Every finding on record at Wingfield Skilled Nursing and Rehabilitation Cente

Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) a resident's drinking water placed on the floor was not in close proximity to a urinal holding the resident's bodily fluids for 1 of 23 sampled residents (Resident #17), 2) clean linens were kept covered during transport and delivery, 3) a Licensed Practical Nurse (LPN) cleaned a tablet splitter before and after use during medication administration, 4) hand hygiene supplies were readily available to staff and staff performed hand hygiene as required when performing wound care for 1 of 23 sampled residents (Resident #4), 5) Enhanced Barrier Precautions (EBP) were implemented appropriately for 1 of 23 sampled residents (Resident 13), and 6) Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 23 sampled residents (Resident #100). This deficient practice had the potential to spread infectious organisms throughout the facility. Findings Include: Urinal Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including pneumonia, unspecified organism, methicillin resistant staphylococcus aureus infection, unspecified site, and cognitive communication deficit. On 02/09/2026 at 11:19 AM, Resident #17 had a portable urinal approximately 1/10 full of dark brown urine. The urinal was on the ground at the resident's feet, next to the resident's bed. Next to the urinal was the resident's gray pitcher of water. The urinal and the pitcher were approximately 2 inches apart. On 02/09/2026 at 11:35 AM, a Certified Nursing Assistant (CNA1) verbalized the CNAs were responsible for rounding on the resident every two hours to take care of the resident's urinal. The urinal was to be emptied and only stored on hooks of the bed or on the side of the resident's trash can. CNA1 explained the resident's urinal should not be stored on the ground nor stored on the ground next to the resident's cup of water. The urinal could spread bacteria into the resident's drinking water creating an infection control issue. On 02/11/2026 at 8:31 AM, the Director of Nursing (DON) verbalized the expectation was for CNAs to empty, clean, and return urinals to the resident's bedside during rounds or when the resident called after use. The urinals could be placed on the side of the bed rail if needed, but most of the time they were kept at the bedside. The DON explained urinals were not to be kept on the ground because they might not be accessible for the resident and created an infection control issue due to bodily fluids. Urinals placed on the ground could spill and create an environmental hazard for staff and residents. The DON confirmed it would not be appropriate to keep a water pitcher and urinal approximately 2 inches apart for health and safety reasons. The facility policy titled Standard Precautions, adopted 02/01/2019 and reviewed annually, documented standard precautions were used in the care of all residents regardless of diagnoses, suspected, or confirmed infection status. Standard precautions presume all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Standard precautions included resident care equipment. Resident care equipment soiled with blood, body fluids, secretions, and excretions were handled in a manner preventing skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents or environments. Linen On 02/10/2026 at 4:16 PM, a blue laundry cart was outside room [ROOM NUMBER], uncovered. The cart contained nine folded white bed sheets and one folded beige blanket. On 02/10/2026 at 4:19 PM, the Unit Manager Registered Nurse (RN) confirmed the cart contained clean linens and was left uncovered. The Unit Manager RN verbalized the CNAs usually delivered the linens to the residents' rooms. On 02/10/2026 at 4:24 PM, the DON, confirmed the laundry was left uncovered and unattended, and should have been covered to maintain infection control practices and to prevent potential cross contamination. The facility policy titled, Linen and Laundry, updated 05/2020, documented clean linen would be transported and stored according to best practices for infection prevention and control, and placed in a cart with a cover for transport. Cleaning of tablet-splitter Resident #43 Resident #43 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified and localized edema. On 02/11/2026 at 8:43 AM, LPN1 began preparing medications for Resident #43. LPN1 retrieved one tablet of Potassium Chloride extended release 10 milliequivalents (meq) from the medication cart. LPN1 verbalized Resident #43 liked the Potassium Chloride broken in half as the tablet was large and hard to swallow if left whole. LPN1 retrieved a tablet splitter from the top drawer of the medication cart, placed the Potassium Chloride tablet inside the tablet splitter, cut the tablet in half, and returned the tablet splitter to the drawer. LPN1 did not clean the tablet-splitter prior to and after use. On 02/11/2026 at 3:20 PM, LPN1 verbalized if a medication tablet needed to be cut/broken, staff were to use a tablet splitter and explained staff should clean the tablet splitter before and after each use to help prevent the potential spread of infection. Sanitizing cloths were used to clean the tablet splitter. LPN1 confirmed LPN1 did not clean the tablet splitter before and after use for Resident #43 during the morning medication administration pass. On 02/12/2026 at 10:55 AM, the DON verbalized staff could use a tablet splitter to cut medication tablets in half, if necessary, when preparing medications for administration. Tablet splitters were to be cleaned after each use. The DON explained it was important for tablet splitters to be cleaned before and after each use as it was an infection control concern and could result in cross contamination. The facility policy titled Preparation and General Guidelines, Equipment and Supplies for Administering Medications, dated 05/2024, documented if breaking tablets was necessary to administer the proper dose, hands were to be washed with soap and water or alcohol gel and examination gloves worn prior to handling tablets. A tablet-splitter was to be used to ensure accuracy and to minimize contact with the tablet. The splitter blade and surfaces contacting the tablet were to be cleaned before and after each use. Hand hygiene supplies readily available and performance of hand hygiene during wound care Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including unspecified atrial fibrillation and hypertensive heart disease with heart failure. A Physician's Order dated 02/02/2026, documented left lower leg vascular wound: cleanse with Normal Saline (NS), apply zinc oxide to peri-wound, apply collagen particles to wound bed, cover with foam dressing. Every day shift, every other day. On 02/12/2026, LPN2 performed wound care for Resident #4. The following was observed: -At 1:17 PM, LPN2 entered Resident #4's room, donned a pair of gloves, wiped the resident's bedside table with a sanitizing cloth, doffed the pair of gloves, donned a new pair of gloves, opened and placed a clean drape on the bedside table, doffed the pair gloves and discarded the gloves in a garbage can, touched the resident's foot, exited the resident's room, unlocked a wound care cart, grabbed the handle of the bottom drawer of the cart and opened the drawer, retrieved a bottle of Alcohol-Based Handrub (ABH) and applied the ABH to LPN2's hands. LPN2 did not perform hand hygiene after removing the second pair of gloves, before touching the resident, after touching the resident, prior to/upon exiting the resident's room, and before touching the wound care cart. -At 1:22 PM, LPN2 entered Resident #4's room, explained the procedure to the resident, entered the resident's bathroom and washed LPN2's hands with soap and water. The paper towel dispenser in the bathroom was empty, and the bathroom lacked any additional supply of paper towels or clean towels. LPN2 used LPN2's elbow to open the bathroom door, walked to the resident's doorway and asked another staff member to retrieve paper towels so LPN2 could dry LPN2's hands. -At 1:36 PM, after completing the wound care for Resident #4, LPN2 entered the resident's bathroom and washed LPN2's hands with soap and water. LPN2 verbalized LPN2 kept forgetting there were no towels in the bathroom, exited the resident's room, knocked on the door of another resident's room, entered the room and retrieved paper towels from the resident's bathroom. On 02/12/2026 at 1:43 PM, LPN2 verbalized staff were supposed to perform hand hygiene before and after contact with residents. ABH was appropriate to use unless LPN2 was performing wound care, then LPN2 would wash LPN2's hands with soap and water. LPN2 confirmed paper towels were not available in Resident #4's bathroom and confirmed towels were a necessary supply to complete hand hygiene when washing with soap and water. LPN2 acknowledged LPN2 did not perform hand hygiene after touching Resident #4 and before unlocking and opening the wound care cart. On 02/12/2026 at 1:48 PM, the DON verbalized staff were expected to perform hand hygiene before and after resident care. Hand hygiene was important in controlling infections due to the potential for cross contamination. The DON explained housekeeping staff were responsible to keep the paper towel dispensers in resident bathrooms stocked and clinical staff were expected to communicate with housekeeping when the clinical staff ran out of paper towels. The DON confirmed the DON would expect staff to perform hand hygiene when exiting a resident's room and prior to touching a wound care cart. The DON confirmed paper towels were considered an essential supply necessary for hand hygiene, however; verbalized a clean hand towel could be used in an emergency. The facility policy titled Handwashing/Hand Hygiene, dated 02/01/2019, documented all personnel were to follow handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) were to be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Supplies necessary for hand hygiene were alcohol-based hand rub containing at least 62 percent alcohol, running water, soap, paper towels, a trash can, lotion and non-sterile gloves. Alcohol-based hand rub or soap and water were to be used for the following situations: before and after contact with residents, before handling clean or soiled dressings or gauze pads, after contact with objects in the immediate vicinity of the resident, and after removing gloves. The procedure for washing hands included drying hands thoroughly with paper towels and turning off the faucet with a clean, dry paper towel. EBP Implementation Resident #13 Resident#13 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis, dysphagia, and contractures. A physician's order dated 09/17/2025, documented EBP for G-tub every shift. On 02/11/2026 at 1:30 PM, LPN3 was changing the feeding of Resident #13 G-tube wearing gloves and no gown. On 02/11/2026 at 2:00PM, the LPN3 verbalized the LPN3 believed neither the LPN3 nor staff were required to don a gown when changing the feeding on a G tube for Resident #13. On 02/12/2026 at 2:19 PM, the DON verbalized the EBP should have included hand hygiene, gloves, and gowns. The DON stated staff should have donned gloves and a gown when placing the new feeding for Resident #13's G-tube. The facility policy titled, Enhanced Barrier Precautions (EBP), updated 03/21/2024, documented EBP were infection control intervention designed to reduced transmission of resistant organisms that employs targeted gown and glove use during contact resident care activities. TBP Implementation Resident #100 Resident #100 was admitted to the facility on [DATE], with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere. An aerobic bacterial urine culture report dated 12/02/2025, documented heavy growth of MRSA. A physician's order dated 12/24/2025, documented the resident was on single room contact isolation for MRSA to the left heel wound every shift. A care plan focus initiated 12/26/2025, documented Resident #100 had MRSA and was on contact isolation for MRSA to the resident's left heel. An intervention initiated 04/06/2025, documented to instruct family, visitors, and caregivers to wear a disposable gown and gloves during physical contact with the resident. An intervention initiated 07/18/2025, documented contact precautions would be followed when providing treatment to the resident's wound. On 02/09/2026 at 10:39 AM, TBP signage was posted at the entrance of Resident #100's room. The sign documented contact precautions. Everyone must clean hands before entering and when exiting the room. Staff must also don gloves and gowns prior to room entry and upon exit. On 02/09/2026 at 10:39 AM, a CNA2 entered Resident #100's room. The CNA did not use an alcohol-based hand rub (ABHR) and did not don gloves or a gown. On 02/09/2026 at 10:44 AM, CNA2 explained the CNA believed Resident #100 was on contact precautions for an infection related to the resident's stool. CNA2 confirmed the signage on the resident's entryway documented contact precautions required staff use ABHR and wear gowns and gloves prior to entering the resident's room. CNA2 verbalized the CNA only donned a gown and gloves when assisting the resident to the restroom. The CNA confirmed the CNA did not use and ABHR nor did the CNA don a gown and gloves. CNA2 explained the CNA was in the resident's room to assist the resident to the restroom. The CNA kept a gown inside the resident's bathroom to reuse each time the resident required assistance. On 02/12/2026 at 9:05 AM, LPN4 verbalized contact precautions required all staff to use ABHR and don gloves and a gown prior to entering the resident's room. LPN4 verbalized Resident #100 required contact precautions due to an active diagnosis of MRSA. On 02/12/2026 at 9:56 AM, the Infection Preventionist (IP) verbalized contact precautions were used to prevent the transmission of infectious diseases among residents and staff. Contact precautions required staff use ABHR and don new gloves and gowns prior to entering the resident's room because surfaces in the room could be contaminated. The IP explained Resident #100 was admitted to the facility with an active diagnosis of MRSA and should be on contact precautions. The facility policy titled Isolation-Transmission Based Precautions, adopted 02/01/2019, documented TBP were additional measures to protect staff, visitors and other residents from becoming infected. The CDC maintained a list of diseases, modes of transmission recommended precautions and recommendations for discontinuation. Contact precautions required staff and visitors to wear clean gloves and disposable gowns when entering the room. The CDC document titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated 09/2024, documented Multidrug Resistant Organisms (MDROs) were generally defined as microorganisms which were resistant to one or more classes of antimicrobial agents. MDROs of concern included MRSA. Documented outbreaks in long-term care facilities were caused by various viruses and bacteria and could lead to substantial morbidity and mortality and increased medical costs. Prompt detection and implementation of effective control measures were required. Placement of a resident in a single room was preferred when there was concern about transmission of an infectious agent, including residents on contact and droplet precautions. Recommendations for residents infected or colonized with an MDRO judged as clinically important by the infection control program included contact in addition to standard precautions.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the enteral nutrition was administered in accordance with physician orders and facility policy for 1 of 23 sampled residents (Resident #13). This deficient practice had the potential to place the resident at risk for aspiration and inadequate nutritional intake.Findings include: Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis, dysphagia, and contractures. A physician order dated 04/08/2025, documented Jevity 1.5 continuous feeding at 65 milliliters (ml) per hour, to be turned off at 10:00 AM for four hours and restarted at 2:00 PM. On 02/10/2026 at 8:56 AM, Resident #13 had a tube feeding (a surgically placed device that delivers nutrition, fluids, and medicine directly into the stomach) running at a rate of 60 ml per hour. A physician order, dated 04/07/2025, documented to have the head of bed up 30-45 degrees during feeding and for one hour after gravity or bolus feeding. On 02/10/2026 at 8:58 AM, Resident #13 was observed in bed lying in a fetal position on the flat portion of the mattress near the lower part of the head of the bed. On 02/10/2026 at 9:00 AM, a Licensed Practical Nurse (LPN) verbalized Resident #13's head of bed was at approximately thirty degrees and should have been elevated higher. Resident #13 continued to be observed in a fetal position on the flat portion of the mattress near the lower part of the head of the bed. The LPN verbalized Resident #13 should have been repositioned due to aspiration risks.The LPN confirmed the feeding rate was set at 60 mL per hour and stated it should have been set at 65 mL per hour. The LPN verbalized that not setting the correct rate could result in the resident receiving an insufficient amount of nutrition. On 01/06/2022 at 10:26 AM, the Director of Nursing (DON) verbalized staff were expected to follow physician orders for the G tube (gastrostomy tube). The DON verbalized Resident #13's head of bed should have been elevated due to the risk of aspiration during feeding, and the resident should have been repositioned to reduce aspiration risk. The facility's policy titled Enteral Feedings - Safety Precautions, updated 02/01/2019, documented staff were to check the enteral nutrition label against the physician order before administration, including method (pump, gravity, syringe) and rate (milliliters per hour) and required elevating the head of bed at least thirty degrees during feeding and for at least one hour afterward to prevent aspiration. If head of bed elevation was medically contraindicated, the reverse Trendelenburg position was to be used.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure an oxygen administration was stopped and the concentrator removed from the resident's room when the physician's order for oxygen was discontinued for 1 of 23 sampled residents (Resident #70). The deficient practices had the potential to cause residents to use an unnecessary medication with possible adverse effects.Findings include:Resident #70Resident #70 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and emphysema.A physician's order dated 11/13/2026, and discontinued on 01/29/2026, documented to administer oxygen at 3 liters per minute (lpm) via nasal cannula continuously every shift for emphysema.Resident #70's clinical record lacked documentation of an active physician's order for oxygen therapy.An alert progress note dated 01/29/2026, documented Resident #70's oxygen saturation was 95 percent (%) on room air. The resident did not use their oxygen in the previous 24 hours. The oxygen order would be discontinued.An oxygen saturations summary documented the following:-On 01/30/2026 at 8:33 AM oxygen saturation was 90%. Oxygen administered via nasal cannula.-On 01/31/2026 at 12:37 AM oxygen saturation was 90%. Oxygen administered via nasal cannula.-On 02/06/2026 at 10:56 PM oxygen saturation was 90%. Oxygen administered via nasal cannula.-On 02/08/2026 at 7:11 PM oxygen saturation was 91%. Oxygen administered via nasal cannula.On 02/09/2026 at 3:11 PM, Resident #70 was in bed in the resident's room. An oxygen concentrator was placed next to the bed and was set to an oxygen flow of 3 liters per minute. The nasal cannula and oxygen tubing were on the floor.Resident #70 verbalized the resident did not require oxygen therapy and was unsure why the oxygen concentrator was present in the resident's room.On 02/09/2026 at 3:20 PM, a Registered Nurse (RN) verbalized believing Resident #70 required continuous oxygen therapy at two liters per minute via nasal cannula.The RN was informed Resident #70's oxygen was not being used by the resident, and the nasal cannula was on the floor. The RN entered the resident's room and encouraged the resident to wear the nasal cannula. The resident replied no, I don't need it. The RN exited the resident's room.On 02/09/2026 at 3:23 PM, the RN confirmed Resident #70 was not wearing the nasal cannula and the nasal cannula was on the floor. The RN verbalized the RN educated the resident and resident refused to wear the nasal cannula. The RN verbalized the RN would monitor the resident's oxygen saturation and left to retrieve a pulse oximeter. Upon return, the RN verbalized the RN was mistaken and the physician's order for oxygen therapy was discontinued on 01/29/2026.On 02/12/2026 at 9:03 AM, a Licensed Practical Nurse (LPN) explained Resident #70 previously received oxygen therapy. However, the resident was stable on room air so the facility requested to titrate the oxygen and the physician's order was discontinued. The LPN recalled the LPN was the nurse to discontinue the oxygen order in the resident's electronic health record. The LPN explained when an oxygen order was discontinued, the LPN would immediately remove the concentrator from the resident's room to ensure the oxygen therapy was not administered without a physician's order.02/12/2026 1:26 PM, the Unit Manager RN verbalized staff were expected to round on residents every two hours to ensure the nasal cannula was placed properly on the resident's face, oxygen tubing was not on the floor, and the humidifier and the tubing were properly labeled with the date changed. The Unit Manager RN explained when oxygen therapy was discontinued, the oxygen concentrator would immediately be removed from the room, and the oxygen safety sign would be removed from the resident's entryway.The Unit Manager RN defined an unnecessary medication as one administered without a physician's order. The Unit Manager RN would consider oxygen to be a medication. The Unit Manager RN explained unnecessary oxygen therapy administered to residents with COPD could result in embolism and other complications.On 02/12/2026 at 3:20 PM, the Director of Nursing (DON) defined an unnecessary medication as one administered without an order prescribed by the physician. If a medication was administered after the medication order was discontinued, the DON would consider it unnecessary medication. When a physician's order for oxygen was discontinued, the concentrator would need to be removed from the resident's room, cleaned, and placed into the storage area.The facility policy titled Storage of Medications, adopted 02/01/2019, documented the facility would not use discontinued drugs or biologicals. All such drugs would be returned to the dispensing pharmacy or destroyed.The facility policy titled Adverse Consequences and Medication Errors, adopted 02/01/2019, documented an example of a medication error included an unauthorized drug, or a drug administered without a physician's order.Cross reference with tag F0657.

