La Bella Of Aurora

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent diversion of resident's money by a staff member.This applies to 1 of 3 residents (R3) reviewed for misappropriation of funds in the sample of 11.This failure resulted in psychosocial harm when R3 stated she feels terrible and bothered when the staff member took her hard-earned money without her consent. The findings include:R3 was admitted to the facility on [DATE]. R3 had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus without complications, generalized muscle weakness, unspecified lack of coordination, and anxiety disorder, based on the face sheet.R3's quarterly MDS (Minimum Data Set), dated February 6, 2026, showed the resident was cognitively intact.On March 6, 2026, at 2:04 PM, R3 was sitting on her bed inside her room. R3 was alert and was able to answer questions. R3 stated she had a car accident sometime in July 2025 and since admission at the facility, there were several suspicious transactions in her bank account. R3 stated her bank sent the statements, and she noticed her bank card is being used by someone here at the city where she currently resides (city where the facility is located) and she did not recognize the charges. During the same interview, R3 stated after her car accident, she had no place to store her car while she was residing at the facility. R3 also stated V4 (Receptionist) was storing her car for her at her (V4) place. R3 stated she told V4 that she could use the car if she needed it to pick up her kids or get groceries. According to R3, while V4 was using her car, V4 went 10 miles over the speed limit and V4 received a ticket. Since V4 did not have any money to pay for the ticket, R3 stated she paid for it, however, she does not remember how much.On March 6, 2026, at 3:22 PM, the above information shared by R3 was brought to the attention of V1 (Administrator) and V2 (Director of Nursing).On March 9, 2026, at 12:35 PM, during an over the phone interview, V4 (Receptionist) stated she was suspended from the facility starting March 6, 2026. V4 stated from August 2025 through March 6, 2026, she was storing R3's car at the back of her house and V1 (Administrator) and V9 (Social Worker) were aware of it. V4 stated on the afternoon of March 6, 2026, after being told that she was suspended, the facility had R3's car towed to the facility's parking lot. According to V4, I just wanted to help [R3], then R3 wanted to pay for storing the car at her property. V4 stated R3 decided to keep the car at her property because eventually the resident wanted to use her car when she got discharged from the facility. V4 stated R3 told her that she could use the car when she needed it. V4 admitted R3 had given her a total of $1,490.00 from January through February 2026. According to V4, the $1,490.00 payments were made by R3 using her (V4) phone-based application (an application that enables her to accept credit card payments). V4 was asked how those transactions were made. V4 stated randomly, R3 would tell her she wanted to give some money for storing the car, so she (V4) would accept the money by using the phone-based application. R3 would enter the amount she wanted to give on the phone-based application then R3 would tap the credit card on the phone, and the credit card would be charged paid to V4. V4 was asked to account for the $1,490.00 that she received from R3. According to V4, out of $1,490.00, the $500.00 was for the release of R3's car from the impound. V4 stated while driving R3's car, she received a speeding ticket and the car was impounded. She (V4) showed R3 the ticket and told the resident she was working on paying for the $500.00 ticket so the car could be released, but R3 offered to pay for it, and since R3 was the owner of the car, the resident also had to sign the documents for the car to be released. Per V4, the remaining $990.00 was given to her by R3 randomly, as payment for storing the resident's car. V4 stated she did not know she cannot receive any money or other financial compensation from the residents.On March 9, 2026, at 1:14 PM, R3 was sitting on her bed. In the presence of V1 (Administrator), R3 stated since V4 was keeping her car at her property, she offered V4 to use her car if she needed to pick up her kids, shop, or do groceries. According to R3, she remembered giving money to V4 for cleaning the car because according to V4 her friend offered to clean it. R3 added she also remembered giving money to V4 at least twice for gas, which she claimed was not much, possibly between 20 to 50 dollars, and she also gave some money to V4 possibly around Christmas time. R3 stated the money was sent through the phone. R3 denied giving money to V4 through the phone as payment for storing her car. During the same interview, R3 expressed she had suspicion that V4 might be the one using her bank card, but she could not be certain.On March 9, 2026, at 1:50 PM, V9 (Social Worker) stated she was aware V4 (receptionist) was keeping R3's car at her property and thought V4 was just being helpful. V9 was not aware V4 was receiving money from R3 for storing the car, nor was she aware R3 had to pay for the release of the resident's car from the impound because V4 had the driving ticket.On March 9, 2026, at 1:57 PM, V1 (Administrator) was informed V4 (receptionist) admitted to receiving money from R3 in the amount of $1,490.00 for storing the car at her property and for the release of R3's car that was impounded because of a speeding ticket that was incurred by V4. V1 stated he was aware V4 was keeping R3's car at her property. According to V1, V4 told him that she has space to keep the car and since R3 was residing at the facility, she (V4) can keep it until such time. V1 commented he thought V4 was doing it out of the goodness of her heart. V1 was not aware V4 was receiving money from R3 for storing the car and was also not aware R3 paid for the release of the car from the impound because of V4's driving ticket. During the same interview, V1 stated the facility staff, including V4, had received an in-service regarding abuse, which included the prohibition of accepting and/or receiving money or financial assistance from any resident.On March 9, 2026, at 3:15 PM, R3 stated she used to be a bank auditor and an accountant, I know how to account for my money and other people's money. According to R3, if someone from the facility was taking money from her without her consent, she would feel terrible and bothered because she had worked her whole life for her money. R3 stated, I might lose sleep over it.The facility's policy regarding abuse, neglect, and exploitation, with implementation date of October 1, 2025 and last reviewed/revised on March 6, 2026, showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The facility's policy regarding prohibition on staff requesting or accepting money, gifts or financial assistance from residents or resident representative, with implementation date of October 1, 2025 and last reviewed/revised on March 6, 2026, showed the purpose of this policy is, To protect residents from financial exploitation and ensure compliance with resident rights by prohibiting staff from requesting or accepting money, gifts, loans, or financial assistance from residents or their family members, representatives or visitors. The policy showed under the policy statement that, Employees, contractors, volunteers, students, and agency staff are strictly prohibited from requesting, borrowing, soliciting or accepting money, gifts, or any form of financial assistance from residents or their family members, representatives, or visitors. This policy supports the facility's commitment to preventing financial exploitation, abuse, and misappropriation of resident property and ensuring residents are protected from undue influence or coercion. The same policy showed in-part, under prohibited conduct, Staff members shall not: . 4. Accept gift cards, checks, or electronic payments (e.g., CashApp, Venmo, Paypal).

Based on observation, interview, and record review, the facility failed to perform a pressure risk screen for a resident (R6) at risk for developing pressure ulcers, failed to ensure pressure-reducing interventions were implemented correctly for one resident (R6), and failed to perform weekly facility wound assessments for one resident (R5). These failures affected two of three residents (R5, R6) reviewed for pressure ulcers in the sample size of 6.Findings include:1. R6's face sheet documented an admission date of 11/07/2024, with a past medical history not limited to: hemiplegia and hemiparesis, aphasia, hypertension, type 2 diabetes mellitus and chronic kidney disease. Brief Interview for Mental Status (BIMS), dated 05/23/2025, indicated R6 has moderate cognitive impairment, with a score of 11/15.R6's care plan, with review start date of 05/27/2025, documented R6 is an extensive assist too dependent with activities of daily living (ADL's); has had pressure ulcer development related to disease process and impaired mobility; and has a wound to sacrum, and right/left buttock. Care plan interventions for R6 included but not limited to the following: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning and follow facility policies/protocols for the prevention/treatment of skin breakdown.Weekly pressure ulcer and unstageable pressure ulcer report, dated 07/07/2025, documented R6 acquired at facility on 05/29/2025, an unstageable pressure ulcer to the left buttock, with current measurement of 6.8x4.8x2.8 (length x width x depth) in centimeters, and an unstageable pressure ulcer to the right buttock with current measurement of 3.8x1.8x0.6 in centimeters; and acquired at facility on 07/07/2025, a stage two pressure ulcer to sacral region, with no measurements documented.R6's last documented weight on 07/14/2025 at 11:42 AM indicated weight of 148.6 Lbs.Review of R6's clinical assessment log on 07/16/2025 at 11:30 AM showed no pressure ulcer risk assessment (Braden) on file. On 07/15/2025 at 10:24 AM, 07/16/2025 at 10:57 PM, and 07/17/2025 at 10:35 AM and 12:15 PM, R6 was observed lying in bed on his back and wearing an incontinent brief. Low air loss mattress was in place and set to 350 pounds. R6 was also observed to be lying on top of two incontinent pads and the air mattress was covered with a cotton bottom sheet. R6 was alert to self and not interviewable.R6's active physician orders as of 07/16/2025 included to cleanse left and right buttock wounds with a topical antiseptic (dakins), apply calcium alginate and medical honey then cover with borderer gauze and to cleanse sacral wound with a topical antiseptic (dakins), apply medical honey then cover with borderer gauze daily and as needed. admitted to hospice on 07/12/2025.On 07/17/2025, facility presented a pressure ulcer risk assessment for R6, dated 07/16/2025 at 12:08 PM.2. R5's face sheet documented admission date of 07/15/2024, with a past medical history not limited to: paraplegia, traumatic brain injury, and neuromuscular dysfunction of the bladder. Brief Interview for Mental Status (BIMS), dated 05/01/2025, indicated R5 had no cognitive impairment.R5's pressure ulcer risk assessment (Braden), dated 04/10/2025, indicated resident is at moderate risk for developing a pressure ulcer. Weekly pressure ulcer and unstageable pressure ulcer report, dated 07/07/2025, documented R5 acquired at facility on 12/21/2025, and a pressure ulcer to the sacral region with current measurement of 3.5x3.0x0.1 in centimeters and an unstageable pressure ulcer to the right buttock with current measurement of 3.8x1.8x0.6; and acquired at facility on 07/07/2025, a stage two pressure ulcer to sacral region, with no measurements documented.On 07/15/2025 at 10:12 AM, R5 was observed in room seated in a wheelchair watching television. R5 said he goes out on Mondays to a wound clinic every two weeks and receives daily wound care at the facility between visits to wound clinic. R5 then added the wound nurse has never measured or assessed his wounds until last week. R5 said he was shocked because his wounds have never been assessed at the facility, only done at the wound clinic. Review of R5's care plan on 07/15/2025 showed no documentation related to wounds or wound care. Facility presented undated care plan on 07/16/2025 for R5 that documented resident has actual impairment to skin integrity with current wounds to sacral, lateral right and left ankles. Interventions included but not limited to weekly treatment documentation to include measurement of each skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R5's active physician orders as of 07/16/2025 included to cleanse sacrum with normal saline/wound cleanser then apply (aquacel silver) dressing and cover with bordered gauze nightly and cleanse left lateral ankle with normal saline/wound cleanser then apply (aquacel silver) dressing and cover with absorbent bordered gauze dressing nightly every Monday, Thursday, and Saturday.On 07/11/2025 at 1:54 PM, V3 (Wound Nurse) said if a resident goes out for wound care, he does not perform a wound assessment and goes by the measurements and assessments done by the wound clinic. V3 added R5 goes to an offsite clinic for wound care. At 2:48 PM, V3 said there was not a wound nurse when he first took the position as wound nurse, and did not really receive any training on how to do the job; V3 is still learning things.On 07/15/2025 at 09:50 AM, V3 (Wound Nurse) said he has not received any extensive training in wound care and is not wound care certified. V3 added he received about four hours of training when he took the job that was mostly on paper and on a laptop. V3 also said the regional consultant provided some guidance. V3 stated V3 was nurse for 20 yrs, other than that, he said he has not had any specific wound training or certification.On 07/16/2025 at 2:02 PM, V12 (Medical Director) said, Staff nurses should assess a resident's wound weekly, do dressing changes and follow physician's orders and monitor wounds for improvement. If a resident goes out to the wound care clinic, facility nurses should do their own wound assessment with every dressing change, document their findings and inform the physician of any significant changes. On 07/16/2025 at 3:02 PM, V3 (Wound Nurse) said wound care/dressing changes were all changed on day shift so that he can supervise the wounds and wound care.On 07/17/2025 at 09:38 AM, V2 (Director of Nursing) said pressure ulcer risk assessments should be done upon admission, readmission, quarterly, annually, and with a significant change in condition.On 07/17/2025, facility presented pressure ulcer risk assessment log, dated 07/16/2025, that documented both R5 and R6 were at high risk for developing a pressure injury.On 07/17/2025 at 11:20 AM, V3 (Wound Nurse) said the protocol for a low air loss mattress is that nothing should be between the mattress and the resident, such as layers of pads and/lines because that defeats the purpose of the mattress. V3 added only a turning sheet should be placed. V3 then said the mattress is set to the resident's weight and to their preference level. V3 then said R5 is able to reposition himself in bed, and R6 is on a turning schedule and should be turned every two hours.On 07/17/2025 at 1:02 PM, V1 (Administrator) indicated he was informed by supplier that the low air loss mattress setting is auto adjusted based on the resident's weight.On 07/17/2025 at 2:55 PM, V2 (Director of Nursing) indicated R6 cannot communicate his preference for his low air loss mattress settings.Skin Assessment policy, last revised 03/2025, reads: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury.Pressure Injury Prevention Guidelines, last revised 03/2025, reads: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment.prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses).interventions will be documented in the care plan and communicated to all relevant staff.the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound.Repositioning: reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition.routine positioning schedule: every two hours, using both side-lying and back positions.avoid positioning resident on bony prominences/turning surfaces with existing pressure injurie.Wound Treatment Management policy, last revised 03/2025, reads: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.the effectiveness of treatment will be monitored through ongoing assessment of the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a resident's discharge correctly for 1 of 3 residents (R2) reviewed for discharge. This failure resulted in R2 losing his Medicare coverage from [DATE]-[DATE], having to cancel important diagnostic testing and a follow-up appointment with his neurosurgeon, not having CPAP (continuous positive airway pressure) supplies due to lack of medical coverage, and having to spend many hours and days trying to get his Medicare coverage reinstated.The findings include:R2's admission Record, printed by the facility on [DATE], showed he had diagnoses including, but not limited to partial intestinal obstruction, type II diabetes mellitus with hyperglycemia, gastrointestinal hemorrhage, anemia, acute kidney failure, neoplasm of unspecified behavior of bone, soft tissue, and skin, long-term use of non-insulin antidiabetic drugs, hypertension, anuria, and oliguria (reduced urine output or complete absence of urine output). The admission Record showed R2 was discharged to home on [DATE]. R2's progress note, dated [DATE], showed R2 was discharged to home with his wife (V9).R2's Oder Summary Report, provided by the facility on [DATE], showed an order for blood glucose checks daily. The report showed Patient may discharge to home [DATE] with orders for Home Health care services to be provided by (name of home health services company) for PT/OT, Nursing, CNA, and DME (medical equipment) to include a wheelchair. The Report also showed needs appointment in [DATE] for MRI per neurosurgeon.R2's Progress Note, dated [DATE], showed R1 transported home with wife via (transportation service) at 10:15 AM.The facility's Admission, Discharge, and Transfer Report, printed by the facility on [DATE], lists R2 as deceased .On [DATE] at 8:35 AM, R2 said he discharged from the facility to home on [DATE]. R2 said he had to cancel his scheduled MRI (Magnetic Resonance Imaging) and an appointment with his neurosurgeon, due to the facility putting him down as deceased , causing him to lose his Medicare coverage. V9 (R2's wife) was also on the phone and said R2 was not able to schedule any appointments to have his stage 1 pressure ulcer looked at, adding he has a lot of medical issues and needs to see his doctors. V9 said she kept a log of everything and would email IDPH (Illinois Department of Public Health) the specific details of everything they had to do to get the facility's error resolved. On [DATE] at 5:11 PM, V9 sent an email to IDPH that described the difficulties R2 encountered as a result of the facility incorrectly documenting R2's discharge as deceased .On [DATE] at 3:02 PM, V9 sent an email to IDPH with an update showing R2's Medicare account was active as of today. On [DATE] at 5:01 PM, V9 said, The facility error has taken up a lot of our time and has been very stressful on him. R2 agreed. We have been through a lot. (R2) and I have not been able to do anything because they have been on the phone trying to get it taken care of. (R2) was going to ask his neurosurgeon at his next appointment about an order for therapy, but the appointment had to be canceled due to the facility entering (R2) as deceased . Medicare would not cover the cost for (R2's) lancets and glucose test strips because the facility marked him as deceased . (R2) ran out of his CPAP (continuous positive airway pressure) supplies, and had to sleep without his CPAP for about 30 days, because he did not have the supplies. He did have trouble sleeping. R2 agreed. V9 said, (R2) was so mad because the facility was not returning our calls. It was very frustrating. He missed the MRI scheduled for [DATE] and the follow-up appointment on [DATE]. They had to be cancelled due to facility's mistake. (R2) just found out yesterday that it has finally been resolved, and (R2's) Medicare was reinstated. [NAME] departments from the hospital kept calling us and asking when the issue was going to be resolved so they could resubmit their claims. (R2) and I were told the date the facility's error went through the system on [DATE]. If we wanted to schedule any appointment, they would tell us we had to pay up front. We can't afford to do that. That is what we are paying the insurance company for. We felt the facility did not care about us. Like we were not important, like trash. No one should have to go through that.On [DATE] at 1:44 PM, V15 (Regional Business Manager for the facility) said, The nurse that discharged (R2) entered him into PCC (the facility's electronic medical record charting system) as discharged expired. We take that information from PCC, and that is how we enter it for billing purposes. V15 said she was notified on [DATE] that R2 went to make an appointment recently, and that is when R2 and V9 found out about the error. V15 said she was informed R2 missed a neuro appointment and some kind of test for his neuro appointment. V15 said she contacted Medicare and informed them that was an error. V15 said she contacted R2 and V9 to inform them it was corrected and would take about 7-10 business days. V15 said yesterday ([DATE]) was business day 4. V15 said she informed R2 if it has not been corrected by Tuesday, to give her a call and she would take care of it. V15 said, Medicare does not require a death certificate to stop Medicare coverage. Social Security needs one wrong key stroke and it could interfere with the resident's benefits. All the more reason to make sure that the information is entered in correctly. The nurse should make sure when they enter discharge information, they enter the correct information. If the nurse puts something in the system, the Business Office Manager (BOM) does not have access to the clinical side. The facility can put something in place where if someone is listed as expired, that we verify before we enter it into the Medicare billing. We can change how we are doing it to make sure that when a resident is entered as expired or deceased that we (the BOM) verify with the facility that the resident has expired before they enter information into the system, regardless of whether or not the resident is Medicare or Medicaid, so there is no disruption in the resident's Medicare coverage.On [DATE] at 3:00 PM, V8 (Registered Nurse-RN) said she was the nurse on duty that discharged R2 home with his wife. V8 said there is a place in PCC to enter whether the resident was discharged home, to a hospital, deceased , etc. V8 said she usually does not enter information to take a resident out of the system in case someone still needs to document on them. V8 said R2 was very much alive. V8 said, It is important to make sure you enter information into the system correctly for the billing, financial aspect, as well as for the resident, so it does not delay their medical care.On [DATE] at 3:12 PM, V1 (Administrator) identified V14 (second shift nurse) entered it incorrectly in the system. V1 said he thinks V14 went to edit R2 in the system and mistakenly checked deceased instead of discharged to home. On [DATE] at 7:41 AM, V14 said she may have been the one that took R2 out of the system, she does not recall. V14 said no one has said anything about there being an error yet to her. She said she would talk to V1 and see what might have happened. She said it is important to make sure you document correctly whether a resident is discharged to home or discharged due to being deceased . V14 said R2 went home with his wife (V9).On [DATE] at 8:56 AM, V16 (Social Services Director) said she was not the one that took R2 out of the system. I do not do that. If I print out a form, my name would be at the top as the user. I did not print out any forms for (R2) or (V9), or for anyone related to this issue. (R2) was at the facility for short-term therapy. He discharged to home with his wife. When (R2) and (V9) mentioned that he was ready to go home, we started putting things in place like home health services. We did not try to prolong the discharge. We just had to get everything set up to ensure a safe discharge for (R2).On [DATE] at 10:18 AM, this surveyor called V21's (R2's neurosurgeon's) office and asked V21 to return the call to discuss what the follow up appointments for R2 were for and how the delay could affect R2. At 11:30 AM, V19 (V21's nurse) returned call. V19 said she would let V21 know the reason for the call and ask him to return this surveyor's call. No return call was received prior to exiting the facility on [DATE].On [DATE] at 1:56 PM, V12 (facility's Medical Director) was informed about the discharge to home for R2 being incorrectly documented as deceased . V12 said, Oh no. V12 was informed the error caused R2 to lose his Medicare coverage. V12 said, You mean he had to go for months without insurance? V12 said it is important for the nursing staff to make sure they enter information into the system carefully, so they do not kick a resident off their Medicare, or other insurance. V12 said this is the first time he was hearing of this. The facility's policy and procedure titled Transfer and Discharge (including AMA), with a review date of 11/2024, did not include how to remove a resident from the facility electronic system when a resident is discharged .

