AM to 3:00 PM shift on 3/9/26. RN #8 recalled the incident occurred around lunch time. RN #8 was heading into the medication room when a nurse aide, (unable to recall who) reported Resident #42 was ambulating with his/her walker towards the exit. A few minutes later, the same aide reported Resident #42 was no longer on the unit. RN #8 did not immediately intervene when it was reported Resident #42 was heading towards the exit as he wanted to complete the medication pass. When it was reported Resident #42 was unaccounted for, RN #8 asked the nurse aide look for Resident #42. The nurse aide left the unit and returned a short time later with Resident #42 who was gone for a few short minutes. RN #8 did not assess Resident #42 upon return as he felt there was no need to, did not initiate a reportable event form, document the incident in the clinical record or provide any notifications. RN #8 did recall having a discussion with the DNS following the second incident and implementing a wandering device. Interview with Bartender #1 on 6/17/26 at 3:39 PM identified Resident #42 previously came to the restaurant/pub when he/she lived independently. Bartender #1 identified she recalled in recent months, Resident #42 came to the restaurant/pub unattended, and was served a non-alcoholic drink before a staff member came to return him/her to the unit. Bartender #1 further identified she did not contact the health center when Resident #42 arrived at the restaurant/pub, was not spoken to about the interaction following the incident and was not given any instruction should Resident #42 come to the restaurant/pub in the future. An interview with the Administrative Assistant on 6/18/26 at 10:50 AM identified she was working on 3/9/26 at the time of the incident but could not recall the time. The Administrative Assistant indicated she observed Resident #42 ambulating in the hall with his/her walker, not the hall near the exit and briefly speaking to someone but could not recall who. The Administrative Assistant did not hear Resident #42 state he/she was going to the restaurant/pub and did not observe him/her near the exit. The Administrative Assistant indicated she only heard NA #6 state Resident #42 was not on the unit and exited the unit, returning a short time later with Resident #42. The Administrative Assistant further identified RN #8 was in the nurse's office at the time of the incident. Review of the Missing Resident Protocol directed any missing resident is to be reported to the supervisor and DNS. The nursing supervisor or DNS organizes a search of the Health Center by assigning staff to search specific areas. Once confirmed a resident is not in the Health Center, a 'Silver Alert' is initiated by the DNS or nursing supervisor and notification is made to all department heads. All available staff report to the North Desk for further directions and will receive a picture of the resident, a search of the grounds is conducted and the family and physician are notified. Once the resident was located, all parties were to be notified, the resident assessed for injuries and treatment provided. An incident report is to be completed and required reporting to the overseeing state agency.

Based on review of the clinical record, facility policy, and interviews for 1 resident (Resident #80) reviewed for abuse, the facility failed to ensure enhanced barrier precautions were implemented in a timely manner for a resident with an indwelling medical device. The findings include:Resident #80 was admitted to the facility in May 2026 with diagnoses that included acute and chronic kidney failure, hydronephrosis, tubule-interstitial nephritis, and displacement of an indwelling ureteral stent. The admission MDS dated [DATE] identified Resident #80 had intact cognition and had an indwelling catheter. The care plan dated 5/25/26 identified Resident #80 had a new left nephrostomy tube related to severe left hydronephrosis, with interventions that included keeping the insertion site clean and dry, applying split gauze at the insertion site and to change daily and as needed. The late entry nurse's note (undated/untimed) identified that the DNS received a call from Resident #80's family friend stating that the staff were not handling the nephrostomy tube appropriately. The writer followed up with Resident #80, who reported that staff were not using the appropriate PPE when handling his/her nephrostomy tube. The writer listened to Resident #80's concerns and identified that the staff would be in-serviced on appropriate PPE. A physician's order dated 5/21/26 (3 days following admission) directed to implement enhanced barrier precautions (EBP)-indwelling medical device (nephrostomy). The Nurse's note dated 6/11/26 at 4:53 AM identified that Resident #80 complained of 9/10 pain at his/her urethra and stated he/she felt like he/she had a UTI. The on-call medical provider was notified, and new orders were obtained for the administration of 5mg of Oxycodone and to obtain a CBC and BMP, and a bladder scan, if there is urine in the bladder send a UA/CS (urinalysis and culture/sensitivity). The bladder scan amount was 300ml; a urine sample was obtained via straight catheter and 250ml of cloudy urine was noted. The nurse's note dated 6/11/26 at 7:28 AM identified that the Medical Director was in to evaluate Resident #80, and he/she was send to the ED for evaluation. Resident #80 was not available for interview, due to MLOA. Interview with RN #6 on 6/17/26 at 6:12AM identified that on she was not Resident #80's admitting nurse but did provide care for him/her on 5/21/26, and Resident #80 was not put on EBP right away; Resident #80 was placed on EBP in the afternoon of 5/21/26, following a complaint from a resident representative.Interview with the DNS on 6/17/26 at 6:37 AM identified that Resident #80 was not placed on EBP upon admission, and that on 5/21/26 Resident #80's family friend called on Resident #80's behalf reporting that some nurses were not wearing gloves while handling the nephrostomy tube and bag or during dressing changes. The DNS indicated that Resident #80 was then placed on EBP and she spoke with the Infection Preventionist (LPN #1) and began in-servicing staff on EBP. The DNS indicated that Resident #80 should have been placed on EBP upon admission due to his/her indwelling medical device, and that if