Based on observation, interview, clinical record review, and document review, the facility failed to identify, report, and address signs and symptoms of dehydration for 1 of 23 sampled residents (Resident #13) by not ensuring staff assessed, documented, or implemented required care plan interventions and physician orders related to hydration needs. The deficient practice had the potential for worsening dehydration, electrolyte imbalance, delayed treatment, and compromised physical well being.Findings include: Resident #13 Resident#13 was admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis, dysphagia, and contractures. On 02/10/2026 at 8:26 AM, Resident#13 was observed lying in bed with dry, cracked lips. On 02/11/2026 at 1:30 PM, Resident #13 was observed with dry, cracked lips and sunken eyes. A Licensed Practical Nurse (LPN) assigned to Resident #13's care, confirmed the resident had dry, cracked lips, signs, and symptoms consistent with dehydration. The LPN stated the Certified Nursing Assistants (CNAs) had not reported the resident's condition to the nursing staff and acknowledged there was no documentation regarding the resident's current condition. On 02/11/2026 at 3:33 PM, Resident #13 was observed with dry, cracked lips and sunken eyes. A CNA stated that signs and symptoms of dehydration include cracked lips, sunken eyes, and a dry mouth. The CNA was brought to Resident #13's room and confirmed the resident was showing signs of dehydration. The CNA stated this condition should have been reported to the nursing staff. Resident #13's Dehydration Risk Evaluation dated 01/09/2026, documented the resident did not show any signs or symptoms of dehydration. A physician's order dated 04/07/2025, directed staff to assess and provide oral and nasal care every shift. Resident #13's care plan dated 04/07/2025, identified the resident was at risk for dehydration and electrolyte imbalance. The care plan indicated the resident had a history of dehydration, weight loss, and poor appetite related to stroke side effects. Resident #13's care plan goals included maintaining adequate hydration as evidenced by stable vital signs, good skin turgor within normal limits, and moist mucous membranes.Care plan interventions included the following: Observed, documented, and reported as needed any signs or symptoms of dehydration, such as decreased or no urine output. The resident received staff assistance with fluid intake to meet daily requirements. Monitored vital signs per protocol and reported significant abnormalities to the physician. Checked tube placement. Monitored and recorded weights. Observed for signs or symptoms of significant weight loss and dehydration and reported to the physician as needed. Observed, documented, and notified the physician as needed for symptoms of dehydration such as dry mucous membranes, poor skin turgor, increased lethargy, and increased confusion. On 02/12/2026 2:19 PM, the Director of Nursing (DON) explained the signs of dehydration included dry, cracked lips; sunken eyes; and dry, flaking skin on both lower extremities. The DON verbalized the CNAs were expected to provide oral care and complete a dehydration risk evaluation when a resident exhibited symptoms of dehydration. The facility policy titled Hydration-Clinical Protocol, dated 09/2017, documented the staff would provide supportive measures. The staff would identify and report to the physician individuals with signs and symptoms of existing fluid or electrolyte imbalance. physicians would manage significant fluid and electrolyte imbalance, and staff would provide support measures.

Based on interview, clinical record review, and document review, the facility failed to ensure a resident's care plan related to oxygen administration was revised when the resident's oxygen order was discontinued for 1 of 23 sampled residents (Resident #70). This deficient practice had the potential to result in staff being unaware of the services required by the resident to reach and maintain their highest practicable level of functioning.Findings include:Resident #70Resident #70 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and emphysema.A physician's order dated 11/13/2026, and discontinued on 01/29/2026, documented to administer oxygen at 3 liters per minute (lpm) via nasal cannula continuously every shift for emphysema.Resident #70's clinical record lacked documentation of an active physician's order for oxygen therapy.A care plan focus, initiated 01/14/2026, documented Resident #70 had emphysema and COPD. A goal, initiated 01/14/2026, documented the resident would have no signs and symptoms of respiratory difficulty with use of supplemental oxygen through the review date.An alert progress note dated 01/29/2026, documented Resident #70's oxygen saturation was 95 percent (%) on room air. The resident did not use their oxygen in the previous 24 hours. The oxygen order would be discontinued.Resident #70 verbalized the resident did not require oxygen therapy.On 02/09/2026 at 3:23 PM, a Registered Nurse (RN) verbalized Resident #70's physician's order for oxygen therapy was discontinued on 01/29/2026.On 02/12/2026 at 9:03 AM, a Licensed Practical Nurse (LPN) explained Resident #70 previously received oxygen therapy. However, the resident was stable on room air, so the facility requested to titrate the oxygen and the physician's order was discontinued. The LPN recalled the LPN was the nurse to discontinue the oxygen order in the resident's electronic health record.02/12/2026 1:26 PM, the Unit Manager RN verbalized both the nursing staff, and the Minimum Data Set 3.0 (MDS) staff were responsible for care plan implementation and revision. If a change was made to a resident's treatment plan, the Unit Manager would document the change in an interdisciplinary team (IDT) note and the MDS staff would revise the care plan.On 02/12/2026 at 2:33 PM, the MDS Coordinator explained the MDS Coordinator received a daily 24-hour report comprised of changes made to resident treatment for all residents in the facility. The MDS Coordinator used the report to guide Care Plan implementation and revision. All staff were responsible for ensuring the care plan was complete and accurate. A care plan focus would be removed from the care plan when the related treatment ceased. The MDS Coordinator verbalized Resident #70's oxygen order was discontinued; however, the care plan documented the resident received oxygen therapy.The facility policy titled Care Plans, Comprehensive Person-Centered, adopted 02/01/2019, documented the comprehensive, person-centered care plan would describe services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents were ongoing, and care plans were revised as information about the residents and the residents' conditions changed.Cross reference with tag F0757.

Based on observation, interview, and document review, the facility failed to enforce its non smoking policy and failed to ensure staff refrained from smoking on facility property. The deficient practice created potential fire hazards and compromised the safety of residents, staff, and visitors.Findings include:On 02/09/2026 at 7:45 AM, two staff members were observed standing outside the front entryway near the handicap parking spaces next to the facility van, while smoking. Both employees extinguished the cigarettes and re entered the front entrance at 7:51 AM. The area was within the main entrance zone of the facility.On 02/09/2026 at 8:41 AM, there was an open ash tray with cigarette butts outside of the back entrance to the kitchen area of the facility.On 02/09/2026 at 9:41 AM, the Administrator verbalized the facility was a non-smoking campus. Residents and staff who smoke cigarettes, were to smoke off of the property. The Administrator confirmed the facility followed the facility smoking policy.On 02/11/2026 at 11:04 AM, there was an ashtray with two cigarette buts outside of the back door near the kitchen area of the facility and one staff member was observed smoking a cigarette while seated on the curb in the same area. On 02/11/2026 at 11:11 AM, the Housekeeper smoking on the property verbalized smoking every day, a few times a day, in the same area in the back of the facility, outside of the kitchen. When the Housekeeper was finished smoking a cigarette, the cigarette butt would be extinguished in the ash tray and left for someone to clean out the ashtray. The Housekeeper believed Maintenance was responsible for emptying the ashtray, had been slacking in the past few weeks, and was allowing the ashtray to overflow with cigarette butts.On 02/11/2026 at 11:12 AM, the Kitchen Manager explained the ashtray was always outside of the backdoor to the kitchen and was used for staff to dispose of the cigarette butts when the staff were finished smoking. The Kitchen Manager was not sure who was responsible for emptying the ashtray but the cigarette butts would be taken to the trash dumpster a few feet away for disposal. The Kitchen Manager confirmed an employee was smoking on the facility property and verbalized all staff were supposed to be smoking off of the property on the sidewalk, behind the Housekeeper actively smoking on the property.On 02/11/2026 at 2:28 PM, the Regional Minimum Data Set (MDS) Registered Nurse (RN) and the Owner of the facility both confirmed the facility was a non-smoking campus. Residents were able to smoke outside of the facility parking lot and employees could smoke on the pathway, behind the facility; however, staff and residents were not allowed to smoke on the property.The facility policy titled Smoking Policy-Residents and Employees, last updated March 2022, documented the facility was committed to providing a safe, orderly and productive environment for the residents, employees, and visitors who come to the facility. The facility was a smoke free environment, prohibiting smoking in all indoor and outdoor areas.