Based on interview and record review, the facility failed to ensure dressing changes were done as ordered (R1), and failed to ensure weekly wound assessments and documentation of the assessments were completed, for 2 of 5 residents (R1, R4) reviewed for non-pressure wound care in the sample of 6.This failure resulted in R1's wound getting a maggot infestation, and the wound dehiscing and getting infected. R1 was sent out to a local emergency room, diagnosed with osteomyelitis, requiring two intravenous (IV) antibiotics to prevent sepsis, surgical intervention, and critical care hospital admission. This failure resulted in an Immediate Jeopardy.The Immediate jeopardy began on 7/3/2025 when the facility failed to do the dressing change as ordered and failed to assess R1's surgical site and document an assessment. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/16/2025 at 12:16 PM. The surveyor confirmed by observation, record review, and interview, that the Immediate Jeopardy was removed on 7/17/2025, but noncompliance remains at Level Two, because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include: 1. R1's admission Record, provided by the facility on 7/10/2025, showed she had diagnoses including, but not limited to, transient cerebral ischemic attack (stroke), atherosclerotic heart disease, aneurysm of the ascending aorta without rupture, myocardial infarction (heart attack), cellulitis of unspecified part of limb, and hypertension.R1's Discharge Instructions from a local hospital, dated 6/26/25, showed Wound Care: Dressing to be left in place until seen in the office next week. Do not get wet. R1's 7/1/2025 notes from the follow up appointment showed Wound cleansing and dressings. Dry protective dressing. Do not get wet. The document showed V4 (LPN) clarified the order to be done every other day.R1's Order Summary Report, provided by the facility on 7/10/2025, showed an order, dated 7/1/2025, for Wound #3 right toes area of great toe, 2nd toe, 3rd toe. Wound cleansing and dry protective dressing to be changed every other day. R1's July 2025 Treatment Administration Record (TAR) showed no treatment was documented as being completed from 7/2/2025-7/6/2025.The facility's weekly Skin Condition Report, dated 7/4/2025, showed R1 had arterial ulcers to her right posterior leg, right medial great toe, right second toe and her right third toe. V3 said the measurements on the form were taken from notes from the wound clinic R1 goes to.R1's Progress notes from 7/1/2025-7/5/2025 do not document any dressing change to the surgical site on R1's right foot/toes area. The progress notes only show RLE ((right lower extremity) wound documentation, which was a different wound on R1's right posterior lower leg. There was no documentation of a dressing change or assessment to R1's right foot surgical site until 7/6/2025 at 8:20 PM where it showed, Resident noted with an excessive amount of exudate drainage and possible presence of larvae in wound during wound care. MD (doctor) made aware and gave orders to send resident out for further eval (evaluation).R1's progress note, dated 7/6/2025 at 9:20 PM, showed R1 was noted with an excessive amount of exudate drainage and possible presence of larvae in wound during wound care, Doctor made aware and gave orders to send resident out for further evaluation. when an excessive amount of drainage and larvae were found on R1's right foot surgical wound and she was sent to a local hospital. R1's progress notes from 7/1/2025-7/6/2025 do not show any documentationR1's 7/6/2025 Emergency Department Physician Report from a local hospital showed, Right foot with multiple toe amputations, extensive wound at distal tip with sutures, wound dehiscence, necrotic tissue, copious maggots cleaned from wound, mild surrounding erythema with warmth. the notes showed, admission is required due to the severity of the right foot wound infection with suspected osteomyelitis, need for IV antibiotics, and risk of clinical deterioration. The notes showed Critical Care Statement: Given the patient's presentation with a right foot wound infection and osteomyelitis, which carried a high-risk for rapid clinical deterioration due to potential progression to severe sepsis or septic shock. The emergency room doctor provided 40 minutes of critical care time exclusive of other billable procedures. this time was spent in direct patient care involving high-complexity medical decision making and required constant attendance to prevent sudden, significant deterioration in the patient's condition. The Podiatry Consultation Physician's Report, dated 7/7/2025, showed R1 had surgery approximately two weeks ago due to amputation of the first, second, and third digits of the right foot. This was due to gangrenous changes due to severe peripheral arterial disease. Patient was seen in the office for follow-up and incision site looked good with the wound edges well coaptated and sutures in place. Patient presented to the emergency room last night with dehiscence of the wound and maggots in the wound. The physician debrided the wound and the maggots out. The notes showed R1 was started on IV antibiotics and admitted for further workup. V6's operative notes on 7/8/2025 showed R1, was placed under general anesthesia, the sutures were still in place, however they were not holding any skin or flaps at this time. The sutures were all removed. the wound base and wound edges were debrided back to healthy tissue .several dead bodies of maggots were noted .bony exposure is noted in the wound site. A wound was also noted on the medial aspect of the first metatarsal phalangeal joint area that was likewise debrided .Surgery site was dressed and covered .The area was anesthetized, and patient was extubated .Patient will continue antibiotics.On 7/9/2025 at 3:46 PM, V7 (R1's Power of Attorney/POA) said, (R1) had surgery on 6/25/2025 to amputate her toes. After a brief hospital stay, she returned to the facility. She had a follow up with the surgeon on 7/1/25. The doctor said it was healing nicely on her 7/1/2025 follow up appointment, and everything was okay at that point. V7 said he had not heard any updates from the facility until Sunday night (7/6/2025) after R1 was sent out to the hospital. V7 said the facility staff were supposed to look at her wound every two days. V7 said, Someone from the emergency room (ER) called me on 7/6/2025 and told me (R1) was at the hospital and there were maggots in her surgical wound. (V4, Licensed Practical Nurse-LPN) from the facility called me 10 minutes later. By the time I arrived at the hospital, the emergency room staff had already gotten the maggots out of her wound. There were three maggots in a specimen cup and at least 10 more in a baggie. The reason for (R1's) toes being amputated was due to poor circulation to her feet. Some days (R1) is coherent, but lately she is not as coherent. V7 said he did not think R1 understands why she is in the hospital and did not feel that R1 would be able to say if the facility was doing the dressing changes as ordered. V7 said he spoke with V1 (Administrator) and V2 (Director of Nursing), and they said the facility was doing the dressing changes as ordered. V7 said R1 had to have her surgical site debrided (surgical removal of non-viable tissue). V7 said, It is just too much. This should not have happened. On 7/10/2025 at 10:48 AM, V2 (DON) was shown R1's July 2025 Treatment Administration Record (TAR). V2 said the dressing change for R1's right surgical site/wound in her toes area is not marked off as being completed 7/2/2025-7/6/2025. On 7/11/2025 at 11:50 AM, V3 (Wound Nurse) said the wound clinic provided notes regarding wounds for R1. V3 said the facility got an order to clean the wound and do a dry dressing every other day on 7/1/2025. V7 said he did not do any dressing change or assessment of R1's amputation site. V3 said he did not see any documentation of an assessment being done by any other nurse for R1's surgical site on her right foot in her electronic medical record. V7 said surgical sites should be monitored, assessed, and the assessment should be documented. At 12:51 PM, V3 said, It is important to monitor surgical sites for signs and symptoms of infection, wound dehiscence, a decline, or any changes, and to notify the surgeon of any changes. At 2:11 PM, V3 said the last assessment of R1's right toes, with measurements, was on 6/20/2025. V3 said, When (R1) came back from surgery on 6/26/2025, there was an order to leave covered until her follow up appointment. (R1's) follow-up was on 7/1/2025. The doctor gave an order to cleanse the site and cover with dressing every other day. There was no dressing change completed, no facility assessment, or measurements that I can tell from 7/1/2025-7/6/2025 for (R1's) right foot. V3 said he will do the assessment and dressing change for the residents that are followed by the wound doctor that comes to the facility. He said he does not do the assessments and dressing changes for the residents that go out to wound clinic. V3 provided R1's Skin Impairment/Wound forms for 6/26/2025 and 7/1/2025. V3 said he got the information for the forms from the wound clinic, and did not do the assessments himself. On 7/10/2025 at 3:20 PM, V4 (Licensed Practical Nurse-LPN) said V5 (Certified Nursing Assistant-CNA) told her it looked like the bandage on R1's right foot had some blood on it. V5 said she went in to check it and thought to herself that is not blood. It had a slight odor, and brown drainage was on the sock. V4 said as she was unwrapping the bandage, she saw maggots on the bandage. She notified R1's doctor and he said to send her out to the emergency room (ER) for evaluation. V4 said she worked on 7/1/2025. She called the doctor to verify the treatment orders. V4 said the order was to do the dressing change every other day. V4 said she had not done any assessment or dressing change for R1, because she did not work again until 7/6/2025. V4 said she started her shift at 2:00 PM on 7/6/2025. V4 said she did not recall seeing a date on the dressing, but she was also concerned with what was going on. The color and smell of the drainage is what was concerning me. (R1) was having pain that day. Normally we don't have to give her anything for pain until about 8:00 PM. That day she was having more pain than normal. V4 said as she was unwrapping the bandage to R1's foot, R1 voiced it hurt and pulled back her foot. I had to stop because it was hurting her too much. She was saying 'Oh, Oh, Oh.' V4 said when she saw the maggots, she stopped, called the doctor, and about 15 minutes later, R1 was going out the door. V4 said based on the odor and drainage, she felt it could have been noticed earlier. There was a strong smell and the bandage was saturated. V4 said, It is important to make sure to assess wounds to make sure the wound does not get infected, to notice right away and catch it before it gets bad, and update the doctor, to see if he wants to give any new orders. The earlier you catch something the better.On 7/11/2025 at 2:53 PM, V5 (Certified Nursing Assistant/CNA) said he worked the shift that R1 was sent out to the hospital. He said, I was assisting an agency CNA with (R1) and noticed something on the dressing at the top of her foot, where she had the surgery. It was dark in color, something unusual that you would not see on a sock. It did not really look like blood. It was discolored. I went to (V4) and asked her to check (R1's) foot and then went to assist other residents. V5 said he saw R1 leaving on a stretcher. He went into her room after hearing what happened and checked the linen on her bed. V5 said he saw 8-10 maggots on R1's linen, so he threw her linen away in the garbage. On 7/11/2025 at 3:05 PM, V1 (Administrator) and V2 (Director of Nursing-DON) agreed it is important for the nurses to do an assessment on residents with wounds, at least weekly, even if the resident goes out to the wound clinic. V1 and V2 said unless there is an order not to touch the dressing, it is important the facility nurses assess the resident's wound to monitor and determine if the wound is improving or getting worse, so the doctor can be updated, and new orders can be received if needed.On 7/15/2025 at 10:31 AM, V6 (Wound Clinic Doctor) said R1 had her great toe, second and third digits on her right foot amputated on 6/25/2025. She stayed in the hospital overnight and was sent back to the facility on 6/26/2025. I gave an order to not touch the dressing until her follow-up appointment. When I saw her on 7/1/2025 for the follow-up, the wound was a closed surgical site, no opening, drainage or swelling. It looked very good. V6 said, I gave orders on 7/1/2025 to change the dressing every other day. Keflex was ordered prophylactically to prevent infection. The next time I saw (R1) was the day after she was sent to the hospital (7/7/2025). The stitches were no longer holding the tissue together. It was an open wound. (R1) had the wound cleaned out in the ER due to there being maggots in the wound. On 7/8/2025, I had to take out all the stitches, which were still there, but not holding the tissue in place, debride the wound and flushed it out. Bone was exposed. When bone is exposed to the air, you assume it is infected. Osteomyelitis can occur. V6 said R1 was tested for, and he believes she was diagnosed with, osteomyelitis. The wound was infected and had an infestation of maggots. Two antibiotics were given intravenously (IV) for broad-spectrum antibiotic therapy. It was very serious. Infestation and infection. Infection could get in the blood and the patient could become septic. It is important for the facility nurses to do the dressing changes as ordered. If not done as ordered, it will slow the wound healing and increase the risk of infection. I would expect the nurses to assess the wound during the wound changes, so if there is a problem, they could contact me for guidance on how to proceed. V6 said he has a 24-hour answering service. V6 said, If the facility would have done the dressing changes and monitored the surgical site, it may have prevented the wound from getting infected and infested with maggots, and I would not have had to perform the surgical debridement procedure.On 7/16/2025 at 8:24 AM, V1 (Administrator) said, When (R1) came back from her follow up appointment on 7/1/25, there was some ambiguity about the orders. (V4, LPN) called the doctor and clarified the order. (V4) entered the order into the system wrong. She entered it into other orders (no documentation required), not into the Treatment Administration Record (TAR). When an order is entered into the system like this, the nurses cannot see the order. V1 said he investigated what happened, however, he did not document his investigation. V1 said the order was discontinued on 7/6/2025 and entered in the system correctly. V1 said V3 (Wound Nurse) could have followed up to see what the new orders were after her follow up visit and made sure the treatment was being done as ordered, just like any management team member is expected to do with their department. V1 said he let V2 (DON) know the nurses need training on entering medication orders because that is not acceptable. V1 was asked if the nurses that worked on all three shifts from 7/2/2025-7/6/2025 should have verified the orders for R1 after her follow-up appointment to make sure there was no treatment ordered. V1 nodded yes. On 7/16/2025 at 1:56 PM, V12 (facility's Medical Director) said, Some residents go out for wound care, then come back to the facility. They are here for us to provide medical care. It is important to follow the doctor's orders for wound care. If a resident goes out for wound care and comes back with an order to do dressing changes, the facility nurses should be doing their own wound assessment with every dressing change, document their findings, and notify the physician if there are any changes. The facility's 10/2023 policy and procedure, titled Wound Treatment Management, showed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician's orders.1. Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. The facility presented an abatement plan to remove the immediacy on 7/16/2025 at 3:34 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 7/17/2025 at 11:29 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a second revised abatement plan on 7/17/2025 at 2:37 PM, and the survey team accepted the abatement plan on 7/17/2025.The Immediate Jeopardy that began on 7/3/2025 was removed on 7/17/2025, when the facility took the following actions to remove the immediacy:1. Corrective Actions which will be accomplished for those residents found to be affected by the deficient practice. i. Facility Medical Director was notified of the incident on 7/16/2025 at 2:50 PM. ii. The DON completed a chart audit on every resident with wounds and skin conditions and compared the wound physician's orders and evaluations for accuracy. iii. The DON completed a chart audit on every resident with wounds and skin conditions to ensure all have a completed weekly skin evaluation assessment. iv. The wound nurse assessed all residents with wound and skin conditions to ensure wound treatments were rendered as ordered per MD/NP.2. How the facility will identify other residents having the potential to be affected by the same deficient practice by: The DON and/or designee completed a chart audit on every resident with wounds and skin conditions and compared the wound physician's orders and evaluations for accuracy.The DON and/or designee completed a chart audit on every resident with wounds and skin conditions to ensure all have a completed weekly skin evaluation assessment.The MDS(Minimum Data Set) coordinator and/or designee conducted an audit on every resident with wounds and skin conditions to ensure the care plan reflects their current plan of care. All residents were screened for pressure risk on 7/16/2025, and will be assessed upon admission/re-admission initially, then x 4 weeks, then quarterly. Assessments will be conducted after a change of condition or after any newly identified pressure injury. All residents with wounds and skin conditions treatment orders clarified with medical practitioner and have been changed to AM shift for wound nurse to provide treatments as ordered per MD starting on 7/17/2025. Floor nurses to render wound treatment on weekends and in the absence of wound nurse. Nurse on the floor will render treatment, conduct assessments, and document.A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse and by the wound nurse upon admission/re-admission, quarterly and annually. The assessment will be performed after a change of skin condition, or after any newly identified skin condition a/or pressure injury initially and weekly until resolved. The QAPI (Quality Assurance Performance Improvement) committee reviewed the Skin Assessment and Wound Treatment Management, Quality of Care policies to determine if any revisions needed to be made and determined the policies did not need changes.3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur:The facility initiated in-service training for staff on 7/15/2025 on Skin Assessment and Wound Treatment Management policy. This training will be conducted by the DON and/or designee, is ongoing and will continue with all the new staff upon hiring, and orientation and agency nurses prior to the start of their next shift. The training includes, but is not limited to: A full body, or head-to-toe assessment will be conducted by a licensed or registered nurse and by the wound nurse upon admission/re-admission, quarterly and annually. The assessment will be performed after a change of skin condition, or after any newly identified skin condition a/or pressure injury initially and weekly until resolved.Wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and the frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatments will be documented on the Treatment Administration record or in the electronic health record. The effectiveness of treatments will be monitored through ongoing assessment of the wound until healed. Considerations for needed modifications include:a. Lack of progression towards healing. b. Changes in the characteristics of the wound.c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.d. Documentation and Completion of Skin Assessment:Include date and time of the assessment, your name, and position title.Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.)Document type of wound.Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Document if resident refused assessment and why.Document other information as indicated or appropriate. 2. The facility initiated in-service training for staff on 7/16/2025 on Provision of Quality of Care. The training is ongoing and the DON and/or designee will continue with all the new staff upon hiring and orientation and agency nurses prior to the start of next shift.The training includes but is not limited to each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 3. The facility initiated in-service training for nursing assistants on 7/17/2025 on Skin Audits by Nursing Assistants policy. The training is ongoing, and the DON and/or designee will continue with all the new nursing assistant staff upon hiring and orientation and agency nursing assistants prior to the start of next shift. The training includes, but is not limited to: Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. Skin Conditions that shall be reported include, but are not limited to:Redness, bruising, swelling rashes, hives, blisters (clear or blood filled), skin tears, open areas, ulcers, lesions. Notification shall be made to the nurse verbally or in writing.Notification shall be made to nurse verbally or in writing on any noted soiled or non-intact dressings. The Director of Clinical Excellence scheduled Mandatory All Nursing Staff, DON and Wound Nurse wound care training with (the contracted wound care company that comes to the facility and oversees residents' wounds). DON and/or designee conducted a wound care competency with wound nurse on 7/14/2025 and will conduct one weekly with the wound nurse and nursing staff on all shifts until every staff has participated at least once. This will be ongoing and will continue to be held weekly for two months. Findings will be reviewed at the monthly QAPI committee meeting. 4. Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1. Facility created quality assurance tool Wound Treatment Orders and Assessments will be implemented on 7/16/2025 used by the DON and/or designee to assess all residents and new admissions/re-admissions with wounds and/or skin conditions daily for month and then weekly for 3 months, then quarterly for a year to monitor that the facility is following the policy, and treatments are being completed as ordered, and assessments are being done and completed. Findings will be reported at the monthly QAPI Committee meeting.2. Facility-created quality assurance tool Quality of Care will be implemented on 7/16/2025 and used by the DON and/or designee daily to randomly assess 2 residents daily for a month, then monthly for 3 months, then quarterly for one year to monitor that the facility is following the policy and residents are provided with Quality of Care and Services. The results will be reviewed during the facility's QAPI meetings. Any issues identified will be immediately addressed. On 7/17/2025, a review of the facility's in-service documentation showed all the facility's nurses received the in-service training from the contracted wound care company on 7/17/2025. The Agency nurses, and any new staff will be educated prior to the start of their next shift. The Certified Nursing Assistants working received in-service training on reporting any changes to nurses. The remainder of staff, and any new staff will receive education prior to the start of their next shift. Interviews with staff working on 7/17/2025 showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan. 2. R4's admission Record, provided by the facility on 7/16/2025, showed diagnoses including, but not limited to type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes. Symptoms include pain, numbness, and slow healing of leg or foot sores), hypertension, congestive heart failure, acquired absence of left leg below the knee, iron deficiency anemia, ischemic cardiomyopathy, acute hematogenous osteomyelitis, chronic obstructive pulmonary disease, and acquired absence of right foot. R4's Order Summary Report, printed by the facility on 7/11/2025, showed an order, dated 7/11/2025, to clean wound on right foot with normal saline. Apply xeroform to wound. Cover with abdominal pad and (rolled gauze) once daily and as needed. The report showed an order, dated 7/11/2025, for a nuclear stress test on 7/21/2025 (a cardiac imaging procedure that assesses blood flow to the heart muscle at rest and during stress. It helps doctors diagnose coronary artery disease and determine the extent of any blockages or damage).R4's care plan, dated 5/20/2025, showed, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations.R4's July 2025 TAR showed the dressing changes were being done as ordered. On 7/10/2025 at 9:59 AM, R4 was sitting in his wheelchair in his room. R4's left leg was amputated below the knee. R4's right foot and lower leg was wrapped with rolled gauze. No drainage or odor was observed on R4's dressing. R4 said when he was first admitted to the facility, they missed a couple dressing changes. R4 said the nurses change his dressing every morning now. R4 said the dressing had already been changed at 6:30 AM. R4 said he goes to (a local wound clinic) once a week on Mondays. The doctor said I am making steady progress in healing, especially with my circulatory issues. R4 said since he was admitted to the facility, he has not had any infection or decline in his wound. R4 said he is not sure if the nurses do an assessment of the wound or not. No nurse at the facility has measured it that he is aware of. Sometimes his wound does have drainage, that is why it is wrapped, and he has a boot on his foot. R4 said his wound doctor at the wound clinic said he is pleased with the progress so far considering all R4's circulation issues. R4 said the wound doctor thinks something else may be going on and has ordered a nuclear test be done. R4 said he also has anemia, diabetes, and other issues. R4 said he had the amputations prior to admission. I came to the facility because I could not take care of the wounds. They were very bad.On 7/11/2025, R4's wound assessments from 6/1/2025 through the present were requested from V3. V3 (Wound Nurse) said he did not do weekly assessments on R4 due to R4 going out to the wound clinic for wound care. V3 said the facility nurses change R4's dressing daily as ordered; however, weekly wound assessments are done at the wound clinic. V3 said he gets the information from the wound clinic notes, and uses the information from the wound clinic to fill out the Skin Impairment/Wound Forms on R4. On 7/11/2025 at 1:54 PM, V3 said, I will do measurements and wound assessments for the residents that use (contracted wound company that comes to the facility) when I do rounds with the wound doctor. If a resident is not seen by (the contracted wound company), and goes out for wound care, then we go by the measurements and assessments done by the outside wound clinics. There are 3 residents in the facility with wounds that go out for wound care. (R1), (R4) and (R5) are the residents that go out to wound clinics. At 2:48 PM, V3 said there was not a wound nurse when he first took the job, so he did not really receive any training on how to do the job. V3 said he is still learning things.On 7/15/2025 at 10:00 AM, V3 said, Initially, (R1) was being seen by (contracted wound company) that comes to the facility. (R1) was referred to (a local wound clinic) around the end of April/beginning of May. She had a doppler scan and other tests and was referred to the wound clinic. V3 said, The only trainingI received for the wound nurse position was about 4 hours of training when I took the job. Mostly on paper and laptop. A regional consultant provided some guidance. V3 was asked if he had any specific wound training or certification prior to taking the Wound Nurse position. V3 said he had been a nurse for 20 yrs. Other than that, he said he has not had any specific wound training or certification.V3 provided Skin Impairment/Wound Forms for R4, dated 6/23/2025, 7/1/2025, and 7/8/2025. V3 said he filled out the forms with the information provided by the local wound clinic. V3 also provided wound clinic notes for R4, dated 6/30/2025, 7/7/2025, and 7/14/2025, as well as R4's initial admission assessment form for the local wound clinic. The only other assessment V3 provided was dated 6/12/2025; V3 did assess R4's wound and documented a partial assessment (No measurements. Just the wound bed characteristics). The facility's September 2024 policy and procedure titled Skin Assessment showed. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. The policy showed documentation and Completion of Skin Assessment: A. Include date and time of the assessment, your name and position title. B. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). C. Document type of wound. D. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). E. Document if resident refused assessment and why. F. Document other information as indicated or appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R13 had multiple diagnoses including contracture on the left and right hand, based on the face sheet.
R13's quarterly MDS (minimum data set) dated March 13, 2025 showed that the resident was moderately impaired with cognition. The same MDS showed that R13 had functional limitation in ROM (range of motion) to both upper extremities and required assistance from the staff with regards to personal hygiene.
On April 15, 2025 at 10:57 AM, R13 was in bed, alert and oriented. R13 had accumulation of long facial hair. R13 stated that he needs help from the staff with shaving.
On April 16, 2025 at 1:30 PM, R13 was in bed, alert and oriented. R13 had accumulation of long facial hair. In the presence of V2 (Corporate Nurse), R13 stated that he needs help with shaving and wants the staff to shave him.
R13's active care plan initiated on November 12, 2024 showed that the resident has an ADL (activities of daily living) self-care performance deficit related to limited range of motion/contractures in both hands.
3. R21 had multiple diagnoses including lack of coordination, legal blindness and unspecified intellectual disabilities, based on the face sheet.
R21's quarterly MDS dated [DATE] showed that the resident was cognitively intact and required total assistance from the staff with personal hygiene.
On April 15, 2025 at 11:02 AM, R21 was in bed, alert and oriented. R21 had accumulation of long facial hair. R21 stated that he needs staff assistance with shaving and that he wanted to be shaven.
On April 16, 2025 at 1:31 PM, R21 was in bed, alert and oriented. R21 had accumulation of long facial hair. In the presence of V2 (Corporate Nurse), R21 asked to be assisted with shaving.
R21's active care plan initiated on January 21, 2016 showed that the resident has an ADL self-care performance deficit. The same care plan showed multiple interventions including, The resident is dependent of 1 staff for personal hygiene.
On April 16, 2025 at 1:35 PM, V2 stated that it is part of the nursing care and service, and the staff are expected to assist residents needing assistance with ADL including removal/shaving of facial hair to ensure and maintain resident's hygiene and grooming.
Based on observation, interview and record review, the facility failed to ensure grooming for residents who require assistance for ADLs (Activities of Daily Living).
This applies to 3 out of 3 residents (R13, R21, and R51) reviewed for ADL care in the sample of 20.
The findings include:
1. On April 15, 2025, at 1:05 PM, R51 was in the dining room, sitting in her wheelchair. R51's fingernails had black and brown substances underneath nails and nail beds had brownish discoloration. R51 also has curly facial hair on her chin. R51 was able to respond to yes or no question, however, she was unable to coherently answer questions that needs explanation. V15 (CNA, Certified Nursing Assistant) stated that R51 is confused.
On April 16, 2025, at 1:39 PM, V15 and V22 (CNA) rendered peri-care and catheter care to R51. R51's nails remained with brownish discoloration on the nail bed, and with black/brown substances underneath nails, and with curly facial hair on her chin. R51 was pleasant and cooperative during provision of peri-care. V15 and V22 did not offer to provide nail care and shaving to R51 after they completed providing the peri-care.
Minimum Data Set (MDS) dated [DATE], shows that R51 requires assistance for personal hygiene.
On April 17, 2025, at 3:01 PM, V2 (Cooperate Nurse) stated part of the grooming/hygiene is to offer shaving and nail care and if resident refuses the staff must report and document refusal and update care plan.
There was no evidence in the progress notes from April 1, 2025, to present, that R51 was refusing care, and there was no care plan showing that R51 was non-compliant with ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to further assess a resident for changes in breathing and notify resident's physician.
This applies to 1 of 3 residents (R55) discharged records reviewed in the sample of 20.
The findings include:
The admission record showed R55 was admitted to the facility on [DATE], with diagnoses of fracture of the right femur subsequent encounter for closed fracture with routine healing, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea and cerebral infarction due to embolism of the cerebral artery.
On April 16, 2025, at 2:10 PM, V11 (RN) stated during the overnight shift of January 30-31, 2025, V11 was R55's nurse. V11 stated during the first rounds between 10:30 PM and 11:00 PM, V11 observed R55 sleeping on his side with regular respirations. V11 stated the next time she did rounds was between 2:30 AM and 3:00 AM, she observed R55 appeared to be sleeping, but was making coughing type noises while breathing. V11 stated she did not further assess R55 at that time.
There is no documentation in R55's progress note of January 31, 2025, of V11's observations regarding R55's change in breathing.
On April 16, 2025, at 5:40 PM, V12 (Medical Director) stated if a nurse observes a change in a resident's breathing, a further assessment should be done, especially a resident new to the facility. V12 stated an assessment should be documented in the medical record and report new findings to the physician.
The facility's policy titled Notification of Changes, dated September 2024, showed Compliance guidelines: the facility must .consult with the resident's physician when there is a change requiring such notification .Circumstances that require notification include: .3. Circumstances that require a need to alter treatment. This may include: a. new treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter was secured.
This applies to 1 out of 2 residents (R51) reviewed for catheter care in the sample of 20.
The findings include:
Face sheet shows that R51 is 78 years-old who has medical diagnoses including urinary tract infection (UTI). R51 was admitted to the facility on [DATE]. Minimum Data Set, dated [DATE], shows R51 requires assistance with toileting and hygiene.
On April 15, 2025, at 1:05 PM, R51 was in the dining room sitting in her wheelchair in the dining room. R51 was actively moving in her wheelchair and had an indwelling urinary catheter bag handing under her wheelchair seat. R51 was able to respond to yes or no question, however, she was unable to coherently answer questions that needs explanation. V15 (CNA) stated that R51 was confused.
On April 16, 2025, at 1:39 PM, V15 and V22 (Both Certified Nursing Assistants/CNA) rendered peri-care and catheter care to R51. The catheter tube was not secured to R51 and was hanging loosely. V15 and V22 did not attempt to secure or apply security device for R51's urinary catheter.
On April 16, 2025, 1:51 PM, V8 (Nurse/RN) stated that indwelling urinary catheter must be always secured to the resident to prevent pulling of the catheter and prevent dislodging, and potential infection.
On April 17, 2025, at 3:07 PM, V2 (Corporate Nurse) stated the urinary catheter should be secured or anchored to the resident to prevent any trauma and to ensure placement of indwelling urinary catheter.

