Every finding on record at Woodlyn Heights Healthcare Center

Based on observation, interview and document review, the facility failed to provide adequate nursing staff to meet assessed resident needs for 1 of 1 residents (R29) reviewed for restorative nursing; 1 of 1 residents (R43) reviewed for activities of daily living (ADLs); and 12 residents (R3, R14, R18, R29, R82, R33, R39, R5, R44, R57, R67, R74) and 3 staff members (NA-F, NA-E, NA-H) who voiced concerns with a lack of staffing. The lack of sufficient nursing staffing had the potential to affect all 46 residents in the facility. Findings include:RESTORATIVE PROGRAM:R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no rejection of care behaviors during the look-back period (LBP). The MDS indicated R29 had impaired ROM on both lower extremities. The MDS indicated R29 required maximum assistance with bed mobility and lower body dressing. R29's Therapy Referral for Maintenance Program dated 10/24/24, indicated that physical therapy recommended staff assist R29 with passive ROM to bilateral hips, knees, and ankles daily. R29's care plan dated 8/10/25, indicated R29 was to receive passive ROM to the bilateral hips, knees, and ankles daily. R29's task list dated 11/30/25 to 12/28/25, indicated that staff were to complete passive ROM on R29's bilateral hips, knees, and ankles daily. The report indicated the task had been refused five times, completed 17 times, charted as not applicable five times (with no further entry indicating it was completed or refused that day), and had no entry on 12/7/25, 12/19/25, and 12/20/25. During an interview on 12/29/25 at 3:37 p.m., R29 stated that staff were supposed to complete ROM with her daily, but never do it. During an interview on 12/31/25 at 8:46 a.m., nursing assistant (NA)-D stated she had worked with R29 in the past, and she would rarely refuse to complete ROM when she had time to complete it with R29. NA-D stated she often didn't feel like she had enough time to complete everything she had to do during her shift, so she often did not complete ROM when she worked with her as a result. During an interview on 12/31/25 at 9:18 a.m. with NA-B and NA-C, NA-B stated it was often hard to complete everything they needed to do during their shift. NA-B stated that if they had time to do ROM, they would, but it often didn't get done. NA-B stated that if they did complete ROM with R29, they would chart it as completed on her tasks list. During an interview on 12/31/25 at 9:10 a.m., the director of nursing (DON) stated that if a resident needed ROM, it would be added to tasks where staff could document if it was completed or not. The DON stated that after reviewing R29's medical record, staff should be completing ROM with her daily. The DON stated the NAs had notified her that they were having a hard time finding enough time to complete ROM, so the facility was looking to get a restorative aide to assist, but it had not yet happened. ADLS NOT COMPLETED:R43R43's admission Minimum Data Set (MDS), dated [DATE], identified R43 had intact cognition and required full assistance with personal hygiene cares. R43 had diagnoses of respiratory failure, muscle weakness, malignant neoplasm of left breast and chronic pain.R43's care plan, dated 11/14/25, identified R43 had an ADL self-care deficient with grooming, and required assistance of one by staff.R43's weekly body audit, dated 12/24/25, identified R43 finger and toenails were not cleaned or trimmed.During observation and interview on 12/29/25 at 3:42 p.m., R43 stated her nails were long and dirty. She stated requested an unknown staff member to have them cleaned and trimmed, but it was not performed. R43's fingernails were observed, nails were approximately 1/4 inch long, with brown substance under nails. Her toenails were approximately 1/4 inch long and no sign of discolored substance under them.During observation and interview on 12/30/25 at 11:24 a.m., R43 stated that nails were not cut or cleaned by staff. However, family member (FM)-G trimmed right thumb and pointer finger.During interview on 12/30/25 at 2:54 p.m., nursing assistant (NA)-I stated R43's nails were not clean or trimmed on both hands, except for pointer finger and thumb on right hand. NA-I stated nail care was usually done on bath/shower days.During interview with director of nursing (DON)-B stated the expectation for nail care was to be completed on bath/shower days and as needed. If a resident asked to have nails cleaned and trimmed it was expected for staff to perform that function. Nail care was important for hygiene and overall skin integrity.R44R44's quarterly Minimum Data Set (MDS) assessment, dated 11/18/15, identified R44 had intact cognition with no hallucinations or delusions, behaviors or rejection of care. MDS indicated R44 needed moderated assisted for personal hygiene which included shaving.During an interview on 12/29/25 at 1:46 p.m., R44 stated that he does not like to have any facial hair as it becomes very itchy. R44 stated he has told staff this previously. R44 stated the staff only shave him on showers days but his preference would be to be shaved daily with morning cares. R44 was observed to have approximately a quarter in beard and mustache.During an interview on 12/30/25 at 11:21 a.m., R44 was observed in his room and observed to continue to have unshaven facial hair. Two nursing assistants came in after surveyor entered to see why R44's call light was on, so surveyor ended the interview to they could assist him.R44's care plan, printed 12/31/25, identified R9 has an ADL self-care performance deficient related to limited mobility and musculoskeletal impairment and requires assistance with dressing/undressing and requires 1 staff assistance to use toilet.R44's care plan lacked identification of level of assistance R44 needs for personal hygiene such as shaving or showers.R44's Tub/Shower Transfer log, printed 12/31/25, indicated R44 last shower was 12/23/25 and required maximal assistance.R44's progress notes, dated 12/1/25 to 12/31/25, were reviewed. The progress notes lacked evidence that R44 was offered and refused to be shaved. During an interview on 12/30/25 at 1:55 p.m., nursing assistant (NA)-E stated they listen to what residents want when completing morning cares. NA-E verified they are familiar with R44 and completed morning cares with R44. NA-E stated R44 needs assist of 1 with cares and assist of 2 with transfers. NA-E stated they have not shaved R44 facial hair today, stating sometimes I am not able to get to the small stuff. I can't get to it all. NA-E verified that had facial hair that could be shaved.During an interview on 12/30/25 at 2:04 p.m., registered nurse (RN)-B stated morning cares should include washing a resident's face, underarms, peri-area, changing clothes, oral cares and shaving. RN-B stated typically, shaving is done on showers done but we can shave a resident anytime. RN-B stated any nursing staff should be asking a resident preference every step of the way when getting them ready in the morning or at night.During an interview on 12/31/25 at 10:27 a.m., R44 was observed to continue to have unshaven facial hair. R44 stated, it's still growing, and getting real itchy. During an interview on 12/31/25 at 10:37 a.m., NA-F stated shaving should be offered with morning cares. NA-F stated it appears that R44 hasn't been shaved for about 5-7 days based on the length of the facial hair. NA-F verified R44 has a razor in his bathroom. During an interview on 12/31/25 at 10:47 a.m., NA-F stated morning cares should include the following: washing face, hands, underarms, peri-area, combing hair, shaving, brushing teeth, changing clothes. NA-F stated they assisted R44 today with morning cares. NA-F stated they did not shave R44 or offer to shave R44 as it takes him a long time to brush his teeth and I have to multitask. NA-F stated they would shave R44's facial hair and stated it should have been done with morning cares. During an interview on 12/31/25 at 11:36 a.m., director of nursing (DON) stated the expectation would be a resident's facial would be done with bathing and as needed when staff notice that it is growing per resident's preference. RESIDENT CONCERNS WITH LACK OF STAFFING:R3's admission Minimum Data Set (MDS) assessment dated [DATE], identified R3 had intact cognition. During an interview on 12/29/25 at 2:10 p.m., R3 stated that some days they only have one person in the evening, and they take a long time to answer the call light. R3 stated he will wait 45 minutes to an hour.R3's Device Activity Report, from 12/1/25 to 12/30/25, identified the following information:-longest response time was 124 minutes and 11 seconds (2 hours 4 minutes)-40 call lights response times over 15 minutesR29's quarterly MDS assessment dated [DATE], identified R29 had intact cognition. During an interview on 12/29/25 at 3:29 p.m., R29 stated they are always short and things they don't change her at night due to staffing.R29's Device Activity Report, from 12/1/25 to 12/30/25, identified the following information:-longest response time was 119 minutes and 58 seconds-95 call lights response times over 15 minutesR82's tracking MDS indicated R82 was admitted to the facility on [DATE]. admission MDS not completed at this time. During an interview on 12/29/25 at 1:23 pm., R82 stated sometimes I must wait and wait, and I dribble. R82 stated, I used the urinal but sometimes I get wet.A Device Activity Report for the month of December was requested and not received.R33's quarterly MDS assessment dated [DATE], identified R33 had intact cognition. During an interview on 12/29/25 at 2:54 p.m., R33 stated a couple of days ago it took one and half hours when he put the call light on for staff to come assist him to use the bathroom. R33 stated about 3 months ago it took 3 hours for staff to come and assist.R33's Device Activity Report, from 12/1/25 to 12/30/25, identified the following information:-longest response time was 145 minutes and 21 seconds (2 hours 25 minutes)-136 call lights response times over 15 minutesR39's significant change of condition MDS assessment dated [DATE], identified R39 had intact cognition. During an interview on 12/29/25 at 4:49 p.m., R39 stated she will wait upwards 3 hours after she pushes her call light for staff assistance. R39 stated she needs staff assistance with any transfers as she uses a lift to transfer.R39's Device Activity Report, from 12/1/25 to 12/30/25, identified the following information:-longest response time was 101 minutes and 20 seconds (1 hour and 41 minutes)-43 call lights response times over 15 minutesR5's quarterly MDS assessment dated [DATE], identified R5 had intact cognition. During an interview on 12/29/25 at 4:41 p.m., R5 stated when she pushes the call light it takes about 45 minutes for assistance. R5 stated she needs assistance with all transfers.R5's Device Activity Report, from 12/1/25 to 12/30/25, identified the following information:-longest response time was 128 minutes and 11 seconds (2 hours 8 minutes)-82 call lights response times over 15 minutesR44's quarterly MDS assessment dated [DATE], identified R44 had intact cognition. During an interview on 12/29/25 at 1:33 p.m., R44 stated he needs staff assistance for many things such as transfers, going to the bathroom, sometimes grabbing items. R44 stated that he will push the call light and he will be waiting 30 minutes at least.A Device Activity Report for the month of December was requested and not received.R57's annual MDS assessment dated [DATE], identified R57 had moderately impaired cognition. During an interview on 12/29/25 at 12:37 p.m., R57 stated it will sometimes take over an hour for staff to respond when you put the call light. R57 stated she needs assistance to use the bathroom, for medications, and to transfer from one chair to another.R57's Device Activity Report, from 12/1/25 to 12/30/25, identified the following information:-longest response time was 99 minutes and 13 seconds (1 hour 39 minutes)-28 call lights response times over 15 minutesR67's admission MDS assessment dated [DATE], identified R67 had moderately impaired cognition. During an interview on 12/29/25 at 4:09 p.m., R67 stated sometimes he waits a long time to get his call light answered.R67's Device Activity Report, from 12/4/25 to 12/30/25, identified the following information:-longest response time was 24 minutes and 6 seconds-8 call lights response times over 15 minutesR37's quarterly MDS dated [DATE], identified R37 had intact cognition. During an observation on 12/31/25 at 8:35 a.m., the call light screen was observed that R37's call light had been on since 7:56 a.m. (39 minutes). At 8:38 a.m., R37 was observed lying in bed. R37 stated she was waiting for staff to come and assist her. R37 stated she was waiting for some ice water and thinks she might need to be changed as her underwear may be wet. At 8:43 a.m., a nursing assistant was observed to go in R37's to see what R37 needed (47 minutes after call light had been put on for assistance). Nursing assistant was observed to bring R37 water and ask her if she wanted to get up which R37 declined.During resident council interview on 12/31/25 at 12:30 p.m., R14, R18 and R74 all stated when they turn their call lights on for help, staff will come into their room and turn off the call light without asking or addressing their needs. R74 stated her brief is soaked with urine by morning because staff are not coming in to help her because they are always short staffed. R74 stated staff are so busy that she often takes herself to the bathroom, even though she is not supposed to. R81 added that she often waits hours overnight for her brief to be changed and it makes her feel like I [R81] want to pack up leave. STAFF CONCERNS WITH LACK OF STAFFING:During an interview on 12/30/25 at 11:42 a.m., nursing assistant (NA)-F stated that there was not enough staff to complete the work. NA-F stated one aid per hallway was not enough as that was 12-14 residents per aid. NA-F stated they are not able to complete showers or range of motion for resident. NA-F stated they are not able to meet residents needs and it is too much.During an interview on 12/30/25 at 1:55 p.m., NA-E stated the workload was not manageable. NA-E stated the first two hours of their shift, they are doing laundry as the residents' beds are full of piss and BM. NA-E stated the nightshift put sheets over the soiled sheets to cover it up. NA-E stated they have reported this to the administrator, director of nursing and staffing. NA-E stated residents will wait for staff to help them and call lights will be on hours. NA-E stated they are not able to get residents cares done such as shaving due to the workload adding I can't get to it all, and I don't get breaks. During an interview on 12/31/25 at 8:46 a.m., NA-H stated nursing assistants try to get to the call lights as soon as possible. NA-H stated, we don't have enough time to do showers, range of motion or walking and shaving is hard to get done. NA-H stated there wasn't a specific amount time that call lights are to be answered, just the first light on is supposed to be the first light answered. NA-H stated they feel the residents' needs are affected by not having enough staff as things can't always be done.During an interview on 12/31/25 at 11:46 a.m., director of nursing (DON) stated staffing is based on census and resident needs. DON stated the expectation was to answer call lights as soon as you are able and would like to keep it under the 15-minute mark. DON reviewed call light log and stated the longer call lights are not acceptable. DON stated she had been told by staff that they are not able to complete their work and care for the residents.During an interview on 12/31/25 at 11:51 a.m., assistant director of nursing (ADON) stated that at times staff forget to turn the call lights off after helping a resident. ADON stated this happens on occasion. ADON acknowledged that they had heard staff were not able to complete their work.During an interview on 12/31/25 at 12:03 p.m., executive director (ED) stated staff levels have typically been at or above recommended HPPD (hour per patient day). ED stated she had not been told specifically that staff are not able to complete their work. ED stated she had worked with staff on completing documentation which had increased. ED stated the expectation was all staff answer call lights, to be answered in the order they are pressed and has provided education to residents and staff to keep the call lights on the walls as when they are removed and carried around the facility this can lead to difficulty finding the resident when the call light was pressed and longer call light response times.A facility policy titled Nursing Services and Sufficient Staff, updated 2/23/25, indicated The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: Except when waived, licensed nurses; and Other nursing personnel, including but not limited to nurse aides.