Based on observation, interview and document review the facility failed to ensure 1) medications were secured in a locked cart and inaccessible to residents, visitors, and unauthorized staff when two medication carts and a treatment cart were left unlocked and unattended by a nurse, and 2) expired medications were removed from 1 of 2 medication carts inspected for medication storage. This deficient practice had the potential for residents, visitors, and unauthorized staff to have access to medications not prescribed or intended for the individual and for expired medications with diminished efficacy to be administered to residents. Findings include: Medication carts and treatment cart: On 02/09/2026 at 12:03 PM, the medication cart located at the entrance to the 100 Hall was unlocked and unattended. The top left drawer was pulled open approximately six inches. On 02/09/2026 at 12:04 PM, the Registered Nurse (RN) walked out of the Cafe room, walked up to cart and closed the top left drawer. The RN verbalized having stepped away from the medication cart to take blood sugar readings and confirmed the medication cart was left unlocked, unattended and out of site. The RN verbalized the medication cart should have been locked when the cart was not within view of the nurse. On 02/12/2026 at 3:17 PM, the DON verbalized having expected all medication carts to be locked at all times when not in view. On 02/10/2026 at 8:40 AM, a medication cart was against the wall on the second floor, next to room [ROOM NUMBER], with the drawers facing the hallway. The medication cart was unlocked, and there were no staff members in sight of the cart. On 02/10/2026 at 8:46 AM, a Licensed Practical Nurse (LPN) came out of room [ROOM NUMBER] and confirmed the medication cart had been left unlocked with the keys in the LPN's pocket while the cart was unattended and out of sight. On 02/12/2026 at 2:19 PM, the Director of Nursing (DON) verbalized the procedure for leaving a medication cart unattended was for the medication cart to be locked and the medication cart keys would always be with the nurse. On 02/09/2026 at 11:01 AM, a treatment cart was against the wall in the 100 hallway, next to room [ROOM NUMBER], with the drawers facing out into the hallway. An RN walked up to the treatment cart, opened a drawer without the use of keys, retrieved medication from the cart, closed the drawer, and walked away, without locking the cart. The treatment cart was not within view of any other staff members. On 02/09/2026 at 11:01 AM, the RN verbalized the RN was passing medications or something like that. On 02/09/2026 at 11:04 AM, RN2, opened the door from the inside of room [ROOM NUMBER], exited the room, performed hand hygiene, and walked past the treatment cart. On 02/09/2026 at 11:04, RN2 explained the treatment and medication carts could remain unlocked, without staff present, if the carts were pushed against the wall. RN2 confirmed the treatment cart was unlocked, unsecured, and contained resident medications used to treat wounds. RN2 explained residents had access to medications not prescribed to them, should a resident access the treatment cart. Inside of the treatment cart were the following unsecured items: Zinc Oxide Ointment Therahoney Gel Hydro Amorphous Dressing Curad Triple Antibiotic Ointment Collagenase Santyl Ointment 250 unit/gram Triamcinolone Acetonide Ointment USL 0.1% 1% Silver Sulfadiazine Cream (SSD) Two boxes of Therahoney HD Sheet Honey Impregnated Wound Dressing Several Zinc Ointment Oxide Skin Protectant Aquaphor packets Several Thera Moisturizing Body Sheild packets Several Dermafungal Antifungal Cream packets, 2% Miconazole Nitrate Several Vitamin A & D Ointment Powder Stimulant Enhance Collogen Powder packets At the bottom of the treatment cart were all resident specific medications. The unsecured medications were the following: Two bottles of Ammonium Lactate 12% Moisturizing Lotion Aspercreme 4% Lidocaine Pain Relief Spray, 4 ounces Lidocaine Diclofenac Sodium Topical Gel 3% Antifungal Cream, 2% Miconazole Nitrate Two bottles of Nystatin Powder 100,000 Remedy Antifungal Powder Four tubes of Clobetasol Propionate USP 0.05% Diclofenac Sodium Topical Gel 1% Triamcinolone 0.1% Lubricant, 454 grams Two tubes of Ketoconazole Cream 2% Two tubes of Hydrocortisone Cream 2.5% Two packages of Epsom Salt Magnesium Sulfate Saline Laxative Triamcinolone Acetonide Ointment USP 0.1% Cetaphil Moisturizing Cream 20 ounces On 02/11/2026 at 8:36 AM, the Director of Nursing (DON) explained the facility had two kinds of carts. One cart was a treatment cart containing necessary supplies to address resident wounds. The second cart was a medication cart containing all resident medications used for daily administration to the residents. If the carts were not in use, the carts were to have the drawers facing the wall and locked at all times. If the carts were in use, the carts could face away from the wall; however, the carts must be locked at all times. The DON verbalized if the treatment carts or the medication carts were left unlocked, it could be a safety concern for the residents because any resident could access the medications contained in the carts. If the residents accessed the medications, the residents could use or ingest the medications themselves. The DON explained staff were not trained to leave the treatment or medications carts against the wall, unlocked if the drawers were facing the wall. The carts could still be maneuvered and would need to be locked at all times. On 02/11/2026 at 9:09 AM, the DON provided the in-service training dated 10/13/2025, related to the security of treatment and medication carts. The DON verbalized all licensed staff were trained on the security of treatment and medications carts upon hire at the facility, and during the monthly facility meetings. The training titled Nurses Monthly Meeting, dated 10/13/2025, documented 28 staff members were present for the training. The topics covered during the training were: Missing medications/unavailable Hospital Lab Specimen Pick up Liberalized Medications Medication at Bedside; and, Medication Carts Should always be locked when out of vision. The facility policy titled Security of Treatment Cart, adopted 02/01/2019, documented the nurse must secure the treatment cart during usage and non-usage to prevent unauthorized entry. When it was not possible to face the cart toward the resident room, the cart had to be pushed against the wall, with the drawers facing the wall, and the cart must be locked before the nurse entered a resident's room. Treatment carts were to be securely locked at all times when out of the nurse's view and when the cart was not being used, it must be locked and parked either at the nurses' station or inside of a medication room. Expired medications in a medication cart On 02/12/2026 at 2:08 PM, the following medications were found in a medication cart on the second floor of the facility: -A bubble pack containing 32 tablets of Hydroxyzine Hydrochloride (HCl). The expiration date printed on the bubble pack was 01/30/2026. -A box of Allegra 60 milligram (mg) tablets, with 25 tablets remaining inside. The expiration date printed on the box was 07/2025. On 02/12/2026 at 2:21 PM, LPN2 confirmed the expiration dates printed on the medication containers had passed and the medications were expired. LPN2 verbalized medications should be removed from carts no later than the expiration date printed on the container. On 02/12/2026 at 2:23 PM, the DON verbalized nurses were expected to remove discontinued and expired medications from medication carts and place the medications in the medication storage room pending destruction. The DON explained it was important to remove medications from the cart as soon as the medications expired to prevent an expired medication from being administered to a resident. The facility policy titled Storage of Medications, dated 02/01/2019, documented the facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs were to be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a safety sign was posted on the outside of a resident door related to oxygen (O2) therapy for 1 of 23 sampled residents (Resident #50) and 2) a resident requiring oxygen therapy was assessed timely when the resident complained of shortness of breath for 1 of 23 sampled residents (Resident #113). These deficient practices had the potential to result in improper handling of oxygen equipment increasing the risk of fire and compromising resident safety as well as the potential to result in physical and emotional distress.Findings include: Resident #50 Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic pulmonary hypertension, and congestive heart failure. A physician's order dated 01/29/2026, documented to administer oxygen (O2) @ 4 liters/minute via nasal cannula continuously. A care plan dated 01/30/2026, documented monitor peripheral capillary oxygen saturation (SPO2) every hour may titrate O2 to 5-6 liters via mask. Notify provider for any significant changes. O2 SETTINGS: O2 4 liters via nasal cannula as ordered. every shift. A Medication Administration Record (MAR) documented change nasal cannula and O2 tubing one time per week every night shift, every Tuesday. Start date 02/03/2026. On 02/09/2026 10:50 AM, observed no O2 sign postage at entry door. On 02/09/2026 10:50 AM, Resident #50 wearing O2 with a concentrator next to bed. Resident #50 confirmed wearing O2 at all times and checked O2 levels to keep the saturations between 92 and 95 percent. On 02/10/2026 8:53 AM, a Registered Nurse (RN) confirmed the facility has a schedule to check O2 every Tuesday night by checking tubing, and bottles, as well as checking as needed. The facility had physician orders and sheets to show how many liters to administer. RN confirmed the expectation of staff was to always have a sign on the resident room door when there was O2 in the room. The sign stated O2 in use and was posted outside the resident room door. It was intended to notify staff for safety purposes, like fire hazards. On 02/12/2026 2:12 PM, the Director of Nursing (DON) confirmed when residents admit with O2, facility staff was expected to place a sign stating O2 in use outside the resident room entrance door as soon as the facility received a physician's order for O2. The DON confirmed not placing an O2 sign outside the resident room door could result in a resident getting hurt, which could become a safety hazard. The facility policy titled, Oxygen Administration, dated 02/01/2019, documented the facility would post an Oxygen in Use sign on the outside of the room entrance door. Resident #113 Resident #113 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, other nonspecific abnormal finding of lung field, cognitive communication deficit, and anxiety disorder, unspecified. A physician's order, dated 08/18/2025, documented to administer oxygen at three liters per minute via nasal cannula continuously every shift for chronic obstructive pulmonary disease (COPD) with acute exacerbation. A care plan focus, initiated 07/29/2025, documented Resident #113 had oxygen therapy related to ineffective gas exchange and COPD with acute exacerbation. An intervention initiated 07/29/2025, documented to monitor the resident for signs and symptoms of respiratory distress to include restlessness. On 02/09/2026 at 2:37 PM, Resident #113 sat in the resident's wheelchair wearing oxygen via nasal cannula at the nurse's station and verbalized I can't breathe. A Certified Nursing Assistant (CNA1) and a Support Aide were present. The resident was not acknowledged. On 02/09/2026 at 2:40 PM, Resident #113 sat in the resident's wheelchair wearing oxygen via nasal cannula at the nurse's station and verbalized I can't breathe. CNA1 and a Support Aide were present. The resident was not acknowledged. On 02/09/2026 at 2:46 PM, Resident #113 sat in the resident's wheelchair wearing oxygen via nasal cannula at the nurse's station and verbalized I can't breathe, I can't breathe. The resident became tearful. Resident #113's oxygen tank gauge read refill. CNA1 and a Support Aide were present. The resident was not acknowledged. On 02/09/2026 at 2:51 PM, CNA1 verbalized the CNA1 did not respond to Resident #113 because the CNA1 was recently hired at the facility and was unfamiliar with Resident #113's care needs. On 02/09/2026 at approximately 2:53 PM, the Support Aide confirmed hearing Resident #113 verbalize the resident could not breathe and explained the Support Aide was new to the facility and was not familiar with Resident #113's care needs. On 02/09/2026 at approximately 2:55 PM, the following events occurred: -A CNA2 approached the nurse's station. -The CNA2 explained Resident #113 required continuous oxygen via nasal cannula. -The CNA2 checked Resident #113's oxygen tank. -The CNA2 verbalized the oxygen was low and needed to be replaced. The CNA2 verbalized the CNA2 would replace the oxygen tank. On 02/09/2026 at 3:00 PM, the CNA1 verbalized the CNA1 received training from the facility on oxygen use to include observing nasal cannula placement, replacing the tank before the oxygen was low, observing the chest rise, and measuring oxygen saturations using a pulse oximeter. Should a resident complain of shortness of breath, the CNA1 would monitor the resident's oxygen saturations and locate a nurse to assess the resident. On 02/12/2026 at 8:47 AM, a CNA3 explained Resident #113 required continuous oxygen therapy. When Resident #113 verbalized being unable to breathe, staff would check the resident's oxygen flow and tubing to confirm the resident received oxygen. On 02/12/2026 at 8:50 AM, a Licensed Practical Nurse (LPN) verbalized Resident #113 previously expressed anxiety surrounding the resident's oxygen. When the resident complained of shortness of breath, staff would measure the resident's oxygen saturations and administer an Albuterol inhaler. The LPN verbalized Resident #113 required continuous oxygen therapy at 3 liters per minute per physician's order. On 02/12/2026 at 9:28 AM, the Director of Nursing (DON) explained when a resident complained of shortness of breath, staff were expected to assess the resident's oxygen saturation levels and provide assurances to the resident. Staff should always address a resident's complaint of shortness of breath as an emergency. On 02/12/2026 at 1:02 PM, the Administrator explained any staff member present would be responsible for assisting a resident complaining of shortness of breath. If the staff member available was unfamiliar with the resident's care needs, the staff would be expected to find a CNA, notify a nurse, or refer to the resident's chart. The facility policy titled Oxygen Administration, adopted 02/01/2019, documented before administering oxygen and while the resident received oxygen therapy, staff were to assess for signs or symptoms of cyanosis, hypoxia, and oxygen toxicity to include difficulty breathing or slow shallow breath, as well as vital signs and oxygen saturation. Staff were to check the mask, tank, and humidifying jar to ensure all were in working order. Staff would observe the resident upon oxygen setup and periodically thereafter to ensure oxygen was tolerated.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with an ileostomy received care consistent with professional standards of practice and the resident's care plan for 1 of 23 residents (Resident #32), by not conducting and documenting a formal assessment of the residents ability to safely perform ileostomy self-care before allowing independent management of the pouch, not providing and documenting education on safe infection control, when to report problems; and, not ensuring staff provided and accurately documented ileostomy care and monitoring in accordance with physician orders and the care plan. This deficient practice had the potential to result in improper ostomy management, leakage, skin breakdown, infection, and inaccurate documentation of care.Findings include:Resident #32Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including ileostomy status, cognitive communication deficit, and myoclonus.A Hospital Discharge summary dated [DATE], documented the resident emptied the ostomy; however, often made a mess.Physician's orders dated 01/26/2026, directed staff to change the ileostomy bag/wafer and to cleanse the ileostomy nag/wafer as need for leaking or accidental removal.A Care Plan initiated on 02/27/2026, identified alteration in bowel function related to neurogenic bowel and documented the resident had an ileostomy. The interventions included the following: Ostomy remained patent and functional daily. Resident remained clean and free from unpleasant odor. Assess stoma characteristics. Change ostomy bag/wafer every other shower day and as needed. Cleanse ostomy site daily and as needed. Monitor output and stoma condition. Provide ostomy care per facility protocol.Staff were to complete the interventions listed in the resident's care plan.The care plan lacked goals and interventions related to ostomy self-care, including assessment, education, supervision, and monitoring of Resident #32 performing independent ostomy care.On 02/09/2026 at 1:16 PM, Resident #32 explained the resident and the resident's spouse managed the ileostomy pouch because staff did not know how to properly change it. Resident #32 verbalized the Certified Nursing Assistants (CNA) had changed the pouch after admission; however, the CNAs were not properly trained which caused the ileostomy to leak fecal matter. As a result, Resident #32 and the resident's spouse initiated taking over the resident's own care of changing the ileostomy pouch.On 02/12/2026 at 10:42 AM, a CNA confirmed the resident was independent with changing the ileostomy and had been managing it. The CNA verbalized the CNAs were to ensure the wafer site looked clean, change the ileostomy bag if soiled or if gas accumulated, and notify a nurse if anything appeared abnormal with the wafer.On 02/12/2026 at 10:46 AM, a Licensed Practical Nurse (LPN) explained nurses supervised the resident while the resident emptied the ileostomy bag and changed the bag only on an as needed basis while monitoring the stoma site for signs of infection. The LPN was unsure if an assessment existed to determine whether the resident could safely perform the resident's own ostomy care.On 02/12/2026 at approximately 10:55 AM, a Registered Nurse (RN) explored the resident's clinical record and confirmed there was no assessment to determine the resident's ability to perform ileostomy self-care.On 02/12/2026 at 11:16 AM, the Director of Nursing (DON) explained CNAs were to empty the ileostomy bag and nurses were to clean the site. The nurses would change the bag as needed or at least weekly per physician's order. The DON verbalized in order for residents to perform self-care and change their own ostomy bag, the residents would need to be assessed for safety before being permitted to perform self-care. The DON confirmed Resident #32 had not been educated or assessed for safe self care and was unaware the resident was changing the ostomy bag themselves. The DON verbalized this posed a risk for improper supply use, incorrect sizing, and potential skin issues.On 02/12/2026 at 1:28 PM, the Regional Minimum Data Set (MDS) RN explained staff were signing off on the resident's ostomy care daily, which indicated staff performed the care, even though Resident #32 had been changing the ostomy bag on their own. The Regional MDS RN verbalized an assessment should have been completed prior to letting the resident change the ostomy bag and the assessment would determine cognitive safety and infection control understanding. The Regional MDS RN explained Occupational Therapy (OT) had conducted an assessment, which was sufficient. The OT assessment reviewed the dexterity of the resident's movements to determine if the resident could change the ileostomy pouch independently. The Regional MDS RN confirmed OT could not assess the resident further to include education to the resident related to infection control, concerns to watch for, when to report concerns to staff, or any other nursing concern. The Regional MDS RN confirmed Resident #32 lacked a formal assessment and education for ostomy self-care, and verbalized the facility lacked a formal assessment process for residents performing ostomy self-care.The facility policy titled Changing an Ostomy Bag, undated, described steps to measure the stoma, prepare, and apply the pouch system, cleanse and protect the peristomal skin, ensure the closure clamp was secure, and document the reason for the change, skin condition, and client teaching or participation. The facility was unable to provide a policy for assessing a resident's ability to perform self-care of an ileostomy pouch.

Based on observation, document review and interview, the facility failed to ensure nursing hours were posted daily in the facility.This deficient practice had the potential to prevent residents and visitors from being informed of the total number of nursing staff and the actual hours worked each day.Findings include: On 02/09/2026 at 8:02 AM, the daily nursing hours posted behind the front desk reception area was dated 02/06/2026. On 02/09/2026 at 8:09 AM, the Administrator confirmed the posting at the front desk was dated 02/06/2026 and should have been changed to the current date. The Administrator verbalized the Certified Nursing Assistant (CNA), Nursing Aide Staffing Coordinator, was responsible for updating the postings daily. On 02/09/2026 at 8:26 AM, the nursing hours posted at the first-floor nurses' station was dated 02/06/2026. On 02/09/2026 at 8:29 AM, the nursing hours posted at the second-floor nurses' station was dated 01/31/2026. On 02/09/2026 at 10:30 AM, the CNA, Nursing Aide Staffing Coordinator, responsible for updating the postings, confirmed all three of the postings in the facility had not been updated but should have been. The facility policy titled, Posting Direct Care Daily Staffing Numbers, dated 08/02/2019, documented the facility would post on a daily basis in a prominent location, the number of nurses and aides directly responsible for resident care.

Based on interview, clinical record review and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) performed the duties as outlined in the State Board of Nursing Nurse Practice Act with safe medication administration when the LPN failed to check blood sugar levels prior to the administration of insulin for 1 of 23 sampled residents (Resident #212). The deficient practice had the potential to expose the resident to medication errors resulting in additional health complications. Findings include: Resident #212 Resident #212 was admitted to the facility on [DATE], with a diagnosis including type two diabetes mellitus without complications. On 12/02/2024 at 2:17 PM Resident #212 explained while waiting for lunch on 12/02/2024, the resident was sitting with the resident's daughter and a nurse approached the table to check the resident's blood sugar levels. The nurse told the resident the nurse would be back to administer the resident's insulin and the nurse walked away. The nurse came back over one hour later to administer the insulin to the resident, however, did not recheck the resident's blood sugar levels prior to administration of the insulin. On 12/02/2024 at 2:17 PM, Resident #212's daughter explained being seated in the dining room at a table waiting for lunch on 12/02/2024, and a nurse approached the table at 12:45 PM to take Resident #212's blood sugar levels. The nurse told the resident the nurse would return with the resident's insulin and walked away. Resident #212 was served lunch, ate lunch and the nurse did not return prior to the resident eating lunch to administer the insulin. The resident's daughter verbalized the nurse approached the resident at 2:00 PM, did not recheck the resident's blood sugar levels, and administered four units of insulin to the resident. A physician's order dated 11/26/2024, documented Humalog Injection Solution 100 unit/milliliter (ml) (Insulin Lispro). Inject as per sliding scale: if 131-180=2; 181-240=4; 241-300=6; 301-350=8; 351-400=10; 401+, if greater than 400, administer 12 units and notify doctor, subcutaneously before meals for diabetes mellitus. Resident #212 Blood Sugar Summary documented on 12/02/2024, the resident's blood sugar levels were checked at 8:19 AM and 12:51 PM. The December 2024 Medication Administration Records (MAR) documented Humalog Injection Solution 100 unit/ml (Insulin Lispro. Inject as per sliding scale: -If 131-180=2; 181-240=4; 241-300=6; 301-350=8; 351-400=10; 401 + if greater than 400, administer 12 units and notify doctor, subcutaneously before meals for diabetes Mellitus. On 12/02/2024, the MAR documented the resident received insulin at 7:00 AM, for a blood sugar level of 164, and at 12:00 PM, for a blood sugar level of 225, a code 4 was marked. The legend on the MAR defined a code 4 indicated vitals were outside of parameters for administration. On 12/05/2024 at 10:13 AM, the LPN explained when a resident was to be administered insulin, per a sliding scale, the nurse was to take blood sugar levels and based on what the blood sugar levels were and per the physician's order, insulin would be administered. The LPN verbalized it was not appropriate to take blood sugar levels and walk away from a resident without administering insulin to the resident based on the sliding scale. If a resident were to miss an administration of insulin, per the physician's order, the resident could experience an incident of shaking and confusion. The LPN recalled on 12/02/2024, it was a hectic day and remembered checking the resident's blood sugar levels during lunch, walking away from the resident, and having to tend to a different resident to take their vitals. The LPN could not recall when the LPN returned to the resident to administer insulin, however thought it may have been in the afternoon sometime and at no point in time on 12/02/2024, did the resident refuse insulin. The LPN reviewed the Blood Sugar Summary for Resident #212 and explained the blood sugar levels were documented at 225, which would require insulin to be administered to the resident. The LPN reviewed the December 2024 MAR for Resident #212 and verbalized the resident was administered insulin at 12:00 PM and believed code 4 on the MAR was defined as administering 4 units of insulin to the resident. The LPN recalled checking Resident #212's blood sugar levels around 12:00 PM on 12/02/2024, walking away from the resident for an indeterminate amount of time, returning to the resident in the afternoon, not rechecking the resident's blood sugar levels and administering insulin to the resident based off of the blood sugar levels earlier in the day. On 12/05/2024 at 10:32 AM, the Director of Nursing (DON) explained the process for administering insulin, if it was based on a sliding scale, would be to check the resident's blood sugar levels, compare the blood sugar levels with the sliding scale numbers on the physician's order and administer the amount of insulin per the physician's order. The DON verbalized blood sugar levels were to be checked every time prior to the administration of insulin because the resident could experience symptoms such as swelling, shaking or confusion if the blood sugar levels were not checked immediately preceding the administration of insulin. The DON explained it was not within the nursing scope of practice to check a resident's blood sugar levels, walk away without administering the proper units of insulin, come back a few hours later and administer the resident's insulin without rechecking the blood sugar levels. The DON verbalized the LPN was trained in proper administration of insulin. The Registered Nurse (RN)/LPN Medication Pass Checklist dated 01/18/2023, documented the LPN was trained on the proper protocols and procedures for checking blood sugar levels and administering insulin. The training was checked off by the DON indicating the LPN successfully completed the training. The LPN's Job Description, signed by the LPN on 03/28/2022, documented the LPN was responsible to carry out assignments, such as administering medications per regulation and was to provide professional nursing care to assigned residents in a nursing home environment. A Competency Fair dated 04/23/2024 through 04/26/2024, attended by the LPN, documented the LPN was trained on medication administration. The facility policy titled Insulin Administration, adopted on 02/01/2019, documented the type of insulin, dosage requirements, strength, and method of administration must be verified before administration to assure the dosage corresponds with the physician's order. The proper steps for administering insulin was to check blood glucose levels per the physician's order, check the physician's order for the amount of insulin to be administered, pick a site for injection of the insulin, and administer the insulin. The facility policy titled Adverse Consequences and Medication Errors, adopted on 02/01/2019, documented a medication error was defined as the preparation or administration of drugs or biologicals which was not in accordance with physician's orders, manufacturer specifications or accepted profession standards and principles of professional (s) providing care. An example of a medication error included the wrong time and failure to follow accepted professional standards. The Nurse Practice Act Nevada Administrative Code (NAC) 632.236 Understanding and verifying orders, documented before an LPN carries out a physician order, the LPN must understand the reason for the order, verify the order was appropriate, and verify there were no documented contraindications in carrying out the order. Cross Reference F760

Based on interview, record review, and document review, the facility failed to ensure a resident was treated with dignity and respect when the staff did not provide brief changes and the resident was left wet overnight for 1 of 23 sampled residents (Resident #36). This had the potential to cause psychosocial distress to the resident. Findings include: Resident #36 Resident #36 was admitted to the facility on [DATE], with diagnoses including rhabdomyolysis, a disease which causes muscle pain and weakness and trouble moving arms and legs, repeated falls, muscle weakness, unsteadiness on feet, other reduced mobility, and pressure ulcer of sacral region, unspecified stage. On 12/02/2024 at 9:28 AM, Resident #36 verbalized the resident was ignored by the night shift staff and was only receiving a brief change once overnight. The resident explained the night shift staff should change the resident every two to three hours, however the staff only came in and changed the resident once, shortly before the morning shift came on duty. The resident would spend the night wet; the resident's linens and disposable absorbent under pad would be wet as well. The resident verbalized the staff would change the brief, but not the wet bedding, so the resident would be uncomfortable even though the brief was changed. The resident explained they were extremely stiff and weak, as well as incontinent, and was unable to get up and use the bathroom. The resident relied on the staff for incontinent care. The resident verbalized the resident had informed trusted staff the following morning, as well as the Social Worker, who responded they would look into the resident's concerns. On 12/03/2024 at 2:49 PM, a Certified Nursing Assistant (CNA) verbalized they worked with Resident #36 and the resident was incontinent, needed maximum assistance for all activities of daily living (ADLs), and required a Hoyer lift for transfers. The resident was very stiff, and staff needed to be careful and take their time when providing care. The resident was able to make their needs known and used the call light to request assistance. The CNA recalled Resident #36 had told the CNA the resident was not changed overnight several times. The CNA explained Resident #36 was truthful and easy going about cares and if the resident stated they had not been changed frequently enough, the CNA believed the resident. The CNA felt the resident was only changed once overnight and the disposable pad under the resident was damp at times. The CNA informed the Unit Manager nurses of the resident's concerns each time the resident had complaints of care. On 12/04/2024 at 11:48 AM, Resident #36 verbalized the resident was being ignored by staff at night and was still having trouble being changed overnight. The resident explained they laid in urine all night long the previous night. Staff would change the resident once; however the resident was so soaked with urine, the disposable pads and bedding under the resident was wet. The night staff did not change the resident's bedding when they changed the residents brief, resulting in the resident laying in an uncomfortably damp bed. The resident was frustrated because they could not get up and walk to the bathroom due to paralysis and their legs not working. The night shift staff would enter the resident's room and turn off the call light, stating they would return, but did not come back. The resident felt ignored, lying in bed helpless all night. The resident verbalized the resident had told morning staff and the Social Worker of their concerns of lack of care overnight. On 12/04/2024 at 3:23 PM, the Licensed Social Worker (LSW) verbalized Resident #36 informed the LSW at least once a week they were not being changed overnight. The LSW explained the resident had made several complaints about staff not caring for them overnight and the resident thought everyone was ignoring them. On 12/04/2024 at 4:09 PM, the Director of Nursing (DON) verbalized incontinent residents should be changed every two hours and/or as needed and lack of care could impact their dignity. The facility policy titled Residents Rights, undated, documented residents had the right to be treated with consideration, respect, and dignity. The facility policy titled Urinary Continence and Incontinence - Assessment and Management, dated 02/01/2019, documented a check and change strategy involved checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals were to maintain dignity and comfort and to protect the skin. Cross Reference Tags 585, 677, and 745