Based on observation, interview and record review, the facility failed to provide double portions of protein to a resident with weight loss.
This applies to 1 out of 3 residents (R41) reviewed for nutrition in the sample of 20.
The findings include:
R41's EMR (electronic medical records) included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, end stage heart failure, gastro-esophageal reflux disease without esophagitis, chronic kidney disease, stage 3 unspecified.
R41's quarterly MDS (minimum data set) dated January 20, 2025 showed that R41 was cognitively intact.
R41's diet order on POS (Physician Order Sheet) showed General diet, Mechanical Soft texture, Regular/Thin consistency, Double proteins at each meal for Nutritional health (revised March 20, 2025), Offer Super Cereal with breakfast (revised March 27, 2025).
R41's weight history recorded in lbs (pounds) in EMR included as follows:
148.4 lbs (March 1, 2025)
153.2 lbs (February 1, 2025)
158.4 lbs (January 1, 2025)
169.2 lbs (December 1, 2024)
163.0 lbs (November 1, 2024)
161.4 lbs (October 1, 2024)
161.4 lbs (September 1, 2024)
Dietitian Weight Change Note dated March 14, 2025 included the following in summary with pertinent information:
R41 with continued gradual weight loss after initial significant weight loss. Weight loss of 12.3% times 3 months, 20.8 lbs. Diet: General diet, Mechanical Soft texture, Regular/Thin consistency. R41 on Hospice care- comfort measure in place. Current body weight 148.4 lbs, Ht: 67 inches, Body Mass Index 23.2. Intake: overall good at 75-100% meals. Recommend to offer super cereal in the morning. Dietitian to follow up as needed.
On April 15, 2025 at 10:18 AM, R41 stated I lost about 4 lbs as I got Prostate cancer. They haven't given me supplements. I would like some.
On April 16, 2025 at 11:40 PM, R41 stated that he only receives one portion at meals. R41 stated When ever I ask for more portions they say that I can't have it. R41 patted his frame and stated I could really use it. R41 stated that he receives grits at breakfast.
On April 16, 2025 at 12:12 PM, during lunch meal service at tray line, R41 received ground bratwurst served with a #10 scoop in a bun with cooked peppers and onions and a side order of tater tots, ice cream for dessert. R41's diet card only showed Dental soft, mechanical soft, super grits (for breakfast).
The diet spread sheet (Week 4, Wednesday) for lunch included (one) portion size for ground bratwurst as #10 scoop with bun.
Portion control chart showed that #10 =3 ounces.
On April 16, 2025 at 12:14 PM, when V4 (Dietary Manager) was asked why R41 only received one portion of bratwurst when his diet order showed double protein, V4 stated that R41's diet card only shows one portion. V4 later added that he was not notified that R41 should have double protein portions.
On April 17, 225 at 2:44 PM, V17 (Dietitian) stated that when she wrote (above referred) progress note, she only added supercereal. On checking the order on POS, V17 stated that the recommendation for double portions came from nursing and should have been implemented if its a diet order. V17 stated that after the order for double protein was added on the POS she is not aware of what happened after that. V17 stated that R 41 could use the extra calories with double protein as he has weight loss and more so if resident is asking for it.
On April 18, 2025 at 12:57 PM, V24 (Regional Director of Operations) stated that facility does not have a policy and procedure on how a diet order change notification to dietary is made.
R41's care plan revised September 23, 2024 included that R41 has nutritional potential nutritional problem related to cancer of prostate with metastasis to bone. Interventions included to provide and serve diet as ordered, provide and serve supplements as ordered.