the IP was not available to initiate the EBP, the admitting nurse would be expected to review the resident's clinical record and initiate and implement the appropriate precautions, which would be to wear a gown and gloves while providing care.Interview with the IP (LPN #1) on 6/17/26 at 11:12 AM identified that Resident #80 should have been placed on EBP upon admission to the facility on 5/18/26 due to his/her nephrostomy tube, and that gloves and a gown should be worn during direct care. LPN #1 indicated that she could not recall if she was in the facility from 5/18 through 5/20/26, but she did initiate EBP on 5/21/26 once she was aware of the indwelling device; however, in her absence the nurses were trained on EBP and should initiate precautions, when appropriate.The Enhanced Barrier Precaution signage directs everyone must clean their hands, before entering and when leaving the room, and providers and staff must also: wear gloves and a gown for the following high contact resident care activities, dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tubes, and tracheostomy, and wound care or any skin opening requiring the dressing.The Enhanced Barrier Precautions policy directs staff to wear a gown and gloves for certain residents during specific high contact resident care activities that have been found to increase the risk for MDRO. Implementing EBP includes posting clear signage on the door or the wall outside of the resident room indicating the type of precaution and required PPE, making PPE including gowns and gloves available immediately outside of the resident room, and ensuring access to alcohol-based hand rub in every resident room.

Based on review of the clinical record, facility policy, and interviews for 3 of 3 admitted residents (Resident #93, 96, and 97) reviewed for resident assessment, the facility failed to ensure quarterly MDS assessments were completed no less than every 3 months, between comprehensive assessments. The findings include:1. Resident #93 was admitted to the facility in November 2022. Review of Resident #93's clinical record identified that the Quarterly MDS dated [DATE] was in progress and had not been completed within 14 days of the Assessment Reference Date (ARD). Only Section K: Swallowing/Nutritional Status was completed. Further, the Quarterly MDS dated [DATE] had not been completed within 14 days of the ARD. Only Section K: Swallowing/Nutritional Status was completed. 2. Resident #96 was admitted to the facility in October 2024. Review of Resident #96's clinical record identified that the Quarterly MDS dated [DATE] had not been completed within 14 days of the ARD. Only Section K: Swallowing/Nutritional Status was completed. 3. Resident #97 was admitted to the facility in January 2024. Review of Resident #97's clinical record identified that the Quarterly MDS dated [DATE] had not been completed within 14 days of the ARD. Only Sections C: Cognitive Patterns, D: Mood, and K: Swallowing/Nutritional Status were completed. Further, the Quarterly MDS dated [DATE] had not been completed within 14 days of the ARD. Only Section K: Swallowing/Nutritional Status was completed. Interview with the [NAME] President of Health and Well-Being on 6/15/26 at 8:25 AM identified that the facility was behind in the completion of MDS's, and she was made aware about 3 weeks ago. As a result, the facility had begun working with outside consultants to assist with getting caught up and ensuring the facility would not run into a similar issue, in the future. Interview with the MDS Coordinator (RN #1) on 6/15/26 at 12:45 PM identified that she began working at the facility in September of 2024 and the facility was without a social worker, so in addition to doing the MDS assessments she was managing all of the care updates and resident care conferences, as a result, she was always a little behind with completing MDS assessments. The facility hired a social worker in December of 2024 and she was able to reallocate some responsibilities to the social worker and her workload was manageable. RN #1 indicated that in April of 2026, the facility got 38 admissions and she got really behind so she notified the DNS. RN #1 indicated that the facility has since hired outside consultants that would continue to assist with completing outstanding MDS assessments. RN #1 further indicated that when she gets a lot of admissions, she has to prioritize which MDS assessments get completed, and that the discharges got pushed to the back, but the consultants were working on completing those, too. RN #1 indicated the expectation is that admission, quarterly, and discharge assessments would be completed within 14 days. Interview with the DNS on 6/16/26 at 7:27 AM identified that RN #1 was responsible to complete the nursing sections of the admission, quarterly, and discharge MDS assessments and collaborate with other members of the IDT such as the dietitian, therapy, and social worker. The expectation was that RN #1 would submit the completed MDS within the appropriate timeframe. The DNS indicated that RN #1 had expressed concerns about her workload about 6 months after she began working at the facility, sometime in 2025, so they relieved her of some of her responsibilities. After modifying the workload, RN #1 didn't report that she had any on-going issues. The DNS identified that she was under the impression that RN #1's workflow had gotten better. The DNS further identified that at the end of April/beginning of May of 2026, RN #1 reported that she was behind with MDS assessments, and the large volume of admission in April put her further behind, so the decision was made to bring in an MDS consulting group to assist with backlog. The MDS 3.0 policy directs that all members of the interdisciplinary team will assist the MDS coordinator in completing the MDS completely, accurately, and in a timely manner, meeting all required deadlines. All sections of the MDS will be completed by members of the interdisciplinary team and reviewed for completeness by the MDS Coordinator, designated members of the inter disciplinary team will complete their sections completely, accurately and within the time limit determined by the MDS coordinator; all team members will adhere to the regulatory guidelines. The MDS coordinator will address all MDS exceptions, triggers, and individualized care plans.