Based on interview, clinical record review, and document review, the facility failed to ensure a resident dependent upon staff for Activities of Daily Living (ADLs) had brief changes overnight for 1 of 23 sampled residents (Resident #36). This deficient practice had the potential to compromise resident hygiene, comfort, and dignity, and increase the risk of skin breakdown and infections. Findings include: Resident #36 Resident #36 was admitted to the facility on [DATE], with diagnoses including rhabdomyolysis, a disease which causes muscle pain and weakness and trouble moving arms and legs, repeated falls, muscle weakness, unsteadiness on feet, other reduced mobility, and pressure ulcer of sacral region, unspecified stage. On 12/02/2024 at 9:28 AM, Resident #36 verbalized the resident was ignored by the night shift staff and was only receiving a brief change once overnight. The resident explained the night shift staff should change the resident every two to three hours, however the staff only came in and changed the resident once shortly before the morning shift came on duty. The resident would spend the night wet; the resident's linens and disposable absorbent under pad would be wet as well. The resident verbalized the staff would change the brief, but not the wet bedding, so the resident would be uncomfortable even though the brief was changed. The resident explained they were extremely stiff and weak, as well as incontinent, and was unable to get up and use the bathroom. The resident relied on the staff for incontinent care. The resident verbalized the resident had informed trusted staff the following morning, as well as the Social Worker, who responded they would look into the resident's concerns. On 12/03/2024 at 2:49 PM, a Certified Nursing Assistant (CNA) verbalized they worked with Resident #36 and the resident was incontinent, needed maximum assistance for all activities of daily living (ADLs), and required a Hoyer lift for transfers. The resident was very stiff, and staff needed to be careful and take their time when providing care. The resident was able to make their needs known and used the call light to request assistance. The CNA recalled Resident #36 had told the CNA the resident was not changed overnight several times. The CNA explained Resident #36 was truthful and easy going about cares and if the resident stated they had not been changed frequently enough, the CNA believed the resident. The CNA felt the resident was only changed once overnight and the disposable pad under the resident was damp at times. The CNA informed the Unit Manager nurses of the resident's concerns each time the resident had complaints of care. On 12/04/2024 at 11:48 AM, Resident #36 verbalized the resident was being ignored by staff at night and was still having trouble being changed overnight. The resident explained they laid in urine all night long the previous night. Staff would change the resident once; however the resident was so soaked with urine, the disposable pads and bedding under the resident was wet. The night staff did not change the resident's bedding when they changed the resident's brief, resulting in the resident laying in an uncomfortably damp bed. The resident was frustrated because they could not get up and walk to the bathroom due to paralysis and their legs not working. The night shift staff would enter the resident's room and turn off the call light, stating they would return, but did not come back. The resident felt ignored, lying in bed helpless all night. The resident verbalized the resident had told morning staff and the Social Worker of their concerns of lack of care overnight. On 12/04/2024 at 11:59 AM, CNA2 verbalized incontinent residents should be checked and changed every two hours and as needed, during the day and overnight. Brief changes should be documented by the CNAs in the medical record. CNA2 explained they worked with Resident #36 and the resident was incontinent. The resident's level of care was dependent, total assist, and used Hoyer lift to get out of bed. CNA2 recalled they had been told by Resident #36 the resident was only changed once overnight. The CNA informed the day shift nurses whenever the resident had concerns about care. On 12/04/2024 at 3:23 PM, theLicensed Social Worker verbalized Resident #36 informed the social worker at least once a week they were not being changed overnight. On 12/04/2024 at 4:02 PM, the Unit Manager/Licensed Practical Nurse (LPN) verbalized they were made aware of the resident's concerns regarding lack of brief changes overnight just today and once in October. Resident #36's Comprehensive Care Plan dated 07/27/2024, documented the resident had a self-care Activity of Daily Living (ADL) performance deficit related to rhabdomyolysis and weakness. The resident needed assistance in ADLs. The resident was dependent on staff for toileting hygiene. Resident #36's Minimum Data Set 3.0 (MDS) Assessment, Section GG0130 - Self Care, dated 09/27/2024, documented toileting hygiene: substantial/maximum assistance - helper does more than half the effort. On 12/04/2024 at 4:09 PM, the Director of Nursing (DON) verbalized incontinent residents should be checked and changed every two hours and as needed during the day and overnight. The facility policy titled Activities of Daily Living, Supporting, dated 02/01/2019, documented residents who were unable to carry out ADLs independently would receive the services necessary to maintain good personal hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, including appropriate support with hygiene and elimination (toileting). The policy defined substantial/maximum assistance as the helper does more than half the effort. The helper lifts or holds the trunk or limbs and provides more than half the support. The policy defined dependent assistance as the helper does all the effort. The resident performed none of the effort to complete the activity or the assistance of two or more helpers was required for the resident to complete the activity. The facility policy titled Urinary Continence and Incontinence - Assessment and Management, dated 02/01/2019, documented a check and change strategy involved checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals were to maintain dignity and comfort and to protect the skin. Cross reference with Tag 550, 585, and 745

Based on interview, clinical record review and document review, the facility failed to ensure a resident gave informed consent prior to the administration of a psychotropic medication for 1 of 23 sampled residents (Resident #80). This deficient practice had the potential for a resident to experience adverse side effects of a medication without deciding if the benefit to the resident was greater than the risk. Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], with a diagnosis of depression, unspecified. The physician's order dated 10/17/2024, documented Escitalopram Oxalate oral tablet 5 milligrams, give one tablet by mouth in the morning for depression as evidence by lack of energy and feeling of sadness. The Psychoactive Medications Disclosure and Consent form signed 12/05/2023, did not indicate if the resident accepted or declined the Escitalopram. On 12/05/2024 at 8:45 AM, the Director of Nursing (DON) verbalized the consent form should have indicated if the resident accepted the medication prior to administration. The DON confirmed the resident was scheduled for administration and received it in the morning. The facility policy titled, Psychoactive Medication Use, adopted 02/01/2019, documented psychoactive substances will not be initiated until the resident or guardian's consent was received. The facility policy titled, Resident Rights, adopted 02/01/2019, documented the resident had the right to be informed in advance of the risks and benefits of proposed care.

Based on interview, record review, and document review, the facility failed to ensure a grievance process was initiated, an investigation was conducted, and a verbal or written response was communicated to the resident regarding their concerns for the lack of incontinent care provided overnight for 1 of 23 sampled residents (Resident #36). This deficient practice had the potential to allow a resident's complaints of care to not be investigated and a resident provided with a resolution. Findings include: Resident #36 Resident #36 was admitted to the facility on [DATE], with diagnoses including rhabdomyolysis, a disease which causes muscle pain and weakness and trouble moving arms and legs, repeated falls, muscle weakness, unsteadiness on feet, other reduced mobility, and pressure ulcer of sacral region, unspecified stage. On 12/02/2024 at 9:28 AM, Resident #36 verbalized the resident was ignored by the night shift staff and was only receiving a brief change once overnight. The resident explained the night shift staff should change the resident every two to three hours, however the staff only came in and changed the resident once, shortly before the morning shift came on duty. The resident would spend the night wet; the resident's linens and disposable absorbent under pad would be wet as well. The resident verbalized the staff would change the brief, but not the wet bedding, so the resident would be uncomfortable even though the brief was changed. The resident explained they were extremely stiff and weak, as well as incontinent, and was unable to get up and use the bathroom. The resident relied on the staff for incontinent care. The resident verbalized the resident had informed trusted staff the following morning, as well as the Social Worker, who responded they would look into the resident's concerns. On 12/03/2024 at 2:49 PM, a Certified Nursing Assistant (CNA recalled Resident #36 had told the CNA the resident was not changed overnight several times. The CNA informed the Unit Manager nurses of the resident's concerns each time the resident had complaints of care. On 12/04/2024 at 11:48 AM, Resident #36 verbalized the resident was being ignored by staff at night and was still having trouble being changed overnight. The resident verbalized the resident had told morning staff and the Social Worker of their concerns of lack of care overnight. On 12/04/2024 at 3:23 PM, the Licensed Social Worker (LSW) verbalized when a resident had concerns about staff not providing care, the LSW would notify the nursing Unit Managers of the resident's concerns. If the complaints were habitual, the LSW would submit a grievance on behalf of the resident. An investigation into the resident's concerns would be initiated and would include interviews with the resident of concern, other residents on the hall, and the care staff assigned. The LSW clarified a resident did not have to formally request to file a grievance in order for the LSW to submit a grievance. The LSW verbalized Resident #36 informed the LSW at least once a week they were not being changed overnight. The LSW recalled Resident #36 thought everyone was ignoring the resident. The LSW explained they were not sure if the resident had been diagnosed with delusions and the LSW did not submit a grievance on behalf of the resident because the resident was a big ball of anxiety and the LSW felt the resident's concerns were not really happening. The LSW was not sure if the care was lacking because the resident complained about day shift as well. The LSW decided it was better to work with the resident's psychosocial needs by listening, validating, and performing breathing exercises with the resident. The LSW further explained they would not submit a grievance for this resident's complaints because they would not want the investigation to be unsubstantiated and then the resident be known as the one who made complaints about their care. The LSW further explained the LSW did not feel the resident's complaints of lack of care arose to the level of a grievance. The LSW explained they verbally notified the Unit Manager nurses and the DON of the resident's concerns regarding lack of care. The LSW explained the Unit Managers would conduct an investigation. The LSW was not aware if an investigation was conducted. The LSW did not receive an outcome from the Unit Managers, nor did the LSW follow up with the Unit Managers or the Director of Nursing (DON) for their findings into the matter and did not document the resident's concerns, notification, and outcome, however the LSW thought the outcome was the concerns were unfounded. On 12/04/2024 at 4:02 PM, the Unit Manager/Licensed Practical Nurse (LPN) verbalized they were made aware of the resident concerns regarding lack of brief changes overnight just today and once in October. The Unit Manager verbalized they could not recall what actions were taken in October; however, they believe they spoke with the staff regarding the resident's complaints. The Unit Manager explained the resident was very anxious. The Unit Manager verbalized they would have notified the DON of the resident's complaints. On 12/04/2024 at 4:09 PM, the DON verbalized the DON had not been made aware of Resident #36's concerns from the LSW or the Unit Managers. The DON was not aware of the resident's complaints of lack of care overnight and if they had been notified, the DON would have started an investigation immediately, interviewing the resident, other residents in the hall, and staff involved in the resident's care. The DON confirmed the DON was not notified of the resident complaints by the Unit Managers or the LSW and the DON would expect to be notified right away. The DON confirmed the DON had not spoken with the resident regarding their complaints. The signed job description for the Licensed Social Worker, dated 12/14/2022, documented the primary purpose of the job position was to support the day-to-day needs of the residents within the facility, participated in resident care management, actively participated in care coordination, and assured social services progress notes were informative and descriptive of the services provided and of the resident's response to the service. The facility policy titled Grievances and Complaints, Filing, dated 02/01/2019, documented residents had the right to file grievances and make complaints, either orally or in writing, to the facility staff. The policy defined the following: Complaint: stems from minor issues which can usually be resolved by the staff members who were present when a resident verbalized a concern. Unresolved complaints could turn into grievances. Grievance: a more serious concern with respect to care and treatment which has been furnished as well as which has not been furnished. Any resident may file a grievance or complaint concerning care or treatment. Grievances may also be voiced or filed regarding care which has not been furnished. Residents had the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. Grievances and complaints may be submitted orally or in writing. The Administrator has delegated responsibility of grievance investigation to the Grievance Coordinator, who was a member of the Social Services Staff and could be contacted by asking to speak with the Social Services Staff. Upon receipt of a grievance, the Grievance Coordinator would review and investigate the allegations and submit a written report of the findings to the Administrator within 14 working days of receiving the grievance. The resident would be informed of the findings of the investigation and the actions taken to correct any identified problems. A written or verbal summary of the investigation would be provided to the resident and a copy filed in the Grievance Complaint Log Book. Cross reference with Tag 550, 677, and 745

Based on interview, clinical record review and document review, the facility failed to ensure residents with an acquired serious mental disorder diagnosis after admission were submitted for a pre-admission screening and resident review (PASARR) level II screening for 2 of 23 sampled residents (Resident #80 and #57.) This deficient practice had the potential to not obtain additional resources for a resident with a serious mental disorder. Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], and obtained a diagnosis of delusional disorder on 12/09/2023. The resident admitted to the facility with a PASARR level I completed 07/21/2023. The Minimum Data Set 3.0 (MDS) assessment, Section I - Active Diagnoses, dated 11/30/2024, documented I5800 depression and I5950 psychotic disorder. On 12/04/2024 at 2:38 PM, the Licensed Social Worker (LSW) explained it was the LSW's responsibility to submit all PASARRs for review. The LSW reviewed the requirements for submission of a PASARR level II and confirmed Resident #80 met the requirements when the new diagnosis of delusional disorders was acquired. The LSW explained it was not the LSW's responsibility to submit the PASARRs at the time of the diagnosis (12/2023) however, it had not been submitted for review at any point in the past twelve months or since taking responsibility for the submissions. Resident #57 Resident #57 was admitted to the facility on [DATE], readmitted on [DATE], and obtained the a diagnosis of major depressive disorder on 10/17/2022. The resident admitted to the facility with a PASARR level I completed 04/07/2022. The MDS assessment, Section I - Active Diagnoses, dated 11/07/2024, documented I5800 depression and I5950 psychotic disorder. On 12/04/2024 at 2:57 PM, the LSW confirmed a PASARR level II was not submitted after Resident #57 acquired major depressive disorder as a diagnosis and did meet the criteria for submission. The LSW verbalized being familiar with the resident and explained the resident exhibited major depressive disorder when the resident was angry, was racist, or when the resident accused Certified Nursing Assistants (CNA) of talking about him. The facility policy titled, Behavioral Assessment, Intervention and Monitoring, adopted 02/01/2019, documented new onset or changes in behavior indicating newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR level II evaluation.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the activities care plan addressed a resident's visual impairment and the need for staff to support and assist the resident with personalized activities for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to prevent staff caring for the resident to be aware of the resident's personalized interests and how the staff could assist the resident to meet the resident's activity related goals. 2) A care plan was developed to address monitoring for a resident with bilateral lower extremity edema for 1 of 23 sampled residents (Resident #86). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for signs of leg swelling. 3) A care plan was developed for the use of bed rails for 1 of 23 sampled residents (Resident #208). This deficient practice had the potential for the resident to not receive accurate and appropriate care related to Activities of Daily Living (ADLs). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unqualified vision loss, both eyes and depression, unspecified. On 12/02/2024 at 9:08 AM, Resident #9 verbalized the resident would participate in group activities when the activities were accessible for the resident, but the resident did not have any activities the resident could do while the resident was by themselves. An Activity Interview for Daily and Activity Preferences, dated 11/04/2024, documented it was very important to the resident to have mystery and history audiobooks and to be able to listen to oldies music. It was very important for the resident to do the resident's favorite activities including listening to music of interest and listening to books on tape. The activities care plan for Resident #9, revised on 11/20/2024, documented the resident would maintain involvement in cognitive stimulation, social activities as desired through review date. The interventions listed were to invite the resident to scheduled activities and provide a program of activities of interest to the resident by encouraging choice, self-expression, and responsibility. The position responsible for the interventions was Activities. On 12/03/2024 at 8:58 AM, Resident #9 verbalized the resident had been given a device to listen to audiobooks but no one had assisted the resident in using the device and the resident had difficulty using the device due to the resident's inability to see, so the resident had stopped attempting to listen to audiobooks. The resident verbalized the resident did not have any music or a radio in the resident's room and the facility had not offered the resident any options to listen to music in the resident's room. The resident explained the resident sometimes felt bored when in the resident's room due to not having any activities of interest available and accessible to the resident. On 12/03/2024 at 2:52 PM, the Licensed Practical Nurse (LPN) for Resident #9 verbalized the LPN would offer to bring the resident to a group activity if the resident requested or was already up, but the LPN was not aware of any individual activities the resident wished to do in the resident's room. The LPN verbalized the LPN would refer to the resident's care plan if there were individual activities to provide. On 12/04/2024 at 8:57 AM, the Activities Director (AD) verbalized the AD conducted the Activity Interview for Daily and Activity Preferences to gather the necessary information to formulate a care plan for the resident. The AD verbalized individualized activities would be offered based on a resident's preferences. The AD verbalized the facility had an audiobook player, but the AD had not provided instruction to the nurses or CNAs on how to operate the player. The AD verbalized the AD had not provided a music player for the resident. The AD confirmed the activities care plan for Resident #9 did not include the individualized activities the resident had communicated as being very important for the resident and did not include the need for staff caring for the resident to offer the resident assistance with the activities. On 12/04/2024 at 10:42 AM, the Director of Nursing (DON) verbalized the AD was responsible for personalizing the resident's activities care plan. The DON verbalized the care plan should include the amount and type of assistance a resident needed and all positions responsible for assisting the resident. The facility policy titled Care Plans, Comprehensive Person-Centered, adopted 02/01/2019, documented the care plan would reflect the resident's expressed wishes and identify the professional services responsible for each element of care. Cross reference with tag F679 34524 Resident #86 Resident #86 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, stage 3 and acute kidney failure. On 12/03/2024 at 8:24 AM, Resident #86 verbalized the resident had swelling in both legs, especially the right leg. The resident informed the nurse and was told to put their legs up. A physician order dated 11/07/2024, documented Furosemide oral tablet 40 milligram (mg), give 40 mg by mouth in the afternoon for bilateral lower leg edema for three days. A Physician Progress Note dated 11/08/2024, documented Resident #86 had worsening bilateral lower leg edema. Resident #86's clinical record lacked documented evidence a care plan for the management and monitoring of edema had been developed. On 12/05/2024 at 12:45 PM, the DON confirmed Resident #86's clinical record did not include a care plan for the management of the resident's edema. The DON verbalized the resident was at risk of retaining fluid and lack of monitoring could result in more symptoms of fluid retention. 30748 Resident #208 Resident #208 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified sequalae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness (generalized). A physician's order dated 11/17/2024, documented upper quarter side rails on each side of the bed to promote independent bed mobility. On 12/04/2024 at 8:50 AM, Resident #208 had two quarter size bed rails, on each side of the bed. On 12/04/2024 at 10:13 AM, the resident verbalized the resident used the bed rails on a daily basis and preferred the bed rails for mobility. Resident #208's comprehensive care plan lacked documented evidence of the use of bed rails. On 12/04/2024 at 2:06 PM, the DON confirmed the resident lacked a care plan for the use of bed rails for Resident #208 and verbalized bed rails were required to be care planned so staff could coordinate proper care needs for the resident. On 12/04/2024 at 2:15 PM, the Regional MDS Registered Nurse confirmed Resident #208 did not have a care plan relating to the use of bed rails and verbalized staff referred to the care plans to determine appropriate care for the resident. The lack of the comprehensive care plan for the use of bed rails was not beneficial to the care needs of the resident. The facility policy titled Care Plans, Comprehensive Person-Centered, adopted 02/01/2019, documented comprehensive care planning included an assessment of residents strengths and needs and would include goals for care required for the resident. The purpose of the person-centered care plan was to describe services furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. Cross Reference with F700