Based on observation, interview, and document review, the facility failed to perform adequate testing, per the manufacturer's instructions, to ensure proper sanitization of dishware used for meal preparation and meal service when using a low-temperature dishwashing machine. This had the potential to affect all 65 residents residing in the facility. Findings include: The National Sanitation Foundation (NSF) Data Plate for dishwasher Model ADC-44 dated 12/1/11, indicated that if the dishwasher was utilizing chemical sanitizer, the sanitizer required was 50 parts per million (PPM) of available Chlorine.An undated Ecolab Chlorine Test Paper (ECTP) instruction card, indicated that to test for PPM of free available chlorine, the strip should be dipped into the solution and immediately compared to the color chart. The card did not include an expiration date.The Hydrion Papers QT-10 (PPQT-10) instruction card dated 8/1/14, indicated they were used for the testing of n-alkyl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride. The card included an expiration date of 8/1/14. The card indicated the paper should be dipped in quat solution for 10 seconds, and the color should be compared at once. The instructions indicated that the testing solution should be at 75 degrees, should have a neutral pH, and the manufacturer's instructions for dilution should be followed carefully. The Hydrion Chlorine (HC) instruction card dated 2/1/26, indicated the paper was to be dipped and removed quickly. The user was then to immediately blot with a paper towel and compare to the color chart at once. The card had an expiration date of 2/1/26. During an observation and interview on 12/31/25 at 9:57 a.m., dietary aide (DA)-A was observed filling a hard plastic rack with serving utensils, taking an ECTP test paper, and placing it in the rack. DA-A was then observed placing the rack in the Model ADC-44 chemical sanitizing single rack dishwashing machine. The rack was observed to exit the other side of the machine, but DA-A was unable to locate the test paper. DA-A was then observed to take the rack back to the other side of the machine, place another ECTP test paper on the rack, and run it through the machine again. DA-A was able to locate the test paper, but on observation, the test strip was clear. DA-A stated she always used these strips but had not tested the machine yet today. DA-A confirmed her usual method for testing the chemical level of the sanitizer was sending it through the machine as observed above. DA-A confirmed she had completed most of the dishwashing from the previous meal already. DA-A stated she was not sure if the strips were defective and did not know if they had an expiration date. The dietary manager (DM) then provided the HC test papers. The DM placed a strip on the hard plastic rack and stated this was how they always tested the chemical level of the dishwasher, so she was unsure why they kept losing the strips. The DM then put a plate on a rack through the machine. The DM then took an HC test paper and left the paper in the water that had accumulated on the plate for about 30 seconds. The test paper was read at about 25 PPM. The DM stated she wasn't sure why these strips weren't working and confirmed that the HC test paper had not read at an acceptable level of sanitization. The DM was observed to come back with PPQT-10 test papers and was not observed to put the paper in the water but stated she had placed the test paper in the water for a few seconds. The DM stated the result was 300 to 400 PPM. The DM stated that this was an acceptable result and confirmed that no further testing was needed. The DM stated she would expect the PPM to reach at least 100, and either the PPQT-10 or the HC test papers were acceptable to use for the dishwasher. The facility Cleaning Dishes/Dish Machine policy dated 2021, indicated that proper chemical concentrations and machine function should be verified before machine use. The policy indicated that the sanitization level should reach 50 PPM.

During observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on a mobile medication cart in the long-term care unit. This had the potential to affect 11 residents (R7, R10, R12, R14, R15, R20, R31, R43, R55, R56, R60) whose personal information was left unattended on a medication cart in the hallway corridor. Findings include: During continuous observation on 12/30/25 at 10:42 a.m., to 11:04 a.m., there was an unattended care sheet on top of unattended medication cart. Care sheet was titled Nurse/TMA and had personal information on 11 residents of the long-term care unit. The care sheet included, name, room number, bath days, diets, hospice provider, and information regarding dialysis, urinary catheter use, and blood sugars. During continuous observation there were seventeen (17) instances where staff, residents, and visitors walked or were wheeled past the unattended care sheet.During interview with registered nurse (RN)-B on 12/30/25 at 11:04 a.m., RN-A approached the unattended medication cart and verified the unattended care sheet was his and it should not be left unattended. RN-B stated expectation of personal information to not be exposed.During interview with director of nursing (DON) on 12/30/25 at 11:07 a.m., DON stated expectation of staff to follow HIPAA and ensure personal information is not exposed or unattended.Facility policy titled Notice of Privacy Practices/HIPAA revised September 23, 2013 identified requirement to appropriately safeguard your information.

Based on observation, interview, and document review, the facility failed to ensure resident rooms were maintained at a comfortable temperature between 71- and 81-degrees Fahrenheit for 7 of 7 residents (R64, R4, R7, R38, R27, R29, R29) reviewed who indicated their rooms were cold. In addition, the facility failed to provide a homelike dining experience by serving meals on hard plastic trays for 1 of 1 resident (R29) reviewed for dining, which had the potential to affect all residents who ate in the dining room.Findings include: Temperature R64's quarterly Minimum Data Set (MDS) dated [DATE], indicated a diagnosis of type 2 diabetes with circulatory complications with intact cognition. A progress note dated 11/28/25, indicated R64 reported their room was cold and wore a flannel shirt over another shirt and long pants. Maintenance director (MD)-H performed a laser temperature which revealed it was 70.5 degrees Fahrenheit (F). On 12/29/25 at 12:22 p.m., R64 was interviewed and stated it had been cold in their room, additionally, family brought in sweats and sweatshirts. Surveyor obtained temperature in the room on 12/29/25 it was 69.5 degrees F, however, the temperature by the window was 63.5 degrees F. R4's annual MDS on 6/3/25 indicated diagnosis of spinal stenosis and no cognitive impairment. On 12/29/25 at 12:53 p.m., R4 was interviewed and stated their room ranged from slightly cool, to cold every day. R4 was observed wearing at least two blankets, one up to his chin and over his arms. The temperature by head of bed was 66.6 degrees F. R7's admission MDS on 6/10/25 indicated diagnoses of osteomyelitis, failure to thrive and pressure ulcer of sacral region, and type 2 diabetes with intact cognition. On 12/29/25 at 1:38 p.m., R7 was interviewed and stated he was cold all the time. R7 wore a winter stocking hat and thick winter gloves on with four thick blankets up to his chin. The temperature in room by head of bed was 67.4 degrees F, however, by window temperature was 57 degrees F. R38's annual MDS on 1/14/25 indicated a diagnosis of traumatic brain injury with intact cognition. On 12/29/25 at 2:04 p.m., R38 was interviewed and stated it was cold in their room and the plastic on the windows stayed up all year. They stated they did not want to permanently move rooms, but it was cold in their room. R38 wore a winter hat, was fully dressed, wore an insulated hoodie, and had three blankets on with a fleece blanket over that. The radiator vent appeared broken and pulled apart. The temperature in room was 58 degrees F by the head of bed, however, temperature by window was 35 degrees F. R27 's admission MDS on 11/13/25 indicated a diagnosis of metabolic encephalopathy with intact cognition. On 12/29/25 at 2:30 p.m., R27 was interviewed and stated it was so cold here in my room and the whole building, and the help layer their clothes too. I close my bathroom door because there is absolutely no heat in there and when staff open this door (door to hallway) I can feel a breeze. It is too cold for me. R27 was wearing a long-sleeved shirt and sweatshirt, shawl and covered with blanket in recliner and had two blankets on the bed. The temperature in room by the head of bed was 64.4 degrees F, however, in bathroom it was 57 degrees F. R29's annual MDS on 7/22/25 indicated a diagnosis of chronic respiratory failure with intact cognition. On 12/29/25 at 3:30p.m., R29 was interviewed and stated it was cold in the room, especially at night. The temperature by the head of bed was 69.5 degrees F. R39's quarterly MDS on 9/30/25 indicated a diagnosis of cellulitis of left lower limb and alcoholic cirrhosis of the liver with intact cognition. On 12/29/25 at 4:59 p.m., R39 was interviewed and stated the room was cold, especially overnights, and they woke up freezing in the morning. The temperature by the head of bed was 69.1 degrees F. During an interview on 12/29/25 at 5:25 p.m., MD-H stated the rooms in the facility did not have thermometers or thermostats. A laser thermometer was used to test room temperatures. The building had two heat sources, one was on the roof that regulated sensors the hallways, the thermostat was set to 73 to 76 degrees, the second was the boiler. The rooms had vents above each door in some of the rooms and the vents were shut which decreased the heat's ability to enter room. MD-H stated the building was old, the windows only had a single pane of glass, if they were incorrectly shut, wind blew through them. During interview on 12/29/25 at 7:14 p.m., Executive Director stated some residents declined moving rooms, the facility offered plastic on the windows, however, the intervention did not increase the temperature to meet the required 71 to 81 degrees. During resident council meeting minutes on 12/11/25 residents stated they were cold, MD-H mentioned keep doors to rooms open because thermostat sensors were in the hallway. Also, keep windows closed, and cover windows with plastic. A facility's policy/procedure documentation regarding room temperatures, maintenance, and TELS reports for the last 6 months requested, but not received. Dining R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition and was independent with eating. During an observation on 12/30/25 at 12:12 p.m., 10 residents, including R29, were observed sitting in the main dining room. The room had multiple tables present with residents seated at each. The residents were observed to have hard-plastic trays with plates, cutlery, and drinks on top of them. During this time, no staff were observed asking or offering to remove the items from the tray and place them onto the table. During an interview on 12/31/25 at 7:33 a.m., R29 stated that meals were normally served on hard plastic trays when she ate in the dining room. R29 stated this practice made her feel like she was in a hospital, and she wished they wouldn't use the trays. During an interview on 12/31/25 at 7:52 a.m., dietary aide (DA)-A stated she assisted with passing trays in the dining room. DA-A stated they normally will give residents their food on trays that stay in place, to ensure residents have all the items needed for their meal. During an interview on 12/31/25 at 8:01 a.m., the dietary manager (DM) stated that it was a lot easier and quicker for her staff to utilize and leave food and drinks on trays, which has been their practice. The DM stated she had not realized that utilizing the trays in the dining room had bothered anyone, so now she would have her staff place the food and drinks on the table and remove the trays. A policy regarding staff assistance with dining was requested but not received.

Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 1 of 5 residents (R9) reviewed for unnecessary medications.Findings include:R9's quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated R9 had moderately impaired cognition with delusions, no hallucination, no behaviors, wandering or rejection of care.During an interview and observation on 12/29/25 at 1:13 p.m., R9 was lying in bed and appeared to be waking up from taking a nap. R9 stated she had no concerns. R9 was pleasant but appeared confused in some of her responses to questions. R9's Order Summary Report, dated 12/31/25, included the following orders: -risperidone (an antipsychotic medication) - Give 0.5 milligrams (mg) by mouth two times a day for psychosis with a started date of 9/11/25.-Seroquel (an antipsychotic medication) give 50 mg by mouth two times a day for delirium with a start date of 12/18/25. R9's December Medication Administration Record (MAR), printed 12/31/25, included the following: -risperidone - Give 0.5 milligrams (mg) by mouth two times a day for psychosis with a started date of 9/11/25. The record indicated the medication was administered 31 times in the month of December. -Seroquel - give 50 mg by mouth three times a day for delirium with a start date of 8/22/25 and an end date of 12/18/25. The record indicated the medication was administered 23 times from 12/1/25 to 12/18/25. -Seroquel - give 50 mg by mouth two times a day for delirium with a start date of 12/18/25. The record indicated the medication was administered 15 times since 12/18/25. Review of R9's electronic medication record (EMR) lacked evidence of signed consent for either antipsychotic medication (risperidone or Seroquel) which would include risks, benefits and alternatives. During an interview on 12/31/25 at 11:25 a.m., registered nurse (RN)-B stated consents for any psychotropic medications were obtained by nurses on the floor. RN-B stated when a resident got admitted or when a resident started on a new psychotropic medication, the nurse obtained consent prior to administering the medication. RN-B stated if the resident could not give consent, then the family/guardian/power of attorney would be called to obtain consent. RN-B stated after consent for the medication was given, the medication would be started, and the form would be given to medical records to be uploaded in the electronic medical record (EMR) in the documents/attachment's sections. During an interview on 12/31/25 at 11:43 a.m., director of nursing (DON) stated the expectation would be that consents for psychotropic medications were completed by floor nurses prior to starting or increasing the medication. DON was unable to locate the consents for R9's risperidone or Seroquel and would follow up with surveyor if able to locate them. During follow up on 12/31/25 at about 3:15 p.m., DON stated they were unable to locate signed consents for R9 antipsychotic medications. During an interview on 12/31/25 at 2:00 p.m., R9's guardian (GUA)-A verified that they were the guardian for R9. GUA-A stated they did receive a call a while ago about R9 needing to start a new medication for agitation. GUA-A stated they gave consent to start a medication but was not sure the name of the medication or the risks of the medication. GUA-A stated they never signed a consent that reviewed risks and benefits of medications. A facility policy titled Use of Psychotropic Medications, updated 4/21/25, indicated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black b ox warnings for antipsychotic medications, in advance of such initiating or increase.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care and shaving) was completed and provided for 2 of 2 residents (R44, R43) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R44 - Shaving R44's quarterly Minimum Data Set (MDS) assessment, dated 11/18/15, identified R44 had intact cognition with no hallucinations or delusions, behaviors or rejection of care. MDS indicated R44 needed moderated assisted for personal hygiene which included shaving. During an interview on 12/29/25 at 1:46 p.m., R44 stated that he does not like to have any facial hair as it becomes very itchy. R44 stated he has told staff this previously. R44 stated the staff only shave him on showers days but his preference would be to be shaved daily with morning cares. R44 was observed to have approximately a quarter in beard and mustache. During an interview on 12/30/25 at 11:21 a.m., R44 was observed in his room and observed to continue to have unshaven facial hair. Two nursing assistants came in after surveyor entered to see why R44's call light was on, so surveyor ended the interview to they could assist him. R44's care plan, printed 12/31/25, identified R9 has an ADL self-care performance deficient related to limited mobility and musculoskeletal impairment and requires assistance with dressing/undressing and requires 1 staff assistance to use toilet. R44's care plan lacked identification of level of assistance R44 needs for personal hygiene such as shaving or showers. R44's Tub/Shower Transfer log, printed 12/31/25, indicated R44 last shower was 12/23/25 and required maximal assistance. R44's progress notes, dated 12/1/25 to 12/31/25, were reviewed. The progress notes lacked evidence that R44 was offered and refused to be shaved. During an interview on 12/30/25 at 1:55 p.m., nursing assistant (NA)-E stated they listened to what residents wanted when completing morning cares. NA-E verified they were familiar with R44 and completed morning cares with R44. NA-E stated R44 needed assist of 1 with cares and assist of 2 with transfers. NA-E stated they had not shaved R44's facial hair today, stating sometimes I am not able to get to the small stuff. I can't get to it all. NA-E verified that had facial hair that could be shaved. During an interview on 12/30/25 at 2:04 p.m., registered nurse (RN)-B stated morning cares should include washing a resident's face, underarms, peri-area, changing clothes, oral cares and shaving. RN-B stated typically, shaving is done on showers done but we can shave a resident anytime. RN-B stated any nursing staff should be asking a resident preference every step of the way when getting them ready in the morning or at night. During an interview on 12/31/25 at 10:27 a.m., R44 was observed to continue to have unshaven facial hair. R44 stated, it's still growing, and getting real itchy. During an interview on 12/31/25 at 10:37 a.m., NA-F stated shaving should be offered with morning cares. NA-F stated it appeared that R44 hadn't been shaved for about 5-7 days based on the length of the facial hair. NA-F verified R44 had a razor in his bathroom. During an interview on 12/31/25 at 10:47 a.m., NA-F stated morning cares should include the following: washing face, hands, underarms, peri-area, combing hair, shaving, brushing teeth, and changing clothes. NA-F stated they assisted R44 today with morning cares. NA-F stated they did not shave R44 or offer to shave R44 as it takes him a long time to brush his teeth and I have to multitask. NA-F stated they would shave R44's facial hair and stated it should have been done with morning cares. During an interview on 12/31/25 at 11:36 a.m., director of nursing (DON) stated the expectation would be a resident's facial would be done with bathing and as needed when staff notice that it is growing per resident's preference. A policy on activities of daily was requested and not received. R43 R43's admission Minimum Data Set (MDS), dated [DATE], identified R43 had intact cognition and required full assistance with personal hygiene cares. R43 had diagnoses of respiratory failure, muscle weakness, malignant neoplasm of left breast and chronic pain. R43's care plan, dated 11/14/25, identified R43 had an ADL self-care deficient with grooming, and required assistance of one by staff. R43's weekly body audits, dated 11/26/25 and 12/24/25, identified R43's fingers and toenails were not cleaned or trimmed. During observation and interview on 12/29/25 at 3:42 p.m., R43 stated her nails were long and dirty. She stated requested an unknown staff member to have them cleaned and trimmed, but it was not performed. R43's fingernails were observed, nails were approximately 1/4 inch long, with brown substance under nails. Her toenails were approximately 1/4 inch long and no sign of discolored substance under them. During observation and interview on 12/30/25 at 11:24 a.m., R43 stated that nails were not cut or cleaned by staff. However, family member (FM)-G trimmed right thumb and pointer finger. During interview on 12/30/25 at 2:54 p.m., nursing assistant (NA)-I stated R43's nails were not clean or trimmed on both hands, except for pointer finger and thumb on right hand. NA-I stated nail care was usually done on bath/shower days. During interview on 12/31/2025 2:04 p.m., director of nursing (DON)-B stated the expectation for nail care was to be completed on bath/shower days and as needed. If a resident asked to have nails cleaned and trimmed it was expected for staff to perform that function. Nail care was important for hygiene and overall skin integrity. A policy and procedure for ADLs was requested but not received.