Based on observation, interview, and record review, the facility failed to ensure that the insertion site of a resident's midline catheter is visible under a transparent dressing for assessment and failed to ensure that the central IV dressing was clean and intact.
This applies to 1 of 2 residents (R158) reviewed for intravenous (IV) catheter in the sample of 20.
The findings include:
Medication Administration Record (MAR) dated April 2025, shows R158 receives Vancomycin HCL Intravenous Solution 1 gram (gm) twice a day and Ampicillin- Sulbactam Sodium Intravenous Solution 3 gm every 8 hours for osteomyelitis.
On April 15, 2025, at 11:14 AM, R158 was resting in bed he was alert and oriented upon interview and was able to respond well to questions. R158 stated that he had a recent amputation of the right big toe due to osteomyelitis. R158 has a midline catheter dressing in the left arm. The insertion site was covered with gauze dressing that was soiled with dry blood. There was a transparent dressing on top of the gauze dressing. The edges of the transparent dressing were stained with black substances and was wrinkly and somewhat loose at the bottom. R158 stated that the dressing was changed sometime last week, but he was unable to recall the exact date it was done.
On April 16, 2025, at 1:34 PM, R158 remained with the same soiled IV dressing, with insertion site not visible for assessment.
Physician Order Summary (POS) dated April 1, 2025, shows to change midline dressing every Monday night for prophylaxis.
On April 17, 2025, at 1:10 PM, V19 (Nurse/RN) attempted to measure the IV line from the insertion site to the tip of the catheter. V19 approximately measured the length of the catheter as 14 cm (centimeter) and she measured the arm circumference as 12 inches (30.48 cm). V19 stated that it's hard to get accurate measurement because the insertion site was covered with gauze and not visible. R158's midline should be covered with transparent dressing for accurate assessment. V19 also said the midline dressing should be change weekly and as needed when it is soiled to prevent infection and ensure cleanliness of IV site.
On April 17, 2025, at 3:19 PM, V2 (Consultant Nurse) stated that midline catheter insertion site should be visible for assessment and measurements.
The Medication Administration Record (MAR) dated April 2025, shows to measure R158's arm circumference and the IV line from the insertion site to the port every shift. The MAR documented 15 cm every shift. However, there was no measurement for the arm circumference, and there was no evidence of documentation of when the IV dressing was changed.
There was no evidence of documentation in the progress notes about the arm circumference of R158, though there was documentation of length of catheter in the MAR, it was questionable about its accuracy because the insertion site was not visible under the gauze.
R158's care plan for intravenous (IV) access device dated April 1, 2025, shows interventions including to check cannula site for signs of infiltration, dislodgement or infection and to monitor IV site for signs and symptoms of infection or indication of pain, infiltration, swelling, redness, the skin surrounding the insertion site is cool to touch. However, the IV insertion site and its immediate surrounding was covered with gauze, and not visible for accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the physician's order for oxygen administration was followed. The facility also failed to ensure that the oxygen tubing and nebulization tubing were changed and labeled per facility policy.
This applies to 2 of 2 residents (R2 and R53) reviewed for oxygen therapy in the sample of 20.
The findings include:
1. R2 had multiple diagnoses including COPD (chronic obstructive pulmonary disease) and chronic respiratory failure with hypoxia, based on the face sheet.
R2's annual MDS (minimum data set) dated March 10, 2025 showed that the resident was moderately impaired with cognition and required moderate to maximum assistance with most of her ADLs (activities of daily living).
On April 15, 2025 at 10:35 AM, R2 was in bed, alert and oriented. R2 had an ongoing oxygen via nasal cannula at 5 liters per minute, using an oxygen concentrator. R2 denied having shortness of breath. R2's oxygen tubing and humidifier bottle was not labeled to indicate the date it was changed. V8 (RN (Registered Nurse) was present in the room and readjusted the oxygen setting to 3 liters per minute. According to V8, R2 should be at 3 liters per minute and not 5 liters.
R2's active order summary report showed an order dated May 15, 2024 for, oxygen 2-4 liters per nasal cannula PRN (as needed) to keep oxygen saturation at 93% or greater.
R2's active care plan initiated on August 8, 2020 showed that the resident had altered respiratory status and occasionally had difficulty breathing related to diagnoses of COPD and asthma. The same care plan showed multiple interventions including, changing and labeling of the oxygen tubing weekly while in use and oxygen via nasal cannula at 3 liters per minute PRN to keep oxygen saturation at 93% or higher.
R2's MAR (medication administration record), TAR (treatment administration record) and progress notes for the month of April 2025 showed no documentation with regards to the weekly changing and labeling of the resident's oxygen tubing.
On April 16, 2025 at 1:36 PM, V2 (Corporate Nurse) was informed that on April 15, 2025 at 10:35 AM, R2's oxygen level was observed at 5 liters per minute and the nasal cannula tubing had no label to determine when the tubing was changed. V2 was also informed that based on R2's care plan, the nasal cannula should be changed and labeled weekly while in use. According to V2, R2's physician order should be followed with regards to the amount of oxygen to be administered. V2 further stated that if the care plan indicated that the nasal cannula should be changed and labeled weekly, it should be performed because it is part of R2's oxygen care.
The facility's policy regarding oxygen administration last reviewed by the facility in January 2025 showed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy showed in-part under explanation and compliance guidelines, 5.b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.d. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated.
2. R53's electronic medical record showed R53 is a [AGE] year old admitted to the facility on [DATE] with diagnoses that includes acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and Type 2 Diabetes Mellitus.
R53 has a physician order dated January 23, 2025 that showed R53 should have continuous oxygen at 2-3 liters via nasal cannula or mask.
On April 15, 2025 at 10:55 AM, R53 was receiving 3 liters of oxygen via nasal cannula. R53 stated the facility has not changed his nasal cannula in at least 2 weeks. R53 nasal cannula tubing was not dated. R53 stated his nebulizer tubing had not been changed in over a week. R53's nebulizer tubing was not dated.

Based on observation, interview and record review the facility failed to ensure that an RN (Registered Nurse) was assigned to serve as a full time DON (Director of Nursing) to coordinate nursing care and supervision, to provide quality care to residents.
This applies to all the 52 residents that reside at the facility.
The findings include:
The facility's CMS (Centers for Medicare & Medicaid Services) 671 (Long Term Care facility application for Medicare and Medicaid) dated April 15, 2025 showed the total resident at the facility was 52.
On April 15, 2025 at 1:17 PM, V2 (Corporate Nurse) stated that the facility's designated DON had resigned, and she (V2) comes to the facility once a week, since the DON left.
On April 17, 2025 at 2:15 PM, V1 (Administrator) stated that he received a text message from V14 (RN/former DON) on April 4, 2025 stating that she was not coming in the facility that day and that she (V14) will be sending an official letter of resignation by the end of the day. V14 stated that on April 7, 2025 he received a call from V14, informing him that she will be resigning effective May 2, 2025 and will be sending her resignation letter. According to V1, V14 never came to report to the facility from April 4 to the current (April 17, 2025) to perform her duties. V1 stated that the facility has not heard from V14 and have not received any letter of resignation from her (V14). V1 believes that V14 will not be coming back to work at the facility, so he went ahead and hired a new DON. V1 acknowledged that the facility does not have a full time DON from April 4 until the newly hired DON starts on April 22, 2025.
During the entire survey from April 15 through April 18, 2025, the facility did not have a designated RN to serve as the DON (Director of Nursing). During this survey deficient practice were identified on the following areas: ADL (activities of daily living) care, urinary catheter care, IV (intravenous) care, oxygen therapy and care, labeling of medications, controlled medication inventory and storage, addressing pharmacy recommendations, infection control surveillance, advance directive, and development of care plan.

Based on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that narcotic medication was stored in a sealed packaging.
This applies to 4 of 4 residents (R2, R28, R37, R47) reviewed for controlled medications in the sample of 20.
The findings include:
On April 15, 2025, at 5:45 PM, the controlled medication was counted with V7 (Nurse/LPN), and the following were observed:
1. R37's blister pack of Tramadol HCl 50 mg (milligrams) number 8 and number 16 tablets, the seal of the packagings were broken.
2. R47's blister pack of Oxycodone 50 mg with 19 tablets remaining that were intact and sealed. R47's controlled drug receipt/record/disposition form for the Oxycodone showed that there should be 20 remaining in the blister pack. V7 stated that she gave the Oxycodone tablet to R47 earlier and has not signed it out yet.
3. R28's blister pack of Alprazolam 0.25 mg with 3 tablets left that were intact and sealed. R28's controlled drug receipt/record/disposition form for the Alprazolam showed that there should be 4 tablets remaining in the blister pack. V7 stated that she gave the Alprazolam tablet to R28 earlier and has not signed it out yet.
4. R2's blister pack of Phenobarbital 64.8 mg with 12 tablets left that were intact and sealed. R2's controlled drug receipt/record/disposition form for the Phenobarbital showed that there should be 13 tablets remaining in the blister pack. V7 stated that she gave the Phenobarbital tablet to R2 earlier and has not signed it out yet.
On April 17, 2025, at 2:52 PM, V2 (Corporate Nurse) stated the nurse must document in the MAR (Medication Administration Record) and sign out the controlled medication from the controlled drug receipt/record/disposition form as soon as the medication was given to the resident. This was according to the facility's policy and for accuracy of record. If the seal is broken from the blister pack of the controlled medication, the medication should be disposed with a secondary nurse as a witness, to prevent drug discrepancy or unlawful drug diversion.
Facility's Policy and Procedure for Controlled Substance Administration and Accountability dated May 2024, shows:
Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure.
Policy Explanation and Compliance Guidelines:
g. In all cases, the dose noted on the usage form or entered to the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to address resident pharmacy medication regime review (MRR) recommendations.
This applies to 2 of 5 residents (R31 and R28) reviewed for unnecessary medications in the sample 20.
The Findings include:
1. R31's electronic medical record showed R31 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, malignant neoplasm of the larynx, tracheostomy, chronic respiratory failure with hypoxia and hypercapnia, hypertensive heart disease with heart failure and morbid obesity.
R31 had the following active orders as of April 17, 2025 at 12:26 PM:
1) Lorazepam 0.5 milligrams, 1 tablet every eight hours as needed for anxiety and the order was dated November 10, 2022
2) Guaifenesin Extended Release 12 Hour 600 MG (guaifenesin ER) 1 tab in the morning, and 2 tabs at night, and the order was dated November 18, 2022.
3) Guaifenesin Tablet Extended Release 12 Hour 600 MG (guaifenesin ER) 1 tab in the morning, and 2 tabs at night, and the order was dated November 18, 2022.
R31's pharmacy MRR sheets for the last six months were reviewed and included the following:
a) The pharmacist MRR's dated October 15, 2024, November 18, 2024, January 21, 2024, February 18, 2025, March 18, 2025 stated the following: Per Centers for Medicare and Medicaid services regulations, as needed psychotropic order(s) are limited to a 14 day duration. An as needed order may continue past 14 day if a clinical rationale for administration on an as need basis is documented within the residents chart.
b) The pharmacist MRR's dated December 17, 2024 and February 18, 2025 showed the following: R31 had been receiving Guaifenesin extended release 600 milligrams every morning and 1200 milligrams every night since November 2022. Please assess if continued scheduled treatment is still necessary. Please consider discontinuation or reduction to an as needed basis for congestion.
On April 17, 2025 at 12:26 PM, V8 (Registered Nurse) stated she has not given R31 Lorazepam in a very long time. V8 looked up R31's last administration of Lorazepam on her computer. V8 stated R31's last dose of Lorazepam was May 13, 2024. V8 looked in her control substance locked drawer to see if R31 had any Lorazepam after May 13, 2024, and R31 did not receive any.
Review of R31 electronic medication administration record showed that R31 had not been administered Lorazepam in the last 6 months, however, R31 had been given guaifenesin ER twice per day.
2. R28's electronic medical record showed that R28 was admitted to the facility on [DATE] with diagnoses that includes vascular dementia with behavioral disturbances, cerebral infarction, schizoaffective disorder depressive type, anxiety disorder, and major depressive disorder.
R28's pharmacy MRR sheets for the last six months were reviewed and included the following recommendations:
a) The pharmacist MRR dated February 18, 2025 stated Resident is receiving Depakote 500 MG daily and 250 mg every evening. I was unable to locate a recent valproic acid level within his lab records. Please assess if obtaining a valproic acid level with a future blood draw would be beneficial.
b) Review of recent labs drawn in January found a slightly reduced vitamin D level. Resident is not currently receiving a vitamin D supplement. Please assess if starting Vitamin D 1000 units daily would be beneficial and/or ordering a follow-up vitamin D level would be appropriate.
All of the pharmacy MRR recommendation forms mentioned above were blank and were not signed off by the attending physician to show that the recommendations were reviewed. There was no documentation presented that showed the pharmacy recommendations were addressed.
On April 18, 2024 at 2:03 PM, V2's (Corporate Nurse) voicemail was full and was not able to leave a message or contact V2 for interview.
On April 18, 2025 at 8:30 AM, V1 (Administrator) stated that V2 (Corporate Nurse) is the person that receives the medication regimen review recommendations from the pharmacy.
On April 18, 2025 at 4:25 PM, V1 stated he was not able to reach V2 either as her voicemail box was full.
The facility's MRR policy dated January 2025 stated the pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. The facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on observation, interview, and record review, the facility failed to label medication for the date it was opened to determine expiration date.
This applies to 4 of 5 residents (R2, R8, R37, R49) reviewed for labeling and storage in the sample of 20.
The findings Include:
On April 15, 2025, at 5:29 PM, the unit 2 medication cart was inspected with V7 (Nurse), and the following were observed:
1. R2's Incruse Ellipta was opened and not dated. The manufacturer's recommendation shows to safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label of the inhaler.
2. R37's Insulin Lispro was opened and not dated. The pharmacy list for expiration date shows that this medication expires 28 days after first use or removal from refrigerator.
3. R49's Insulin Lantus was opened and not dated. The pharmacy list for expiration date shows that this medication expires 28 days after first use or removal from refrigerator
4. R8's Fluticasone Furoate/Vilanterol Ellipta Inhalation Powder was opened and not dated. The manufacturer's recommendation shows to safely throw away BREO in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label of the inhaler.
On April 17, 2025, at 2:56 PM, V2 (Corporate Nurse) stated that the medications mentioned above should be dated upon opening to determine the expiration dates.