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a visually impaired resident received individualized activities based on the resident's preferences and goals for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in a resident feeling a loss of independence and negatively impact the resident's psychosocial well-being. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unqualified vision loss, both eyes and depression, unspecified. On 12/02/2024 at 9:08 AM, Resident #9 verbalized the resident would participate in group activities when the activities were accessible for the resident, but the resident did not have any activities the resident could do while the resident was by themself. An Activity Interview for Daily and Activity Preferences, dated 11/04/2024, documented it was very important to the resident to have mystery and history audiobooks and to be able to listen to oldies music. It was very important for the resident to do the resident's favorite activities including listening to music of interest and listening to books on tape. The activities care plan for Resident #9, revised on 11/20/2024, documented the resident would maintain involvement in cognitive stimulation, social activities as desired through review date. The interventions listed were to invite the resident to scheduled activities and provide a program of activities of interest to the resident by encouraging choice, self-expression, and responsibility. The position responsible for the interventions was Activities. The Task: Activities for Resident #9, reviewed from 11/04/2024 through 12/04/2024, documented the resident participated in individual activities for one day in the 30-day period. On 11/18/2024, the Task documented the resident had participated in the individual activity of reading and puzzles. On 12/03/2024 at 8:58 AM, Resident #9 verbalized the resident had been given a device to listen to audiobooks but no one had assisted the resident in using the device and the resident had difficulty using the device due to the resident's inability to see, so the resident had stopped attempting to listen to audiobooks. The resident verbalized the resident did not have any music or a radio in the resident's room and the facility had not offered the resident any options to listen to music in the resident's room. The resident explained the resident sometimes felt bored when in the resident's room due to not having any activities of interest available and accessible to the resident. On 12/03/2024 at 2:52 PM, the Licensed Practical Nurse (LPN) for Resident #9 verbalized the LPN would offer to bring the resident to a group activity if the resident requested or was already up, but the LPN was not aware of any individual activities the resident wished to do in the resident's room. The LPN verbalized the LPN would refer to the resident's care plan if there were individual activities to provide. On 12/04/2024 at 8:57 AM, the Activities Director (AD) verbalized the AD conducted the Activity Interview for Daily and Activity Preferences to gather the necessary information to formulate a care plan for the resident. The AD verbalized individualized activities would be offered based on a resident's preferences. The AD verbalized the facility had an audiobook player, but the AD had not provided instruction to the nurses or CNAs on how to operate the player. The AD verbalized the AD had not provided a music player for the resident. The AD confirmed the activities care plan for Resident #9 did not include the individualized activities the resident had communicated as being very important for the resident and did not include the need for staff caring for the resident to offer the resident assistance with the activities. The AD verbalized the activities staff would document under the activities task when the staff assisted the resident with an individual activity. The AD confirmed the Task: Activities for Resident #9 only had documentation for one day in the 30 days look back period. On 12/04/2024 at 10:42 AM, the Director of Nursing (DON) verbalized the AD was responsible for personalizing the resident's activities care plan. The DON verbalized the care plan should include the amount and type of assistance a resident needed and all positions responsible for assisting the resident. The facility policy titled Activity Programs, adopted 02/01/2019, documented individualized activities would be provided and would reflect the interests and personal preferences of the resident. Activities would not be limited to formal activities being provided only by activities staff. Other facility staff would also provide the activities. All activities would be documented in the resident's medical record. Cross reference with tag F656

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's medication for neuropathy (a nerve condition causing pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) was refilled timely to prevent the resident from missing eight doses of the medication for 1 of 23 sampled residents (Resident #9). This deficient practice had the potential to result in a resident experiencing unrelieved nerve pain the medication was prescribed to treat. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other chronic pain, pain, unspecified, pain in left ankle and joints of left foot, and pain in right knee. On [DATE] at 9:18 AM, Resident #9 verbalized the resident had not received a scheduled pain medication over the weekend. The resident explained the medication was usually given three times a day to prevent the resident from having pain in the resident's feet. The resident verbalized the resident had asked the nurse about the medication because the resident was feeling a burning sensation in the resident's feet. The resident verbalized the resident had been told someone had forgotten to renew the medication and the facility had been unable to get an on-call provider to write a new order. Medication orders for Resident #9 documented the following: - pregabalin oral capsule 200 milligrams (mg), give one capsule by mouth three times a day for neuropathy for 30 days. The start date for the medication was [DATE]. - pregabalin oral capsule 200 mg, give one capsule by mouth three times a day for neuropathy for 30 days. The start date for the medication was [DATE]. The November and [DATE] Medication Administration Records for Resident #9 documented the resident did not receive the medication on [DATE] or [DATE], and only received the evening dose on [DATE]. A care plan for Resident #9, revised on [DATE], documented the resident had an alteration in comfort related to complaints of chronic pain, pain in the left ankle, pain in the right knee, and neuropathy. The interventions included to administer medications including pregabalin. On [DATE] at 2:50 PM, the Licensed Practical Nurse (LPN) for Resident #9 verbalized the facility practice was to reassess the need for narcotic medications every 30 days to ensure the medication was still effective. The LPN explained the nurse caring for the resident would be responsible for requesting a new order from the provider three days prior to the end of the order. The LPN verbalized if an order was received the nurse would be able to retrieve the medication from the facility's medication system while waiting for the pharmacy to deliver the medication. On [DATE] at 9:29 AM, the Director of Nursing (DON) explained the facility procedure was for a narcotic to be ordered for 30 days at a time. The DON verbalized the renewal order should have been requested two to three days prior to the order expiring. The DON confirmed the order expired on [DATE] and was not renewed until [DATE]. The DON confirmed the resident had not received the medication on [DATE], [DATE], and only received the evening dose when the medication was reordered on [DATE]. The DON verbalized the medication was not renewed because the need for a renewal order was overlooked due to a lack of communication between the staff. The DON verbalized the staff could have requested a different medication to be given until the ordering provider was able to renew the medication. The DON confirmed no medications were added to replace the pregabalin. The facility policy titled Pain Management, updated ,d+[DATE], documented the facility took a proactive approach to pain management and pain management was best achieved with scheduled medications.

Based on observation, interview, clinical record review and document review the facility failed to attempt to use appropriate alternative interventions and create a comprehensive care plan prior to installation and use of bed rails for 1 of 23 sampled residents (Resident #208). This failure had the potential to increase accidental entrapment or injury when an alternate assistive device may have been effective and care planned interventions implemented. Findings include: Resident #208 Resident #208 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness (generalized). Resident #208's five day Minimum Data Set 3.0 (MDS) assessment dated [DATE], section P0100 (Restraints and Alarms-Physical Restraints) documented the resident used bed rails daily as a physical restraint that could not be removed easily which restricted freedom of movement or normal access to one's body. On 12/04/2024 at 8:50 AM, Resident #208 had two quarter size bed rails, on each side of the bed. On 12/04/2024 at 10:13 AM, the resident verbalized the resident used the bed rails on a daily basis and preferred the bed rails for mobility. Resident #208's comprehensive care plan lacked documented evidence of the use of bed rails. A physician's order dated 11/17/2024, documented upper quarter side rails on each side of the bed to promote independent bed mobility. Resident #208's clinical record lacked documented evidence of interventions attempted prior to the installation and use of bed rails. On 12/04/2024 at 2:06 PM, the Director of Nursing (DON) explained the resident requested the bed rails and the facility was honoring the resident's wishes. The DON verbalized if a resident had requested bed rails, other interventions would be attempted prior to installing the bed rails on the resident's bed. The DON verbalized once the bed rails were in use by the resident, the bed rails would be care planned with appropriate interventions. The DON confirmed no prior interventions were attempted prior to the installation and use of bed rails for Resident #208. On 12/04/2024 at 2:16 PM, the Regional MDS Registered Nurse confirmed no prior interventions were attempted prior to the installation and use of bed rails for Resident #208 and verbalized alternative interventions were required to be attempted prior to the installation and use of bed rails. The bed rails were to be care planned to include interventions to ensure the safety of the resident. The facility policy titled Proper Use of Side Rails, adopted 02/01/2019, documented less restrictive interventions would be attempted prior to the use of bed rails. Documentation would be completed to indicate if the less restrictive approaches were not successful prior to considering the use of bed rails. The facility policy titled Use of Restraints, adopted 02/01/2019, documented restraints were only to be used for a specific medical symptom after other less restrictive methods had been attempted and care plans would reflect interventions to include the resident's medical symptom and underlying problems contributing to the medical symptom. Cross Reference with F656

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a bed bound resident with a pressure ulcer was repositioned every two hours and assistive heal protectors were applied correctly, resulting in additional pressure ulcers for 1 of 22 sampled residents (Resident #81). Findings include: Resident #81 Resident #81 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encephalopathy, unspecified, cognitive communication deficit, muscle weakness, generalized, contracture of muscle, left lower leg, osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region, stage IV, unspecified protein calorie malnutrition, personal history of traumatic brain injury. Resident #81's Minimum Data Set 3.0 (MDS) assessment, dated 07/04/23, was initiated at admission and an observation end date of 07/10/23. Section M (skin conditions) documented a Braden skin assessment was completed and the resident was at risk of developing pressure ulcers. -Section M0300, documented Resident #81 had one stage IV pressure ulcer present upon admission. The MDS assessment lacked documented evidence Resident #81 had any additional pressure ulcers present upon admission. -Section M1200 (skin and ulcer treatment) documented a pressure reducing device for bed, pressure ulcer care, and the application of ointments/medications and non-surgical dressings. -Section M1200(C) turning and repositioning program was not selected. Resident #81's MDS assessment dated [DATE], documented a re-entry date of 10/25/23, following an acute care hospital stay. The observation end date was 11/01/23. Section M (skin conditions) documented a Braden skin assessment was completed and the resident was at risk of developing pressure ulcers. -Section M0300, documented Resident #81 had one stage IV pressure ulcer present upon re-admission. The MDS assessment lacked documented evidence Resident #81 had any additional pressure ulcers present upon admission. -Section M1200 (skin and ulcer treatment) documented a pressure reducing device for bed, nutrition, or hydration intervention to manage skin problems, pressure ulcer care, and the application of ointments/medications. -Section M1200(C) turning and repositioning program was not selected. A Weekly Wound Evaluation form, dated 12/12/23, completed by the Wound Care Nurse/Licensed Practical Nurse (LPN) documented Resident #81 had a stage IV pressure ulcer to the sacrum. The pressure ulcer was first identified on 07/04/23, the date of admission. A Weekly Wound Evaluation form, dated 12/12/23, completed by the Wound Care Nurse/LPN, documented Resident #81 had an unstageable pressure ulcer to the left trochanter (hip). The pressure ulcer was facility acquired and first identified on 11/13/23. A Weekly Wound Evaluation form, dated 12/12/23, completed by the Wound Care Nurse/LPN, documented Resident #81 had a stage III pressure ulcer to the right hip. The pressure ulcer was facility acquired and first identified on 11/21/23. A Weekly Wound Evaluation form dated 12/13/23, completed by the Wound Care Nurse/LPN, documented Resident #81 had an unstageable pressure ulcer to the right heel. The pressure ulcer was facility acquired and first identified on 12/13/23. A Weekly Wound Evaluation form dated 12/13/23, completed by the Wound Care Nurse/LPN, documented Resident #81 had an unstageable pressure ulcer to the right outer ankle. The pressure ulcer was facility acquired and first identified on 12/13/23. Resident #81's Kardex for care provided by Certified Nursing Assistants (CNA), printed on 12/14/23, documented to turn/reposition Resident #81 from side to side for skin breakdown prevention/wound healing. The Kardex documented the resident was dependent upon staff for bed mobility but did not include how often Resident #81 was to be repositioned and did not include instruction to ensure Resident #81's heel protectors were applied and aligned correctly. On 12/11/23 at 9:28 AM, Resident #81 was resting in bed. The resident was wearing a pair of heel protectors with an opening in the heel. The resident's right foot was uncovered, and the right heel could not be visualized in the opening of the heel protector. On 12/13/23 at 2:43 PM, CNA1 demonstrated how to apply Resident #81's heel protectors. Resident #81's heels were placed in the heel protector with the resident's heels resting directly on the interior wall of the heel protector, including the portion of the heel with a newly identified unstageable pressure injury. The CNA confirmed the facility had not provided CNA1 with training related to the application of the heel protectors. On 12/13/23 at 2:44 PM, the Wound Care Nurse/LPN confirmed Resident #81's heels were resting on the interior of the heel protector and had not been correctly applied. The Wound Care Nurse confirmed incorrectly applying the heel protectors could cause skin breakdown including pressure injury. The Wound Care Nurse/LPN confirmed Resident #81 was bed bound and required assistance for repositioning. On 12/14/23 at 9:32 AM, CNA2 verbalized heel protectors were applied by aligning a resident's toes with the top of the heel protector and ensuring the resident's heels were touching the cushioning inside of the heel protector. CNA2 verbalized bed bound residents should be turned/repositioned every two hours. Repositioning was documented in the residents' Electronic Health Record (EHR). CNA2 reviewed Resident #81's EHR documentation entered by CNAs and confirmed Resident #81's EHR included an area to chart resident repositioning once each shift, and did not include an option for CNAs to chart the resident was repositioned every two hours. On 12/14/23 at 9:51 AM, CNA3 verbalized the CNA ensured heel protectors were applied by matching colored straps to each other unless a resident wanted the heel protectors applied differently. CNA3 verbalized CNA3 would document turning residents every two hours if the option to document every two hours was available. On 12/14/23 at 10:38 AM, the Director of Nursing (DON) confirmed heel protectors were to be applied by ensuring the resident's foot was properly aligned and alignment should be checked at a minimum every two hours. The DON verbalized proper alignment meant ensuring the resident's heel was placed in the opening of the heel protector to ensure skin break down, such as a deep tissue injury, did not occur on the heel. The DON confirmed application of heel protectors was on the CNA skills check list, but a return demonstration of application was not required. The DON verbalized the expectation was a physician's order for the use of heel protectors would be obtained prior to use and confirmed Resident #81 did not have a physician's order for the use of heel protectors. On 12/14/23 at 10:48 AM, the DON confirmed Resident #81 was bed bound and verbalized Resident #81's EHR should have had documentation in place for CNAs to document when the resident was repositioned. The DON confirmed Resident #81's clinical record lacked documented evidence the resident was repositioned every two hours and the DON could not confirm Resident #81 was repositioned every two hours. On 12/14/23 at 12:21 PM, the DON verbalized the facility did not require an order for repositioning residents every two hours. The need to reposition a resident every two hours was entered in residents' charts as a task. The DON confirmed the task was not entered in Resident #81's EHR and should have been entered. On 12/14/23 at 12:38 PM, the Wound Care Nurse/LPN confirmed Resident #81 was admitted on [DATE], with a pressure ulcer to the sacrum/coccyx and Resident #81 had new facility acquired pressure ulcers identified as follows: -left hip, first identified on 11/13/23 -right hip, first identified on 11/21/23, -right lateral ankle, first identified on 12/13/23, and -right heel, first identified on 12/13/23. The facility policy titled Skin and Wound Management, last revised 10/2022, documented residents with skin breakdown/pressure ulcers received the services and treatment to prevent infection, promote wound healing, and prevent new pressure sores from developing. The facility policy titled Prevention of Pressure Ulcers/Injuries, last revised 07/2017, documented skin was inspected on a daily basis when providing personal care or assisting with activities of daily living and included the sacrum, heels, buttocks, coccyx, ischium, and trochanter. Residents were repositioned as indicated in the care plan. The frequency for repositioning was based on the resident's mobility, the support surface in use, skin condition, and tolerance. Bed bound residents were repositioned frequently with the head of the bed elevated. Interventions and strategies for effectiveness were reviewed on an ongoing basis. The facility policy titled Support Surface Guidelines, last revised 09/2013, documented support surfaces alone were not effective in the prevention of pressure ulcers. Interventions such as turning, repositioning, and moisture management assisted in the reduction of pressure ulcer development. Residents dependent on staff were repositioned frequently per the resident's care plan. The facility policy titled Pressure Ulcers/Injuries Overview, last revised 07/2017, documented avoidable meant a resident developed a pressure ulcer/injury and task/processes including defining and implementing interventions consistent with resident needs, resident goals, and professional standards of practice were not completed. Cross reference with F656