Based on observation, interview, and document review, the facility failed to consistently implement a restorative nursing program (RNP) to prevent a possible decrease in range of motion (ROM) for 1 of 1 residents (R29) reviewed for ROM. Findings include:R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 had intact cognition with no rejection of care behaviors during the look-back period (LBP). The MDS indicated R29 had impaired ROM on both lower extremities. The MDS indicated R29 required maximum assistance with bed mobility and lower body dressing. R29's Therapy Referral for Maintenance Program dated 10/24/24, indicated that physical therapy recommended staff assist R29 with passive ROM to bilateral hips, knees, and ankles daily. R29's care plan dated 8/10/25, indicated R29 was to receive passive ROM to the bilateral hips, knees, and ankles daily. R29's task list dated 11/30/25 to 12/28/25, indicated that staff were to complete passive ROM on R29's bilateral hips, knees, and ankles daily. The report indicated the task had been refused five times, completed 17 times, charted as not applicable five times (with no further entry indicating it was completed or refused that day), and had no entry on 12/7/25, 12/19/25, and 12/20/25. During an interview on 12/29/25 at 3:37 p.m., R29 stated that staff were supposed to complete ROM with her daily, but never do it. During an interview on 12/31/25 at 8:46 a.m., nursing assistant (NA)-D stated she had worked with R29 in the past, and she would rarely refuse to complete ROM when she had time to complete it with R29. NA-D stated she often didn't feel like she had enough time to complete everything she had to do during her shift, so she often did not complete ROM when she worked with her as a result. During an interview on 12/31/25 at 9:18 a.m. with NA-B and NA-C, NA-B stated it was often hard to complete everything they needed to do during their shift. NA-B stated that if they had time to do ROM, they would, but it often didn't get done. NA-B stated that if they did complete ROM with R29, they would chart it as completed on her tasks list. During an interview on 12/31/25 at 9:10 a.m., the director of nursing (DON) stated that if a resident needed ROM, it would be added to tasks where staff could document if it was completed or not. The DON stated that after reviewing R29's medical record, staff should be completing ROM with her daily. The DON stated the NAs had notified her that they were having a hard time finding enough time to complete ROM, so the facility was looking to get a restorative aide to assist, but it had not yet happened. A policy regarding ROM was requested and not received.

Based on observation, interview, and document review, the facility failed to follow developed interventions for eating assistance to reduce the risk of aspiration or choking for 1 of 2 residents (R6) reviewed for nutrition. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had severely impaired nutrition. The MDs indicated R6 required moderate assistance with transfers and personal hygiene and was independent with eating. R6's care plan dated 9/13/25, indicated R6 required setup help for eating and was to be encouraged to get out of bed for all meals. The care plan indicated R6 had a history of dysphagia (difficulty swallowing) and hemiplegia (one-sided paralysis or weakness) with a goal of having no choking episodes when eating or drinking through the review date. R6's order summary dated 11/5/25, indicated R6 had an order for a mechanical soft (soft, easier to chew food for those with chewing or swallowing difficulty) diet, was to be upright in a chair or bed while eating/drinking, should be given small bites/sips, and required total assistance with feeding. During an observation on 12/29/25 at 12:46 p.m., R6 was observed in his room lying in bed. The head of the bed was in an upright position, and the bedside table was in front of him with a meal tray with food and a beverage on it. No staff members were observed in the room with R6. R6 was observed to drink what appeared to be milk with no signs of choking or coughing noted. During an observation on 12/30/25 at 8:13 a.m., R6 was observed sitting at a table in the dining room with another resident present, but no staff at the table. Registered nurse (RN)-B was observed standing in front of a medication cart, looking at a laptop at one end of the dining room. R6 was observed to drink what appeared to be coffee independently. R6 was observed to take a piece of toast that had been cut in half and put about 75 percent of it in his mouth and chew it. R6 showed no signs of choking or coughing. During an interview on 12/30/25 at 8:16 a.m., RN-B stated that R6 was supposed to have someone sitting with him to help with eating to ensure he was eating safely. RN-B stated an aide was supposed to be assisting in the dining room, but he was unsure who was supposed to be helping and why they were not. During an interview on 12/30/25 at 10:25 a.m., the director of nursing (DON) stated staff should either be in R6's room with him or sitting with him in the dining room while he is eating to ensure he was safe. A policy regarding staff assistance with eating was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure ordered nutritional interventions were provided to promote weight gain for 1 of 2 residents (R6) reviewed for nutrition. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had severely impaired nutrition. The MDS indicated R6 required moderate assistance with transfers and personal hygiene and was independent with eating. R6's care plan dated 9/13/25, indicated R6 had a potential for a nutritional problem related to dysphagia (difficulty swallowing) and hemiplegia (one-sided paralysis or weakness). The care plan indicated R6 would receive supplements per the provider's order. R6's order summary dated 11/5/25, indicated R6 had an order for a house nutritional supplement one time a day for nutritional support. The summary did not include an order for house nutritional supplements three times a day. R6's dietitian's note dated 12/17/25, indicated R6 had weight loss likely related to inadequate intake. The note indicated the dietician would continue to assess the resident monthly and would like the house nutritional supplement to be increased to three times a day between meals. R6's Weights and Vitals Summary dated 12/29/25, indicated that on 11/19/2025, the resident weighed 140 pounds (lbs) and on 12/17/2025, the resident weighed 137 lbs, which was a 2.14 percent weight loss. During an interview on 12/30/25 at 9:57 a.m., the dietician stated that because R6 had continued weight loss after she had started him on a house supplement, she had increased the frequency from once a day to three times a day on 12/17/25. The dietician stated she filled out a sheet with her order and sent it to the nurse manager and the director of nursing (DON) to be entered in the electronic medical record.During an interview on 12/30/25 at 9:11 a.m., registered nurse (RN)-D stated R6 got a house nutritional supplement once a day that was usually given to R6 after breakfast.During an interview and observation on 12/31/25 at 9:13 a.m., the DON was observed reviewing her emails and stated that it looked like they had received an email from the dietician to increase R6's supplement to three times a day. The DON stated it was the nurse manager's responsibility to enter this order into the electronic medical record, but this must not have been completed. The facility's Nourishment and Oral Nutritional Supplements policy dated 2021, indicated the director of food services or designee would maintain the nutritional supplement list using written orders and individual requests as a guide.

Based on observation, interview and document review, the facility failed to ensure pharmacist recommendations were acted upon timely for 1 of 5 residents (R9) reviewed for unnecessary medication use.Findings include:R9's Pharmacist's Recommendation to Prescriber and Residents reviewed with No Recommendation, dated July 2025 to December 2025, were reviewed and identified the following:7/18/25: no recommendations8/17/25: Seroquel an antipsychotic medication needs appropriate diagnosis. This was signed by provider 8/20/25.9/23/25: recommendation was to consider a trial discontinuation of the agents to reduce poly-pharmacy as receiving risperidone 0.5mg twice a day and Seroquel three times a day. Prescriber responded on 12/18/25 to change Seroquel to twice a day and plant to d/c (discontinue) if possible.10/20/25: no recommendations12/16/25: recommending gradual dose reduction. Provider responded GDR being completed.The November 2025 Pharmacist Recommendation to Prescriber was not provided.During an interview on 12/31/25 at 11:42 a.m., director of nursing (DON) stated she believes she has the November 2025 pharmacy review for R9. DON verified R9's November 2025 had not been provided at this time and will provide it when located. No further information was given.A facility policy titled Medication Regimen Review Policy, updated 10/19/22, indicated all medication regimen review documents will be maintained in the resident medical record.

Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R4) reviewed for immunizations. Also, the facility failed to document shared clinical decision making for 2 of 5 residents (R16, R27) identified as needing or being offered an updated pneumococcal immunization per CDC's Recommendation of Adult Immunizations Schedule for Ages 19 Years or Older, United States, 2025, Revised October 7, 2025.Findings include:During interview and record review with director of nursing (DON) on 12/30/25 at 11:12 a.m., DON reviewed electronic medical records (EMR's) and verified the following:R4's date of birth was 2/9/53, and the EMR lacked information on pneumococcal immunization status. DON stated they expected the facility to have documentation to support him being offered or having declined the vaccine.R16's date of birth was 6/22/1957, and the EMR identified R16 received an unnamed pneumococcal vaccine on 9/23/2015 at age [AGE], Pneumovax 23 given 3/4/2019 at age [AGE], and another Pneumovax 23 given 7/11/22 at age [AGE]. DON reviewed the CDC guidance which identified R16 should receive 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21, at least one 1 year after the last PPSV23 dose and stated it was not done. R27's date of birth was 12/22/1940, and the EMR identified Prevnar 13 was given on 10/23/2018 at age [AGE] and Pneumovax 23 was given on 11/19/2019 at age [AGE]. DON reviewed the CDC guidance which identified, Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose applied to R27 which was not done. DON stated facility was expected to follow the facility policy and CDC guidelines when assessing and discussing vaccination status upon admission and as recommended. In addition, DON verified there was no documentation or evidence that facility or providers discussed with R4, R16, and R27 any shared decision making on providing pneumococcal immunizations.During interview with medical director (MD) on 12/30/25 at 11:39 a.m., MD stated it was important for health care providers to include documentation of shared decision making and that R16's and R27's EMRs failed to identify this was done. In addition, MD stated R4's EMR lacked evidence of pneumococcal immunization was offered or administered at any time.Facility's Infection Control manual, updated 11/13/2024, identified, Upon admission, the resident will be assessed for: 2) Pneumococcal vaccination status, by history and All residents will be provided with the opportunity and encouraged to receive pneumococcal vaccinations.

Based on interview and document review, the facility failed to ensure staff were offered, and or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for 3 of 3 staff (LPN-A, LPN-B, HSK-A) reviewed for COVID-19 vaccinations. Findings include:Review of Centers for Disease Control and Prevention (CDC) Clinical Guidance for COVID-19 Vaccination, updated 7/11/25, indicated the CDC recommended an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get one dose of an updated COVID-19 vaccine. People 65 years and older who live and work in LTC settings should receive 2 doses of an updated COVID-19 vaccine, spaced 6 months apart.During an interview on 1/9/24 at 11:38 a.m., human resources director (HR)-F stated the facility did not have any documentation of COVID-19 vaccine being offered or education provided for licensed practical nurse (LPN)-A; LPN-B or housekeeper (HSK)-A.During an interview on 1/9/25 at 1:20 p.m., director of nursing (DON) stated she was unaware if employees were offered the COVID-19 vaccine. During an interview on 1/9/25 at 12:49 p.m., medical director (MD) stated her expectation would be for the facility to ensure staff were provided education on risk versus benefits and be offered the COVID-19 vaccine when available.The facility policy on COVID-19 vaccine dated 11/2024, identified when COVID-19 vaccine is available each staff member will be offered and provided education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine. The policy also identified the facility maintains documentation that staff were offered and provided education regarding benefits and potential risks of COVID-19 vaccination.

Based on interview and document review, the facility failed provide appropriate side effect monitoring (i.e., orthostatic hypotension) with antipsychotic medication consumption for 1 of 5 residents (R9) reviewed for unnecessary medication use. Findings include: R9's quarterly Minimum Data Set (MDS) assessment, dated 12/9/25, indicated R9 had moderately impaired cognition with delusions, no hallucination, no behaviors, wandering or rejection of care. The MDS indicated R9 took antipsychotic medication. Furthermore, MDS indicated R9 required the use of a walker and wheelchair and supervision for chair to bed transfers. R9's diagnosis report included the following diagnoses: orthostatic hypotension (sudden drop in blood pressure when a person stands up), dementia (decline in mental ability), syncope and collapse (temporary loss of consciousness-fainting), and myocardial infarction (heart attack).During an interview and observation on 12/29/25 at 1:13 p.m., R9 was lying in bed and appeared to be waking up from taking a nap. R9 stated she had no concerns. R9 was pleasant but appeared confused in some of her responses to questions. R9's Order Summary Report, dated 12/31/25, included the following orders: -risperidone (an antipsychotic medication) - Give 0.5 milligrams (mg) by mouth two times a day for psychosis with a started date of 9/11/25.-Seroquel (an antipsychotic medication) give 50 mg by mouth two times a day for delirium with a start date of 12/18/25. R9's order summary lacked orders to obtain orthostatic blood pressures. R9's December Medication Administration Record (MAR), printed 12/31/25, included the following: -risperidone - Give 0.5 milligrams (mg) by mouth two times a day for psychosis with a started date of 9/11/25. The record indicated the medication was administered 31 times in the month of December. -Seroquel - give 50 mg by mouth three times a day for delirium with a start date of 8/22/25 and an end date of 12/18/25. The record indicated the medication was administered 23 times from 12/1/25 to 12/18/25. -Seroquel - give 50 mg by mouth two times a day for delirium with a start date of 12/18/25. The record indicated the medication was administered 15 times since 12/18/25. R9's MAR lacked any orthostatic blood pressures orders or evidence orthostatic blood pressures were obtained. R9's blood pressure summary report from July 2025 through December 2025 lacked evidence of completion of any orthostatic blood pressures. R9's progress notes, dated 12/1/25 to 12/31/25, reviewed and lacked evidence R9 refused orthostatic blood pressures. During an observation and interview on 12/31/25 at 10:14 a.m., nursing assistant (NA)-C stated R9 was able to transfer to her wheelchair. R9 transferred from her bed to her wheelchair with supervision from NA-C. During an interview on 12/31/25 at 10:40 a.m., registered nurse (RN)-C stated nurses were responsible for obtaining orthostatic blood pressures on residents. RN-C stated orthostatic blood pressures were not automatically done on a resident if they were on an antipsychotic medication as they were done if there was a doctor order to complete them or reason to do them. RN-C verified that R9 was able to stand. RN-C stated that antipsychotic medications can cause orthostatic hypotension. During an interview on 12/31/25 at 11:23 a.m., RN-B stated orthostatic blood pressures were completed if there was an order to obtain them. RN-B was unsure of orthostatic blood pressures were completed if a resident was on antipsychotic medications. During an interview on 12/31/25 at 1:38 a.m., director of nursing (DON) stated the expectation would be orthostatic blood pressures would be obtained if a resident was starting on an antipsychotic medication and monthly thereafter. DON reviewed R9's electronic medical record and verified orthostatic blood pressures had not been obtained for R9 and should have been as R9 as she currently took antipsychotic medications. A facility policy titled Use of Psychotropic Medications, updated 4/21/25, indicated The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis.