Based on observations, interview and record review, the facility failed to provide modified diet consistency for residents on thickened consistency liquids.
This applies to 2 of 2 residents (R28, R24) reviewed for thickened liquids in the sample of 20.
The findings include:
1. R24's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysphagia, unspecified.
R24's POS (Physician Order Summary) showed General diet, General diet, Pureed texture, Nectar consistency (revised October 17, 2023).
On April 16, 2025 at 11:46 AM, during tray line service at the lunch meal R24 received a pureed diet with nectar thickened beverages in glasses and also received a bowl of ice cream in addition to other nutritionally enhanced supplements. R24's meal ticket showed Pureed texture, mildly thick nectar thick liquids.
R24's dietary care plan updated on October 14, 2023 included that R24's appetite has decreased, continue pureed/nectar thick liquids .
2. R28's face sheet included diagnoses of cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia with behavioral disturbance, dysphagia, oropharyngeal phase, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, aphasia.
R28's POS showed General diet, Pureed texture, Honey consistency for 1:1 feed, may eat all meals while up (order date May 12, 2021).
R28's current care plan included that R28 has a swallowing problem related to stroke, is receiving Pureed diet with honey thick liquids. Interventions included that diet to be followed as prescribed.
On April 16, 2025 at 11:46 AM, during tray line service at the lunch meal R28 received a pureed diet with honey thickened beverages in glasses, 4 oz/ounce portion of mighty shake (nutrition health shake) and also received a bowl of ice cream. R28's meal ticket showed Pureed diet, honey thick liquids.
When V4 (Dietary Manager), who was in the vicinity, was asked if the consistency of mighty shake was honey thick, and whether ice cream was suitable for thickened liquids, V4 responded to my knowledge it's (ice cream) pretty thick and the (mighty) shake is already thickened. V4 stated that he added milk to the ice cream.
On April 17, 2025 at 10:28 AM, V18 (Speech Language Pathologist) stated that residents on thickened liquids cannot have ice cream as it starts of as a solid form and eventually melts to thin liquids. V18 stated that mighty shake is nectar thick and not honey thick consistency. V18 added that the facility would have to add more thickener to this mighty shake to obtain the honey thick consistency.
Facility policy on Consistency Altered Diets taken from Simplified Diet Manual (Twelfth Edition, 2016) included as follows for Liquid Consistency Levels: Liquids that change thickness at room temperature or body temperature may not be appropriate for persons on thickened liquids. Examples include milkshakes, ice cream, sherbet, frozen yogurt, and gelatin. A variety of commercial thickeners are available to modify liquids' consistencies. Follow the manufacturer's direction to achieve the preferred thickness.

Based on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen.
This applies to all 52 residents that received foods prepared in the facility kitchen.
The findings include:
Facility's CMS Form 671 dated April 15, 2025 showed that the facility census was 52 residents. Facility provided information that there were no residents on NPO (nothing by mouth) status.
On April 15, 2025 at 09:20 AM, the initial tour of facility kitchen was done in presence of V4 (Dietary Manager).
The hand sink area had unknown grime and had 2 scrub pads inside the sink that appeared to be used to prewash dishes at the dish machine. When questioned why the hand sink area was soiled, V4 stated that they do not have enough space in the kitchen to manage all tasks.
The reach in, two door steel refrigerator in the kitchen had marked grime and unknown smears on the handle and the surface of the refrigerator. V5 (Cook) and V4 were seen opening and closing the refrigerator during meal prep and or service. There was a large pan inside the top shelf of the refrigerator which was half full of stagnant water. V4 stated that there was a leak in the refrigerator and the pan was placed to catch the drips of water. V4 added that it was the same problem that was identified in the last year annual survey and it was never fixed.
A drawer at the prep station near the stove that stored utensils used for cooking, had grime and dust. The surface areas on shelves beneath the center workstation that stored multiple inverted pans also had food debris, dust and unknown grime.
The ice scoop used to scoop ice from the ice machine was placed on workstation that had dust and unknown debris. V4 stated Does it (ice scoop) have to be covered. I don't remember. During the tour V4 was also notified of the above unsanitary surfaces.
On April 15, 2025 at 11:40 AM, V6 LPN (Licensed Practical Nurse) was seen coming into the kitchen and taking the scoop from the workstation and get ice from the ice machine V6 did not wash her hands or wear gloves. V6 stated that she is getting the ice to add it into the water pitcher on her medication cart as some residents like cold water.
On April 15, 2025 at 11:43 AM, prior to start of meal service, V5 (Cook) was requested to take the food temperatures. The pureed spaghetti and pureed garlic bread both showed 120 degrees Fahrenheit respectively. V4 had to be prompted to reheat the items prior to serving the same.
On April 17, 2025 at 2:44 PM, V17 (Dietitian) stated that the food prep and refrigerator door surface area should be clean for sanitary purposes. V17 stated that staff coming from outside the kitchen should wash their hands prior to getting ice from the ice machine and that the ice scoop should be in a scoop holder. V17 stated that hot foods at the steam table should be at minimum 135 degrees Fahrenheit.
Facility policy and procedure taken from 'Guideline & Procedure Manual 2020' included as follows:
Storing Utensils, Tableware, and Equipment-
Guideline: Employees will store utensils, tableware and equipment according to the following guideline
Procedure: 2. Food contact surfaces of fixed equipment should be protected from contamination by splash, dust or other means. 3. Clean and sanitize drawers and shelves before clean items are stored.
Ice Handling and Cleaning:
Guideline: Ice will be stored and served to residents in a sanitary manner.
Procedure: 1. Ice will be handled, transported and stored to protect against contamination.
3. Ice buckets, other designated containers, and scoops will be kept clean and sanitized. Scoops will be stored in a protected manner .
Monitoring Food Temperatures for meal Service:
Guideline: Food temperatures will be monitored to prevent foodborne illness and to ensure foods are served at palatable temperatures.
Procedure: 3d. If the serving holding temperature of hot food item is not at 135 degrees Fahrenheit or higher, when checked prior to meals service, the item will be reheated to at least 165 degrees Fahrenheit for a minimum of 15 seconds.

Based on observations, interview and record review, the facility failed to ensure that the resident refrigerators in the room are maintained in safe and sanitary manner.
This applies to 2 of 2 residents (R36, R43) reviewed for personal food storage in the sample of 20.
The findings include:
On April 15, 2025 at 11:12 AM, R43's room had a refrigerator near her bed. R43 spoke primarily in Spanish and R43 was notified that the temperature of her refrigerator was going to be checked. The refrigerator contained multiple cans of soda, bags of (few) grapes in each bag, a tub of cream cheese, a bottle of salsa, salad dressing and sweet and sour sauce with use by date April 9, 2025. There was no thermometer inside the refrigerator and no temperature logs were seen. R43 then motioned that this refrigerator belongs to her roommate R36, who was not in the room. R43 pointed to another refrigerator in the corner of the room near the foot of her bed and stated that is the refrigerator that belonged to her. With R43's permission, her refrigerator was also checked and noted to have multiple items including four food storage (plastic) containers of unknown prepared foods which were unlabeled with dates brought in. R43 stated that her family brings the foods. The refrigerator also had 2 cartons of milk, one unopened and the other one almost empty. R43's refrigerator also did not have a thermometer and no temperature logs were seen.
On April 15, 2025 at 11:19 AM, V15 (Certified Nursing Assistant), who was in the vicinity, when asked stated that she doesn't know who checks the refrigerator and remarked Maybe the Maintenance.
On April 17, 2025 at 9:46 AM, V16 (Housekeeping Director) stated I am in charge of the refrigerators in resident rooms. I check once a month for expired stuff and throw it out. We don't check the temperatures. My department also cleans it (refrigerators) out once a month.
Facility policy and procedure titled Use and Storage of Food brought in by Family or Visitors (dated January 10, 2024) included as follows:
Policy: It is the right of the residents of this facility to have food brought in by family or other visitors , however, the food must be handled in a way to ensure the safety of the residents.
Policy Explanation and Compliance Guidelines:
2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.
b. The prepared food must be consumed by the resident within 3 days.
c. If it is not consumed by the resident in 3 days, food will be thrown out by the facility staff.
9. The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitor if the resident is not able to do so on their own.
Facility policy and procedure titled Refrigerators in Resident Rooms (Manual 2000) included as follows:
Procedure:
1. The Housekeeping Department will keep a current list of rooms with resident refrigerators.
2. Each refrigerator shall have a thermometer log with daily entry. Each refrigerator will have an inside thermometer. The refrigerator temperature will be maintained at or below 41 degrees Fahrenheit. If the temperature is not maintained at 41 degrees Fahrenheit or below, the food will be discarded.
3. The housekeeper will enter the temperature once daily. Any temperature not in range will be immediately reported to the Housekeeping Supervisor or Nursing Supervisor and Maintenance.

2. Face sheet shows that R44 has multiple medical diagnoses including paraplegia, urinary tract infection, neuromuscular dysfunction of bladder. Care plan report shows that R44 has indwelling urinary catheter, intravenous catheter, and R44 was placed on Enhance Barrier Precaution (EBP).
On April 15, 2025, at 10:27 AM, V15 and V23 (Both Certified Nursing Assistant/CNA) provided morning care to R44. V15 and V23 donned gloves while providing care to R44. They provided peri-care, emptied catheter bag, applied petroleum jelly to R44's legs and thighs, and transferred R44 via mechanical lift from bed to wheelchair. Though they changed gloves and sanitized hands in between tasks, they did not wear an isolation gown throughout the care.
Enhance Barrier Precautions (EBP) shows Providers and Staff must also wear gloves and a gown for the following High-Contact Resident Care Activities such transferring, changing briefs or assisting with toileting, device care or use central line, urinary catheter, feeding tube, and tracheostomy.
3. On April 15, 2025, at 4:07 PM, V7 (Nurse) administer medications to R49, then she donned a pair of gloves to checked R49's blood glucose. After getting the glucose level and while wearing same gloves, she went back to the medication cart and documented R49's glucose in the computer. V7 continued to open the medication drawer to get the BP (blood pressure) apparatus. V7 removed her gloves and checked R49's BP. V7 returned to the cart and opened the drawer to get cell phone to call the NP (Nurse Practitioner). V7 did all these different tasks from the dirty to clean and did not perform hand hygiene during R49's medication administration and assessments.
4. On April 15, 2025, at 4:26 PM, V21 (Nurse/RN) prepared and attempted to administer medications to R36. When R36 refused the medications, V21 started to prepare the medication of R43. At 4:33 PM, V21 adjusted the Oxygen tube of R43 with her bare hands, then she donned gloves and check the blood glucose level. V21 removed her gloves and without hand hygiene, left R43's bedroom to administer medication to another resident (R5) who was asking her for a pain reliever. After V21 gave the pain reliever to R5, V21 returned to R43's bedroom to continue to give the nebulizing treatment. V21 did all the different tasks and assisted different residents without performing hand hygiene in between tasks and residents.
On April 17, 2025, at 3:09 PM, V2 (Corporate Nurse) stated the nurses must perform hygiene before and after resident care, in between tasks and in between residents, regardless of wearing gloves. Gloves are not a substitute for hand hygiene for infection control. Whenever the staff is providing hands on care to resident who is identified under enhance barrier precaution, the nurse must wear complete personal protective equipment such as gown and gloves as part of infection prevention.
Facility's Hand Hygiene Policy and Procedure dated October 2023, shows: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working within the facility.
Policy Explanation and Compliance Guidelines shows:
6. Additional considerations:
a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.
Based on observation, interview and record review, the facility failed to provide hand hygiene during medication administration, failed to use PPE (Personal Protective Equipment) while providing direct care for a resident on EBP (Enhanced Barrier Precautions) and failed to do complete infection control surveillance monitoring for the facility.
This applies to all 52 residents who reside in the facility.
The Findings include:
Facility's CMS Form 671 dated April 15, 2025 showed that the facility census was 52 residents.
1 On April 17, 2025, at 2:50 PM, V1(Administrator) stated V3 (MDS Nurse) was in the role of IP (Infection Preventionist) but was not trained. V3 was not in the facility and unavailable for interview. V1 provided the infection prevention surveillance documentation for January, February and March 2025, and V1 stated there was no infection surveillance the month of April 2025, and no residents who required TBP (Transmission Based Precautions).
V1 provided the Infection Log the facility utilizes for tracking infection. The Infection Log included a column for documentation for the following: Unit, Date, Resident, Room #, Site, Organism, Lab/Culture, Antibiotic, Isolation/Precautions, Symptoms present on admission, and Acquired in Facility (HAI). The total resident days per month and the infection incidence rate for the month were at the top of the form to complete the documentation.
The Infection Log dated January 2025, showed missing data and no infection Incidence rate. There were 12 residents listed on the infection log. The log showed 9/12 residents missing the Site of the infection, 6/12 residents missing the Organism, 12/12 did not specify if any Lab/Culture results were completed, 10/12 did not identify if symptoms were present, if isolation precautions were needed, or if the infection was acquired in the facility or was community acquired.
The Infection Log dated February 2025, showed missing data and no infection incidence rate. There were 7 residents listed on the infection log. The log showed: 7 of 7 residents listed, had no data entered for Site, Isolation/Precautions, Symptoms, Labs/Cultures or if Acquired in the facility.
The Infection Log dated March 2025, showed incomplete data and no infection incidence rate. There were 12 residents listed on the infection log. The log showed: 7 of 12 residents did not have the Site recorded or if Facility Acquired, 8 of 12 residents did not specify if Labs/Culture was done or if Symptoms were present, and 9 of 12 had no data for Isolation /Precautions.
The Facility's policy titled Infection Surveillance dated August 2024, showed Policy: A system of infection surveillance serves as the core activity of the facility's infection prevention and control program .5. Surveillance activities will be monitored facility-wide, and may be broken down by department or unit depending on the measure observed. A combination of process and outcome measures will be utilized .6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected .i. the infection site, pathogen (if available), signs and symptoms, and resident location including summary and analysis of the number of residents (and staff) who developed infections .9. All resident and infections will be tracked.