Based on interview, clinical record review and document review, the facility failed to administer significant medications per physician order resulting in death for 1 of 31 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including cardiac arrest, cause unspecified, and non-ST elevation myocardial infarction (NSTEMI). A hospital Discharge Summary dated [DATE], documented Resident #1 was admitted to the hospital on [DATE] for cardiac arrest. The resident received a cardiac catheterization and suffered another brief arrest during the procedure. Resident #1's discharge medications included Brillinta (ticagrelor) 90 milligrams (mg), take one tablet by mouth two times a day for 30 days. A Nursing Progress Note dated [DATE], documented Resident #1 was admitted to the facility and did not have shortness of breath, breathing difficulties, or chest pain. The resident's heart rate and rhythm were regular. Resident #1 reported the hospital medication list was accurate and medication orders were verified with the provider. A physician's order dated [DATE], documented the following: Brillinta (ticagrelor) oral tablet, give 90 mg by mouth two times a day for NSTEMI. The Medication Administration Record (MAR) dated [DATE]-[DATE], documented Resident #1 did not receive Brillinta on the following dates and administration times: -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM Nursing Progress Notes documented the following for the Brillinta medication: -[DATE] 9:05 PM: Brillinta oral tablet, awaiting delivery -[DATE] 8:54 AM: Brillinta oral tablet, newly admitted , awaiting delivery from pharmacy -[DATE] 10:27 PM: Brillinta oral tablet, awaiting delivery -[DATE] 7:32 AM: Brillinta oral tablet, awaiting delivery from pharmacy -[DATE] 7:15 PM: Brillinta oral tablet, awaiting delivery -[DATE] 10:57 AM: Brillinta oral tablet, waiting for delivery -[DATE] 10:38 PM: Brillinta oral tablet, awaiting delivery -[DATE] 8:08 AM: Brillinta oral tablet, awaiting for pharmacy delivery -[DATE] 7:08 PM: Brillinta oral tablet, awaiting delivery Resident #1 had not received the Brillinta medication for nine medication administrations. A Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated [DATE] at 2:35 AM, documented the following for Resident #1: -Change in condition, symptoms, or signs observed and evaluated were cardiac arrest, respiratory arrest, and unresponsiveness. -Mental status evaluation: unresponsiveness -Functional status evaluation: without pulse and respirations -Respiratory evaluation: respirations ceased -Cardiovascular evaluation: without pulse -Observation and evaluation summary: 2:30 AM Resident #1 was diaphoretic, pursed lipped breathing and unresponsive upon entering room. Eyes fixated. The resident's respirations and pulse ceased when the blood pressure cuff was applied. 2:35 AM, cardiopulmonary resuscitation (CPR) initiated per full code status, call placed to 911. Six rounds of compressions with oxygen at 15 liters per minute given until paramedics/fire took over code, intubated resident, administered epinephrine twice along with intravenous fluids, and transported resident to the hospital at 3:00 AM with continued chest compressions. A Hospital Nursing Progress Note dated [DATE], documented Resident #1 arrived with pulseless electrical activity, had received CPR in the field for over 30 minutes, and did not have a pulse. An Emergency Department Physician Record dated [DATE], documented Resident #1 arrived in the Emergency Department at 3:15 AM. Resident #1 presented with cardiac arrest and CPR was in progress upon arrival. The resident was intubated to establish an airway. A total of 45 minutes of CPR was administered and Resident #1 never achieved a return of spontaneous circulation. The resident expired on [DATE] at 3:33 AM, with a high suspicion for an in-stent thrombosis leading to a fatal cardiac arrest. A Nursing Progress Note dated [DATE], at 4:14 AM, documented a call was placed to the hospital for a status update on Resident #1 and was informed by the hospital nurse the resident had expired. On [DATE] at 3:42 PM, a Licensed Practical Nurse (LPN) explained if a medication was missing, and not stocked in the automated medication dispensary (Passport), the nurse should call the pharmacy and find out why the medication was not sent. The LPN verbalized the facility pharmacy could send a prescription to a local pharmacy and have it delivered to the facility. The LPN explained missing medication, the follow up, and physician notification should be documented in the clinical record as a progress note. The LPN confirmed Brillinta was not stocked in Passport and would have to be ordered through the pharmacy. On [DATE] at 3:57 PM, the Director of Nursing (DON) explained the expectation of nursing staff to follow up on missing medications was to call the pharmacy, find out where the medication was, what caused the delay, and notify both the physician and the Nurse Supervisor or DON. The DON verbalized it was the nurse's responsibility to follow up on any medication issues and would expect a missing medication to be available by the next scheduled administration. The DON confirmed the facility pharmacy was available seven days per week and for 24 hours per day. On [DATE] at 4:00 PM, the DON confirmed Resident #1 did not receive the prescribed medication Brillinta from [DATE]-[DATE]. The DON verbalized the DON did not know the resident had not received the medication until the resident was transferred out to the hospital on [DATE], and should have been notified of any issues with obtaining the medication. The DON explained a resident with a cardiac diagnosis could experience cardiac arrest or a blood clot without the prescribed medication. On [DATE] at 4:09 PM, the Administrator explained the expectation of nursing to follow up on a missing medication by calling the pharmacy, the physician, and the Nurse Manager or DON. The Administrator verbalized the missing medication was expected to be present by the next administration time. The Administrator confirmed it was not acceptable for a resident to miss a critical medication for five days and explained the medication order transcribed by the nurse had indicated the medication was on hand and part of house stock, therefore it was not filled through the pharmacy. On [DATE] at 10:09 AM, the Pharmacy Manager explained each new admission required an electronic notification to add the resident to the system. The nurse would enter all medication orders into the electronic system, the orders would go to the pharmacy, and the pharmacy would fill the orders. The nurse would have to indicate the status of each medication as on hand, house stock, or pharmacy fill. A medication indicated as on hand or house stock would not be filled by the pharmacy because it was not identified as a pharmacy fill. The Pharmacy Manager confirmed the Brillinta was not filled for Resident #1 until [DATE], as the fill request was not made until the evening of [DATE]. An Order Audit Report, dated [DATE], documented Brillinta oral tablet 90 mg, give one tablet by mouth two times a day for NSTEMI and had an original status of On Hand with a source of House Stock. On [DATE], the medication was auto-linked with a prescription number, had a source of Pharmacy-Partners, and was dispensed on [DATE]. The medication was not filled until [DATE], after the resident had transferred to the hospital and expired. A facility policy titled Liberalized Medication Administration Policy and Procedure, dated February 2023, documented it was the policy of the facility to administer medication to residents in a safe manner. Medications prescribed by the physician would be given as such. The medical director and pharmacist would provide direction for any concerns that arose in order to optimize the care and safety for medication administration effects for each individual resident based on their needs. The general nursing standard of practice for medication administration would include the Five Rights of Medication Administration, maintaining infection control standards for medication administration, and maintaining resident dignity. A facility policy titled Resident Rights, revised [DATE], documented the Resident had a right to receive treatment and support for daily living safely. Complaint #NV00069059

Based on interview, clinical record review and document review, the facility failed to prevent neglect of a resident when medication was not administered per a physician's order resulting in death for 1 of 31 residents sampled for medication review (Resident #1) and prevent resident to resident abuse for 8 of 8 residents sampled with documented resident to resident altercations (Resident #9, #10, #11, #12, #13, and #14). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including cardiac arrest, cause unspecified, and non-ST elevation myocardial infarction (NSTEMI). A hospital Discharge Summary dated [DATE], documented Resident #1 was admitted to the hospital on [DATE] for cardiac arrest. The resident received a cardiac catheterization and suffered another brief arrest during the procedure. Resident #1's discharge medications included Brillinta (ticagrelor) 90 milligrams (mg), take one tablet by mouth two times a day for 30 days. A Nursing Progress Note dated [DATE], documented Resident #1 was admitted to the facility and did not have shortness of breath, breathing difficulties, or chest pain. The resident's heart rate and rhythm were regular. Resident #1 reported the hospital medication list was accurate and medication orders were verified with the provider. A physician's order dated [DATE], documented the following: Brillinta (ticagrelor) oral tablet, give 90 mg by mouth two times a day for NSTEMI. The Medication Administration Record (MAR) dated [DATE]-[DATE], documented Resident #1 did not receive Brillinta on the following dates and administration times: -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM -[DATE]: 8:00 AM -[DATE]: 8:00 PM Nursing Progress Notes documented the following for the Brillinta medication: -[DATE] 9:05 PM: Brillinta oral tablet, awaiting delivery -[DATE] 8:54 AM: Brillinta oral tablet, newly admitted , awaiting delivery from pharmacy -[DATE] 10:27 PM: Brillinta oral tablet, awaiting delivery -[DATE] 7:32 AM: Brillinta oral tablet, awaiting delivery from pharmacy -[DATE] 7:15 PM: Brillinta oral tablet, awaiting delivery -[DATE] 10:57 AM: Brillinta oral tablet, waiting for delivery -[DATE] 10:38 PM: Brillinta oral tablet, awaiting delivery -[DATE] 8:08 AM: Brillinta oral tablet, awaiting for pharmacy delivery -[DATE] 7:08 PM: Brillinta oral tablet, awaiting delivery Resident #1 had not received the Brillinta medication for nine medication administrations. A Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated [DATE] at 2:35 AM, documented the following for Resident #1: -Change in condition, symptoms, or signs observed and evaluated were cardiac arrest, respiratory arrest, and unresponsiveness. -Mental status evaluation: unresponsiveness -Functional status evaluation: without pulse and respirations -Respiratory evaluation: respirations ceased -Cardiovascular evaluation: without pulse -Observation and evaluation summary: 2:30 AM Resident #1 was diaphoretic, pursed lipped breathing and unresponsive upon entering room. Eyes fixated. The resident's respirations and pulse ceased when the blood pressure cuff was applied. 2:35 AM, cardiopulmonary resuscitation (CPR) initiated per full code status, call placed to 911. Six rounds of compressions with oxygen at 15 liters per minute given until paramedics/fire took over code, intubated resident, administered epinephrine twice along with intravenous fluids, and transported resident to the hospital at 3:00 AM with continued chest compressions. A Hospital Nursing Progress Note dated [DATE], documented Resident #1 arrived with pulseless electrical activity, had received CPR in the field for over 30 minutes, and did not have a pulse. An Emergency Department Physician Record dated [DATE], documented Resident #1 arrived in the Emergency Department at 3:15 AM. Resident #1 presented with cardiac arrest and CPR was in progress upon arrival. The resident was intubated to establish an airway. A total of 45 minutes of CPR was administered and Resident #1 never achieved a return of spontaneous circulation. The resident expired on [DATE] at 3:33 AM, with a high suspicion for an in-stent thrombosis leading to a fatal cardiac arrest. A Nursing Progress Note dated [DATE], at 4:14 AM, documented a call was placed to the hospital for a status update on Resident #1 and was informed by the hospital nurse the resident had expired. On [DATE] at 3:42 PM, a Licensed Practical Nurse (LPN) explained if a medication was missing, and not stocked in the automated medication dispensary (Passport), the nurse should call the pharmacy and find out why the medication was not sent. The LPN verbalized the facility pharmacy could send a prescription to a local pharmacy and have it delivered to the facility. The LPN explained missing medication, the follow up, and physician notification should be documented in the clinical record as a progress note. The LPN confirmed Brillinta was not stocked in Passport and would have to be ordered through the pharmacy. On [DATE] at 3:57 PM, the Director of Nursing (DON) explained the expectation of nursing staff to follow up on missing medications was to call the pharmacy, find out where the medication was, what caused the delay, and notify both the physician and the Nurse Supervisor or DON. The DON verbalized it was the nurse's responsibility to follow up on any medication issues and would expect a missing medication to be available by the next scheduled administration. The DON confirmed the facility pharmacy was available seven days per week and for 24 hours per day. On [DATE] at 4:00 PM, the DON confirmed Resident #1 did not receive the prescribed medication Brillinta from [DATE]-[DATE]. The DON verbalized the DON did not know the resident had not received the medication until the resident was transferred out to the hospital on [DATE], and should have been notified of any issues with obtaining the medication. The DON explained a resident with a cardiac diagnosis could experience cardiac arrest or a blood clot without the prescribed medication. The DON confirmed it was neglect when the facility did not administer the Brillinta to Resident #1. On [DATE] at 4:09 PM, the Administrator explained the expectation of nursing to follow up on a missing medication by calling the pharmacy, the physician, and the Nurse Manager or DON. The Administrator verbalized the missing medication was expected to be present by the next administration time. The Administrator confirmed it was not acceptable for a resident to miss a critical medication for five days and explained the medication order transcribed by the nurse had indicated the medication was on hand and part of house stock, therefore it was not filled through the pharmacy. The Administrator confirmed it was neglect when the facility did not administer the Brillinta to Resident #1. On [DATE] at 10:09 AM, the Pharmacy Manager explained each new admission required an electronic notification to add the resident to the system. The nurse would enter all medication orders into the electronic system, the orders would go to the pharmacy, and the pharmacy would fill the orders. The nurse would have to indicate the status of each medication as on hand, house stock, or pharmacy fill. A medication indicated as on hand or house stock would not be filled by the pharmacy because it was not identified as a pharmacy fill. The Pharmacy Manager confirmed the Brillinta was not filled for Resident #1 until [DATE], as the fill request was not made until the evening of [DATE]. An Order Audit Report, dated [DATE], documented Brillinta oral tablet 90 mg, give one tablet by mouth two times a day for NSTEMI and had an original status of On Hand with a source of House Stock. On [DATE], the medication was auto-linked with a prescription number, had a source of Pharmacy-Partners, and was dispensed on [DATE]. The medication was not filled until [DATE], after the resident had transferred to the hospital and expired. The facility policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, revised [DATE], documented signs of actual physical neglect included improper use/administration of medication, inadequate provisions of care, and caregiver indifference to resident's personal care and needs. The facility policy titled, Abuse Prevention Program, revised [DATE], documented residents had the right to be free from neglect and the facility would protect residents from abuse including abuse from facility staff. A facility policy titled Liberalized Medication Administration Policy and Procedure, dated February 2023, documented it was the policy of the facility to administer medication to residents in a safe manner. Medications prescribed by the physician would be given as such. The medical director and pharmacist would provide direction for any concerns that arose in order to optimize the care and safety for medication administration effects for each individual resident based on their needs. A facility policy titled Resident Rights, revised [DATE], documented the Resident had a right to receive treatment and support for daily living safely. Cross Reference to tag F760 Complaint #NV00069059 31739 Facility Reported Incident (FRI) #NV00069006 documented on [DATE] a resident hit another resident. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, vascular dementia, and anxiety disorder. Resident #9's Care Plan dated [DATE], documented the resident had the potential to be verbally aggressive with inappropriate language and yelling. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including discitis, unspecified, thoracic region, hyperlipidemia, essential primary hypertension, and chronic pain. An Incident Progress Note dated [DATE], documented Resident #10 reported to staff Resident #9 had hit Resident #10 after asking to change the television channel. On [DATE] at 10:40 AM, Resident #10 was in bed watching television. The resident verbalized remembering the incident happening and reported it to staff. On [DATE] at 1:16 PM, the Director of Nursing (DON) confirmed Resident #10 had reported having been hit by Resident #9 after asking to change to television channel. The DON verbalized Resident #9 had documented behaviors and did not want to give up the television remote control and hit Resident #10. FRI #NV00069113 documented on [DATE], a resident was observed yelling and cursing at another resident who had thrown water at the first resident. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, dysphagia and depression. Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including discitis, unspecified, lumbar region, anxiety disorder, depression, and bi-polar disorder. A Behavior Progress Note dated [DATE], documented Resident #11 had come out of the resident's room yelling the resident's roommate had thrown water at the resident. A Social Services Progress Note dated [DATE], documented Resident #12 had reported Resident #11 would not stop singing and after asking Resident #11 to stop multiple times, Resident #12 threw water from a cup at Resident #11. On [DATE] at 1:13 PM, the DON confirmed Resident #12 had thrown water at Resident #11 after asking multiple times for Resident #11 to stop singing. FRI #NV00069356 documented on [DATE], a resident reported striking another resident causing the resident to hit the floor resulting in a forehead laceration and a left rib abrasion. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of tongue, unspecified dementia, mood disturbance, and anxiety. Resident #14 Resident #14 was admitted to the facility on [DATE] with diagnoses including acute cystitis without hematuria, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety. An Incident Progress Note dated [DATE], documented Resident #13 had reported striking Resident #14 after Resident #14 would not stop going through Resident #13's personal property. Resident #14 was found in the resident's bathroom washing blood from the resident's face. Resident #14 reported arguing with Resident #13 and Resident #14 hit Resident #13 resulting in the resident falling to the floor causing a laceration to the forehead and redness and superficial abrasion to the left ribs. Resident #14 was transferred to the hospital for evaluation and treatment. Resident #14's Care Plan dated [DATE], documented the resident had an unwitnessed fall with minor injuries from a resident to resident altercation, neurological checks were initiated and the resident was sent out to the emergency department for further evaluation and treatment. On [DATE] at 1:08 PM, the DON confirmed Resident #13 had reported striking Resident #14 resulting in Resident #14 hitting the floor causing a laceration to the forehead and abrasion to the left ribs. The incident was unwitnessed and Resident #14 was transferred to the hospital for treatment and received several stitches. The facility policy titled, Resident Rights, revised [DATE], documented the resident's had the right to a safe environment. The facility policy titled, Abuse Prevention Program, revised [DATE], documented residents had the right to be free from abuse, and the facility would protect residents from abuse including abuse from other residents. FRI #NV00069006, FRI #NV00069113, FRI #NV00069356