Based on observation, interview, and document review, the facility failed to assess potential signs of constipation to determine what, if any, interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R15); failed to comprehensively assess and develop interventions to ensure a consistent nursing approach with a developed, non-pressure skin condition for 1 of 2 (R5); and failed to ensure orders for a peripherally inserted central catheter (i.e. PICC line) were clarified and the line was managed in accordance with professional standards of care for 1 of 1 residents (R28) reviewed who had a PICC. Findings include: BOWEL MANAGEMENT: R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS outlined R15 was totally incontinent of bowel and consumed multiple medications including both psychotropic and narcotic medications. On 12/2/24 at 3:07 p.m., R15 was observed laying in bed while in her room. R15 was interviewed and expressed she felt constipated adding she had only been having a stool every other day when her normal pattern was daily. R15 stated nobody from the care center, at least to her recall, had visited with her or asked about constipation nor what, if any, interventions could help it (i.e., prune juice, medication adjustment). R15 stated she wished someone would though. R15's care plan, printed 12/4/24, identified R15's current and potential issues or complications. The care plan identified R15 needed assistance of one for toileting and R15 was incontinent of bladder and bowel due to limited mobility and hospice-focused cares. The care plan listed interventions for this identified problem including barrier cream applied to her skin, observing for signs of a urinary tract infection (i.e., UTI), and peri-cares after incontinent. Further, the care plan identified R15 was at risk of dehydration due to constipation and listed two interventions for this including observing her skin integrity and, Observe/document bowel sounds and frequency of BM [bowel movement]: provide medication per order. The care plan lacked any further information on R15's constipation including what, if any, other interventions for it aside from medication administration were being done or had been discussed/used prior. When interviewed on 12/4/24 at 9:01 a.m., nursing assistant (NA)-A stated they had worked with R15 and described her as having poor mobility adding, [She] stays in bed mostly all the time. NA-A stated R15 had incontinence of bladder and bowel but felt she was good at calling for someone to change her. NA-A stated residents' bowel movements were tracked in the point-of-care charting on their computer system, and staff could select the size of stool each time. NA-A stated they had last helped R15 with bowel incontinence about two weeks prior and, at that time, the stool didn't seem hard adding R15 had not reported any concerns about her bowels to them. NA-A stated if a resident complained about constipation, then it was the nurses' job to address it adding, They handle it. R15's POC (Point of Care) Response History, printed 12/4/24, identified a 14 day look-back period and recorded R15's bowel movements. A labeled field reading, Size of BM, was listed which provided a check mark on the corresponding size of stool (i.e., small, large) for each date R15 had one recorded. This information identified the following: 11/23/24 - R15 had one large BM recorded. 11/24/24 - R15 had one small BM recorded. 11/25/24 to 11/27/24 (three days) - R15 had no BM recorded. 11/28/24 - R15 had one large BM recorded. 11/29/24 - R15 had one medium BM recorded. 11/30/24 - R15 had one large BM recorded. 12/1/24 to 12/2/24 (two days) - R15 had no BM recorded with dictation, Response Not Required. 12/3/24 - R15 had one large BM recorded. R15's medical record was reviewed and lacked evidence R15's bowel patterns (i.e., multiple days without one, no staff data) had been identified or evaluated to determine what, if any, interventions were needed to promote more regular bowel movements and reduce the risk of complication despite R15 consuming narcotic medications, having a history of constipation as identified on the care plan, and going multiple day periods without a stool. Further, R15's medical record contained multiple previous assessments labeled, Continence Evaluation, however, the last completed or recorded one was dated 12/2022 (two years prior). When interviewed on 12/4/24 at 10:22 a.m., registered nurse (RN)-A stated the night shift nurse typically pulled a report and would tell the morning shift nurse what residents were on multiple days without a bowel movement. RN-A stated the morning nurse would then follow-up, if needed, and could use the facility' standing orders to address it. RN-A stated R15 was already on some scheduled bowel medications, such as Senna and Miralax, adding the nurse manager would help oversee assessments and complete them, if needed. RN-A verified the NA staff use only the POC charting to record bowel movements. On 12/5/24 at 10:16 a.m., the director of nursing (DON) and registered nurse unit manager (RN)-C were interviewed. DON verified they had reviewed R15's medical record and explained bowel status should be evaluated upon admission, quarterly and when warranted. DON stated this was done using the Continence Evaluation, however, one had not been completed for several years adding, It has not been done. DON verified there was no documented evidence to show R15's bowel status had been evaluated and expressed it should be done adding aloud, That is the expectation. DON stated the NA staff use the POC to document residents' bowel movements and, upon reviewing R15's charting, it seemed the aides were not documenting well and recording incontinence but no bowel movement adding there was room for education on appropriate documentation. DON stated it was important to ensure bowel status was assessed due to the high risk of constipation for R15. A facility' policy on bowel status assessment or evaluation was requested, however, none was received. 47495 Non-Pressure Skin Condition R5's admission Minimum Data Set (MDS), dated [DATE], indicated R5 was admitted to the care facility on 10/4/24, was cognitively intact and required substantial/maximum assistance with bathing and lower body dressing and partial assistance with upper body dressing. R5's Hospital History and Physical (H&P), dated 9/25/24, indicated R5 had a past medical history of Darier [NAME] disease (a rare genetic skin condition that causes a number of symptoms, including wart-like bumps that are hard, greasy, and yellowish in color. They can be itchy, weepy, or raw. The lesions can appear on the scalp, forehead, upper arms, chest, back, knees, elbows, and behind the ears. They can also appear in skin folds, like under the breasts or in the groin area) complicated by recurrent wounds and cellulitis. The H&P indicated R5 was hospitalized at that time with worsening of chronic skin wounds, indicating visible skin from head to arms cracked and dry with sloughing and wounds in various stages of healing. R5's Orders, printed 12/5/24, indicated R5 had the following orders related to her Darier [NAME] disease: Wound Care 1. Avoid debridement of skin 2. OK to substitute dilute bleach baths with hydrogen peroxide skin soap, will defer to patient preference. 3. Recommend after cleansing, patient rinse and PAT DRY GENTLY, no rubbing or scrubbing or debriding skin 4. Apply emollients to include betamethasone-clotrimazole, mupirocin and Aquaphor to affected skin. Important to apply barrier repair immediately (within 2-3 mins after bathing) every day shift every Mon[day], Wed[day], Fri[day] and Okay to use stockinette vest after wound and rash treatment. Vest should wash and reuse. Wound care was scheduled for day shift despite R5's showers scheduled for evening shift per her preference. R5's Orders, dated 12/5/24, also indicated the following topical ointment orders: Mupirocin External Ointment 2%; apply to skin topically two times a day for skin care, Emollient External Ointment; apply to skin typically four times a day for skin care, and Clotrimazole External Cream 1%; apply to affected skin area topically two times a day for Darier [NAME] Disease. In addition, R5's Orders, dated 12/5/24, indicated the following oral medications: Seroquel (medication to treat anxiety) Oral Tablet 25 milligrams (mg); give 1 tablet by mouth every 6 hours as needed for anxiety for 14 days, Hydroxyzine Oral Tablet 50mg; give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days, and Oxycodone Oral Tablet; give 10mg by mouth every 4 hours as needed for pain may give 1-1.5 tablets (10mg - 15mg) AND give 15 mg by mouth every 4 hours as needed for pain 6-10. R5's Care Plan, dated 10/4/24, indicated R5 had potential/actual impairment to skin integrity r/t [related to] decreased mobility, incontinence, and Darier [NAME] Disease. Interventions included keep linens dry, wrinkle free, keep skin clean and dry. Apply lotion to dry skin during cares. DO not apply lotion between toes or to open, rashy areas, and observe skin during care. Report changes to nurse. However, R5's Care Plan lacked any specific interventions related to her Darier [NAME] Disease. R5's Medication (and treatment) Administration Record (MAR), dated 11/1/24 - 11/30/24, indicated R5 received wound care to her skin 6 times on 11/8/24, 11/15/24, 11/18/24, 11/20/24, 11/25/24, and 11/29/24. The MAR indicated R5 did not receive wound care to her skin due to refused or other/see progress note 6 times on 11/4/24, 11/5/24, 11/11/24, 11/13/24, 11/22/24, and 11/27/24. R5's MAR, dated 12/1/24 - 12/5/24, indicated R5 did not receive any wound care to her skin due to other/see progress note on 12/2/24 and 12/4/24. R5's Progress Notes, dated 10/4/24 - 12/5/24, lacked an explanation of why wound care was not provided on 11/22/24 and 12/4/24 despite the MAR indicating to see progress note. On 12/2/24 it was documented resident refused wound care and treatment creams. Did fall back to sleep til 1130 am after taking AM morning meds. Writer offered and asked resident if she wanted to get wound done couples of times. Resident stated wanted to take a shower before wound get done. Residents left downstairs for some time. Wirer followed her on 2nd floor and asked if still wanted wound to get done before shift end. Kept pushing til the end of shift and was unable to do it. Reported to evening RN [registered nurse] to follow up. During an interview and observation on 12/2/24 at 3:30 p.m., R5 stated she sat in dirty bandages for 5-6 days when she was first admitted and had concerns about her wound care still not getting done properly, stating she had been doing her wound care for 9 years due to her Darier [NAME] Disease and it required ABD pads, stockinettes, and a 14-ounce jar of Aquaphor with each dressing change since her skin was effected from head to toe. R5's entire skin from head to toe was dry and flaking with denuded areas that were red and shiny in appearance. R5 stated she was supposed to use a vest made of a soft mesh material to hold the abd pads in place on her chest and back, however the facility had not supplied her with the vest and so the skin on her torso was open to air, causing her pain and her skin to weep onto her clothing which caused yellow staining of her clothes. R5 stated she would always need to shower before her wound care to help remove the old dressings and to prevent and remove keratin build up on her skin, stating when she didn't get frequent showers it would cause worsening of her skin breakdown. However, R5 stated without the correct amount of Aquaphor and supplies, she could not shower because of how painful the air was to her skin, stating the facility was also unable to provide her with the needed amount of Aquaphor, the correct stockinettes or the mesh vest that would hold the ABDs in place. R5 stated at her last care conference, on 11/20/24, they scheduled her showers for Monday, Wednesday, and Friday evenings because she preferred to sleep in late, but that due to supply and scheduling issues she was not getting wound care as needed which caused her bandages to have a foul odor and her clothes to have yellow staining. R5 stated, I shouldn't have to feel that undignified, that belittled when other residents tell her that her bandages have a foul odor. During an interview on 12/4/24 at 8:41a.m., nursing assistant (NA)-F stated she does not help with R5's wound care but helps a lot with her showers, stating after her showers she gets ointment over her whole body. NA-F stated she did not believe that R5 refused her showers but that the showers were painful for R5 due to her skin condition and raw, open skin, that at times R5 just felt like she needed to wait to shower. NA-F further stated when R5 was admitted to the care facility, they did not have the supplies she needed for about a month, stating she believed R5 had everything she needed now but could not be 100% sure. NA-F also confirmed R5 had a lot of weeping from her skin which caused her and her room to have an odor. During an interview on 12/4/24 at 10:08 a.m., registered nurse (RN)-H stated she believed R5 was supposed to receive a shower three times a day, during the day shift, stating R5 would postpone and postpone her shower until the end of her shift and it would frequently get missed. RN-H further stated R5 was in pain and bleeding during her showers and that staff try to give her PRN Hydroxyzine, Seroquel and Oxycodone prior to her showers. RN-H stated R5 would use her Aquaphor all over her body, her other ointments (Clotrimazole and Mupirocin) were only used to spot treat any open areas on her skin and a mesh body suit over her ointments with no other dressings (i.e. ABD pads) between her skin and the mesh body suit. RN-H also stated R5's skin was very weepy and would often leak a yellow substance through her clothes creating an odor on the bandages. During an interview, nurse manager and RN-D stated R5 did not come with an order that specified how much Aquaphor she should use, stating a 14 once jar was excessive, however confirming she did use it to cover her entire body. RN-D stated he received an order from the nurse practitioner to use a mesh vest and stockinettes, however they were not able to get a mesh vest for R5 to use and R5 had just received the appropriate size stockinettes on 12/2/24 at approximately 9:30 p.m. RN-D stated R5 was supposed to receive PRN Oxycodone, Seroquel and Hydroxyzine prior to a shower but confirmed the order did not specify that. RN-D further confirmed that while he supplied the ABDs for R5's wound care, the order in her chart did not specify to use the ABDs because she was not admitted to the care facility with the order and the ABDs were only R5's preference. RN-D confirmed the orders did not specify how staff were supposed to use R5's 3 ointments (Aquaphor, Clotrimazole and Mupirocin), but he believed they should all be mixed together and then applied to her skin. RN-D stated R5 did refuse showers a lot but was unable to confirm any comprehensive assessment or reassessment that had been done to determine what R5 needed for her showers and wound care, when she wanted them done, risks vs benefits or refusing and/or why she was refusing her showers and wound care. During an interview on 12/4/24 at 12:45 p.m., R5 stated she had finally received the correct size stockinettes late Monday night. R5 further stated she needed to keep up with her three times a week showers, stating she did not want to refuse them but when she did not have the right supplies she could not shower. R5 stated she could not take her old bandages off, shower and have nothing to put on her skin as it would be too painful causing her to feel forced to keep dirty bandages on. R5 stated she was concerned about still not having a mesh vest to wear which would allow her to cover her chest and back with the appropriate ABDs. R5 further stated was about to run out of Aquaphor sating, I don't know what I am going to do when that happens, I can't afford it on my own. R5 stated she was worried she would end up in the hospital again without the correct supplies to manage her skin properly. During an interview on 12/5/24 at 10:33 a.m., RN-G stated R5's showers were all over the place and sometime NA-F would do it during the day, so it was not clear when her scheduled shower times were. NA-C confirmed R5 should be getting showers in the evenings since R5 preferred to sleep in late in the mornings. During an interview on 12/5/24 at 11:41 a.m., the director of nursing (DON) confirmed that the showers and wound care for R5 were not clear, stating it was because the wound care process R5 wanted was a preference and not an order. The DON stated they tried to work with R5 but was unable to show documentation of a comprehensive assessment or reassessment of R5's wounds/wound care, refusals, or risk versus benefits. The DON further stated the Aquaphor and mesh vest was not covered by R5's insurance, however lacked evidence staff worked with R5 and/or her provider to find an agreeable alternative or to attempt to get it covered. The DON stated she did not believe R5 needed a whole tub of Aquaphor despite R5 needing it to protect her skin on her entire body after every shower. 48065 PICC DRESSING: R28's quarterly Minimal Data Set (MDS) dated [DATE], indicated R28 was cognitively intact, had no behaviors and did not refuse personal cares. The quarterly MDS indicated R28 needed maximal assistance with showers, dressing, toileting and was dependent with all aspect of mobility. R28's Clinical Diagnosis report printed 12/5/24, indicated diagnoses of multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves, disrupting the communication between the brain and the body), pressure areas (an injury to the skin and underlying tissue resulting for prolonged pressure on the skin), neurogenic bladder, (lack of bladder control due to spine or nerve injuries) , constipation, epilepsy (brain disorder that causes recurring, unprovoked involuntary movement), quadriplegia (paralysis that affects all a person ' s limbs and body from the neck down), and colostomy (a surgical procedure that creates an opening in the abdomen to divert stool from the colon to a bag or pouch). R28's Clinical Orders report printed 12/4/24, indicated an order dated 11/20/24 for vancomycin HCL intravenous (IV) solution (antibiotic medication) 1250 milligrams (mg)/250 milliliters (ml) for methicillin-resistant staphylococcus aureus (a bacterial infecion also called MRSA) infection. R28's orders report lacked orders to change the peripherally inserted central catheter (PICC) line dressing, and/or monitoring insertion site for signs and symptoms of infection. R28's Care Plan indicated printed on 12/4/24 indicated R28 had MRSA which required antibiotic therapy. R28's care plan lacked documentation regarding the PICC line and the IV therapy. R28's medication administration record (MAR) and the treatment administration record (TAR) for the months of November and December lacked documentation regarding changing the PICC line dressing and/or monitoring the insertion site for signs and symptoms of infection. R28's progress note dated 11/20/24 at 5:09 a.m. indicated R28 had a PICC inserted in the right upper arm. During observation and interview on 12/4/24 at 10:15 a.m., registered nurse (RN)-F started R28's vancomycin IV infusion via PICC line. R28's PICC line was on the right upper arm. The insertion site was covered with a clear dressing without a date indicating when the dressing was changed. R28 stated nobody has changed the dressing since it was inserted on 11/20/24. RN-F verified the PICC line dressing was separated from the skin around three out of the four sides of the dressing and lacked a date when the dressing was changed. During interview on 12/4/24 at 10:43 a.m., RN-F verified there were no orders to change the PICC line dressing and/or to monitor insertion the site for signs and symptoms for infection. RN-F stated the nurse manager was responsible to make sure the orders were added to the medication administration record (MAR) and the treatment administration record (TAR). During interview on 12/4/24 at 10:56 a.m., nurse manager, RN-C stated R28 had a PICC line and the PICC line cap and dressing needed to be changed every seven days. RN-C stated when a resident had a PICC line, the nurse manager would add it to the medical record including the orders, MAR and TAR. In addition, the TAR would include the orders to care for the PICC line and to observe the PICC line site for signs or symptoms of infection. RN-C stated any nurse could also enter those orders. RN-C reviewed R28's medical record and verified the lack of orders and/or documentation about changing the PICC line dressing. During interview on 12/5/24 at 9:20 a.m., director of nursing (DON) stated a PICC line dressing needed to be changed every seven days. DON stated if a dressing is not changed it could lead to an infection. A facility's policy on PICC line care was requested, however, none was received.