Based on interview and record review the facility had incomplete documentation on the Antibiotic Surveillance log and failed to evaluate the presence of infection utilizing the standardized criteria to define infections, in accordance with facility policy.
This applies to all 52 residents who reside in the facility.
The Findings include:
On April 17, 2025, at 2:50 PM V1 (Administrator) stated he was unsure if the facility utilizes McGeer criteria or any criteria for evaluating the use of antibiotics. V1 provided Antibiotic Surveillance Log for the months of January, February and March 2025. V1 stated there was no Antibiotic Surveillance Log for the month of April 2025. V1 stated V3 (MDS Nurse) was assigned the role of IP (Infection Preventionist) but was not trained and was not available for interview.
Upon request for the documents related to the facility Antibiotic Stewardship program the facility provided the policy and 3 months of Antibiotic Surveillance Logs.
The Antibiotic Surveillance Log had 8 columns for data to be entered. The columns were titled:
Date, Resident, Room #, Antibiotic order, Diagnosis, Ordering Practitioner, Documentation Supports Necessity, and ordered upon admission.
The Antibiotic Surveillance Log dated January 2025, showed 11 residents listed on the log.
The log was incomplete. The log showed 4 of 11 residents did not have diagnosis for use of antibiotic, and 10 of 11 residents had no data in the columns for ordering Practitioner, Documentation supports necessity, and ordered upon admission.
The Antibiotic Surveillance Log dated February 2025, showed 6 residents listed on the log. The log was incomplete. The log showed 1 of 6 residents did not have a diagnosis for antibiotic use, and 6 of 6 residents had no documentation for the columns for ordering Practitioner, Documentation Supports Necessity and Ordered upon admission.
The Antibiotic Surveillance Log dated March 2025 showed 8 residents listed on the log. The log was incomplete. The log showed 3 of 8 residents did not have a diagnosis listed for use of antibiotic, and 8 of 8 residents did not have documentation for the column Documentation Supports Necessity.
The Facility did not provide completed assessment forms to define infections (i.e. McGeers criteria, Loeb's Minimum criteria or NHSN surveillance definitions), antibiotic stewardship meeting minutes or records related to education of physicians, staff, residents and families as outlined in the facility policy.
The facility's policy titled Antibiotic Stewardship Program dated January 2025, showed Policy: It is the policy of the facility to implement an Antibiotic Stewardship program as part of the facility's overall infection control program .4. The program includes antibiotic use protocols and a system to monitor antibiotic use .a. Antibiotic use protocols: iii. The facility uses the (CDC's NHSN Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections .iv. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics .9. Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents and family.

Based on interview and record review the facility failed to ensure that the facility's IP (Infection Preventionist) had completed specialized training in infection prevention and control.
This applies to all 52 residents who reside in the facility.
The findings include:
On April 17, 2025, at 2:50 PM, V1 (Administrator) stated the facility's trained IP was the former Director of Nursing, who last worked in the facility on April 4, 2025. V1 stated V3 (MDS Nurse) was assigned the duties of the IP. V1 became Administrator on February 24, 2025, and stated V3 was already assigned the IP position. V1 stated currently there is no staff onsite who completed specialized training in Infection Control.
V3 had not received any specialized training in infection control. V3 was not available to be interviewed during this investigation.
The infection control surveillance tracking that V1 provided for January, February and March 2025, was incomplete. There was no infection control surveillance tracking for the month of April 2025.
The in-service training provided by the facility on infection control topics, since the last annual survey was reviewed. The most recent infection control in-service provided for facility staff was provided by V14 (former DON) on December 30, 2024. There was no infection control in service training provided in 2025.
The facility's policy titled Infection Surveillance dated August 2024, showed Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective action made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .6. The facility will collect data to properly identify possible communicable disease or infections among residents and staff before they spread by identifying: a. Data to be collected: i. The infection site, pathogen, signs and symptoms .including summary and analysis .ii. Observations of staff including the identification of ineffective practices .ii. The identification of .infection trends .8. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents signed POLST (Practitioner Order for Life-Sustaining Treatment) form and the physician's order are consistent, to reflect the resident's treatment wishes in an event of a medical emergency.
This applies to 3 of 3 residents (R15, R32, and R51) reviewed for advanced directives in the sample of 20.
The findings include:
1. R15 had multiple diagnoses including flaccid hemiplegia affecting left nondominant side, kidney transplant status and ESRD (end stage renal disease), based on the face sheet.
R15's quarterly MDS (minimum data set) dated [DATE] showed that the resident was cognitively intact.
R15's EMR (electronic medical records) scanned POLST dated [DATE], signed by R15 showed that the resident selected, Do Not Attempt Resuscitation/DNR (Do Not Resuscitate).
R15's active order summary report showed an order dated [DATE] to, Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation).
R15's active care plan initiated on [DATE] showed that the resident has a full code status and to attempt resuscitation/CPR. The same care plan showed multiple interventions including, Code status will be reviewed at least quarterly and with changes in his condition, execute any of wishes for code changes and implement any changes desired, and If code status changes the clinical record will be updated to reflect the changes.
On [DATE] at 3:33 PM, V7 (LPN (Licensed Practical Nurse) stated that if a resident has no pulse and no breathing, she will first check the EMR dashboard section to see the code status and then look at the code status order. V7 stated that whatever was documented on the dashboard should match the actual order and whatever the code instructions written on the dashboard and the physician's order should be followed. During this interview, V7 checked R1's EMR dashboard and the active order then stated that both sources showed that the resident is a full code and CPR should be performed. V7 was asked if she would also check if the resident had a signed POLST in EMR and she (V7) stated yes, if it is in the electronic records. V7 then looked at the EMR for R15's signed POLST. V7 stated that the signed POLST for R15 showed that the resident is DNR. V7 commented, Okay, this is confusing. V7 acknowledged that based on the EMR dashboard and active order, and the resident's signed POLST, there is a conflicting information about R15's code status.
On [DATE] at 3:40 PM, V2 (Corporate Nurse) stated that the resident's signed POLST should be reflected on the physician's order. V2 was shown R1's physician order to attempt resuscitation and R1's signed POLST indicating DNR. According to V2, the two information were conflicting and needs to be looked at immediately in case of an emergency.
The facility's policy for resident's rights regarding treatment and advance directives, last reviewed by the facility on [DATE] showed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The same policy under explanation and compliance guidelines showed in-part, 3. Upon admission should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.
2. Face sheet shows that R51 is 78 years-old who has medical diagnoses including urinary tract infection (UTI), site not specified, and hypertension (HTN). R51 was admitted to the facility on [DATE].
R51's Physician Order Summary (POS) advance directives dated February 24, 2025, shows that R51's is a full code (meaning Attempt Cardiopulmonary Resuscitation/CPR).
R51's signed POLST (Practitioner Order for Life-Sustaining Treatment For) dated [DATE], showed that R51 selected, Do Not Attempt Resuscitation/DNR.
On [DATE], at 3:06 PM, V2 (Corporate Nurse) stated that all orders and care plans for advance directives should follow code status or POLST.
R51's care plan for advance directives shows R51 has chosen DNR (Do Not Resuscitate). This care plan was created on [DATE], after surveyor's inquiry.
3. R32's EMR (electronic medical records) included diagnoses of face hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, unspecified convulsions, end stage heart failure, personal history of other diseases of the respiratory system.
R32 EMR dashboard showed special instructions Full Code and POLST form uploaded in EMR showed No CPR (Do Not Attempt Resuscitation (DNAR). There was no order for advance directive on POS (Physician Order Sheet).
On [DATE] at 12:33 PM, R32's nurse (V6, LPN, Licensed Practical Nurse) when asked how she determines the code status of a resident in the event of an emergency, V6 stated Usually the dashboard (of computer) will tell you if it's a DNR or full code. R32 then looked up R32's EMR and stated that he is a full code and that she will attempt full CPR (Cardio Pulmonary Resuscitation) in the advent of an emergency for R32. V6 added that sometimes the code status is also uploaded under miscellaneous section. V6 then made several attempts to look up the miscellaneous section but was unable to do so. V6 stated that she is fairly new at the facility and don't know the system (EMR) here. V10 (LPN) who was in the vicinity stated that the code status is also listed on the crash cart. On reviewing the crash cart listing for full code status R32's name was not found. V6 then remarked that she goes by the dashboard for code status of the patient as the list on the crash cart is not always updated.
On [DATE] at 12:47 PM, as V6 and V7 were not able to access the miscellaneous section of the EMR with multiple tries, V2 (Corporate Nurse) was requested for R32's POLST form. V2 then confirmed that special instructions on R32's dashboard showed Full Code and POLST form uploaded in EMR showed No CPR (Do Not Attempt Resuscitation (DNAR). V2 stated that the facility process is that the social service reviews the resident's clinical records on admission and obtains the advance directive and collaborates with the nursing IDT (interdisciplinary team) to put the orders in the resident's EMR.
On [DATE] at 12:55 PM, V9 (Social Service Director) stated that when she obtains a POLST form she uploads it in the system and then puts a progress note and updates the care plan to reflect what is on the POLST. V9 added that she does not enter the orders for the advance directive as its only the nurses that enters orders on POS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R51's electronic medical records (EMR) shows that R51 is 78 years-old who has medical diagnoses including urinary tract infection, site not specified, and essential hypertension. Minimum Data Set (MDS) dated [DATE], shows that R51's Brief Interview for Mental Status (BIMS) is 10 (moderately impaired cognition) and requires assistance for grooming and hygiene. Though R51's BIMS was 10, R51 was unable to respond well to instructions this was confirmed by V15 (Certified Nursing Assistant/CNA) who stated that R51 is confused.
R51 was observed on April 15 and 16, 2025, displaying nails with black and brown substances underneath her fingernails. R51's nail beds had brownish discoloration. R51 also has curly facial hair on her chin. R51 was verbal and able to respond to yes or no questions. However, she was unable to coherently answer questions that needed explanation.
On April 16, 2025, at 1:39 PM, V15 and V22 (CNA) rendered peri-care and catheter care to R51. R51's urinary catheter was not secured or anchored. R51 also remained with brownish discoloration on her nail beds, and with black/brown substances underneath the nails. R51 remained with curly facial hair on her chin. R51 was cooperative during provision of peri-care. V15 and V22, did not attempt to secure the urinary catheter, and did not offer to provide nail care and shaving to R51.
R51's care plan report was reviewed. There were no specific care plans addressing R51's ADL (activities of daily living) care pertaining to grooming and hygiene, and the care for indwelling urinary catheter.
4. The electronic medical record (EMR) shows that R158 was admitted on [DATE]. R158's past medical history include hypertension, diabetes, and osteomyelitis of the right foot. The nurse practitioner notes dated April 10, 2025, shows that R158 had a surgery on March 26, 2025, with a partial ray amputation of the right foot. R51's treatment from the hospital was completed and he was sent to the facility for wound care and antibiotic therapy.
R158's nutrition/dietary notes dated April 11, 2025, shows R158 was admitted to the facility following hospitalization for infected right foot diabetic ulcer, then diagnosed with osteomyelitis.
On April 15, 2025, at 11:14 AM, R158 was resting in bed, he was alert and oriented and could communicate well during interview. R158's right foot was covered with a wound dressing. R158 stated that he was diabetic, and he had a recent amputation of his right big toe about a month ago. R158 also stated that he has history of amputation of his two other right toes.
From 4/15/25 through 4/17/25, R158 has been observed ambulating the hallway and going outside for smoking.
R158's care plan report was reviewed. There were no specific care plans addressing R158's diabetes and diabetic wound.
On April 17, 2025, at 3:01 PM, V2 (Consultant Nurse) stated that part of the grooming/hygiene is to offer shaving and nail care and if resident refuses the staff must report and document refusal and update care plan. In addition, V2 stated that comprehensive care plan should be develop and implemented within 7 days upon completion of MDS.
Facility's Policy for Comprehensive Care Plans dated January 2025 shows: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standard of quality.
Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.
Policy Explanation and Compliance Guidelines shows:
2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. All Care Assessment Areas (CAA) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will be address in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.
3. The comprehensive care plan will describe, at a minimum, the following:
a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing.
d. The resident's goals for admission, desired outcomes, and preferences for future discharge.
2. R53's electronic medical record showed R53 is a [AGE] year old admitted to the facility on [DATE] with diagnoses that includes acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and Type 2 Diabetes Mellitus.
On April 15, 2025 at 10:55 AM, R53 was receiving 3 liters of oxygen via nasal cannula.
R53 has a physician order dated January 23, 2025 that showed R53 should have continuous oxygen at 2-3 liters via nasal cannula or mask.
As of April 18, 2025 at 9:08 AM, R53 did not have a care plan for his continuous oxygen, respiratory failure with hypoxia, nor his chronic obstructive pulmonary disease.
Based on observation, interview and record review the facility failed to ensure residents have a comprehensive care plan, that identifies their individual needs and includes all aspects of their care including assistance needed with ADLs (Activities of Daily Living), urinary catheter care, oxygen administration, and wound care.
This applies to 4 of 4 residents (R19, R51, R53 and R158) reviewed for care plans in the sample of 20.
The findings include:
1. R19's admission record showed R19 was admitted to the facility on [DATE], with multiple diagnoses including diabetes type 2, essential hypertension, non-displaced fracture of head of right radius, major depressive disorder, obstructive sleep apnea, atherosclerotic heart disease.
R19's MDS (Minimum Data Set) dated March 17, 2025, showed R19 had a stage 3 pressure ulcer, the presence of a pressure reducing device for bed, pressure reducing device for chair, and was receiving care and application of ointments for the pressure ulcer.
R19's order summary dated April 11, 2025, showed an order for barrier cream to be applied to the coccyx every shift and as needed.
On April 16, 2025, at 11:10 AM, R19's wound care was observed and R19's coccyx area remained red, V10 (LPN) stated this site was a pressure ulcer that was healing.
R19's care plan initiated on November 19, 2024, did not identify a plan of care for a pressure ulcer, or a plan for prevention of pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to perform CPR (Cardio-Pulmonary Resuscitation) correctly as per standards of practice, failed to call a code blue within the facility, and failed to call EMS system (911) for an unresponsive resident identified as a full code on the physician's orders in accordance with the Facility policy.
This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE], at 5:25 AM, when R55, who had full code orders, expired in the facility after being found unresponsive and staff did not perform CPR as per the Standards of Practice and did not follow their policy for Medical Emergencies. V1 (Administrator) and V24 (Regional Director of Operations) were informed of the Immediate Jeopardy on [DATE], at 4:17 PM.
The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but the facility remains out of compliance at a severity level two because additional time is needed to evaluate the implementation and effectiveness of the training.
This applies to 31 of 53 residents (R1, R5, R10, R11, R13, R15, R17, R18, R19, R20, R23, R25, R29, R33, R36, R37, R38, R39, R40, R42, R44, R45, R47, R48, R49, R52, R53, R55, R158, R257 and R307) reviewed for code status and request CPR to be performed.
The Findings include:
The admission record showed R55 was admitted to the facility on [DATE], with diagnoses of fracture of the right femur subsequent encounter for closed fracture with routine healing, hypopituitarism, type 2 diabetes, chronic diastolic congestive heart failure, obstructive sleep apnea and cerebral infarction due to embolism of the cerebral artery.
R55's progress note dated [DATE], at 3:00 PM showed R55 was admitted for further rehabilitation, was a full code status and transferred from another SNF (Skilled Nursing Facility), R55's hospital referral notes to prior facility dated [DATE], showed R55 had a fall on [DATE], and had surgery for femur fracture on [DATE]. R55 was hospitalized from [DATE], until [DATE]. R55 transferred to this facility on [DATE]. The transfer orders showed under advanced directives that R55 was a full code. R55's vital signs at the time of admission showed blood pressure 144/80, Pulse 62 beats per minute, Temperature 98.0 F, Respirations 18 breaths per minute and oxygen saturation was 97% on room air.
The next documentation after R55's initial admission note was [DATE], at 08:04 AM written by V11 (RN) that showed R55 was found unresponsive, no pulse and cool to touch at 5:25 AM and pronounced dead by 2 nurses.
During interview of V11 (RN), on [DATE], at 2:10 PM, V11 stated she had seen R55 sleeping on his side with regular respirations during her first round at around 11:00 PM. V11 stated the next time she did rounds was between 2:30 AM and 3:00 AM, she observed R55 and appeared to be sleeping, but was making coughing type noises while breathing. V11 stated she did not assess R55 at that time. V11 stated the next time she saw R55 when she went to his room to administer medications at around 5:20 AM and attempted to wake R55 up but R55 did not respond. V11 stated she then turned on the light, did not find a pulse, found R55 was lying in brown, yellow stained sheets, did a sternal rub and left the room to call for help. V11 stated it appeared R55 had defecated, and stool was on the bed and on the floor. V11 stated she used the nurses desk phone to call the other nurses' station to get the other nurse, (V10) to help and told V13 (CNA) to go to R55's room. V11 stated she did not overhead page a code blue because she had never been taught how to overhead page. V11 then stated she called V14 (former DON) from her cell phone and went back to R55's room. V11 stated while on the cell phone with V14, V11 stated she started to do chest compressions for less than a minute, when V14, who was not in the facility, instructed her to stop compressions and not to call 911. V11 stated she did not bring the crash (emergency) cart to R55's room. V11 stated she was unsure what to do in the situation and was looking for guidance. V11 stated in hindsight she would have called 911 and started CPR as soon as she found R55 unresponsive. V11 stated she was unaware of R55's code status until she was contacting the funeral home. V11 stated as of now she does not know how to use the facility's intercom system to announce a Code Blue.
V14 was no longer employed by the facility and not available for interview.
On [DATE], at 3:47 PM, V10 (LPN) stated she worked the overnight shift with V11 on [DATE]. V10 stated she was in a resident's room when she heard the desk phone ring at the nurses' station, she was unsure of the time but said it was at the end of the shift. She stated she made the resident safe and went to answer the desk phone. V10 stated V11 was calling her to come to R55's room. V10 stated by the time she got to R55's room, V11 was talking on the cell phone to V14, so she left and did not provide any assistance and did not assess R55. V10 stated when she saw V11 talking on the cell phone she left the room and went back to her assignment. V10 stated she did not call a code blue; she did not bring the crash cart and she did not call 911. When asked about who could pronounce a resident dead in the facility, V10 stated she was not sure if the facility had a policy, but only an RN can pronounce a resident dead in the facility.
On [DATE], at 3:15 PM, V13 (CNA) was working on the unit with V10. V13 stated near the end of the shift, V11 asked him to help clean R55 because the family was coming. V13 stated when he walked into R55's room he did a sternal rub, but R55 did not respond. V13 stated he thought R55 might be dead, but he also thought only a doctor could pronounce someone dead. V13 stated there was no crash cart at the room, he was not aware of a code blue and the paramedics were not in the facility.
On [DATE], at 5:40 PM, V12 (Medical Director) stated if a resident is found unresponsive, without a pulse and is a full code, the paramedics should be called. V12 stated CPR should be initiated unless rigor mortis is present. V12 stated the presence of feces on or around the resident is not an indication that CPR should not be performed.
R55's progress notes on [DATE], did not indicate an assessment for signs of clinical death or the presence of rigor mortis was done and was not documented.
On [DATE], at 3:05 PM, V1 (Administrator) stated there was no investigation regarding the death of R55. V1 stated he was not the Administrator at that time, both the Administrator and Director of Nursing at the time of R55's death were no longer employed by the facility.
On [DATE], at 10:30 AM, V24 (Regional Director of Operations) stated the facility does not have a policy regarding nurses determining death and pronouncing time of death of a resident. V24 stated he would have to ask the Regional Clinical Consultant what the policy should be.
On [DATE], at 1:00 PM, the facility provided a list of residents in the facility with their code status and there were 30 residents (R1, R5, R10, R11, R13, R15, R17, R18, R19, R20, R23, R25, R29, R33, R36, R37, R38, R39, R40, R42, R44, R45, R47, R48, R49, R52, R53, R158, R257, and R307) identified as full code status in the facility.
The Facility's policy titled Medical Emergency Response dated reviewed [DATE], showed Policy Explanation and Compliance Guidelines .1. The employee who first witnesses or is first on the sight of a medical emergency, will initiate immediate action, including CPR as appropriate . 3. A Nurse will .b. Stay with the resident . c. Designate a staff member to announce a Code Blue, notify the physician and call 911 .4. A Code Blue will be announced over the intercom system. 5. All available staff will respond to the emergency accordingly .6. The staff on the unit will take the emergency cart to the code .7. This will continue until emergency personnel arrive and resident is transported to the emergency room via EMS (Emergency Medical Services) .8. If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services, and a. In accordance with the resident's advance directives.
The facility submitted an abatement plan to remove the immediacy on [DATE], at 6:08 PM. The Survey Team reviewed the abatement plan and was unable to accept the plan and returned the abatement plan to the facility for revisions. The Facility presented a revised abatement plan on [DATE], at 12:34 PM. The Survey Team reviewed the plan and was unable to accept the abatement plan and it was returned to the facility for revisions. The Facility presented a revised abatement plan on [DATE], at 5:34 PM. The Survey Team reviewed the abatement plan and was unable to accept the third revision. The abatement plan was returned to the facility for fourth revision. The Facility submitted the revised abatement plan on [DATE], at 6:15 PM. The Survey Team accepted the abatement plan on [DATE], at 6:20 PM.
The Immediate Jeopardy that began on [DATE], was removed on [DATE], when the facility took the following actions to remove the immediacy:
-Administrator/ designee will provide training for all staff, initiated on [DATE], on Medical Emergency Response and CPR policy. This includes the employee who first witnesses or is first on the site of a medical emergency will initiate immediate action. The training also includes if a resident experiences cardiac arrest or unresponsiveness, the facility staff will provide basic life support including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives. The Training will continue until all staff have attended. Agency staff and staff who missed the training will receive training prior to working their next scheduled shift.
-Administrator/designee will provide training for all staff, initiated on [DATE], on Resident Rights regarding Treatment and Advance Directives.
-Provide Mock Code evaluation drills, initiated on [DATE], in a Mandatory Meeting and continue until all staff have attended a drill. The Mock Code Blue Audit tool will be used during the drill as a guide for staff roles and tasks during a Code Blue. The Administrator/designee will provide the training. The training will continue until all staff have been trained.
-The Maintenance Director will provide training on the use of the intercom system, to announce Code Blue on the overhead page, to all staff, as part of the Mock Code evaluation drills initiated on [DATE]. The training will continue until all staff have been trained.
-The facility developed a process to determine if a resident has executed an advance directive. The Social Service Director reviewed Advance Directive with the residents, initiated [DATE], and the process is ongoing.
- Upon admission, the Nurse will ensure a resident with an advance directive, will communicate the resident's choice to the Health Care Practitioner and obtain the order, and provide a copy of the Advanced Directive to Social Services/designee, initiated [DATE], and ongoing.
-The Facility Quality Assurance Committee (Administrator, Regional Director of Operations, Regional Clinical Director and Medical Director) met on [DATE], at 5:00 PM to review the F678 IJ (Immediate Jeopardy).
-The Facility created a Quality Assurance audit tool to be implemented on [DATE], used by the DON (Director of Nursing)/Designee, for all Licensed Nurses, for Medical Emergency Response. The Audit will be done with every nurse and then twice weekly with random nurses for three months. The results of the Audits will be reviewed with the QA (Quality Assurance) Committee at their monthly meetings.
-The Facility created a QA audit tool to be used by Social Service/designee daily to assess all new admissions and readmissions for Code Status and or POLST orders, care plan and update the list of resident code status. The audit tool will be done daily for one month, then monthly for 3 months and then quarterly for a year. The audit tool to be implemented on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received monthly medication regimen review (MRR) by a licensed pharmacist. This applies to 1 of 1 resident (R15) reviewed for medication regimen review in the sample of 14.
The findings include:
R15 is a [AGE] year old female who was admitted to the facility on [DATE] with medical diagnoses that include Dementia, Hypertension, Delusional Disorders, Depression, Hyperlipidemia, Osteoarthritis, and Anxiety. R15's medication orders include Seroquel 12.5 milligrams (mg) for delusional behavior, and Venlafaxine Hydrochloride Extended Release (HCL ER) Capsule 75 mg for depression.
Review of R15's medical record on the morning of May 14, 2024 showed no medication regimen reviews completed by the pharmacist.
On May 14, 2024 at 1:11 PM, V2 (Director of Nursing) stated the facility does not have any medication regimen reviews by the pharmacist for R15. V2 stated she checked with the pharmacist and they did not have any either.
R15's Psychotropic medication care plan showed to consult with pharmacy.
The facility's Medication Regimen Review policy dated 1/2024 showed the following: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. 1. The MRR includes: a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.