Based on review of the clinical record, facility policy, and interviews for 7 of 9 residents (Resident #1, 2, 4, 5, 6, 40 and 96) reviewed for resident assessment, the facility failed to ensure MDS assessments were transmitted to the CMS System within 14 days after completion. The findings include: 1. Resident #1 was admitted to the facility in January 2026 and was discharged in February 2026.Review of Resident #1's clinical record identified that the Discharge Return Not Anticipated/End of PPS Part A Stay MDS was dated 2/4/26 and the status was export ready however, it had not been electronically transmitted to the CMS System. 2. Resident #2 was admitted to the facility in January 2026 and was discharged in February 2026.Review of Resident #2's clinical record identified that the Discharge Return Not Anticipated/End of PPS Part A Stay MDS dated [DATE] and the status was export ready however, it had not been electronically transmitted to the CMS System. 3. Resident #4 was admitted to the facility in February 2026 and was discharged in February 2026.Review of Resident #4's clinical record identified that the Discharge Return Not Anticipated/End of PPS Part A Stay MDS dated [DATE] and the status was export ready however, it had not been electronically transmitted to the CMS System. 4. Resident #5 was admitted to the facility in December 2025 and was discharged in January 2026.Review of Resident #5's clinical record identified that the Discharge Return Not Anticipated/End of PPS Part A Stay MDS dated [DATE] and the status was export ready however, it had not been electronically transmitted to the CMS System. 5. Resident #6 was admitted to the facility in February 2026 and was discharged in March 2026. Review of Resident #6's clinical record identified that the Discharge Return Not Anticipated/End of PPS Part A Stay MDS dated [DATE] and the status was export ready however, it had not been electronically transmitted to the CMS System. 6. Resident #40 was admitted to the facility in December 2025.Review of Resident #40's clinical record identified that the admission MDS dated [DATE] was export ready however, it had not been electronically transmitted to the CMS System. 7. Resident #96 was admitted to the facility in October 2024.Review of Resident #96's clinical record identified that the Quarterly MDS dated [DATE] status was export ready however, it had not been electronically transmitted to the CMS System. Interview with the [NAME] President of Health and Well-Being on 6/15/26 at 8:25 AM identified that the facility was behind in the completion of MDS's, and she was made aware about 3 weeks ago; as a result the facility had begun working with outside consultants to assist with getting caught up and ensuring the facility would not run into a similar issue, in the future. Interview with the MDS Coordinator (RN #1) on 6/15/26 at 12:45 PM identified that she began working at the facility in September of 2024 and the facility was without a social worker, so she was managing all of the care updates and resident care conferences, as a result she was always a little behind with completing MDS assessments. The facility hired a social worker in December of 2024 and she was able to reallocate some responsibilities to the social worker, then her workload was manageable. RN #1 indicated that in April of 2026, the facility got 38 admissions and she got really behind, and she notified the DNS. RN #1 indicated that the facility has since hired outside consultants that would continue to assist with completing outstanding MDS assessments. RN #1 further indicated that when she gets a lot of admissions, she has to prioritize which MDS assessments get completed, and indicated the discharges got pushed to the back, but the consultants were working on completing those. RN #1 indicated the expectation is that admission, quarterly, and discharge MDS assessments would be completed within 14 days. Interview with the DNS on 6/16/26 at 7:27 AM identified that the expectation was that RN #1 would submit the completed MDS within the appropriate timeframe. The MDS 3.0 policy directs that all members of the interdisciplinary team will assist the MDS coordinator in completing the MDS completely, accurately, and in a timely manner, meeting all required deadlines. All sections of the MDS will be completed by members of the interdisciplinary team and reviewed for completeness by the MDS Coordinator, designated members of the inter disciplinary team will complete their sections completely, accurately and within the time limit determined by the MDS coordinator; all team members will adhere to the regulatory guidelines. The MDS coordinator will address all MDS exceptions, triggers, and individualized care plans. According to Appendix PP S483.20(f)(3) 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 System.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure nurse aide in-service education and competency evaluations were completed at least annually. The findings include:A review of documentation provided by the facility related to 12 hours of annual in-service education and competencies was completed for 3 nurse aide staff.A review of education and in-service documentation for 2025 and 2026 failed to identify any documentation of education or competencies for NA #1, who began employment at the facility on 7/1/20.Interview with the DNS and RN #3 (Assisted Living DNS) on 6/16/26 at 10:50 AM identified that competency evaluations had not been completed for facility nurse aide or licensed nursing staff for 2025. RN #3, a DNS from a sister facility, identified that a competency skills fair was held annually for all facility nursing staff however she did not believe that any of the facility nursing staff had been invited by the sister facility for 2025. The DNS also identified she was working as a RN supervisor at the time the competency fair was held in September of 2025 and did not remember any of the facility staff receiving an invitation or attending. RN #3 identified that she would ensure that all facility nursing staff participated in the skills fair which was scheduled for September of 2026. The DNS also identified that she was responsible for ensuring in-services were completed by nursing staff however many of the in-services were completed online, the facility had multiple per diem nurse aide staff and also used agency staffing. The DNS identified she was unsure if all nurse aide staff completed in service education for 2025 and since she was still working on 2026, she was unsure who had completed in service education and who had not. The DNS identified in-servicing was completed as time allowed.The facility assessment directed that staff training, education, and competencies would be completed for nurse aides no less than 12 hours per year and would include dementia training and resident abuse. The assessment also directed staff education would include: Abuse, neglect, and exploitation prevention; Resident rights; Fire safety; Pain management; Bloodborne pathogen; hazardous chemicals; SDS; HIPAA; Infection control basics; medical devices; Safe transfers; and Workplace violence.