Based on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 4 of 4 residents (R5, R15, R32, R112) reviewed for dining. This had the potential to affect 35 residents identified to reside on the units with cold food complaints. Findings include: During an observation on 12/5/24 at 7:45 a.m., tall metal meal carts and a plastic cart were observed in the main kitchen with trays placed to have a small bowl of hot cereal covered with a disposable plastic cover sitting on (approximately) every tray. Cook-A (C)-A was observed plating pancakes and sausage patties to each tray. At 8:06 a.m., the 300/400-unit meal carts left the main kitchen. During an observation and interview at 12/3/24 at 8:10 a.m., after the four meal trays were passed from the plastic cart to residents on the 400 hallway, the pancake was measured to be at 108 degrees Fahrenheit and the oatmeal was measured at 119 degrees Fahrenheit. The tray was sampled with the C-A who stated it was hard to keep the pancakes warm and the cereal was a little on the low side. C-A stated they normally wanted the food to be served at approximately 155 degrees Fahrenheit, but it was hard to get the trays out to the residents fast enough as it was only dietary staff who helped to pass the trays, although the nursing assistances were supposed to help. C-A left to assist with passing the trays on the 300 hallway which were observed to have approximately 14 trays left in the metal cart that was observed with both metal doors open. The last food tray was observed to be passed for the 300/400 units at 8:23 a.m. During an interview on 12/4/24 at 10:14 a.m., the dietary director (DD) stated around 95 percent of their residents ate their breakfast in their room and it had been hard to ensure room trays stayed warm. The DD stated this was especially hard at breakfast time as the nursing assistants were normally too busy assisting with resident cares to assist with passing food trays. The DD stated she expected the food to be served around 165 degrees. 47495 R5's admission Minimum Data Set (MDS), dated [DATE], indicated R5 was admitted to the care facility on 10/4/24 and was cognitively intact. During an interview on 12/2/24 at 5:25 p.m., R5 stated she did not eat breakfast anymore because it was always served to her cold. 33925 R15's quarterly MDS, dated [DATE], identified R15 had moderate cognitive impairment but demonstrated no delusional thinking. When interviewed on 12/2/24 at 2:59 p.m., R15 stated she typically ate meals within her room served on a room-tray. R15 stated the food was not always served warm but she rarely, if ever, asked staff to re-heat it adding, I just eat it. R15 stated she didn't like to ask staff to re-heat it as they seemed annoyed by the ask adding the look on their face made her feel so. R32's quarterly MDS, dated [DATE], identified R32 had intact cognition and demonstrated no delusional thinking. On 12/2/24 at 5:08 p.m., R32 was interviewed and stated the food served within the care center was not good adding, Most of the time it's cold. R32 stated she ate the lunch meal in the dining room which seemed better, however, most room-trays were still being served cooler. R32 stated she had told staff about it but nothing seemed to change. R32 stated staff would heat it up, if asked, however, the food should be served warm from the start adding, You shouldn't have to do that [heat it up]. On 12/3/24 at 9:21 a.m., R112 was interviewed about the care within the facility. R112 stated they had recently admitted and the food was not served well or warm adding, It's horrible. R112 stated the food seemed to be not cooked right and everything about it was poor adding, It would be nice if that food was warmer. The facility's In-Room Dining policy dated 2/21, indicated hot food must be hot and cold food must be cold when served to residents eating in their room.

Based on observation, interview, and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators and freezers was completed to reduce the risk of foodborne illness. This had the potential to affect approximately 10 residents who regularly consumed deli sandwiches from the facility kitchen. Findings include: During the initial tour with the dietary director (DD) at 12/2/24 at 11:37 a.m., the following foods were found in walk-in cooler in the first-floor kitchen: -Two opened plastic bags of sliced ham dated 11/4/24. -Two opened undated bags of sliced turkey. -An unopened bag of sliced turkey with an expiration date of 11/23/24 that appeared fully thawed. During an interview on 12/2/24 at 11:49 a.m., the DD stated the deli meat was quickly used so she did not expect dietary staff to date it. The DD stated she thought the bag of sliced turkey dated 11/23/24 had come from the freezer and when asked about the process to ensure thawed food was not kept past the date when it was safe to consume, was not able to answer. During a follow-up interview on 12/4/24 at 12:56 p.m., the DD stated the deli meat should have been discarded after 7 days of opening and this was important to prevent residents from getting sick. The DD stated they had about 10 residents in the facility who would normally eat deli sandwiches from the supply listed above. The facility's Food Storage policy dated 3/22, indicated the date marking should be visible on all high-risk foods to indicate the date by which they should be consumed, sold, or discarded.

Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 3 of 4 residents (R4, R12 and R28) whom resided on different wings of the care center. Findings include: A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature identified several examples of high-contact resident care activities including dressing, bathing, providing hygiene, transferring, changing linens or briefs, and wound care. R4 R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition, demonstrated no delusional thinking, and used an indwelling catheter. On 12/4/24 at approximately 7:05 a.m., R4 was observed laying in her bed from the parking lot with her room lights on, and the window blinds pulled up approximately three-quarters (i.e., 3/4) of the window height. R4's window was at ground-floor level and a single female staff member was observed dressed in dark-blue colored scrubs and assisting R4 whose legs and peri-area were exposed and visible from the sidewalk leading up to the main entrance of the care center. The staff member had gloves on and was observed wiping R4 with a cloth on her peri-area. At 7:09 a.m., the surveyor approached R4's room to alert staff of the blinds being raised. R4's room door had an orange-colored sign posted on it which included multiple STOP signs and directions reading, Enhanced Barrier Precautions . Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Changing briefs or assisting with toileting[,] Device care or use: central line, urinary catheter, feeding tube . Do not wear the same gown and gloves for the care of more than one person. R4's room lacked any visible PPE outside to follow these guidelines. The surveyor knocked and opened R4's room door. R4 remained in bed but was now covered with linens as nursing assistant (NA)-B was observed standing in the room. Next to the bathroom was a clear, hard plastic floor-based container which had blue-colored gowns and gloves inside. However, NA-B then did not have any other PPE on aside from a pair of gloves despite the posted signage. Following, at 7:15 a.m., NA-B was interviewed and verified they were the staff providing cares to R4 for the past 15 minutes or so adding R4 had an incontinent stool which needed to be cleaned up. NA-B verified the posted EBP instructions on R4's doorway and stated staff were supposed to use them as R4 had a urinary catheter. NA-B verified they helped R4 with peri-care and personal cares without use of a gown adding R4 had an emergency with the incontinent stool which caused them in a hurry to just assist rather than use the PPE. NA-B stated they had been educated on using the EBP adding it was important to help protect the client. NA-B verified they were assigned care to the other residents on the same hallway adding, I work with all of them. On 12/4/24 at 7:22 a.m., R4 was interviewed while laying in her bed. R4 had a visible catheter drainage bag attached to the bed frame. R4 stated the PPE supplies were just brought inside her room the evening prior (on 12/3/24) by the nurse manager but had been stored outside the door prior to that. R4 stated she was unsure why the supplies were moved inside her room. R4 stated staff use of the PPE was inconsistent during her cares adding aloud, Sometimes they don't use them [gowns]. 48065 R28 R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact, had no behaviors and did not refuse personal cares. The quarterly MDS indicated R28 needed maximal assistance with showers, dressing, toileting and was dependent with all aspect of mobility. R28's Clinical Diagnosis report printed 12/5/24, indicated diagnoses of multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves, disrupting the communication between the brain and the body), pressure areas (an injury to the skin and underlying tissue resulting for prolonged pressure on the skin), neurogenic bladder, neurogenic bladder (lack of bladder control due to spine or nerve injuries) , constipation, epilepsy (brain disorder that causes recurring, unprovoked involuntary movement), quadriplegia (paralysis that affects all a person ' s limbs and body from the neck down) , and colostomy status (a surgical procedure that creates an opening in the abdomen to divert stool from the colon to a bag or pouch). R28's progress note dated 11/20/24 at 5:09 a.m., indicated R28 had a peripherally inserted central catheter (PICC) line inserted in the right upper arm. R28's Clinical Orders report printed 12/4/24, indicated an order dated 11/20/24 for vancomycin HCL (antibiotic medication) intravenous (IV) solution 1250 milligrams (mg)/250 milliliters (ml) for methicillin-resistant staphylococcus aureus (a blood borne infection or MRSA) infection. R28's Care Plan, printed 12/4/24, indicated R28 had MRSA requiring IV antibiotic therapy. The care plan lacked documentation about R28's PICC line and enhanced barrier precautions (EBP). R28's medication administration record (MAR) and the treatment administration record (TAR) for the months of November and December 2024 lacked information about R28's infection precautions. During observation on 12/4/24 at 10:15 a.m., R28's room door had an orange-colored sign posted on it which included multiple STOP signs and directions reading, Enhanced Barrier Precautions . Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities . Changing briefs or assisting with toileting [,] Device care or use: central line, urinary catheter, feeding tube . Do not wear the same gown and gloves for the care of more than one person. a personal protective equipment (PPE) bin containing gloves, disinfectant, and gowns was outside R28's room door. Registered nurse (RN)-F entered R28's room without wearing gloves or a gown. Once in the room RN-F put on gloves and without a gown on proceeded to start R28's IV antibiotic through the PICC line. During interview on 12/4/24 at 10:47 a.m. RN-F stated she failed to follow EBP precautions. RN-F stated I didn't wash my hands before putting on gloves and didn't wear a gown, it's not right. RN-F stated this was a concern due to a possible spread of infection. During interview on 12/4/24 at 10:56 a.m., nurse manager (RN)-C stated the nurses need to put on gloves and gowns when working with EBP resident to prevent infections. 49034 R12 R12's quarterly MDS dated [DATE], indicated R12 had moderately impaired cognition and was diagnosed with heart failure, asthma, and dementia. R12's wound care note dated 11/27/24, indicated R12 had an unstageable pressure ulcer on her coccyx that the wound care team was assessing weekly. The note indicated nursing staff were to cleanse the wound and then cover with Santyl (collagenase enzyme topical medication used in wound healing) and a foam dressing daily. During an observation and interview on 12/3/24 at 8:08 a.m., nursing assistant (NA)-E was observed entering R12's room and was not observed to have on a gown or gloves. R12's room was observed to have a sign on the door indicating staff were to utilize EBP with a cart containing PPE immediately outside the door. NA-C was then observed to room also with gown or gloves. At 8:22 a.m., NA-C stated they had assisted R12 with getting out of bed into her chair. NA-C stated she did not think the EBP sign on R12's door was accurate, so she had not worn a gown when transferring R12. At 8:26 a.m., NA-E was observed exiting R12 room and stated R12 was on EBP for a wound she had. NA-E stated she had not worn a gown while assisting R12 to transferring from the bed to the chair as this was not needed unless they were doing wound care. During an interview on 12/4/24 at 2:02 p.m., the director of nursing (DON) stated staff were expected to follow the EBP signs placed on the door that instructed them on when to utilize additional PPE such as during personal cares. On 12/5/24 at 10:44 a.m., the DON stated she expected PICC line dressings changes to be completed weekly along with a daily cap change. The DON stated the nurse managers were expected to order these when the PICC line was placed so nursing staff could document this in the treatment administration record (TAR). The DON stated she would be confirmed about the PICC line possibly getting infected if these dressing changes were not occurring. The facility Enhanced Barrier Precautions policy dated 11/13/24, indicated EBP would be utilized for residents with chronic wounds and indwelling medication devices. The policy indicated staff should utilize gowns and gloves during high-contact care activities such as dressing, transferring, and device care (central lines, catheters, etc.) for residents on EBP.

Based on observation, interview and document review, the facility failed to ensure privacy was maintained during the provision of personal cares for 1 of 1 resident (R4) observed to be receiving peri-care with their window blinds open to the outside parking lot. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and demonstrated no delusional thinking. On 12/4/24 at approximately 7:05 a.m., R4 was observed laying in her bed from the parking lot with her room lights on, and the window blinds pulled up approximately three-quarters (i.e., 3/4) of the window height. R4's window was at ground-floor level and a single female staff member was observed dressed in dark-blue colored scrubs and assisting R4 whose legs and peri-area were exposed and visible from the sidewalk leading up to the main entrance of the care center. The staff member had gloves on and was observed wiping R4 with a cloth on her peri-area. At 7:09 a.m., the surveyor knocked and opened R4's room door. R4 remained in bed but was now covered with linens as nursing assistant (NA)-B was observed standing in the room. NA-B was alerted to the open blinds, looked at them and stated aloud, Oh, thank you. NA-B then finished care after closing the blinds. Following, at 7:15 a.m., NA-B was interviewed and verified they were the staff providing cares to R4 for the past 15 minutes or so. NA-B verified the blinds were left open but should have been closed adding because it was still dark out it had confused them and maybe caused them to not recognize they were open. NA-B stated they had told R4 the blinds were left open during care after the surveyor knocked on the door, and R4 responded in a calm manner adding, She [R4] was not even aware someone could see her. On 12/4/24 at 7:22 a.m., R4 was interviewed, and stated staff did not always close the blinds while doing cares adding, Sometimes yea [they do]. R4 stated she wasn't necessarily bothered by them being left open, however, then added aloud, Sometimes I'd rather have them closed. R4 stated NA-B did not ask her about leaving the blinds open prior to starting care just prior adding at least being asked or offered about them (i.e., closed or open) would be appreciated. When interviewed on 12/4/24 at 10:41 a.m., the director of nursing (DON) stated staff receive competency training which included the need to ensure privacy was provided during provision of care. DON stated staff should close the doorway and ensure the blinds were pulled down before cares adding such was kind of an expectation. DON stated providing privacy during cares was needed to promote resident dignity along with ensuring their rights to privacy. Further, DON stated they did periodic audits on care, including privacy being provided with it, however, had not completed any of them in recent time. A facility policy on privacy with cares was requested, however, none was received.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 residents (R112) reviewed for Physician Orders for Life Sustaining Treatment (POLST) had the correct code status (i.e., full code, DNR) information outlined within the medical record. This could cause R112 to receive resuscitation efforts (i.e., CPR) against his wishes. Findings include: R112's Medical Diagnosis listing, printed [DATE], identified R112's medical history and diagnoses. This identified R112 had a history of suicidal ideation, opioid use, sleep apnea, diabetes mellitus, and acute kidney failure. R112's PointClickCare (electronic medical record) displayed demographic information (i.e., room number, date of birth, allergies) along the top with a banner-like field. This identified R112 admitted to the care center on [DATE], and included a section labeled, Code Status, which directed, Advanced Directives [click-able link] Code Status: Full code. The link, when clicked, brought up another click-able link to a document saved as, POLST.pdf, with an assigned category reading, Advanced Directives. R112's POLST, dated [DATE], identified R112's name along with options to place a checkmark next to their corresponding wishes in the event he would be found without pulse or breathing. However, a handwritten X was placed next to the option which read, Do Not Attempt Resuscitation / DNR (Allow Natural Death), along with an additional handwritten X was placed next to, Comfort-Focused Treatment (Allow Natural Death) ., The POLST was signed by R112 and the nurse practitioner (NP). There were no additional POLST(s) located in R112's medical record or rationale to explain why R112 was recorded as 'Full Code' on the EMR banner of information. The main-level care center nursing station, located central to each of the respective hallways (i.e., units), contained a black-colored binder labeled, 400 Hallway POLSTS, on the spine. This was reviewed and contained R112's same scanned POLST (dated [DATE]) which directed DNR/DNI orders. When interviewed on [DATE] at 9:41 a.m., R112 recalled someone having a conversation with him about his wishes should he be found without a pulse. R112 stated he wanted nothing done and just let me die. R112 verified a DNR/DNI was his choice as outlined on the completed POLST form (dated [DATE]). When interviewed on [DATE] at 11:51 a.m., registered nurse (RN)-G stated they were currently assigned care for R112 and had worked with him prior. RN-G stated if R112 was found without a pulse or not breathing, they would check him and call for help. RN-G explained they would check the [EMR] banner first to see R112's code status but then double check with the POLST before starting CPR on him. RN-G stated the nurse managers typically reviewed the POLST(s) with each resident and the floor nurse was responsible to update the EMR with the information. RN-G reviewed R112's EMR banner (which indicated 'Full Code') and his POLST (which indicated DNR) and verified they conflicted. RN-G stated they were obviously contradicting and needed to be clarified, however, RN-G stated they would go with this as pointing to the POLST. RN-G stated the EMR and POLST should match otherwise R112 could get CPR when it wasn't wanted adding, It's very huge risk, huge risk there. On [DATE] at 12:18 p.m., the director of nursing (DON) and registered nurse unit manager (RN)-C were interviewed, and DON verified they had reviewed R112's medical record. DON stated the code status information was entered into the EMR via a collective effort but verified the EMR and POLST should match adding the nurse manager should double check to ensure accuracy. RN-C stated R112 admitted on a Friday and they were not there adding they didn't 'double check' the POLST on Monday as they believed the NP had not signed it yet. DON reiterated the expectation was to check the POLST the following day. DON stated it was important to ensure the information matched so staff would be honoring the resident wishes and so there would be clear directions on what they're supposed to do if R112 was found without pulse. Further, DON verified the completed POLST (dated [DATE]) was the only one for R112 they could locate. A provided POLST, DNR, ACP policy, dated ,d+[DATE], identified a physician order with either DNR or Full Code was required in all medical records. The policy directed if resuscitation was needed, the decisions outlined within the POLST would be followed. Further, the policy directed POLSTs would be contained, . in the front of the chart under the Advanced Directive tab. However, the policy lacked information or direction on how staff would ensure the EMR and POLST matched.