Based on observation, interview, and document review the facility failed to ensure a delayed egress door released immediately when the fire alarm was initiated, impacting the safety and well-being of 87 residents (Resident #32, #402, #44, #26, #33, #65, #25, #62, #63, #42, #58, #64, #15, #22, #51, #408, #55, #30, #405, #37, #47, #18, #16, #27, #23, #46, #18, #16, #27, #23, #46, #61, #401, #49, #36, #39, #6, #400, #8, #59, #406, #54, #19, #17, #34, #38, #12, #320, #45, #321, #41, #410, #29, #403, #20,#28, #409, #52, #35, #53, #31, #48, #21, #40, #319, #56, #379, #60, #43 #381, #382, #14, #24, #317, #66, #50, #57, #380, #318, #367, #407, #368, #369, #370, #371, #372, #373, #374, #375, #376, #377, and #378.) Findings include: An Immediate Jeopardy occurred on 03/24/21 and the facility was notified on 03/25/21 at 4:39 PM, due to a delayed egress door not releasing immediately with the fire alarm and not releasing per the instructions on the door. The potential for adverse outcome included the inability to exit in case of fire or other emergency. The Immediate Jeopardy was abated on 03/30/21 at 5:05 PM. On 03/24/21 at 5:30 PM, upon exiting the building, it was revealed the front door would not open after following the instructions on the door. The instructions were to hold the handle down for 15 seconds and the door would release. Three attempts were made to open the door. The door did not release and the alarm did not sound. During the final attempt, the Administrator was observing and verbalized that's weird the door should open. On 03/25/21, in the morning, the Maintenance Director verbalized the doors lock automatically at 4:00 PM and automatically unlock at 6:00 AM. Multiple staff members were interviewed and did not know the code to the front door keypad. On 03/25/21 at 4:03 PM, the Receptionist verbalized the door was locked. On 03/25/21 at 4:07 PM, the lock did not release after the push bar on the door was held for 15 seconds and the alarm did not sound. The door remained locked and would not open upon two attempts. On 03/25/21 at 4:09 PM, the Administrator attempted to open the door. The door did not open within 15 seconds. The Maintenance Director confirmed the delayed egress special locking feature did not open the door when the door was locked and did not sound an alarm for 15 seconds as the sign on the door indicated. The delayed-egress function was then tested to see if the lock released when the manual fire alarm was pulled. At least 15 pounds of force was applied to the main entry egress door (delayed egress) for 26 seconds before the lock released. The Administrator was present when the door was tested . The delayed-egress function was then tested to observe if the lock released when the smoke detector was activated. The Maintenance Director sprayed canned smoke on the smoke detector. The door released after 15 seconds. The Administrator was present when the door was tested . The facility staff, residents, and visitors had the inability to exit the facility immediately upon activation of the fire alarm system or 15 seconds of pressure on the push bar of the door. To exit the facility, a person would be required to enter a code, activate the smoke detector with a 15 second delay to egress, or a manual fire alarm be pulled with a 26 second delay to egress.

Based on observation, interview, record review, and document review the facility failed to ensure 1) a resident (Resident #22) experiencing new onset of respiratory symptoms consistent with potential COVID-19 infection was quarantined and evaluated for COVID-19 per Centers for Disease Control and Prevention (CDC) guidelines potentially exposing 48 of the 49 residents on the second floor of the facility to a potentially infectious respiratory disease, 2) staff working in the designated COVID-19 quarantine unit performed hand sanitizing, 3) staff working in the designated COVID-19 quarantine unit used appropriate Personal Protective Equipment (PPE) when entering a resident room, 4) equipment being removed from the COVID-19 quarantine unit was sanitized before entering the designated COVID-19 free units, 5) Infection Control Policies and Procedures were current based on national standards and CDC guidelines, and 6) staff caring for residents in the COVID-19 quarantine unit were not caring for COVID-19 negative residents during a COVID-19 pandemic. Findings include: An Immediate Jeopardy occurred 03/19/21 and the facility was notified on 03/24/21 at 3:38 PM due to a resident experiencing new onset of respiratory symptoms, the resident had not been placed in quarantine, tested for COVID-19, and additional Personal Protective Equipment (PPE) was not being worn by staff when providing care to the resident. The potential adverse outcome was related to the potential exposure to a symptomatic resident, to include the spread through staff with exposure to negative COVID-19 residents to an infectious and potentially life-threatening respiratory disease. The Immediate Jeopardy was abated at 11:30 AM on 03/25/20. Resident #22 Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/23/21 at 8:56 AM, Resident #22 was sitting in a wheelchair at the entrance to the resident's room and was wearing oxygen. The resident shared the room with another resident. A Nursing Progress Note, dated 03/19/21, documented the resident's oxygen saturation was 85% on room air. The Advanced Practice Registered Nurse (APRN) ordered oxygen to be placed on the resident at two liters per minute (LPM) via nasal cannula and a stat chest x-ray. The resident complained of shortness of breath and the nurse noticed the resident was congested. The nurse encouraged the resident to cough up any phlegm. An APRN Progress Note, dated 03/19/21, documented the resident's nurse reported the resident's oxygen saturation was 85-87% on room air. The resident reported not feeling good. The resident had a productive cough and reported shortness of breath. The resident had some rhonchi in the left lower lobe. A Nursing Progress Note, dated 03/20/21, documented the resident's oxygen saturation went as low as 80% when the resident removed the oxygen. A Nursing Progress Note, dated 03/21/21, documented the resident's oxygen saturation was dropping as low as 82% when the resident removed the oxygen. A Nursing Progress Note, dated 03/22/21, documented the chest x-ray was completed and the results showed large left and modest right basilar infiltrates and basilar effusions. On 03/24/21 at 1:23 PM, a Licensed Practical Nurse (LPN) verbalized the resident's low oxygen saturation levels, congestion, and complaint of shortness of breath were new symptoms. The LPN verbalized the LPN was unsure if a resident with new onset of respiratory symptoms should have been tested or moved to quarantine. The LPN verbalized the staff caring for the resident had not donned additional PPE and the resident did not have designated staff. On 03/24/21 at 2:22 PM, the Director of Clinical Services (DCS) and the Administrator verbalized if the resident was vaccinated it would be appropriate for the resident to stay in their own room and not go into quarantine. On 03/24/21 at 2:29 PM, the DCS confirmed the resident had not been tested for COVID-19 after developing respiratory symptoms. On 03/24/21 at 2:33 PM, the DCS verbalized the facility followed a symptom based strategy and would quarantine residents as necessary. The DCS verbalized the facility could have moved the resident to the quarantine unit. On 03/24/21 at 2:36 PM, the Administrator verbalized the nursing staff would report up the chain of nursing management when a resident experienced a new onset of respiratory symptoms. The Administrator confirmed the facility did not have a Director of Nursing. The Administrator verbalized the nursing staff would report the symptoms to the APRN. The Administrator confirmed the APRN was not a nursing manager. On 03/30/21 at 11:53 AM, the Administrator verbalized the facility did not have a contract or agreement in place with the APRN and the APRN had not been oriented to the facility policies or procedures. On 03/24/21 at 2:41 PM, the DCS verbalized per CDC guidelines the resident should have been quarantined. On 03/24/21 at 4:36 PM, the Vice President of Regulatory Compliance verbalized the resident was not evaluated for COVID-19 due to the resident having a history of pneumonia. The resident would not have been placed in quarantine due to an absence of a fever. The DCS and the Administrator verbalized being unaware of the new onset of symptoms in the resident from 03/19/21 until 03/24/21. The CDC guidance titled Interim Public Health Recommendations for Fully Vaccinated People documented any fully vaccinated person who experiences symptoms consistent with COVID-19 should isolate from others, be clinically evaluated for COVID-19, and be tested for [DIAGNOSES REDACTED]-CoV-2 if indicated. Symptoms consistent with COVID-19 included shortness of breath and congestion. Proper PPE Usage On 03/22/21 at 1:10 PM, a Certified Nursing Assistant (CNA) passed meal trays to residents in the designated COVID-19 quarantine unit without donning a gown before entering the residents' rooms. On 03/23/21 at 7:45 AM, a CNA passed meal trays to residents in the designated COVID-19 quarantine unit without donning a gown before entering the residents' rooms. 03/24/21 at 9:40 AM, a CNA verbalized full PPE, including gowns, should be worn when entering the resident rooms in the COVID-19 quarantine unit. On 03/24/21 at 9:30 AM, the Maintenance Director (MD) went into a resident room to perform maintenance on the COVID-19 quarantine unit without donning a gown. Proper Hand Hygeine On 03/24/21 at 9:43 AM, the MD verbalized when the MD entered a COVID-19 quarantine room the MD did not wear a gown while in the room, did not complete hand sanitizing before exiting the room, and completed hand sanitizing only after exiting the COVID-19 quarantine unit. The MD confirmed the MD would be entering other areas of the facility which were designated COVID-19 free throughout the MD's shift and the MD did not wait until the end of the workday to complete tasks in the COVID-19 observation unit. Sanitizing of Equipment when Removed from COVID-19 Quarantine Unit On 03/24/21 at 9:48 AM, the tray cart was removed from the COVID-19 quarantine unit without being sanitized or disinfected prior to being removed from the COVID-19 quarantine unit and entering the COVID-19 free area of the facility. On 03/24/21 at 9:50 AM, the COVID-19 quarantine unit food tray cart was followed from the quarantine unit doors to the kitchen. The Dietary Manager (DM) pushed the cart into the kitchen, over the black line, and to the sink area. On 03/24/21 at 9:54 AM, the Dietary Manager confirmed the cart was not sanitized prior to leaving the COVID-19 quarantine unit. The DM verbalized the cart was not cleaned prior to leaving the quarantine unit because the staff do not have a food grade antibacterial cleaner on the unit and all cleaning of the food tray carts was completed in the kitchen. On 03/24/21 at 1:40 PM, the tray cart was removed from the COVID-19 quarantine unit without being sanitized or disinfected prior to being removed from the COVID-19 quarantine unit and entering the COVID-19 free area of the facility. On 03/24/21 at 4:00 PM, the Transportation CNA verbalized the quarantine unit was for all new admissions for 14 days because the facility did not know if a new resident was infected. The Transportation CNA verbalized using universal precautions when entering a COVID-19 quarantine residents' room and did not use gowns when entering a room or when transporting a resident from the unit. Infection Control Policy and Procedure On 03/25/21, review of the facility Infection Control Policy and Procedure (ICPP) revealed the last CDC update and guidance in the facility ICPP manual was dated 04/2020. On 03/25/21 at 1:00 PM, the Administrator and the Clinical Services Director (CSD) verbalized the following: -The facility followed the Centers for Disease Control (CDC) guidelines for infection control, -Food carts being removed from the COVID-19 quarantine unit were to be sanitized prior to leaving the unit, -All employees were required to don mask, gown, face shields, and gloves prior to entering a room in the COVID-19 quarantine unit, -All employees were required to complete hand sanitizing when entering or exiting a COVID-19 quarantine room, -Maintenance workers were required to wear gowns when entering a COVID-19 quarantine room and follow all other posted isolation requirements, -Maintenance workers were required to perform hand sanitizing prior to leaving a COVID-19 quarantine room, and -The Administrator or Infection Preventionist were responsible for updating the COVID-19 ICPP manual. On 03/25/21 at 2:00 PM, the CSD verbalized the facility COVID-19 ICPP manual was outdated and did not include the CDC's current recommendations. No Dedicated Staff The facility Daily Staffing Assignment for the 7:00 AM - 7:30 PM nursing shift revealed one nurse was assigned to rooms 116 - 130, the quarantine unit, and rooms 101 - 115, and rooms 131 - 140 the non-quarantine units on 03/05/21, 03/12/21, 03/15/21, and 03/18/21. A review of the facility Daily Staffing Assignment for the 7:00 PM - 7:30 AM nursing shift revealed one nurse was assigned to rooms 116 - 130, the quarantine unit, and rooms 101 - 115, and rooms 131 - 140 the non-quarantine units on 03/01/21, 03/02/21, 03/14/21, and 03/15/21 through 03/20/21. On 03/24/21 at 1:40 PM, the Clinical Services Director confirmed staff entering the COVID-19 quarantine unit should not leave the unit and care for other residents who were not in quarantine. However, the facility would assign staff to work both the COVID-19 quarantine unit and the non-COVID-19 units when experiencing staffing shortages. The facility document Personal Protective Equipment: Infection Prevention and Control, dated 04/13/21, documented facility staff would perform hand hygiene before removing PPE and after removing PPE. The facility Infection Prevention and Control Policies and Procedures, dated 11/27/17, documented the facility based the ICPP on CDC recommendations. The facility document Accepting and Transferring Patients/Residents, undated, documented a resident must stay in quarantine for 14 days with transmission-based precautions in place. The facility policy Staffing Nursing Department in Pandemic, dated 2020, documented the facility would work with regional personnel to develop and implement strategies to mitigate staff shortages. The CDC document Interim Infection Prevention and Control Recommendations to Prevent [DIAGNOSES REDACTED]-CoV-2 Spread in Nursing Homes, updated 03/29/21, documented an N95 or higher-level respirator, eye protection, gloves, and gown should be used with residents in COVID-19 quarantine and all equipment used should be dedicated to the facility COVID-19 unit or sanitized before being removed from the unit. The CDC document Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated 03/10/21, documented appropriate staffing is essential to providing safe resident care, the facility must understand their staffing needs, and the facility should use contingency capacity strategies to mitigate staffing shortages.

Based on interview, record review, and document review the facility failed to 1) report a choking incident, monitor the resident, and refer a resident after a choking incident for 1 of 18 sampled residents (Resident #21) and 2) ensure a resident did not experience a fall for 1 unsampled resident (Resident #11). Findings include: An Immediate Jeopardy occurred on 03/21/21 and the facility was notified on 03/30/21 at 1:05 PM, due to a resident choked and required the [MEDICATION NAME] maneuver. The Physician, Speech Therapist, and the Administrator were unaware of the occurrence. The potential adverse outcome was related to the potential to choke again, leading to hypoxic injury or death. The Immediate Jeopardy was abated on 03/31/21 at 7:00 AM. Resident #21 Resident #21 was admitted to the facility 5/09/19 with early onset cerebellar ataxia, [MEDICAL CONDITIONS], dysphagia, and other diagnoses. A Progress Note dated 03/21/21 at 5:45 PM, documented by a Licensed Nurse, indicated a Certified Nursing Assistant (CNA) reported Resident #21 choked on dinner and the [MEDICATION NAME] maneuver was performed with four thrusts. A Physicians Order Report dated 02/28/21-03/30/21 documented a physician's orders [REDACTED].#21, documented: In dining room for all meals. 1:1 feeding assistance. Safe swallow strategies include: Cut up food to facilitate small bites. Reduced rate of intake. Alternate bites/sips to facilitate oral clearance. Verbal cue for single sips by straw. Check for clear oral cavity after meal. Resident #21's physician's orders [REDACTED]. Special Instructions: thin liquids, can have salad. The Care Plan for Resident #21 dated 5/19/19, last revised 01/21/21, documented the resident required a mechanically altered and therapeutic diet due to [MEDICAL CONDITION] with ataxia/functional [MEDICAL CONDITION] and inability to feed self and the resident will have feeding assistance for all meals. On 03/30/21 at 10:49 AM, the Speech Language Pathologist (SLP) verbalized they were not made aware Resident #21 had a choking incident and required the [MEDICATION NAME] maneuver intervention. The SLP explained Resident #21 was not their patient. The SLP verbalized a referral was not made to speech therapy for Resident #21 after the choking incident. The SLP explained when a resident has choked or has difficulty eating or coughs during feeding, a referral was to be made to the SLP for a swallow evaluation. The SLP explained the referral was usually made verbally or via a handwritten note next to their computer. The referral was usually received from the Head Nurse. On 03/30/21 at 11:16 AM, the Administrator verbalized the Administrator was not aware Resident #21 received the [MEDICATION NAME] maneuver on 3/21/21 and would need to contact the nurse on shift to find out more information. The Administrator explained the facility response to a choking incident with a resident was for the lead nurse to monitor the resident and notify the provider of the choking incident. Speech Therapy may be involved if indicated. The Inter-Disciplinary Team (IDT) would be notified to discuss the resident. The Administrator verbalized they were not aware if the IDT had been informed of Resident #21 choking. The Administrator confirmed the Administrator was part of the IDT. On 03/30/21 at 11:20 AM, CNA#1 verbalized they were familiar with Resident #21 and had assisted with feeding the resident. The CNA explained Resident #21 had swallowing issues and can sometimes have gasping and jerking spells. The CNA explained when Resident #21 was gasping and jerking, the resident just needed to be sat up and given a minute. Resident #21 would gasp for air and then was eventually able to swallow. The CNA verbalized the resident was not choking in these instances, the food or drink goes down the wrong pipe sometimes. The CNA verbalized the CNA would notify the nurse if they were actually concerned Resident #21 was choking. The CNA verbalized they were not aware Resident #21 had received the [MEDICATION NAME] maneuver. On 03/30/21 at 11:24 AM, CNA#2 verbalized they were familiar with Resident #21 and had assisted with feeding the resident. The CNA explained Resident #21 choked a little sometimes when the CNA fed the resident. The CNA explained when the resident choked, the CNA raised Resident #21's arm and instructed the resident to cough. Resident #21 had a hard time drinking water. The CNA confirmed they were not aware Resident #21 had received the [MEDICATION NAME] maneuver. On 03/30/21 at 11:27 AM, CNA#3 verbalized they were familiar with Resident #21 and had assisted with feeding the resident. The CNA verbalized they were not aware Resident #21 had received the [MEDICATION NAME] maneuver. On 03/30/21 at 11:35 AM, a Licensed Practical Nurse (LPN) verbalized they were familiar with Resident #21 and has assisted with feeding the resident. The LPN was not aware Resident #21 had choked and required the [MEDICATION NAME] maneuver. The LPN verbalized the LPN would become aware of the choking at shift change and would see it in the resident's progress notes. The LPN explained if notified the resident had a choking incident, the LPN would take extra precautions with feeding. On 03/30/21 at 11:56 AM, the Administrator explained the progress note documented on 03/21/21 by the Registered Nurse (RN) and the CNA who had fed the resident during the incident were no longer employed with the facility. The Administrator verbalized the Administrator could not tell who performed the [MEDICATION NAME] maneuver per the progress note. On 03/30/21 at 1:10 PM, the Administrator verbalized the Administrator was able to contact the former employees via telephone regarding the choking incident with Resident #21. The Administrator relayed the CNA was feeding Resident #21 when the resident began to choke. The CNA called the RN to assess Resident #21. The RN performed the [MEDICATION NAME] on Resident #21. The RN attempted to contact Resident #21's physician, however the RN did not receive a return call prior to the end of shift. The facility policy titled, Rehabilitation Services Policies and Procedures - Screening, Rehabilitation, dated 3/1/2019 revealed the Speech Language Pathologist (SLP) will screen all residents upon admission for self feeding and swallowing difficulty. Resident #11 Resident #11 was admitted to the facility on [DATE], discharged on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 09/06/20 the Facility Reported Incident (FRI) #NV 944 documented Resident #11 was assisted to the bathroom by a Certified Nursing Assistant (CNA). The CNA left the bathroom and was making the resident's bed. The CNA returned to the bathroom and found Resident #11 on the floor. Resident #11's baseline care plan lacked documented evidence of the residents' fall risk or interventions to prevent falls. Resident #11's care plan updated on 09/10/20, documented the resident was a high fall risk, the resident would remain free from injury, and be placed in a fall prevention program. Resident #11's History and Physical, dated 09/06/20, documented the resident presented to the hospital with hip pain after a fall. The resident reported to the physician they went to the bathroom alone and while attempting to get their pants down, lost their balance and fell backward. Resident #11 verbalized they could not get up without experiencing pain and had to call staff for help. On 03/24/21 at 7:27 AM, a CNA verbalized the facility expectation was a staff member would stay in the room with a resident while they were in the bathroom. The CNA explained the CNA would often be called out of one resident room to take care of other residents due to not having enough CNAs to answer call lights or assist the residents. The facility Nursing Policies and Procedures: Fall Management, dated 03/29/19, documented the facility would identify each resident at risk for falls and would address all risk factors for falls.