Based on review of facility documentation and interviews, the facility failed to provide staff support to ensure the residents right to organize and participate in resident groups (resident council) was honored. The findings include: Review of the Resident Council Meeting binder identified that the last resident council meeting was held on 11/29/23, over a year ago. The binder failed to identify resident council meeting minutes from December 2023 through November 2024. During the Resident Council interview on 12/3/24 at 9:05 AM with Residents #3, 4, 11, 12 and 16, Resident #12 identified that he/she would previously attend a monthly resident council meeting regularly, but the group had not met for a long time. Resident #12 could not recall when he/she had last attended a resident council meeting but indicated that it was a good idea for the residents to all sit together and share ideas. Resident #12 identified that he/she would like to continue to participate in resident council meetings. Interview with the DNS on 12/3/24 at 2:33 PM identified that the resident council had not met since their social worker had left the facility, about a year ago. The DNS indicated that after the prior social worker had left, the facility had not had a social worker to run the meeting. Interview with the Administrator on 12/4/24 at 9:50 AM identified that the former social worker headed up resident council, and he had left his position mid-December of 2023, and it appeared that resident council meetings were not held since. The Administrator indicated that it was an oversight that another facility staff member was not designated to assist with organizing resident council meetings. The Administrator further indicated that due to the small size of resident unit, staff members communicated with residents daily and addressed their needs individually, and no patterns had been identified in resident's concerns. The Administrator identified that a new social worker was hired and was starting on 12/4/24, and that a resident council meeting would be scheduled for later this month. Although requested a Resident Council policy was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #14, 174, 175, and 176) reviewed for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops), the facility failed to ensure that code status was reviewed with the resident or resident representative, upon admission and as needed, to ensure the residents choices were was honored. The findings include: 1. Resident #14 was admitted to the facility in [DATE] with diagnoses that included Alzheimer's dementia, chronic kidney disease, and hypertension, A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, do not resuscitate (DNR) and RN to pronounce death. The quarterly MDS dated [DATE] identified Resident #14 had severely impaired cognition, was always incontinent of bowel and bladder and was dependent on staff assistance with dressing, bathing, and toileting. The care plan dated [DATE] identified Resident #14 had impaired cognitive function and impaired thought processes related to dementia. Interventions included to communicate with the resident representative regarding the resident's needs. A physician's order dated [DATE] directed Resident #14 had advance directives that included do not hospitalize (DNH), A physician's order dated [DATE] directed Resident #14 to have a hospice consult and care. Review of the clinical record failed to identify a signed advanced directive form, a care plan related to Resident #14's advance directives choices or documentation that staff had a discussion regarding advance directives with the resident representative. Interview with the DNS on [DATE] at 8:15 AM identified that she was aware there were issues with advance directive forms being completed for residents of the facility. The DNS identified that the advance directive form should have been signed and completed by the resident or resident representative within 48 hours of admission, and that for Resident #14, the form should have been reviewed again with Resident #14's resident representative with the order for hospice. The facility policy on advance directives directed that when any interdisciplinary team member had a discussion with a resident representative regarding advance directives, the conversation would be documented. The policy further directed that the appropriate advance directive paperwork would be placed in the advance directive section of the resident's medical record, and that the resident's code status would be reviewed at every resident care plan meeting to ensure all information was accurate and current. 2. Resident #174 was admitted to the facility in [DATE] with diagnoses that included lumber fracture and hypertension. The admission assessment dated [DATE] identified Resident #174 was alert and oriented to person, place, and time. The baseline care plan dated [DATE] failed to reflect the residents wishes for a code status. Review of the nurse's notes dated [DATE] to [DATE] failed to reflect that staff had discussed and ascertained Resident #174's wishes for code status and/or documented that discussion in the medical record. Review of the physician orders dated [DATE] to [DATE] failed to reflect a code status. The physician admission note dated [DATE] failed to reflect the physician had discussed and ascertained Resident #174's wishes for code status and/or documented that discussion in the medical record. Interview with the DNS [DATE] at 7:35 AM identified that the admission charge nurse or supervisor was responsible to put the code status in the physician orders using the code status from the hospital and that the code status should have been addressed with Resident #174 within 48 hours of admission and be verified with the physician. Further, the DNS indicated Resident #174 was and able to sign his/her own code status form. After surveyor inquiry, the Resuscitation Status Form dated [DATE] was signed by Resident #174 and MD #1 to reflect that Resident #174 was to receive CPR (cardiopulmonary resuscitation) and a physician's order dated [DATE] at 7:55 AM (7 days after admission) directed Resident #174 to be a full code. Interview with MD #1 on [DATE] at 10:18 AM indicated that when a resident comes from the hospital that she uses the code status from the hospital on admission. MD #1 indicated that on admission she had confirmed the