Based on observation, interview and document review, the facility failed to clean and maintain a resident's wheelchair for 1 of 1 residents (R39) reviewed for safe, clean and homelike environment. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 was cognitively intact and had no delusions, no hallucinations, or behaviors. The quarterly MDS also indicated R39 was dependent with dressing, toileting, and personal hygiene and indicted R39 needed moderate assist with oral hygiene and was independent eating. R39's clinical diagnosis report printed on 12/5/24, indicated diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture), essential hypertension (high blood pressure) , functional quadriplegia (a condition that causes a person to be unable to move due to a severe disability from another medical condition), and constipation. R39's care plan printed on 12/5/24, indicated R39 independently used a motorized tilt wheelchair for locomotion. During observation on 12/2/24 at 2:10 p.m., R39 was sitting on her motorized wheelchair. Dust, and food particles were observed on R39's wheelchair joystick controller, arms rest, foot pedal and wheelchair's frame. The wheelchair cushion and a metal plate covering the motor behind the footrest had yellowish/grey dry stains. During interview on 12/3/24 at 2:26 p.m. nursing assistant (NA)-C verified R39's was unclean. NA-C stated housekeeping was responsible to clean resident's wheelchairs and added NAs don't wipe wheelchairs, it's not expected. During interview on 12/4/24 at 12:31 p.m., NA-B stated we [NAs] clean the wheelchair if it was dirty. NA-B stated she didn't know if there was a cleaning schedule for the wheelchairs but I will think the NAs will wipe the motorized chairs. During interview on 12/4/24 at 1:18 p.m., NA-D stated 'I don't know who cleans the wheelchairs. NA-D added If I see a dirty spot I will clean it up. During interview on 12/4/24 at 12:29 p.m., housekeeper aid (H)-A stated housekeeping cleaned the non-motorized wheelchairs when residents discharged from the facility and the electric WC's were cleaned by the NAs. During interview and observation on 12/5/24 at 8:33 a.m., R39 was sitting on her motorized wheelchair and the wheelchair still had dust, food particles and stains. R39 stated nobody cleaned her wheelchair and added I go out places like the library, doctors' appointments and other places with my wheelchair looking like this [used her hands showing her WC], it's dirty and I don't like it. During interview on 12/5/24 at 8:50 a.m., registered nurse/nurse manager (RN)-C stated the wheelchairs could be cleaned by nursing or housekeeping. RN-C verified R39's wheelchair was dirty and stated, we need to put an order to clean her [R39] chair. RN-C stated the concern with R39's wheelchair being dirty was it could lead to disease or infections. During interview on 12/5/24 at 9:48 a.m., director of nursing (DON) stated her expectations was wheelchairs would be cleaned and if the nursing staff they were unclean, they should be cleaned right away. The DON stated the concern using a unclean wheelchair joystick controller was an infection control issue due to potential germs and bacteria. DON also stated, R39 going out into the community using an unclean wheelchair was also a dignity issue. A facility's policy related on cleaning of wheelchairs was requested, however, none was received.

Based on interview and record review, the facility failed to provide the ordered respiratory care and obtain an order to administer oxygen for one of one resident (R1) reviewed for respiratory status. R1 was harmed when he was admitted to the facility with an order to provide respiratory chest physiotherapy three times a day, was not provided the ordered therapy, contributing to R1's death. In addition, R1 received oxygen therapy without a physician order. Findings include: R1's medical record indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. R1's additional diagnoses included bronchiectasis, dysphagia, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). R1 was discharged from the facility on [DATE]. R1's hospital discharge summary dated [DATE] indicated R1 was inpatient from [DATE] to [DATE]. R1's admitting diagnosis was respiratory failure with hypoxia, including acute kidney injury, delirium, pneumonia, two-time renal transplant, hypertensive heart and chronic kidney disease with heart failure and unspecified stage chronic kidney disease, hypothyroidism, anemia, pacemaker cardiac status, immunodeficiency due to drugs, congestive heart failure, urinary retention, schizoaffective disorder (chronic), and infection and inflammatory reaction due to cystostomy catheter. R1 was diagnosed with severe sepsis from Escherichia coli (E. coli) and Enterobacter cystitis in the setting of suprapubic catheter with possible component of community-acquired pneumonia. R1's hospital course was complicated by recurrent episodes of transient hypoxia thought to be due to either mucus plugging or recurrent aspiration events. R1 continued to have these episodes despite transition to jejunal feeds and while taking nothing by mouth (NPO). R1 was on a modified diet for dysphagia and had scheduled dialysis. R1's heath was improving, and he was free of communicable disease. It was determined R1 required skilled nursing care. Respiratory therapy recommendations included DuoNebs followed by Hypertonic saline nebulizers three times a day done simultaneously with chest vest therapy (Also called chest physiotherapy. Chest physiotherapy is a treatment used to improve breathing by the indirect removal of mucus from the breathing passages.) The facility was to ensure nebulizer was cleaned daily. R1's treatment administration record (TAR) dated [DATE] indicated nursing was to complete a pre-and-post dialysis assessment before dialysis and on return from dialysis on Mondays, Wednesdays, and Fridays. The pre-dialysis assessment included vital signs, level of consciousness, if the resident had experienced any muscle cramping, itching, discomfort, or pain, and if there was a thrill and bruit noted. The post-dialysis assessment included vital signs, if the resident had experienced any dizziness, nausea, vomiting, fatigue, chills, shaking, muscle weakness, skin flushing, itching, or diarrhea, if there was a thrill and bruit noted, and a place to enter access site notes. On [DATE], the TAR signed by registered nurse (RN)-A indicated the pre-and-post dialysis assessment was completed but an assessment was not completed. The pre-and-post dialysis assessment had only been completed on [DATE], [DATE], and [DATE] during his admission. R1's progress note written by the social worker (SW) on [DATE] at 1:39 p.m. indicated the SW was working on getting an order for the vest. R1's medical record indicated no documentation regarding R1's chest physiotherapy vest, the order for the chest physiotherapy vest, or treatments between [DATE] and [DATE]. R1's minimum data set (MDS) dated [DATE] indicated R1 had asthma, COPD, or chronic lung disease such as chronic bronchitis. The MDS indicated R1 received zero days of respiratory therapy for fifteen minutes in the last seven days. R1's provider visit notes dated [DATE] indicated R1 had not been getting his percussion vest treatments and the provider had educated nursing staff on the vest treatments. The provider indicated R1 was to have his percussion vest used routinely. R1's progress note written by the SW on [DATE] at 2:21 p.m., the SW stated R1 has orders for a vest. R1's physician order dated [DATE] indicated staff to administer oxygen two liters as needed via nasal canula. R1's TAR dated [DATE] indicated R1 was to use oxygen as needed at two liters per minute via nasal cannula as needed for shortness of breath and to record rate as needed. This treatment was not signed off by nursing staff from [DATE] to the time R1 was discharged . The TAR indicated staff was to obtain R1's oxygen level and to record the results every shift. R1's TAR indicated nursing staff was to ensure that R1's portable oxygen tank was filled prior to use of N.O. R1's TAR indicated nursing was to check oxygen tubing and set up for usage weekly on the night shift and replace it is had been used. R1's physician orders dated [DATE] indicated R1 was to receive vest treatment therapy every night with nebulizer treatment for bronchiectasis. There was no summary of the provider visit with R1 or the provider assessing R1's lung sounds. R1's TAR dated [DATE] indicated R1's Pul vest was to be used every night with his nebulizer treatment for fifteen minutes one time a day. The dates this treatment was completed was [DATE], [DATE], and [DATE]. This order was discontinued on [DATE] when R1 was hospitalized for an unrelated fall. R1's hospital discharge record indicated R1 was admitted to the hospital from [DATE] to [DATE] after a witnessed fall. R1's admitting diagnosis was a fall including closed fracture of proximal end of right ulna, laceration of left lower extremity, hypomagnesemia, hypophosphatemia, acute hypokalemia, cardiac pacemaker, dysphagia, end stage renal disease, closed fracture of right olecranon process, hypotension, malnutrition, hypovolemia, and anemia. Assessments indicated R1 had crackle/coarse and expiratory wheezes in all lobes of R1's lungs. During R1's hospitalization , respiratory therapy administered R1's nebulizer and performed chest physiotherapy. R1 was to continue with his vest therapy and saline nebulizers and DuoNebs as ordered. R1's medication administration record (MAR) dated [DATE] indicated R1 was to receive ipratropium-albuterol inhalation solution with the directions to inhale 3 milliliters (mL) orally via nebulizer three times a day for shortness of breath. The order indicated for staff to listen to R1's lungs and to record if R1's lungs were clear, crackles, wheezes, rales, or rhonchi. R1's brief interview for mental status (BIMS) dated [DATE] indicated R1 had a score of 14, which indicated R1 was cognitively intact. R1's Admission/Readmission and Care Plan Nursing assessment dated [DATE] indicated R1 was not on a nebulizer, R1 did not have oxygen needs, and R1 had normal lung sounds. R1's progress note written by the nurse manager (NM) on [DATE] at 4:58 p.m. indicated R1 did not have any respiratory devices. R1's vital signs documented on [DATE] at 2:19 a.m., indicated R1's respirations were twenty breaths per minute, ninety-four percent oxygen on room air, blood pressure was one hundred ten over seventy millimeters of mercury (mmHg) while lying and the blood pressure was taken on his right arm, pain level was zero, pulse was eighty-four beats per minute, and temperature was ninety-six point nine degrees Fahrenheit taken by tympanic. R1's vital signs documented on [DATE] at 2:01 p.m. indicated R1's oxygen was ninety-six percent while R1 was on oxygen via nasal cannula, blood pressure was one hundred twenty over seventy-four mmHg while lying and blood pressure was taken on right arm, pain score was five, pulse was seventy beats per minute, and lungs were clear. R1's temperature and respirations were not taken at this time. Medical records indicated lung sounds were clear on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. R1's progress note dated [DATE] at 5:56 p.m., the NM stated he received a voicemail from the dialysis clinic that R1 had shortness of breath, so the dialysis center sent R1 to the emergency room . No additional progress notes were made on [DATE]. R1's hospital discharge record dated [DATE] indicated R1 was transferred from the dialysis clinic to the hospital due to hypotension and shortness of breath. Hospital records indicated R1 was admitted to the hospital due to acute respiratory failure with hypoxia, COPD exacerbation, and pneumonia of left lower lobe due to infectious organism. The records indicated R1 was diagnosed with methicillin-resistant staphylococcus aureus (MRSA). Hospital records indicated family member (FM)-A indicated she saw R1 at the facility on [DATE] and at that time R1 had been visibly distressed, was concerned R1 was not getting his physiology vest treatments, appeared to be disoriented, was exhausted, and poorly cared for. The hospital records indicated R1 had bilateral significant wheezing, crackles, and had coarse sounds in his lungs. Hospital records indicated R1 had respiratory symptoms brewing for a few days. The hospital records indicated R1 had a history of mucous plugging and was unclear whether he was getting his chest physiotherapy at the facility. Hospital records indicated R1 had severe sepsis from community acquired pneumonia, COPD, and aspiration pneumonitis. Hospital records indicated R1 was transferred to the intensive care unit (ICU). Hospital records indicated R1 continued to have increased oxygen requirements, was altered, unresponsive to questions, and unable to tolerate secretions. Hospital records indicated R1 died on [DATE] due to severe sepsis with shock, pneumonia of left lower lobe due to infectious organism, and acute hypoxic respiratory failure. During an interview with nursing assistant (NA)-B on [DATE] at 12:32 p.m., NA-B stated R1 did not have respiratory problems during his admission at the facility. During an interview with registered nurse (RN)-A on [DATE] at 12:49 p.m., RN-A stated he was R1's nurse on [DATE] and R1 had gone to dialysis that morning. Then on [DATE] at 2:48 p.m., RN-A stated he believed he had taken R1's vital signs on [DATE] but could not remember what the vital sign readings were. RN-A stated from what he remembered, R1 had been a little more tired than his baseline, but that his appearance was nothing out of the ordinary. RN-A stated he does not remember R1's lungs being wheezy on [DATE]. On [DATE] at 3:00 p.m., RN-A stated he did not see any concerns with R1 leaving for dialysis on [DATE]. During an interview with the NM on [DATE] at 12:59 p.m., the NM stated R1's dialysis center called him and left a voicemail from the DN stating R1 was having shortness of breath and the dialysis center sent R1 to the hospital and directed him to follow up with the hospital. The NM stated R1 never complained of shortness of breath to him. The NM stated R1 was on continuous oxygen, and he was compliant with his oxygen use. The NM stated he would perform oxygen audits on the residents to see how much oxygen residents are on versus the resident's respirations but noted he did not perform any oxygen audits on R1. During an interview with R1's guardian on [DATE] at 1:09 p.m., the guardian stated R1 had issues with his lungs where he would not cough up his mucous. The guardian stated R1 had an order for a vest treatment weeks prior to his admission to the facility. The guardian stated the vest treatment would help R1 get rid of the mucous in his lungs. During an interview with FM-A on [DATE] at 1:55 p.m., FM-A stated R1 had not been consistently receiving his vest therapy. FM-A stated she would ask R1 if he was getting his vest therapy and R1 stated he was not getting his vest therapy. FM-A stated R1 was cognitively intact. FM-A stated she visited R1 on [DATE] and she had asked R1 if he received his vest therapy, and he stated no. FM-A stated she had called the director of nursing (DON) and left her a voicemail stating R1 was supposed to be getting his vest therapy with his nebulizer treatments, but FM-A stated she had not received a call back. FM-A stated the respiratory specialist at the hospital prior to R1's admission to the facility stated R1's vest treatment was key to R1 staying alive. During an interview with the DON on [DATE] at 3:44 p.m., the DON stated once a resident is accepted and comes to the facility, the nurse managers who review the admission paperwork and till put the orders into the resident's MAR and TAR. The DON stated her expectation was when residents were admitted to the facility with treatment orders, the orders would be transcribed, and the nurses would follow those treatment orders. The DON stated the facility was notified by FM-A that R1 was supposed to be receiving vest treatment orders but that the facility did not have an order for the vest treatments. The DON could not state when FM-A told her R1 was supposed to be receiving his vest treatments. The DON stated the facility received an order for the vest treatments by the in-house physician and put the vest order in R1's TAR on [DATE]. The DON stated the order was discontinued on [DATE] because R1 went to the hospital. The DON stated if a resident was going to be in the hospital for over twenty-four hours, then the facility will discontinue all orders and then revisit the resident's orders when they come back from the hospital. The DON stated if she could remember, the facility did not have an order for the vest treatments when he was admitted to the facility and the facility did not have a vest treatment order prior to [DATE]. The DON stated the vest treatment order was missed by the nurse managers because the actual order was not in R1's after visit summary from his hospitalization from [DATE] to [DATE] or his hospitalization from [DATE] to [DATE]. During an interview with the DON on [DATE] at 4:22 p.m., the DON stated she had been trying to find a respiratory care and services policy and procedure, but she could not find one. The DON stated the facility uses the standards of care. The DON stated the facility did not have a standards of care policy or procedure. During an interview with the dialysis nurse (DN) on [DATE] at 9:13 a.m. indicated R1 came to the dialysis center on [DATE] with labored breathing. DN stated family member (FM)-A came to the dialysis center on [DATE] and stated R1 was supposed to get a vest treatment for mucous plugs and R1 had been declining the weekend prior to [DATE]. DN stated FM-A stated R1 stated he was not receiving his vest treatment. DN stated she sent R1 to the emergency department via ambulance due to his labored breathing. It is unknown whether the dialysis clinic started R1's dialysis. During an interview with the nurse practitioner (NP) on [DATE] at 9:23 a.m., the NP stated R1's hospital discharge paperwork from [DATE] indicated R1 had an order for vest therapy and her order for the vest therapy on [DATE] was just a continuation of that. The NP stated when she saw R1 he stated he was supposed to be receiving his vest therapy and he was not sure the facility had an order to provide that service. The NP stated she had just written the order for the vest treatment anyways. The NP stated the vest treatment was brought up in a conversation between R1 and herself and she had written the vest therapy order to be safe. The NP stated she did not have access to R1's admission paperwork for a month prior to writing the vest therapy order. The NP stated if R1 had not received his vest therapy, R1's lungs would become more congested, and mucus would build up. The NP stated she would have had to consult with the pulmonary specialist about further complications R1 could have received for not receiving his vest therapy. An interview was attempted with the dialysis center on [DATE] at 2:31 p.m., 3:17 p.m., [DATE] at 9:20 a.m., 10:07 a.m., and 3:35 p.m., but the phone kept ringing and was unable to leave a voicemail. During an interview with NA-C on [DATE] at 3:06 p.m., NA-C stated she did not remember R1 wheezing on [DATE]. NA-C stated he looked very tired on [DATE]. NA-C stated she did not remember what R1's appearance looked on [DATE] because she was not focused on R1's appearance. NA-C stated she and RN-A were the only ones who had interactions with R1 on the morning of [DATE]. During an interview with the DON on [DATE] at 3:37 p.m., the DON stated the nurse managers would be completing the resident's orders upon admission. The DON stated if a resident would be in the hospital for over twenty-four hours, the facility would discontinue all physician orders, but would keep the house standing orders if the resident had any. The DON stated the facility assessed R1's lung and respiratory status on [DATE] and his lungs were clear. During an interview with the medical doctor (MD) who saw R1 while he was hospitalized from [DATE] to [DATE] on [DATE] at 9:25 a.m., the MD stated R1's missed vest treatments played a huge part in his passing. The MD stated he had severe sepsis probably from the pneumonia from the mucus in his lungs. The MD stated the vest treatments would have helped cleared the mucus in his lungs. During an interview with licensed practical nurse (LPN)-A on [DATE] at 2:15 p.m., LPN-A stated she worked with R1 on [DATE] but could not tell what R1's condition was that day. LPN-A stated she did not know R1's baseline due to her being newly employed by the facility. LPN-A stated she did not think she had any concerns with R1 on [DATE]. LPN-A stated if she did have concerns with R1 on [DATE] she would have called and reported it to the physician and she does not recall having to contact the physician. During an interview with DON on [DATE] at 2:26 p.m., the DON stated it would have been the nurse working with R1 on [DATE] that deemed him appropriate to send R1 to dialysis that day. During an interview with RN-F on [DATE] at 3:02 p.m., RN-F stated R1 did not get out of bed on [DATE] and RN-F was concerned about it. RN-F stated R1 got out of bed on [DATE] because FM-A was visiting, and RN-F had no concerns. During an interview with the administrator on [DATE] at 4:09 p.m., the administrator stated his expectations when it comes to a resident being admitted to the facility would be the nurses and the nurse managers will enter the orders and communicate with the pharmacy to ensure the facility had everything for that order. The administrator stated if the nurses or nurse managers had any questions or concerns with the order, his expectation would be the nurses and nurse managers would seek clarification from the provider who wrote the order. The administrator stated he would expect nurses and nurse managers to go through a resident's admission paperwork to look for treatments and medication orders prior to the resident being admitted to the facility. A respiratory services and care policy and procedure was requested, and none was received.