Based on observation, interview and record review, the facility failed to follow food storage and thawing procedures and ensure that food service areas are maintained in a clean and sanitary manner. This apples to 44 residents that receive oral diets prepared in the facility kitchen.
The findings include:
Facility provided information that the census on May 13, 2024, was 46 residents, with 2 residents on NPO (nothing by mouth) status.
On May 13, 2024, at 9:47 AM, the initial tour of the kitchen was done in the presence of V6 (Dietary Manager).
At the dish machine, V7 (Cook) was seen at the clean side of the dish machine unloading cleaned dishes from racks that just came out of the dish machine. The cleaned dishes on the racks were atop the conveyor belt that was noted to have unidentifiable debris and food particles.
The reach in freezer had unknown smears on the surface of the door and the bottom part of the door was eroded and had the appearance of rust. There was extensive blackish substance and debris on the inside side compartments and on the racks where food was stored. Multiple open undated hamburger patties were seen stored on one of the shelving. On the top shelf there was a tall plastic cup of half-drunk chocolate milk shake that V6 stated was not for residents.
The reach in refrigerator also had unknown smears and dust on the door handle. The outside panel and the refrigerator was noted to be wobbling when the door was opened. A large pan half filled with water was seen on the top shelf. V6 stated that the water was collecting from a leak from the condenser and V6 had put in a request to get it fixed. Under the same pan there was a plate with sliced ham that was partially covered with a plastic wrap. Another pan contained several packs of opened deli meat (Bologna) which was opened and undated. V6 stated It's from last night. The shelves of the refrigerator were brownish grayish color where the enamel coating had worn off.
Inside the 3-compartment sink (sanitizing well), water was running from a faucet over raw frozen unidentifiable meat in a container. The top part of the meat was exposed out of the pan and the bottom part was submerged in water in the container. Soiled dishes were seen stacked in the wash well of the 3-compartment sink. V6 stated that the 3-compartment sink was not in use and that the soiled dishes will be run through the dish machine.
On May 13, 2024, at 11:27 AM, on return to the kitchen, the same thawing frozen meat was seen half immersed in a container of water in the 3 compartment sink. The water was not running over the frozen meat identified as 'Pork Butt' by V6. V6 added that there are 3 appropriate ways to thaw meat: in a microwave, in a refrigerator or in running water. V6 acknowledged that the water was not running over the defrosting pork butt.
The ice maker screen was covered with extensive dust which had a fan blowing on it to the food prep area and the steam table. The entire kitchen floor under the stove and shelving was covered in dust and unknown debris.
On May 14, 2024, at 10:21 AM, the kitchen was revisited, and the above seen freezer still had extensive blackish substance on the shelving and side compartments. An undated package identified as diced chicken and an undated disposable bowl of ravioli was stored on one of the racks. The refrigerator continued to have a large pan of water collecting in it on the top shelf. Both the freezer and refrigerator had unidentifiable streaks and smears and dust on the outside panel and the door handles. The ice maker screen still had dust with the fan blowing into the food prep area. The floor under the stove and prep areas remained covered in dust and unknown debris.
On May 14, 2024, at 10:23 AM, V6 stated that all items placed in the freezer or refrigerators should have been labeled and dated. V6 added that the kitchen is cleaned daily and deep cleaned weekly every Tuesday.
Facility policy titled Sanitation Inspection (implemented January 2024) included as follows:
Policy: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.
Policy Explanation and Compliance Guidelines:
1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects.
4. Sanitation inspections will be conducted in the following manner:
b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.
Facility policy titled Food Safety Requirements (implemented January 2024) included as follows:
Policy: Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.
3.c. Refrigerated Storage-Practices to maintain safe refrigerated storage include:
iv. Labeling, dating, and monitoring food, including, but not limited to leftovers, so it is used by its use-by date or frozen (where applicable)/discarded.
4. Thawing-approved methods for thawing frozen foods include thawing in the refrigerator, submerged under cold water, thawing in a microwave oven, or part of a continuous cooking process .
6. All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide treatment and services to increase range of motion and prevent a further decrease in range of motion. The facility failed to provide Splints or supportive equipment to maintain or improve mobility. This applies to 2 of 4 residents (R26 and R43) reviewed for range of motion in the sample of 14.
The findings include:
1. R26 has multiple diagnosis including Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness (generalized), based on the face sheet. The MDS (Minimum Data Set) assessment dated [DATE], documents that R26 is cognitively intact and has limitations with range of motion on one side for upper and lower extremities. The same MDS showed that R26 required maximum to total assistance from the staff with most activities of daily living (ADLs).
R26 was observed on May 13, 2024, at 11:11AM in his room. R26 was observed with his left hand, arm and shoulder contracted and pulled close to his body. R26 was observed without a splint in place. R26 stated he had left side weakness related to a previous stroke and he was starting to get additional feeling back in his left hand. R26 added that he had a splint at his previous facility and that he did not have a splint since admission to the facility April 23, 2023.
R26 was observed on May 14, 2024, without a splint in place and V2 (Director of Nursing) referred R26 for an OT (Occupational Therapy) screening.
V12 (Occupational Therapist) was interviewed on May 14, 2024, at 10:45AM and stated that based on the screening that he would recommend a hand splint for R26.
2. R43 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and monoplegia of upper limb following cerebral infarction affecting right dominant side, based on the face sheet. R43's quarterly MDS dated [DATE], showed that the resident was moderately impaired with cognition. R43's MDS showed that the resident had functional limitation in ROM on one side of both upper and lower extremities. The same MDS showed that R43 required maximum assistance from the staff with most of his ADLs (activities of daily living).
On May 13, 2024, at 11:03 AM, R43 was sitting in his wheelchair, alert, oriented and verbally responsive. R43 had weakness on his right side. R43 was not able to lift his right hand and arm and was not able to open his right hand. R43 had no device or splint on his right hand/ wrist. R43 stated that he would like to have a device or splint to help him be comfortable on his right hand/wrist.
On May 14, 2024, at 8:58 AM, R43 was sitting in his wheelchair, alert and verbally responsive. R43 had weakness on his right side. R43 had a splint on his right hand. In the presence of V2 (Director of Nursing), R43 was asked who gave him his right hand splint. R43 stated that his mother bought the splint from an online store and gave the splint to him on May 13, 2024. R43 was asked why he was using the right hand splint. R43 responded that he feels comfortable using the right hand splint. V2 was prompted to request the therapy department to screen and/or evaluated R43 to determine the need for a device or a hand splint and any therapy services. During the same interview, R43 stated that no device was being applied on his right arm/hand during the day and/or night, except this newly bought right hand splint that was provided by his mother.
R43's active order summary report showed an order dated January 10, 2024, for a pool noodle splint at night per OT (Occupational Therapy).
On May 14, 2024, at 4:15 PM, V12 (Occupational Therapist) stated that he screened R43 on May 14, 2024, at around 4:00 PM per facility request. V12 stated that based on his assessment of R43, the resident's right upper extremity was non-functional because it had no muscle control and because of this, he was recommending for R43 to use a right hand splint and a right arm sling to prevent development of hand contracture, for positioning and for comfort.
R43's rehabilitation screening form dated May 14, 2024, created by V12 showed that the reason for screening was, Per nursing request: assess need for [right] resting hand splint for anti-contracture management. The screening documented that R43's right upper extremity had no AROM (active range of motion), but PROM (passive range of motion) was within functional limits. The screening showed, [Patient was provided by family [right] resting hand splint and sling. Assess [right] resting hand splint for proper fit and use of sling. The same screening documented, OT evaluation and [treatment] to see proper fitting and schedule to wear [right] hand splint.
On May 15, 2024 at 9:11 AM, V12 stated that he recommended the right resting hand splint for R43 to maintain his ROM (range of motion), prevent contracture and for his comfort. V12 added that he also recommended the right arm sling for proper positioning. According to V12, the resting hand splint and arm sling will be applied during the day for 2-4 hours as tolerated by R43. V12 stated that during the screening, R43 was educated and was willing to use the devices mentioned. V12 was asked about the current order to apply a pool noodle splint at night. V12 stated that he believes that R43 was seeing an outpatient therapy when he came in the facility and the outside therapy had recommended for R43 to use the pool noodle at night, however, after R43's screening on May 14, 2024, he believes that the resident does not need the pool noodle at night and would benefit more with the use of the resting right hand splint and right arm sling. V12 added that he will recommend for now, to discontinue the use of the pool noodle at night.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to have fall interventions in place for a resident that is at high risk for falls. This applies to 1 of 2 residents (R41) reviewed for falls in the sample of 14.
The findings include:
R41's face sheet showed diagnoses of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side, cerebral infarction, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, end stage renal disease.
R41's MDS (minimum data set) assessment dated [DATE], showed that R41 was severely impaired in cognition. R41's fall risk assessment dated [DATE], documents that R41 was assessed to be a high risk for falls.
On May 14, 2024, at 9:26 AM, R41 was seated in the dining room in a wheelchair after breakfast. R41 stated that he had a fall as he slipped in the room and fractured his hip and cannot walk by himself. R41 could not remember the details. R41 did not have a chair alarm on their wheelchair which was verified by V9 CNA (Certified Nursing Assistant) who was in the dining room.
On May 14, 2024, at 12:27 PM, R41 was seated in a wheelchair in the dining room eating lunch. R41 did not have a chair alarm on his wheelchair. V9, who was seated near R41, stated that she is R41's CNA and she has never seen a chair or bed alarm since she has been here at the facility.
On May 13, 2024, at 02:01 PM and on May 14, 2024, at 12:32 PM, V4 (MDS Coordinator) stated that R41 was walking around with a cane when he was first admitted but his Dementia got worse and he was impulsive and falls as he attempts to do things on his own. V4 stated that R41 had several falls including an unwitnessed fall sustaining a hip fracture. V4 stated that R41 currently has a chair and bed alarm, and the staff are supposed to transfer the chair pad (alarm) from the chair to the bed when they put R41 to bed. V4 added that all interventions for falls are entered in the care plan.
On 05/14/24 at 12:48 PM, R41 was put to bed by V9 and V5 (CNA) and no chair pad alarm was seen on R41's wheelchair and on R41's bedding. V5 stated Chair pads are for those residents who try to get up by themselves.
On 05/14/24 at 1:20 PM, V4 was notified that the chair or bed alarm was not located by staff that transferred R41 to bed. V4 stated It should have been there. V4 was accompanied to R41's room and after looking on R41's bed and R41's chair, V4 located the alarm pad in R41's closet.
R41's fall care plan included as follows: The resident is at risk for falls related to old CVA (cerebrovascular accident) with hemiplegia on left side.
The same care plans listed falls as follows:
November 23, 2023: Fell tripping over his sandal. No injury. Intervention included to remind resident to place sandals together out of his main walking path in his room.
December 9, 2023: Residents family states that he is not himself. Family states he fell but did not report it. Resident complains of soreness to his left hip, sent out for evaluation. Report form hospital on December 10,2023 states hip fracture. Interventions: included weight bearing as tolerated with supervision.
January 13, 2024: Fell emptying his trash. No injury.
February 12,2024: Fell trying to transfer for wheelchair to bed. No injury.
March 29, 2024: Fell no injury was up and down all night. Intervention included bed and chair alarm.
Facility policy titled Fall Prevention Program (implemented January 2024) included as follows:
Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
Policy Explanation and Compliance guidelines:
3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk.
6 High Risk Protocols: a) Implement interventions from low/Moderate Risk Protocols.