admission orders for Resident #174 and had seen Resident #174 on Thanksgiving Day just to do the admission, but she did not see or discuss the code status. MD #1 indicated she signed the code status form today [DATE] because it was left in her communication book. 3. Resident #175 was admitted to the facility in [DATE] with diagnoses that included pelvic fractures and atrial fibrillation. The hospital transportation form dated [DATE] identified Resident #175 was a Do Not Resuscitate (DNR) as of [DATE] per hospital physician. The admission assessment dated [DATE] at 10:43 PM identified Resident #175 was alert and oriented to person, place, and time. Review of the nurse's notes dated [DATE] to [DATE] failed to reflect that staff had discussed and ascertained Resident #175's wishes for code status and/or documented that discussion in the medical record. The baseline care plan dated [DATE] failed to reflect a code status A physician's order dated [DATE] directed Resident #175 was a DNR. The physician admission note, written by MD #2 dated [DATE] failed to reflect a discussion regarding code status. Review of the clinical record on [DATE] at 7:30 AM identified that Resuscitation Status Form was blank and there was no signed advanced directive form in chart. Interview with the DNS on [DATE] at 10:12 AM indicated that although Resident #175 could sign the form him/herself, the Resuscitation Status Form was not completed and had not been addressed with Resident #175. The DNS indicated that the code status should have been addressed by a nurse or MD #2 within 48 hours of the admission. Interview with Resident #175 on [DATE] at 11:30 AM indicated that he/she had discussed his/her wishes regarding code status with staff at the hospital, but no staff at the facility had discussed it with him/her. Resident #175 indicated that he/she wanted to be a DNR. The Resuscitation Status Form dated [DATE] (7 days after admission) identified Resident #175 and MD #2 signed Resident #175 was a do not resuscitate (DNR). 4. Resident #176 was admitted to the facility in [DATE] with diagnoses that included Crohn's disease, hypertension, and anxiety. The hospital discharge summary dated [DATE] identified Resident #176 was a full code. Review of the nurse's note dated [DATE] to [DATE] failed to reflect that staff had discussed and ascertained Resident #176's wishes for code status and/or documented that discussion in the medical record. Physician's admission orders dated [DATE] until [DATE] (13 days) directed Resident #176 was a full code. Review of the admission History and Physical, by MD #1 dated [DATE] failed to reflect a discussion regarding code status. The baseline care plan dated [DATE] failed to reflect a code status. Review of a progress note dated [DATE], [DATE] by MD #1 failed to reflect a discussion regarding code status. Review of the clinical record on [DATE] at 7:30 AM and 11:00 AM failed to reflect a signed Resuscitation Status Form in the clinical record by either Resident #176 or MD #2. Interview with MD #1 on [DATE] at 10:18 AM indicated that she had seen Resident #176 many times but did not discuss code status with the resident. MD #1 indicated that Resident #176 was responsible for him/herself and could sign the Resuscitation Status Form. Interview with Resident #176 on [DATE] at 2:40 PM indicated that his/her wish was to be a DNR. Resident #176 indicated that since he/she was admitted to the facility no one had asked or discussed his/her wishes for code status and if they did, he/she would have informed the staff that he/she requested DNR. Resident #177 indicated that his/her PCP in the community was aware that his/her wishes were to be a DNR prior to going to the hospital and he/she believed that the hospital was aware that he/she wanted to be a DNR. Interview with the DNS on [DATE] at 2:50 PM indicated that Resident #176 was able to sign his/her own Resuscitation Status Form and that there was not a signed Resuscitation Status Form in the clinical record. The Resuscitation Status Form dated [DATE] directed DNR signed by Resident #176. A physician order dated [DATE] at 4:04 PM directed DNR. Interview and review of the clinical records with RN #3 on [DATE] at 7:10 AM indicated that Residents #174, #175, and #176 did not have signed Resuscitation Status Forms in their clinical records. RN #4 indicated that on admission the charge nurse is responsible to get an order from the physician for an code status based on the hospital discharge paperwork until the nurse or physician can go over the code status forms with the resident or resident representative. RN #4 indicated that all residents were to have a Resuscitation Status Form signed by the resident or resident representative and the primary physician within the first couple of days from admission. RN #4 indicated that a full code was a green piece of paper and a DNR was a red piece of paper that would be easily found in the front of every resident's medical record. RN #4 indicated that it was color coded and kept on paper in the front of the medical record so in the event of emergency, it would be quick to find. RN #4 indicated that she did not know why Residents #174, #175, and #176 did not have it completed because these residents could sign form themselves. Interview with the DNS [DATE] at 7:35 AM identified the code status should have been addressed with the residents or resident representatives within 48 hours of admission and the Resuscitation Status Form would be signed by the physician and placed in the resident's medical chart and scanned into the electronic medical record. The DNS indicated that the admission nurse should have used the code status from the hospital and verified it with the covering physician at the facility until the resident had been educated, informed, and the resident or resident representative had signed either for a full code or DNR form. Review of the Advanced Directive Policy last review date [DATE] identified that all resident's will have documented advanced directives in their medical records. When any staff member has a conversation with a resident who is cognitively intact and their own decision maker regarding advanced directives such as a DNR or comfort measures, treatment, etc.- this conversation is to be documented. The attending physician will write orders for resident's code status based on the resident's wishes. The appropriate code status paperwork will be placed in the Advanced Directive Section on the medical record. 46040

Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure that hot and cold food temperatures for meals were obtained and documented appropriately. The findings include: During a tour of the facility kitchen with Dietary Director #1 on 12/2/24 at 9:30 AM identified the following. Review of the food service temperature logs for 11/2024 identified that multiple dates were missing temperatures or were completely blank. Initial review of the food temperature logs for 11/19/24 - 11/30/24 identified breakfast food temperature logs with hot food temperatures documented with no dates (month/day/year) annotated on the logs, no cold food items with any recorded temperatures from 11/19/24 - 11/29/24, and completely blank areas for the following meals: 11/19/24 - no breakfast logs available for review; no food temperatures for lunch items. 11/24/24 - no logs available for review for any meals. 11/26/24 - no breakfast logs available for review; no food temperatures for dinner items. 11/27/24 - no breakfast logs available for review; no food temperatures for lunch items. 11/28/24 - no breakfast logs available for review; no food temperatures for lunch items. 11/29/24 - no breakfast logs available for review; no food temperatures for dinner items. 11/30/24 - no breakfast logs available for review; no food temperatures for dinner items. Further review of breakfast logs identified that the meal items listed were identical (oatmeal/farina/scrambled eggs/pancakes/French toast) for all temperatures records. Further review of additional logs for 9/24 and 10/24 also identified multiple days with incomplete food temperature logs with missing temperatures for main and alternate meals. Review of the logs also failed to identify any documentation related to any cold food items. Interview with Dietary Director #1 immediately following this review identified that he was not aware that the food temperatures were not being logged with every meal and that he would expect that the staff were doing this. Dietary Director #1 identified he would educate that staff regarding the need to ensure that food was provided at the proper temperatures. An initial request was made to Dietary Director #1 for copies of the food temperature logs for all meals served to the facility residents from 9/1/24 - 12/1/24 immediately following these observations by the end of the day on 12/2/24. A follow up request was made on 12/3/24 at 2:00 PM to Dietary Stock Clerk #1, who identified that Dietary Director #1 had completed making copies of the food temperature logs but she was unable to identify where they were located and that she would notify him that the documents were still needed. Following a 3rd attempt made on 12/4/24 to obtain the food temperature logs on 12/4/24 at 7:00 AM, Dietary Stock Clerk #1 identified Dietary Director #1 was not scheduled to work on that date but had put aside the copies of the logs previously requested. Dietary Stock Clerk #1 provided multiple food temperature logs, including the logs previously reviewed by this surveyor. Review of the logs provided identified the logs had been altered, with meal temperatures added for the dates previously reviewed by this surveyor. In addition, the breakfast logs previously reviewed that were not identified by date, now included multiple dates added, including 11/19/24 - 11/30/24. Interview with Dietary Stock Clerk #1 immediately following these observations identified she was only told where the copies were located but was unable to identify why the documents were altered or who had altered them. Interview with Dietary Director #2 (Chef Manager) on 12/4/24 at 9:49 AM identified that he was aware of the issues with food temperature logs and that his associates at the facility had misunderstood the issues with the logs, and that the logs had been filled in after the initial review with Dietary Director #1. Dietary Director #2 declined to identify who filled out the logs or how the temperatures were obtained after the meals had already been served weeks to months prior to the review, or how the breakfast dates were recorded when the logs included identical meals with no dates previously. Dietary Director #2 identified the logs would be completed with all meals going forward, and that the facility had provided in servicing to the dietary staff, provided a copy of an in-service document, and identified that the facility did not have a policy related to food temperature logs. Review of an undated in-service document for Food Temperature logs identified that all food temperature logs must be filled out before the start of each meal service and at any other time if required. Subsequent to surveyor inquiry, interview and document review with Dietary Director #2 on 12/4/24 identified the facility did have a policy related to food temperatures and that he was unaware that the policy existed until the inquiry by this surveyor. The facility policy on food temperatures directed that all food production staff were responsible for recording and maintaining proper food temperatures at the tray line and/or point of service dining areas. The policy further directed that the food temperature log would be used to record temperatures for each meal, and all hot and cold food temperatures were be recorded at the start and end of each meal. The policy further directed that tempter logs would be maintained in the dietary department per the record retention policy.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) who was a new admission from the hospital, the facility failed to transcribe a medication order from the hospital discharge summary into the Electronic Medication Administration Record (EMAR) resulting in a change in condition and re-hospitalization . The findings include: Resident #1 was a new admission with diagnoses that included status post fracture of the left femur, osteoporosis and hypertension. The Hospital Discharge Summary dated 10/27/22 identified under hip fracture instructions, regarding blood clot prevention, an order directed to administer Enoxaparin 40 milligrams (mg)/0.4 milliliters (ml) syringe, Inject 0.4. ml (40mg total) under the skin daily for a total of thirty-five (35) days post operatively. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life. The nurse's note dated 11/1/22 at 4:30 PM identified Resident #1 reported nausea and chest pian during therapy and this was reported to the nursing staff by the physical therapist. Vital signs obtained at 1:00 PM indicated a temperature of 97.6, pulse rate 104, respirations 26 and blood pressure of 117/62. The note identified when questioned further about the chest pain Resident #1 stated the pain and pressure were under the sternum into the left shoulder and radiating down the left upper extremity into the left posterior shoulder, Resident #1 was short of breath with speaking, anxious and non-diaphoretic. The note identified Resident #1's oxygen saturation level was 89% on room air at which time oxygen at four (4) liters per minute via nasal cannula was applied and the oxygen levels ranged from 87-93%. The note indicated all parties were notified and Resident #1 was transferred to the hospital for evaluation and treatment. The Facility Incident Report dated 11/2/22 at 1:00 PM identified Resident #1 had an acute onset of chest pain and shortness of breath on 11/1/22. On 11/1/22, Resident #1 was admitted to the hospital with a diagnosis of a pulmonary embolism. The report identified the facility substantiated after review of the clinical record that the Enoxaparin 40 mg subcutaneous every day had not been transcribed, and Resident #1 missed five (5) doses between the dates of 10/28/22 to 11/1/22. Review of the October and November 2022 Medication Administration Records identified Enoxaparin 40 mg/0.4 ml was not administered. Review of the physician's orders for the months of October and November 2022 failed to identify an order for the Enoxaparin 40 mg/0.4 ml. Review of the Hospital Discharge Summary dated 11/7/22 identified Resident #1 presented to the hospital on 11/1/22 with complaints of chest pain. The summary indicated Resident #1 had completed a left hip hemiarthroplasty on 10/24/22 after the resident sustained a left femoral neck fracture and post-op, Resident #1's hospital stay was uneventful except for a minor episode of post-op delirium. Resident #1 was discharged to rehab on prophylactic dose of Enoxaparin per post-op hip fracture protocol, but apparently had not been receiving the Enoxaparin at the rehab facility. Resident #1 was sent to the emergency department for evaluation of chest pain and was found on Computed Tomography Angiography (CTA, a medical test that combines a CT scan with an injection of special dye to produce pictures of blood vessels and tissue in a part of the body) to have a large saddle pulmonary embolism with additional bilateral central, lobar, segmental and subsegmental pulmonary emboli. Program Evaluation Review Technique ([NAME]) was activated by the emergency department and Resident #1 was admitted to the Surgical Intensive Care Unit and was started on a Heparin drip. The discharge summary identified Resident #1 was transferred to the Step-Down Unit on 11/3/22, then to a unit on 11/5/22 and discharged back to the facility on [DATE], six (6) days later with a new medication order for Eliquis indicated to pulmonary embolism prevention and treatment. The Eliquis order directed to administer Eliquis 5 mg take two (2) tablets (ten (10) mg every twelve (12) hours for seven (7) days until 11/10/22 and then start Eliquis take one (1) tablet, five (5) mg total) every twelve (12) hours until 2/9/22. A physician's progress note dated 11/7/22 identified Resident #1 was seen for re-admission to the facility. Resident #1 was hospitalized from 11/1/22 to 11/7/22 with diagnoses of acute pulmonary embolism and cor pulmonale secondary to not being anticoagulated (medication transcription error) after recent hip surgery. Interview with the Director of Nursing (DON) on 11/17/22 at 10:00 AM identified for all new admissions, the nursing supervisor will perform a medication reconciliation and contact either the attending physician or the on-call provider with any issues or concerns noted. The DON identified she reviewed Resident #1's record with the Nursing Supervisor, Registered Nurse (RN) #1, status-post hospitalization and noted the Enoxaparin 40 mg/0.4mL had not been transcribed into the physician orders. The DON identified RN #1 simply just over-looked the order and did not transcribe the order into the electronic health record. The DON identified RN #1 failed to have another licensed nurse perform a double check as per the facility policy. The DON noted since this incident, the facility has incorporated a triple-check policy to ensure accuracy with transcribing medications to prevent any errors. Interview with the primary care physician, MD #1, on 11/17/22 at 10:30 AM identified she performs medication reconciliation on all new admissions, but MD #1 indicated she used the records from the hospital's electronic charting system due to the facility currently transitioning from paper to electronic, and MD #1 did not have access to the facility's new electronic charting system at that time. MD #1 identified Resident #1 was on Enoxaparin for deep vein thrombus and pulmonary embolism prevention. MD #1 identified with Resident #1 not receiving the Enoxaparin while at the facility, certainly could have contributed to Resident #1's most recent admission to the hospital on 11/1/22. MD #1 indicated deep vein thrombus or pulmonary embolism can be very common status-post surgical procedures, and anti-coagulation therapy is necessary for the prevention of these diagnoses. MD #1 identified Resident #1 was admitted to the hospital on 11/1/22 with a diagnosis of pulmonary embolism, was treated on a Heparin drip, oxygen treatment and was made hemodynamically stable for discharge back to the facility with new orders for Eliquis. Although attempted, interview with RN #1 was unsuccessful. Review of the Medication Reconciliation Policy dated January 2020, identified upon admission, the medication list will be reviewed by the nurse and the physician will be notified of orders on the Inter-Agency Referral Form (W-10), the nurse receiving admission will review the W-10 and then call or present the orders to the physician if the physician is in the Health Center. The nurse will then enter the orders in the eMAR (electronic medical administration records), the orders will be electronically transmitted to the pharmacy (Omnicare), and a second nurse will then review the orders that were entered.