Based on interview and record review the facility failed to provide prescribed pain medications for a resident in severe pain requiring the resident to be readmitted to the hospital for pain management for 1 of 6 residents (Resident #6). Findings include: An Immediate Jeopardy was identified on [DATE] at 4:00 PM, due to a resident's narcotic pain medication not being provided by the facility requiring the resident to be readmitted to the hospital for management of severe pain. The Immediate Jeopardy was abated at 5:32 PM on [DATE]. Resident #6 Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Oxycodone 15 mg tablet every four hours as needed for severe pain. The medication was documented as having been administered seven times from [DATE] to [DATE] for pain ranging from six to eight out of 10 on a numeric pain scale. The medication was last administered on [DATE] at 2:22 AM. A physician order, dated [DATE] at 1:20 PM, documented the physician had ordered a muscle relaxer for the resident's muscle spasms but did not include a refill for the resident's narcotic pain medication. A nursing progress note, dated [DATE] at 3:24 PM, documented the resident's Oxycodone had not been refilled and the resident had been in severe pain since the start of the shift at 7:00 AM. The resident had been given Tylenol and a muscle relaxer but had verbalized the medications had not helped. The resident's daughter contacted the facility to address concerns regarding the resident's severe pain. The facility informed the resident's daughter the facility did not have the medication for the resident. A nursing progress note, dated [DATE] at 4:28 PM, documented the resident was sent to the hospital for severe pain in the resident's lower back at the resident's surgical site. On [DATE] at 10:15 AM , a Licensed Practical Nurse verbalized the correct process to follow when a resident's medications were unavailable would be for the nurse to contact the pharmacy to ascertain if the medication was on route, if the medication was not scheduled for delivery the nurse would obtain an order from the physician if necessary and contact the pharmacy for an emergency authorization code to obtain the medication from the Omnicell. On [DATE] at 11:48 AM, the Director of Nursing (DON) verbalized Resident #6 had been sent back to the hospital for management of severe pain due to the facility being unable to provide the prescribed narcotic pain medication for the resident. The DON verbalized the resident had been admitted from the hospital with a 72 hour prescription and the prescription had expired. The DON verbalized the resident's physician was responsible for reordering the medication and had forgotten to write a prescription when the physician saw the resident earlier in the day. The DON verbalized the on-call providers were unable to fax orders. The DON confirmed the Tylenol provided to the resident was not an equitable substitute for the narcotic pain medication the resident had been taking for severe pain. The Care Plan for Resident #6 documented the resident's immediate health and safety needs included pain management and all staff were responsible for monitoring the resident's pain and treating the pain per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy titled Pain Management, revised [DATE], documented residents would receive treatment and care in accordance with professional standards of practice and the comprehensive care plan related to pain management. Ongoing evaluations of residents for pain would be completed by staff. Based on the evaluation, the interdisciplinary team, physician and the resident would revise interventions as necessary to prevent or manage the resident's pain. On [DATE] at 12:05 PM, the Administrator and the Human Resource (HR) staff person confirmed the list of employees provided to the survey team for review did not contain the names of the staffing agency's employees working in the facility. The Administrator related the (staffing agency) staff qualifications and documentation was given to the facility via email. The Administrator was unable to provide documented evidence the staff from the staffing agency had any orientation to the processes and procedures of the facility regarding use of the Omnicell and other medication related processes for obtaining needed medications when unavailable in the medication cart. The orientation process for the staffing agency involved the employee completing a stack of documentation approximately 2 inches thick, over a 60 - 90 day period while employed. The documentation provided by the facility for the employees working the weekend of the incident contained no evidence of orientation/training to the Omnicell process for accessing needed medications and the process required to get the access code from the pharmacy. The Administrator provided a list of medications stocked in the Omnicell machine for access should the medication carts not have the appropriate medications for the residents. The narcotic needed by Resident #6 was on the list of medications.

Based on observation and interview the facility failed to provide dining supervision to the residents eating meals in 2 of 2 dining rooms. Findings include: Resident #45 Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #54 Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #73 Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/27/20 at 12:50 PM, residents in the first floor dining room were consuming meals without facility staff present to assist the residents or in the case of an emergency. On 01/27/20 at 12:55 PM, Resident #45, Resident #54 and Resident #73 were observed dining in the first floor dining room. Resident #45, #54, and #73 were on the facility's list dated 01/28/20 as residents who had an in house [DIAGNOSES REDACTED]. On 01/27/20 at 1:00 PM, the Case Manager acknowledged there was no staff supervision on the first floor dining room. The Case Manager verbalized it was the facility policy the staff would check on the residents in the dining room when they were passing by the dining room. The Case Manager verbalized it was not adequate for staff to not be present on the first floor dining room during meal times. The Case Manager acknowledged a resident could choke on food and there would not be staff to respond timely. The Case Manager verbalized she did not feel the facility had enough staff to provide proper supervision in the first floor dining room. The Case Manager verbalized the residents who had food provided on Red colored trays were residents who needed set-up and feeding assistance. On 01/27/20 at 12:34 PM, lunch trays were delivered to the second floor dining room and a tray was placed in front of a resident. The tray card for the resident's meal documented Assistance: Red Tray, this documentation was highlighted in red. The Certified Nursing Assistant (CNA) placed the meal in front of the resident and walked away to begin assisting other residents. On 01/27/20 at 12:47 PM, a CNA verbalized a resident with a red tray needed assistance to be set up and should have been monitored while they ate. On 01/27/20 at 1:00 PM, the Licensed Practical Nurse (LPN) and CNA in the second floor dining room left the dining room to return two residents to their rooms. Six residents, including the resident with the red tray card, remained in the dining room with no staff present. On 01/27/20 at 1:04 PM, the LPN returned to the dining room. On 01/27/20 at 1:05 PM, the LPN verbalized the residents had been left alone without supervision. On 01/27/20 at 4:53 PM, the Registered Dietitian (RD) verbalized a minimum of one staff member should have been supervising residents in the dining room. The RD verbalized the staff should have been present to prevent resident altercations from behavior disturbances, prevent choking, and monitor residents' trays for potential allergens. The RD verbalized a resident with a red tray ticket should never have been left unsupervised during a meal. On 01/27/20 at 4:52 PM, the Interim Director Of Nursing (IDON) verbalized the IDON expected one staff member in the dining room at all times due to increased postential for choking with high risk residents. On 01/27/20 at 4:53 PM, the RD verbalized a CNA or Resident Aide (RA) should be in the dining room through out the meal. The CNA or RA should not leave the dining room unless there was another person to take over. The RD verbalized having a staff member present was very important for resident safety due to incidents of behavior disturbances, choking, aspiration, improper diet delivery, improper texture of meals and food allergies [REDACTED]. The facility policy titled, Nutrition-Meal Service in the Dining Room, revision 07/01/16 documented the nursing staff/designee will supervise and take measures to promote meal satisfaction for those residents who choose to eat in the dining room.

Based on observation, interview, clinical record review and document review, the facility served dietary allergans to 2 of 2 unsampled residents (Resident #53 and #1). Findings include: Resident #53 Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record for Resident #53 documented the resident had allergies [REDACTED]. The meal ticket for the lunch tray on 01/26/20, for Resident #53 documented the resident had allergies [REDACTED]. The resident was served fish sticks with the lunch tray. The meal ticket for the lunch tray on 01/27/20, for Resident #53 documented the resident had allergies [REDACTED]. The resident was served a strawberry/banana cup. On 01/27/20 at 5:29 PM, Resident #53 verbalized the resident had received foods the resident was allergic to with several meals. The resident verbalized the resident had recieved strawberries for lunch and the resident would break out in hives and have difficulty breathing if the resident ate strawberries. The resident verbalized the resident received fish sticks for lunch on 01/26/20. The resident verbalized the resident would experience anaphylactic shock if the resident ate fish or shellfish. Resident #53 verbalized the resident also had an allergy to [MEDICATION NAME] and this allergy used to be documented on the resident's meal tickets but had been missing from the allergies [REDACTED]. The resident verbalized the resident would experience inflammation and body aches if the resident ate anything containing [MEDICATION NAME]. On 01/27/20 at 5:59 PM, the Registered Dietitian (RD) verbalized Resident #53 had been receiving strawberries with the residents meal trays and the resident did recieve fish sticks for lunch on 01/26/20. The RD verbalized the practice in the kitchen was for a Dietary Aide to call out the diet order to the Cook during trayline but did not call out the specific foods or allergies [REDACTED]. On 01/27/20 at 6:25 PM, the RD verbalized the meal tickets for Resident #53 had listed [MEDICATION NAME] as an allergy up until a week ago, the RD verbalized the RD did not know why the allergy was no longer listed on the resident's meal tickets. On 01/27/20 at 6:30 PM, a Cook verbalized the kitchen was understaffed and the low staffing was causing many things to be overlooked and missed when preparing residents' meals. On 01/27/20 at 6:33 PM, a Cook verbalized there were no special precautions taken with ensuring utensils in the kitchen did not contact foods a resident was allergic to and there was no procedure in place to ensure a resident's food was prepared in an area free of potentially life threatening allergens. On 01/27/20 at 2:32 PM, the RD verbalized Resident #53 had allergies [REDACTED]. Resident #53 had been served fish sticks, strawberries, and [MEDICATION NAME] daily, over the last four days. The RD confirmed the allergies [REDACTED]. The RD expplained the RD had discussed the errors with the Dietary Manager, however, the errors continued to occur. The meal ticket for the dinner tray on 01/29/20, for Resident #53 documented the resident had allergies [REDACTED]. The resident was served a strawberry/banana cup. Resident #1 Resident #1 was admitted to the facility on [DATE] with weakness and debility. On 01/27/20 at 2:34 PM, the RD verbalized Resident #1 had an allergy to citrus. Resident #1 had received orange juice daily. The RD confirmed citrus listed as an allergy in the dietary system and on the resident's meal cards. On 01/27/20 at 5:38 PM, Resident #1 verbalized the resident received orange juice on the breakfast tray daily. On 01/27/20 at 5:33 PM, the Registered Nurse (RN) verbalized the RN relied on the RD for enforcing food allergies [REDACTED]. The RN confirmed a citrus allergy was listed on Resident #1's clinical chart. On 01/27/20 at 6:25 PM, the Cook verbalized there were no areas in the kitchen set aside as allergy-free areas to prepare meals for residents who had food allergies [REDACTED]. The Cook confirmed allergies [REDACTED]. On 01/27/20 at 6:37 PM, the Dietary Aide (DA) verbalized the DA used meal tickets for preparing resident trays. The DA verbalized the tickets were used to assure proper meal textures served, and allergens removed from the plates before being sent to the residents. The facility policy titled Food allergies [REDACTED]. The Nutrition Director was responsible for training staff on how to avoid any inappropriate foods being served to residents and maintaining a list of menu items that may contain allergens for reference.

Based on record review and interview, the facility failed to provide necessary services to 1 of 18 residents resulting in hospitalization (Resident #15). Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the hospital discharge summary revealed Resident #15 had received hemo-[MEDICAL TREATMENT] three times per week during her hospitalization , and before hospitalization had been receiving [MEDICAL TREATMENT] twice per week on an out patient basis. The orders written on the discharge summary did not mention [MEDICAL TREATMENT]. Discharge medications were listed as [MEDICATION NAME] 300 mgs three times per day, [MEDICATION NAME] 5 mgs daily, [MEDICATION NAME] 5/325 every 4 hours as needed for pain, Aspirin 81 mgs daily,[MEDICATION NAME] mgs twice a day for 3 days, [MEDICATION NAME] 6.25 mgs per day. Diet was listed as renal diet. The admitting orders transcribed by the admitting nurse (Employee #13) listed [MEDICAL CONDITION] as a diagnosis, but there was no order for hemo-[MEDICAL TREATMENT]. The orders had been signed by the physician on 2/3/11. A review of the nursing admit note on 2/1/11 revealed "pt. has a [MEDICAL TREATMENT] port to her upper chest, with no signs or symptoms of infection seen." A review of the patient history and physical completed by the admitting physician at the facility on 2/1/11 indicated an [AGE] year old with [MEDICAL CONDITIONS] on hemo-[MEDICAL TREATMENT] Monday and Friday at ([MEDICAL TREATMENT] center) with lower back pain. There was no documented order for the [MEDICAL TREATMENT]. A telephone interview with the admitting nurse on 3/23/11 revealed the nurse did not recall if he had any other paperwork from the hospital other than the discharge summary to complete the admission. The nurse indicated it was sometimes difficult to obtain all of the necessary information from the hospital prior to an admission. The nurse indicated the hospital normally had made arrangements for [MEDICAL TREATMENT] treatments prior to facility admission, and the nurse assumed it had been done. A review of the physical therapy assessment done on 2/2/11 indicated [MEDICAL CONDITION] with hemo-[MEDICAL TREATMENT] Monday and Friday. The occupational therapy evaluation done on 2/2/11 indicated [MEDICAL CONDITION] with hemo-[MEDICAL TREATMENT]. A review of the nursing progress notes revealed Resident #15 had an episode of emesis on 2/2/11 post narcotic therapy. The plan was to ensure the resident ate before narcotic administration. On 2/6/11 a progress note indicated the resident refused to get out of bed and the family and MD were notified. The family requested the pain medication be held due to the resident's grogginess. The pain medication was withheld on the shift. On 2/7/11 a progress note indicated Resident #15 was up in a wheelchair and intermittently confused. All vitals were taken. A complete metabolic panel was ordered as well as a complete blood count and a urinalysis. According to the complainant, on 2/7/11 the facility staff was questioned about the resident's [MEDICAL TREATMENT] and staff was unaware of it being done. The family indicated they requested an ambulance be called. Resident #15 was transported by ambulance to the hospital ER. The transfer form indicated the resident had an altered level of consciousness and had not received [MEDICAL TREATMENT] 1 time that week. Resident was very lethargic. The laboratory data collected at the facility indicated Resident #15 had a potassium level of 6.3 (reference range 3.5-5.3), a blood urea nitrogen of 84 (reference range 7-25), and a creatinine of 9.28 (reference range 0.63-1.22). The urine was positive for bacteria. On admission to the hospital on [DATE] the [DIAGNOSES REDACTED]. The resident was dialyzed emergently and remained in the hospital for three days and discharged to another skilled nursing facility for rehabilitation. A review of the discharge summary from the facility on 2/7/11 indicated Resident #15 began to develop somnolence on 2/6/11 due to [MEDICATION NAME]. It was discovered that the resident's hemo-[MEDICAL TREATMENT] had not been continued on Friday 2/6/11 as supposed during her one week stay, and she was transferred to the hospital for re-initiation. The facility failed to identify the need for and provide the [MEDICAL TREATMENT] to maintain the highest level of functioning for Resident #15.