Based on interview and document review the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) and did not initiate cardiopulmonary resuscitation (CPR) according to the resident's wishes identified on the POLST of record for 1 of 3 residents (R1) who wished to have CPR. This has the potential to effect all 43 residents who had (CPR status) in the facility. The facility immediately implemented corrective action, so the Immediate Jeopardy (IJ) was issued at past noncompliance. The immediate jeopardy began on [DATE], at approximately 11:15 p.m. when R1 had no respirations or pulse, and CPR was not initiated. The IJ was identified on [DATE], and the administrator, the interim administrator, and director of nursing (DON) were notified of the IJ at past noncompliance on [DATE], at 1:55 p.m. The immediate jeopardy was removed on [DATE], and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's significant change Minimum Data Set, (MDS), dated [DATE], indicated R1 had moderate cognitive impairment and diagnoses of lung cancer and chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems). R1's POLST document, dated [DATE], identified that in the event of cardiopulmonary arrest (heart stops), staff would attempt resuscitation and begin CPR (cardio pulmonary resuscitation). R1's POLST was confirmed by R1 and advanced nurse practitioner (APRN) on [DATE], indicating R1 confirmed her wishes to be full code (attempt resuscitation with chest compressions and rescue breathing). R1's progress note, dated [DATE], indicated R1 signed on with hospice today, R1 will remain a full code at this time and the hospice nurse will talk with R1 regarding code status at a separate time. R1's progress note, dated [DATE], indicated on [DATE] at 11:05 p.m. licensed practical nurse (LPN)-A had just given registered nurse (RN)-A report to the on-coming shift when family member (FM)-A reported that R1 was having shortness of breath, upon assessment R1 was breathing. LPN-A left R1's room to update hospice. An additional note dated [DATE] indicated that on [DATE] at 11:15 p.m. RN-A called hospice to update them on R1's decline when FM-A reported to RN-A that R1 had passed. When RN-A went to go recheck on R1, paramedics had arrived and transported R1 to the hospital. An additional note indicated R1 was at the hospital on [DATE] at 1:30 a.m. where R1 died . Review of police Body Camera 3 footage, identified on [DATE], at 11:34:11 p.m. a uniformed unknown police officer (UPO)-1 walked into R1's room. R1 was lying in the bed, eyes were closed, had nasal cannula on from an oxygen machine that can be heard running. R1 had no movement. Present in the room was FM-A standing at bedside. UPO-1 walked to R1's bedside and put gloves on at 11:34:31 p.m. At this time RN-A walked into the room, UPO-1 asked RN-A if R1 had any paper work regarding R1's DNR status. RN-A replied, she called hospice, they were coming, so we did not do anything with R1. UPO-1 placed his gloved hand on R1's chest and stated, R1 is still warm, then performed a sternal rub with no response. At 11:34:55, UPO-A started chest compressions. At 11:54:34 p.m. UPO-2 asked FM-A the time period in regards to when R1 first started choking. FM-A stated that a minute had passed from the time she told the nurse and had entered R1's room, she (the nurse) had checked R1's oxygen level on her finger. FM-A stated no one here started CPR at all. On [DATE], at at 12:01 a.m. unknown paramedics were continuing to do CPR and announced a pulse for R1. At 12:04 p.m. hospice nurse (HN)-A and nurse manager (NM)-A were standing in the hallway next to R1's room. HN-A stated there was a discrepancy with R1's code status and indicated R1 was DNR and was trying to find R1's DNR paperwork. HN-A stated she was told R1 passed away and was here to do a death visit. At 12:07 a.m. R1 had a pulse and blood pressure, R1 was transported out of the facility on a gurney. At 12:09 p.m. UPO-2 told NM-A the first thing they found when they came in was R1's green POLST order form that indicated R1 was a full code. At 12:23:48 a.m. UPO-2 informed NM-A that facility staff did not initiate CPR on R1. NM-A replied, they didn't? I told the staff to get in the room and start CPR because she was a full code. R1's ambulance report, dated [DATE], indicated the facility called 911 at 11:29 p.m. for R1 who was in cardiac arrest, was not breathing and had no pulse. Upon arrival at 11:32 p.m. R1 was found in bed, no prior treatment had been provided with FM-A and FM-B present. According to FM-A, R1 was having a drink of water and started choking and FM-A had asked staff for help, this was when R1 went unresponsive and in Asystole (flatline-lasts about 5 minutes before brain death begins). R1's Hospice discharge visit note dated [DATE], indicated the facility had called hospice tele-med and reported R1 was gasping for air while on oxygen, while triage was on the phone it was reported that R1 had stopped breathing and passed away. Another call was received from the facility asking what R1's code status was and if CPR should be done. HN-A informed facility staff to not do CPR as R1 was a do not resuscitate do not intubate (DNR/DNI). Upon arrival to the facility EMS was performing CPR on R1 and they stated R1 had a pulse, because there was no POLST indicating DNR/DNI, R1 was transported to the hospital where R1 passed away. During a phone interview on [DATE], at 3:17 p.m. LPN-A indicated that on [DATE] she had worked the evening shift and was R1's nurse. LPN-A indicated during her shift R1's vital signs were within normal limits and her breathing was fine. Around 11:00 p.m. LPN-A had been giving report to registered nurse (RN-A) who was the overnight nurse that night. FM-A had come up to the nursing station reporting that R1 was having shortness of breath. LPN-A explained her and RN-A went to R1's room. LPN-A could not recall if R1 was breathing at that time, could not recall what R1's code status was (at that time), and was unaware who called EMS. LPN-A indicated neither herself or RN-A started CPR on R1. LPN-A stated she and RN-A had been at the nurses station when EMS arrived and EMS started CPR. During a phone interview on [DATE], at 8:59 a.m. LPN-B indicated she was working the evening of [DATE], but was not working on the same unit where R1 resided. LPN- B explained she had heard that R1 stopped breathing so called nurse manager (NM)-A while RN-A tried to get through to hospice. LPN-B stated NM-A had not answered right away and called back. The paramedics showed up at the facility but did not know who had called them. LPN-B indicated she had not started CPR on R1. During a phone interview on [DATE], At 9:06 a.m. RN-A indicated she was the oncoming nurse to work the night shift on [DATE]. RN-A explained she was at the nurse's station getting report from LPN-A. At around 11:00 p.m. FM-A reported R1 was having problems breathing. RN-A indicated she tried calling nurse manager (NM)-A and director of nursing, however they did not answer their phone. NM-A finally called back and directed to start CPR, because her POLST said full code. RN-A explained she also called the hospice nurse (HN)-A who directed her not to start CPR. RN-A indicated paramedics then arrived, she provided them with R1's POLST, then the paramedics started CPR. RN-A indicated R1 passed away. During an interview on [DATE], at 5:25 p.m. nurse manager (NM)-A indicated he was the nurse manager on call for the evening of [DATE]. He thought he had talked to LPN-B at around 11:24 p.m. who reported R1 had stopped breathing. NM-A explained he looked up R1's code status on his computer, saw she was full code, and told the nurse to immediately start CPR. NM-A stated he then immediately called 911. NM-A stated he then decided to drive to the facility because the hospice nurse had said R1 was DNR. When NM-A arrived at the facility he was told CPR had not been immediately started because HN-A had told the nurses not to start CPR. EMS started CPR and since there was not a DNR/DNI order, paramedics continued CPR until R1 was taken to the hospital where she later died . During a phone interview on [DATE], at 4:43 p.m. hospice nurse (HN)-A indicated she was the hospice nurse case manager for R1, however stated that HN-B completed R1's initial visit. R1's POLST should have been reviewed/revised and updated during the initial visit. HN-A indicated upon R1's admission to hospice, there was not an updated POLST in R1's record that identified R1 was DNR/DNI. The only POLST on record for R1 directed full code. HN-A stated patients on hospice could have a full code status, but that was not common. HN-A explained on [DATE], she was notified by the facility, R1 was not breathing and did not have a pulse. HN-A stated she directed the facility not to do CPR because at the time she had thought R1 was DNR/DNI. During a phone interview on [DATE], at 2:00 p.m. police officer (PO)-A indicated on [DATE], around 11:29 p.m. he received a call that R1 was not breathing, that she had taken a sip of water and started choking, they had notified the nurse (unknown) at the facility. NM-A was the one who called 911. PO-A stated he arrived at the facility at 11:33 p.m.; had found either EMS or another officer had started CPR per R1's POLST. To his knowledge no staff member from the facility-initiated CPR, staff were confused as to what R1's code status was. HN-A came out to the facility she had told us she was called by the facility. HN-A had told us R1 was DNR/DNI but she was unable to produce any POLST document that identified DNR/DNI. All that was available at the facility was the POLST order that was signed by R1 and her physician that identified she was full code. CPR was initiated per R1's POLST; the facility should have immediately initiated CPR per the signed POLST order. During an interview on [DATE], at 4:15 p.m. medical record personnel (MRP)-A, reported the only POLST in R1's record was dated [DATE] and identified R1 was full code. During an interview on [DATE], at 9:29 a.m. DON indicated the minute R1 stopped breathing the POLST order should have been checked. If the POLST identified full code, then CPR should have been started immediately. Facility policy entitled, CPR (Cardio Pulmonary Resuscitation), reviewed [DATE], if a resident experiences cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: in accordance with resident's advanced directives, in the absence of advanced directives or a do not resuscitate order. Facility follows the resident/family/guardian's wishes or intentions as indicated on the Directives to Define Scope of Medical Care or POLST document. Facility will provide adequately trained, 24-hour staffing to initiate basic life support within minutes of a residents cardiac or respiratory arrest. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: -Reviewed their policy and system to ensure not a system issue. -Reviewed current hospice resident's POLST to ensure they were consistent between facility and hospice. -On ,d+[DATE] and [DATE] education was provided to facility staff on CPR policy and adhering to advanced directives/POLST with a plan to continue to education staff prior to staff working their shifts. -Interviews with staff on [DATE] confirmed the facility's policies will be followed. -Developed and implemented a system to coordinate and communicate care with hospice to ensure POLST is consistent between the facility and hospice agency. Audits are being performed to ensure this is being completed.