Based on observations, review of the clinical records, facility documentation, staff interviews for two of four residents reviewed for accidents (Residents #9 and 67), and/or for one of three nursing units, the facility failed to prevent an accident and/or provide a hazard free environment. The findings include: 1. Resident #9's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The nurse's note dated 4/19/12 at 6:00 AM indicated that on 4/18/12 at 11:15 PM the resident asked the nurse aide to remove the hydroculator pad and a dark pink area measuring 6 cm x 5 cm was noted. The physician was notified and directed to monitor the area and to call if the area became worse. At 6:00 AM the area had faded except for three reddened areas measuring 1cm x 1/2 cm each. Review of the hydroculator temperature log with the Rehabilitation Manager (RM) on 06/21/12 at 11:20 AM identified that hydroculator temperatures were not obtained from March 2012 through April 2012. The RM stated that temperatures were obtained and recorded starting in May 2012. Further interview with the Rehabilitation Manager indicated hydroculator temperatures obtained were between 171 degrees to 176 degrees, however, the facility did not verify the manufacturer's recommended temperature settings for use of the hydroculator machine. Review of the facility's policy and manufacturer's safe operating conditions indicated to regulate the temperature between 160 to 165 degrees. The RM further indicated that rehabilitation staff were not direction as to how often to moniotor the hydroculator temperature. 2. Resident #67 had [DIAGNOSES REDACTED]. Further assessment noted the resident required assist of one person for transfer and toileting. The assessment identified that the resident was always continent. The fall risk assessment dated [DATE] identified the Resident #67 scored 22 on the risk scale (resident who score 10 or higher are at risk). The care plan dated 6/8/11 identified the resident had frequent falls with interventions that included providing one person assistance for transfers and ambulation. A physician's orders [REDACTED]. A nurse ' s note dated 7/5/11 identified the resident was noted to be searching for the alarms and turning them off. Additionally, the resident requested that the alarms be removed because the noise was bothersome. Review of the treatment kardex indicated the bed and chair alarms were discontinued on 7/5/11. The nurse's note dated 7/6/11 at 4:00 PM indicated the resident was found on the floor in his/her room with the bedside chair on top of the resident and at 4:20 PM the resident was again found on the floor with the telephone in his/her hand. The care plan dated 7/6/11 included to keep the resident in common areas and to encourage the resident to sit while on the phone. The nurse ' s note and reportable event dated 7/15/11 at 2:45 PM identified the resident was found sitting on the floor. The resident went to the bathroom without assistance. Upon return from the bathroom the resident attempted to sit in the bedside chair, however, sat on the arm of the chair. The chair tipped over and the resident fell to the floor. The physician was notified and directed to obtain an x-ray that identified a right femoral neck fracture. Interview and review of the clinical record with the MDS Coordinator on 6/19/12 at 10:42 AM identified that although the bed and chair alarms had been discontinued on 7/5/11, no additional fall interventions were implemented to monitor the resident in his/her room. Interview with the Director of Rehabilitation Services and Occupational Therapist #1 on 6/19/12 at 3:00 PM and review of the physical therapy discharge note dated 7/13/11 identified the resident was discharge from physical therapy on 7/13/11 and required supervision and contact guard assistance (CGA) with transfers and ambulation. 3. Observation 6/20/12 at 12:01 PM identified a nurse aide was moving a resident to the spa room and used a wedge to prop the door open and did not remove the wedge immediately. Further observation identified two staff members enter and then exit the room without removing the wedge.The spa door was noted to be closed 9 minutes later at 12:09 PM. 3. Observation with the Director of Maintenance and the Director of information Services (DIS) on 6/20/12 at 2:00 PM identified the door to the telephone equipment room located in the rehabilitation unit was left unsecured. The DIS indicated that a telephone connection was added two days ago must have left the door unlocked since. Upon surveyor inquiry the door to the telephone equipment was locked.