Based on interview and document review, the facility failed to develop and implement a system for accurate transcription of physician and medication orders for 1 of 1 residents (R4) with a history of [CONDITION(S)] (CHF) who had medication omitted for 26 days, was subsequently hospitalized , and had a decline in activities of daily living (ADLs) as a result of the missed administration of medication resulting in harm. The facility further failed to ensure an International Normalized Ratio (INR a standard lab test used when taking blood-thinning medications) result was sent to the provider and obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to administer [MEDICATION(S)] (a blood-thinning medication) per the INR level for nine (9) days for 1 of 1 (R9) residents reviewed for [MEDICATION(S)] use. Findings include: R4's care plan dated 11/12/21, indicated R4 had an altered cardiovascular status related to [CONDITION(S)] ([CONDITION(S)]) loss of blood flow to part of the brain, which damages brain tissue), [CONDITION(S)] (CHF), [CONDITION(S)] ([CONDITION(S)]) is a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs), and hypertension ([CONDITION(S)]) high blood pressure. R4's care plan directed staff to observe, document, and report to medical practitioner as needed any signs of symptoms of altered cardiac output or pacemaker malfunction such as dizziness, [CONDITION(S)], difficulty breathing, pulse rate lower than programmed rate, or lower than base line blood pressure. R4's significant change status Minimum Data Set (MDS) dated [DATE], indicated R4 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's medication administration record (MAR) dated 5/22, indicated R4 was given one dose of [MEDICATION(S)] 40 mg for diastolic heart failure on 5/27/22. R4's MAR lacked indication R4 was given from 5/28/22, to 5/31/22, which was a total of 4 days of [MEDICATION(S)] was missed. R4's hospital discharge orders dated 5/27/22, indicated R4 had a medication regimen change with [MEDICATION(S)] 40 mg tablet every morning was added for HF chronicity. The hospital discharge orders lacked indicated a second check was completed by another nurse because of the lack of signature. R4's primary nurse practitioner (NP) admission to facility note dated 5/31/22, indicated R4's weight on 5/27/22, at 7:00 a.m. R4 weighed 121 lbs 9.6 oz. R4's was observed to be seated in her chair wearing four (4) liters of oxygen. Weight was 5/31/22, at the facility was 131 pounds. R4's dietary PN dated 6/1/22. at 11:37 p.m. indicated R4's current weight was 131.5 pounds. R4's NP's progress note dated 6/13/22, weight 128.4 lbs. Oxygen saturation (O2 sat) were 94 percent on room air. PN's indicated not on [MEDICATION(S)], weight is up, and had new [CONDITION(S)]. PN further indicated plan to add [MEDICATION(S)] 10 mg daily. R4's PN dated 6/17/22, at 4:42 p.m. indicated to monitor R4 for signs and symptoms of fluid overload due to recent weight gain. R4's MAR dated 6/22, indicated R4 had no doses of [MEDICATION(S)] were given to R4 from 6/1/22 to 6/22/22, which was a total of 22 days of [MEDICATION(S)] was missed. R4' weight summary indicated R4 weights: - On 6/1/22, R4's weight was 131 lbs. - On 6/3/22, R4's weight was 125 lbs. - On 6/4/22, R4's weight was 125 lbs. - On 6/9/22, R4's weight was 128.4 lbs. - On 6/14/22, R4's weight was 130.6 lbs. - On 6/16/22, R4's weight was 135 lbs. - On 6/17/22, R4's weight was 142 lbs. - On 6/18/22, R4's weight was 143 lbs. - On 6/19/22, at 10:24 a.m. R4's weight was 143.2 lbs. - On 6/19/22, at 12:27 p.m. R4's weight was 144 lbs. - On 6/20/22, p.m. R4 weight 142.6 lbs. R4's weight log lacked indication staff weighed R4 daily. R4's PN dated 6/22/22, at 11:02 p.m. indicated R4 was found to have shortness of breath, wheezing was audible on inhalation and expiration. Crackles heard in left lower mid lung with wheezes bilaterally in lungs. Orders received to send R4 to emergency room . R4's hospital Admission History and Physical dated 6/22/22, at 3:39 p.m. indicated R4 was sent to the emergency room for evaluation of shortness of breath from the facility. R4 was admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated R4 was discharged from a previous hospitalization to the facility on [DATE], but R4 reported she had progressively got shorter of breath and wheezing. R4's H&P indicated R4 abdomen was bloated and R4 reported she felt like she had gained quite a bit of weight, and significant lower extremity [CONDITION(S)]. R4 further reported to the hospital staff, when she was talking to family member (FM) -E, FM-E noted she sounded terrible. Her weight was documented at 144 pounds (lb) 6.4 ounces (oz). R4 echocardiogram demonstrated pleural effusion. R4's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 received 40 milligrams (mg) intravenous [MEDICATION(S)] in the emergency room and 40 mgs every eight (8) hours and a thoracentesis. R4's hospital discharge summary 7/1/22, indicated R4 was hospitalized from 6/22/22 to 7/1/22, for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) R4's admission nurse PN dated 7/1/22, indicated R4's weight was 122.4 lbs was 124 lbs. R4's Kardex dated 7/13/22, directed staff to obtain weight. On 7/12/22, at 11:14 a.m. during interview family member (FM)-E, stated she had concerns regarding her mom's care and how the facility missed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/22, at 1:17 p.m. registered nurse (RN)-C stated orders should be placed into the electronic medical record first, then the paper orders are placed on the shelf in the nurse's station for the next shift to complete a second check. The second check nurse would put their initials on the paper orders once reviewed. On 7/12/22, at 1:30 p.m. during interview with licensed practical nurse (LPN)-D stated the order processed is messed up and had changed recently. She further stated orders are sometimes placed anywhere in the chart rather than in the order section of the hard chart. LPN-D stated she is unsure of what the process for orders was and had seen orders get missed recently with another error of a resident not receiving medication. On 712/22, at 2:57 p.m. RN - B stated when we receive an order we enter into the electronic health record, put the order into the hard chart, and put out the red flag, set on the shelf for the next shift to review and sign off on. RN-B stated the orders should be put in the orders tab in the hard chart. On 7/12/22, at 5:30 p.m. nurse practitioner (NP) - A stated R4's recent hospitalization was directly correlated to not receiving her [MEDICATION(S)] 40 mg as ordered from her previous hospital discharge. NP-a further stated R4 could have avoided having a hospitalization and thoracentesis if [MEDICATION(S)] was given as ordered, follow up with assessment such as monitoring for [CONDITION(S)] and weights. NP-A stated R4 was medically complex and a brittle diabetic who needed to be managed carefully. NP-A further stated she is unsure of what happened other than a transcription error. On 7/13/22, at 12:17 p.m. when interviewed the director of nursing (DON) stated the admitting nurse transcribed the order wrong into the electronic health record. She further stated there was no second check completed to verify the order was entered correctly. DON further stated on 5/24/22, the process for entering orders changed from the health unit coordinator starting the process of entering the order into the electronic health record, reviewed by the nurse to sign off on. The facility changed the process to using a two step nurse review to sign off. The DON stated the staff were educated by the interim DON while she was out on leave and verified not all staff including agency were educated on the entering order process. DON further stated her expectation for staff would be to follow provider order and policy/procedure. On 7/13/22, at 4:50 p.m. when interviewed consulting pharmacist stated it was serious concern and significant medication error for R4 not to receive her [MEDICATION(S)] 40 mg for her [CONDITION(S)] for 22 days causing her to be admitted into the hospital. Consulting pharmacist stated he was not notified of the medication error but should be reviewed at the QAPI meeting. On 7/13/22, at 4:50 p.m. when interviewed consulting pharmacist stated it was serious concern and significant medication error for R4 not to received her [MEDICATION(S)] 40 mg for her [CONDITION(S)] for 22 days causing her to be admitted into the hospital. Consulting pharmacist stated he was not notified of the medication error but should be reviewed at the QAPI meeting. The facility policy on standing orders dated 1/17/22, directed staff for heart failure management to - Obtain daily weights. - For weight gain of greater than two and half pounds in 48 hours, or five pounds above admission weight. - Assess lung sounds, peripheral [CONDITION(S)], and respiratory effort daily. R9's hospital Transfer Orders dated 4/22/22, indicated R9 was to take [MEDICATION(S)] 3 mg daily for [CONDITION(S)] (A-Fib). R9's care plan dated 4/22/22, indicated R9 had an alteration in hematological status and directed staff to administer medication as ordered, observe for side effects, and report any complications. R9's care plan further directed staff to obtain lab and diagnostic work as order and report results to the provider as indicated. R9's significant change in status MDS dated [DATE], indicated R9 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS further indicated R9 required extensive assistance from two staff for activities of daily (ADL's) which included bed mobility and transfers. R9's MDS indicated R9 had impairment on one side of her upper extremity and both lower extremities. R9's Order Summary dated 7/13/22, lacked indication R9 was on [MEDICATION(S)] (medication is used to treat or prevent blood clots) and anticoagulant (blood thinner). R9's medication administration record (MAR) dated 7/22, indicated R9 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] sodium tablet three (3) mg one time a day at 6:00 p.m. on 7/9/22, through 7/11/22. - On 7/12/22, [MEDICATION(S)] use: Resident is on [MEDICATION(S)] and directed staff if no active [MEDICATION(S)] orders to follow up with provider and laboratory for orders, every shift. R9's MAR dated 7/22, lacked indication R9 received [MEDICATION(S)] from 7/1/22 to 7/9/22. Medication Error Incident report dated 7/11/22, indicated on 7/9/22, it was discovered nursing staff had not processed the INR lab draw that was done on 6/30/22, and staff did not contact the provider to get new [MEDICATION(S)] orders for the resident. R9's incident report indicated interdisciplinary team (IDT) reviewed the medication error. The root cause for R9's medication error was related to failure to complete INR/[MEDICATION(S)] process. A nurse reported she was not aware R9 received [MEDICATION(S)] due to no order being on R9's MAR. A [MEDICATION(S)] use alert was added to the resident MAR to alert R9 took [MEDICATION(S)]. R9's medication error incident report lacked indication education was completed to staff after this incident occurred. R9's treatment administration record (MAR) dated 7/22, directed staff to check an INR on 7/13/22 and call provider with results. R9's Anti-Coagulant Flow Sheet undated, indicated R9 had A-Fib, and on 6/30/22, R3 had a current dose of [MEDICATION(S)] 3 mg daily with an INR of 4.45 with new dose to be [MEDICATION(S)] 3 mg daily until 7/13/22. R9's Flow Sheet further directed staff to recheck INR on 7/13/22. On 7/13/22 R9's INR was 1.34. On 7/13/22, at 2:00 p.m. the DON stated another medication error occurred for R9 and R9 did not receive [MEDICATION(S)] for many days because nursing staff did not complete the medication order process. DON further stated staff had not been education after the medication error of R9 missing multiple days of missing her [MEDICATION(S)]. DON stated her expectation for staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/13/22, at 4:50 p.m. when interviewed consulting pharmacist (PHARM) stated it was serious concern and significant medication error for R9 not to receive her [MEDICATION(S)] for 9 days who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff should contact provider regarding immediately when [MEDICATION(S)] was not given, INR obtained, and obtain orders The facility's policy Transcribing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy further directed a second nurse will provide a second check on the order to ensure the order is correct. The facility policy directed the nurse to sign off the order to indicate the second checked was done. The facility's Medication Error Incident Report dated 7/12/22, indicated three residents had medication errors from 6/14/22, to 7/11/22.

Based on observation and record review, the facility failed to provide care and treatment necessary to prevent the development and promote the healing of two pressure ulcers for 1 of 1 residents reviewed, (Resident #1) Findings include: Multiple observations of Resident #1 on 12/9/11 revealed the following: At 8:15 a.m., Resident #1 was laying in her bed on her right side. She had foam boots on both lower legs and the right heel was wrapped in a gauze wrap. There were no pillows under the resident's legs to off-load the heels and elevate the legs. At 10:15 a.m., Resident #1 was observed in the main gathering area, asleep in her wheelchair. Her legs and feet were not elevated or supported on any pillows or a foot stool. On 12/9/11 at 10:45 a.m., Resident #1 was observed in her bed on her right side. Her left leg was elevated on one pillow. At 1:05 p.m., Resident #1 was observed in her room in her wheelchair. Her legs and feet were not elevated or supported on any pillows or a foot stool. Her right foot was off the foot support hanging with her toes touching the floor. At 1:30 p.m.,Resident #1 was transferred from the wheelchair back to bed. When the foam boot was removed from the left leg a pressure ulcer was noted to be on the inner aspect of the left heel. There was an approximately 1.5 cm by 1.5 cm. dark purple blister surrounded by an approximately 6 cm. by 3 cm. area of deep pink new skin. There were uneven peeling edges all around the new skin. Pieces of dried tissue were noted to be stuck inside the bottom of the foam boot. Review of the record established Resident #1 was admitted to the facility on [DATE] from another skilled nursing facility. Admitting [DIAGNOSES REDACTED]. Review of the admission skin assessment signed 10/6/11 revealed Resident #1 had no pressure or diabetic ulcers and the resident scored 15 on the Braden scale which is low risk for the development of skin breakdown. The interventions recommended according to the Admission Comprehensive Clinical assessment dated [DATE] were: -provide activity for the resident, -position the resident so that pressure is off the heels while the resident is in bed or in the wheelchair with pillows or protective boots, -turn or reposition the resident every 2 hours with in chair or bed, -provide a pressure reducing mattress, and cushion for the seat of the resident's wheelchair, -keep linens dry and wrinkle free, -apply lotion to the resident's skin twice daily and limit exposure of the skin to incontinence of urine or feces. -weekly skin inspection by licensed staff. Review of the admission care plan dated 10/6/11 revealed the only measure implemented was: pressure reduction mattress. Review of skin assessments dated on 10/7/11 and 10/14/11 revealed there were no pressure ulcers . A physician progress notes [REDACTED]. There was no other documentation in the record of the reason for the additional intervention. Review of a hand-written nurse note dated 10/27/11, revealed knowledge of a 4 cm (centimeter) by 2.5 cm dark purple blister on right heel and a 1.5 cm by 1.5 cm are open and draining serosanguinous drainage. The care plan dated 10/27/11 was created for alteration in skin integrity: Stage II on right heel. The new interventions included foam boots and turning every two hours. Review of the Nurse Aide Care Guides presented as current on 12/9/11 did not reflect the instructions to elevate Resident #1's legs with three pillows in bed or a foot stool when up in the wheelchair. Review of the PT- Therapist Progress Report dated and electronically signed on 10/18/11, stated that on 10/7/11, the physical therapist (PT) assessed Resident #1 as able to walk 40 feet using a 4-wheeled walker on even surfaces, with maximum assistance of two staff. The report also states Resident #1 is able to transfer, (clarified as a pivot transfer) with maximum assistance of two staff. PT progress notes between 10/18/11 and 11/15/11, indicated Resident # 1 became gradually more resistant to weight-bearing and participation in the exercise program. Finally on 11/15/11 the physical therapist discharged Resident #1 from therapy due to decline and reviewed Resident #1's need for the "hoyer" or total-body mechanical lift with nursing staff. Documentation dated 10/25/11 described the ulcer of the right heel wound described it as a deep tissue unstagable pressure ulcer. The skin assessment dated , 10/27/11 clarified the location of the wound as being on the lateral aspect of the right heel described as unstagable with a wound bed, 95% necrotic. This location is consistent with the resident's potion of laying on the right side. There was no evidence in the record or provided by the facility of the Tissue Tolerance Test documented on the treatment record as having been done on 10/29/11. Daily Wound Monitoring sheets for October, November and December, 2011 of the ulcer on the right heel did not give the size or treatment provided to monitor response of the ulcer to the treatment. The skin assessment dated [DATE] noted a pressure ulcer on the medial (or inner part) of the left heel described it as a deep tissue intact dark purple blister measuring 3.2 cm. by 5 cm. This location is consistent with the resident's potion of laying on the right side. Weekly follow-up assessments dated 11/3, 11/10, 11/17, 11/25, two assessments dated 12/1, one dated 12/8, and one dated 12/12/11 did not indicate the stage of the ulcers or designate the locations to distinguish progress or decline of either ulcer. The weekly assessments dated 11/10 of an undesignated wound location describe the area as 100% necrosis. The treatment mentioned was to cleanse the area, apply [MEDICATION NAME] ointment and then Kerlix (gauze) wrap over a non adhering bandage. The only interventions mentioned were foam boots and turning every two hours. There was no evidence in the record or provided by the facility that Resident #1 was resistant to changing her position or insistent on maintaining the position she was place in.