Based on observation, interview and record review the facility failed to ensure that a physician's order was obtained for the administration of oxygen. The facility failed to ensure that there was water in the humidifier bottle and the oxygen nasal cannula tubing and humidifier bottle were labeled. The facility also failed to ensure that the nebulization mask was covered when not in use to prevent contamination. This applies to 1 of 2 residents (R14) reviewed for oxygen use and respiratory care in the sample of 14.
The findings include:
R14 had multiple diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation, and acute and chronic respiratory failure with hypoxia, based on the face sheet.
R14's quarterly MDS (minimum data set) dated February 24, 2024, showed that the resident was moderately impaired with cognition.
On May 13, 2024, at 11:37 AM, R14 was in bed, alert and verbally responsive. R14 had continuous oxygen via nasal cannula running at four liters per minute using an oxygen concentrator. R14 had no shortness of breath. The humidifier bottle that was attached to the oxygen concentrator and the oxygen tubing was empty (no water). R14 stated that his nostrils were dry. R14's oxygen nasal cannula tubing and humidifier bottle had no label. On top of R14's bedside table was a nebulization mask that was not covered/contained. The uncovered nebulization mask was stored on top of the bedside table beside cookies that were not in packaging. V11 (Registered Nurse) was made aware of the empty humidifier bottle and after prompting, placed a new humidifier bottle.
On May 14, 2024, at 10:09 AM, R14 was in bed, alert, oriented and verbally responsive. R14 had continuous oxygen via nasal cannula running at three liters per minute using an oxygen concentrator. R14 had no shortness of breath. R14's oxygen nasal cannula tubing and humidifier bottle that was attached to the oxygen concentrator and the oxygen tubing had no label. V8 (Registered Nurse) who was inside R14's room acknowledged that the resident's oxygen tubing and humidifier bottle had no label. V8 does not know when the nasal cannula tubing and the humidifier were last changed.
R14's active order summary report as of May 14, 2024, showed no order for administration of continuous oxygen via nasal cannula.
On May 14, 2024, at 1:09 PM, V2 (Director of Nursing) stated that there should be a physician's order for the use of oxygen because it was a treatment that was being administered to R14. V2 stated that the humidifier bottle should not be empty when the oxygen concentrator is running, and that the oxygen nasal cannula tubing and the humidifier bottle should be labeled. During the same interview, V2 stated the nebulization mask should be inside a bag or covered when not in use to prevent contamination.
The facility's policy regarding oxygen administration dated January 2024 showed in-part, under policy explanation and compliance guidelines, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: . c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification. d. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. e. Keep delivery devices covered in plastic bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that blister packs containing controlled medications are maintained intact to ensure safe and effective use of the medications.
This applies to 2 of 3 residents (R4, R44) reviewed for controlled medications in the sample of 14.
The findings include:
1. On [DATE], at 10:38 AM with V8 (Registered Nurse) the medication cart #2 was observed with a locked controlled medication compartment. In the presence of V8, the following observations were made:
R4 had a blister pack of Lorazepam 2 mg (milligram), dispensed by the pharmacy on [DATE], originally containing 30 tablets. The said blister pack of Lorazepam 2 mg had 28 tablets remaining that were intact and sealed (from #1 through #28), while there was one additional tablet with a broken seal that was taped over at the back (#29).
R30 had a blister pack of Lorazepam 1 mg, dispensed by the pharmacy on [DATE], originally containing 30 tablets. The said blister pack of Lorazepam 1 mg had 29 tablets remaining that were intact and sealed (from #1 through #29), while there was one additional tablet with broken seal that was taped over at the back (#30).
During the same observation, V8 stated that she does not know who taped the back of R4 and R30's controlled medications.
2. On [DATE], at 11:57 AM with V2 (Director of Nursing) the medication cart #1 was observed with a locked controlled medication compartment. In the presence of V2 it was observed that R44 had a blister pack of Lorazepam 1 mg, dispensed by the pharmacy on [DATE], originally containing 42 tablets. The said blister pack of Lorazepam 1 mg had 41 tablets remaining that were intact and sealed (from #1 through #41), while there was one additional tablet with broken seal that was taped over at the back (#42).
On [DATE], at 8:20 AM, V2 stated that taping the back of the blister pack medications or tampering the blister pack medications, including controlled substances are not acceptable and are not the practice of the facility. V2 stated that any tampered blister packs (taped at the back/seal broken) should be destroyed to prevent any drug theft, misappropriation of drugs, and to ensure the quality and safety of the medications.
The facility's policy regarding controlled substance administration and accountability dated [DATE] showed, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. The same policy under explanation and compliance guidelines showed in-part, 6 . e. If the package has been opened or the tamper seal removed, it must be destroyed.
The facility's policy regarding destruction of unused drugs dated [DATE] showed, All unused, contaminated or expired prescription drugs shall be disposed of in accordance with state laws and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and ensure a resident on a gastrostomy tube feeding was receiving the total amount ordered. This failure resulted in a 10.44 percent weight loss in three months. This applies to 1 of 2 residents (R36) reviewed for gastrostomy tube feedings.
The findings include:
According to the Electronic Health Record (EHR) R36 had diagnoses including Parkinson's Disease, protein calorie malnutrition, hypertension, gastroesophageal reflux disease, and acute embolism and thrombosis of left lower extremity.
The Minimum Data Set (MDS) dated [DATE] showed R36 was totally dependent on one staff for feeding, and was receiving gastrostomy tube feedings. R36 was 69 inches tall and weighed 143 pounds on admission. The MDS showed R36's cognition was severely impaired.
A Care Plan showed R36 had unplanned weight loss with interventions to contact the physician and dietitian immediately if weight decline persists.
The Physician Order Sheet (POS) showed an order dated 03/14/2023 for Osmolite 1.5 calorie at 80 milliliters per hour (ml/hr) to start at 3:00 PM and end at 9:00 AM.
The EHR showed the following weights:
on 01/26/2023, 142.7 pounds;
on 02/23/2023, 142.8 pounds;
on 02/13/2023, 142 pounds;
on 03/01/2023, 129 pounds;
on 03/08/2023, 128.6 pounds;
on 03/15/2023, 129 pounds;
on 03/22/2023, 131 pounds;
on 03/29/2023, 130 pounds;
on 04/05/2023, 130 pounds;
on 04/12/2023, 132 pounds;
on 04/19/2023, 130 pounds;
on 04/26/2023, 127.8 pounds; and
on 04/27/2023, 127.6 pounds.
On 01/26/2023, the resident weighed 142.7 pounds and on 04/26/2023, the resident weighed 127.8 pounds which is a 10.44 % loss.
On 04/25/2023 at 11:35 AM, R36 was lying in bed and did not have any bottles of Osmolite hanging at the bedside. V17 (R36's family member) said R36 receives a feeding through his gastrostomy tube from 3:00 PM until 9:00 AM. V17 said the nursing staff usually starts the feeding later than 3:00 PM sometimes 5:00 PM and V17 does not know what time they discontinue it at. V17 said the dietitian started the continuous feedings to make sure R36 was receiving the correct amount consistently to keep his weight stable.
On 04/26/2023 at 8:50 AM, R36 way lying in bed and did not have the Osmolite feeding infusing. V10 (Certified Nursing Assistant/CNA) and V15 (CNA) said they had provided incontinence care for R36 at 8:00 AM and the feeding was not infusing and was no longer even connected. V10 and V15 weighed R36 using the total body mechanical lift and R36's weight was 127.8 pounds.
On 04/26/2023 at 9:05 AM, V6 (RN) said she had discontinued R36's feeding around 8:45 AM because the bottle was empty. She did not start another Osmolite feeding bottle.
On 04/26/2023 at 3:19 PM, V17 said R36's feeding was started at 3:30 PM on 04/25/2023, a half hour later than scheduled.
On 04/27/2023 at 10:24 AM, V19 (Registered Dietitian) said she only visits the facility once a month and that if the resident receiving gastrostomy tube feedings is losing weight, they should notify her and the doctor. V19 said the facility did not notify me regarding R36's weight loss yesterday. R36 should be receiving a total of 1440 ml of Osmolite 1.5 calorie. V19 said weight loss could happen if he was not receiving the full amount of 1440 ml. V19 said if a feeding was started late, it was more important to ensure the total amount of 1440 ml was received, instead of ending it at a certain time.
On 04/27/2023 at 10:38 AM, V22 (Medical Doctor/MD) said he would not expect any weight loss in residents receiving tube feedings. V22 was not notified of R36 having a weight loss.
On 04/27/2023 at 2:20 PM, V26 (nurse) said she works the night shift from 10:00 PM until 6:00 AM and said the same container, which had been started on the evening shift, will usually last for the entire shift and would not be empty at 6:00 AM. V26 said she did not start a new feeding bottle for R36 on 04/26/2023.
On 04/27/2023 at 4:29 PM, V2 (Director of Nursing/DON) said either she or the nurse should notify the dietitian and the physician when a resident has weight loss. According to V2, the physician and dietitian have not been notified with R36's weight loss as of now. V2 said the Osmolite containers are 1000 ml containers.
The Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2023 do not show any documented total feeding amounts infused.
The facility's Care and Treatment of Feeding Tubes policy dated 12/2022 included the staff should be ensuring the administration of enteral nutrition is consistent with and follows the practitioner's orders. Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders.

Based on observation, interview, and record review, the facility failed to follow the diet spreadsheet and standardized recipes to serve the portions as shown for pureed diets. This applies to 8 of 8 residents (R8, R11, R12, R13, R14, R33, R37, R207) observed for meal service in the sample of 19.
The findings include:
The Diet Spreadsheet Menu: Ontray Fall/Winter 2022/2023 Week 2 Day:11- Wednesday pureed lunch meal included: pureed chicken alfredo #6 dip over fettuccini #10 dip pasta, pureed carrots #12 dip, and pureed bread stick #20 dip. The Pureed Chicken [NAME] Over Fettuccine recipe instructions say To Puree Chicken Alfredo, Place prepared chicken alfredo in a washed and sanitized food processor. Blend until smooth. To Puree Pasta, Place prepared pasta and melted margarine in a clean and sanitized food processor. Blend until smooth. Pureed Bread Stick recipe instructions say, Place bread sticks in a clean and sanitized food processor. Add melted margarine. Gradually add milk as needed and blend until smooth.
On April 26, 2023 at 11:50 AM, V28 (Dietary Aide) was observed serving two #8 dip scoops of a combined pureed mixture of pureed pasta and chicken alfredo, #20 dip pureed carrots, and no pureed breadstick to the 8 pureed diet residents. V13 (Cook) said she did not puree the pasta according to the recipe. V13 said she prepared the pureed chicken alfredo over fettuccine by adding 9 pasta scoopers of pasta and 9 #8 dip scoops of chicken alfredo into the food processor together and pureed it. V13 said the CNAs who feed the residents ask me to mix it together. V13 said pureed bread was not served because she did not make any.
On April 27, 2023 at 10:54 AM, V19 (Dietician) said the bread on the menu should be pureed and served to the residents. V19 said by omitting the pureed breadstick from the meal, the pureed diet residents did not get the carbohydrates or correct nutrients they should have gotten. On April 27, 2023 at 12:26 PM, V14 (Dietary Manager) said the pureed diets yesterday had less carbohydrates on their trays because they did not receive pureed bread. V14 (Dietary Manager) said V13 (Cook) should have prepared a separate pureed pasta and not pureed the pasta and chicken alfredo together. V14 said the pureed diets were not served in the correct portions according to the menu and recipe; therefore, the pureed diet residents did not get the required nutrition which can lead to weight loss.
The facility policy titled Food Preparation Guidelines (3/2023) states, Policy Explanation and Compliance Guidelines: 1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes.
The facility policy titled Standardized Recipes (2020) states, Guideline: Standardized recipes will be used for all menu items, including pureed and therapeutic diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. According to the Electronic Health Record (EHR) R36 had diagnoses including Parkinson's Disease, protein calorie malnutrition, hypertension, gastroesophageal reflux disease, and acute embolism and thrombosis of left lower extremity.
The Minimum Data Set (MDS) dated [DATE] showed R36 was totally dependent on one staff for feeding and was receiving gastrostomy tube feedings. The MDS showed R36's cognition was severely impaired.
On 04/25/2023 at 11:35 AM, V17 (R36's family member) said R36 was admitted to the facility 01/26/2023 and she has never participated in or been invited to a care plan meeting. V17 said she was concerned with the timing of R36's medication and does not know his weight status. V17 said she has given up trying to talk to staff about the timing of the medications because nothing ever changes.
The facility was unable to provide a date, time, or a Care Plan Invitation letter for R36.
Based on interview and record review the facility failed to conduct an interdisciplinary team care plan meeting that included residents and/or their representative. This applies to 3 residents R7, R34 and R36 in a sample size of 19.
1. On April 26, 2023, at 2:53 pm R7 stated he has never attended a care plan meeting and he has never been invited to attend.
On April 26, 2023, at 1:50 pm V28 Social Worker stated that since she has been at the facility only herself and V3 MDS Coordinator (Minimum Data Set Coordinator) have conducted care plan meetings. The sign in sheet is how the facility documents the care plan meeting has occurred. She had not attended a care plan meeting for R7. Care plan meetings should occur on admission, quarterly, after a major change in condition or if the resident or their POA (Power of Attorney) make a request.
R7's EHR (Electronic Health Record) was reviewed. No documentation was noted regarding R7's IDT (Interdisciplinary Team) care plan meeting.
Review of the Signature of the Multidisciplinary Team sign in documents R7's last IDT meeting occurred on October 6, 2022.
2. On April 26, 2023, at 1:50 pm V28 Social Worker stated she did not participate in a care plan meeting for R34.
On April 26, 2023, at 2:18 pm V3 MDS Coordinator stated she makes the MDS schedule monthly and provides it to the receptionist to send out invitation letters and makes calls to invite and schedule time that family representative can participate.
On April 26, 2023, at 2:58 pm V28 Social Worker stated the facility documents the care plan meeting occurred by using the sign in sheet. There is not always a progress note written. Some care plan meetings have been missed.
On April 26, 2023, at 4:16 pm V3 stated a progress note is not necessarily written to document the care plan meeting. The resident's care plan is updated and use the sign in sheet.
On April 27, 2023, at 8:23 am V3 presented an updated sign in sheet. V3 stated the meeting occurred, but she forgot to get signatures. V3 stated she signed R7 and R34's names on the sign in sheet because they are unable to sign for themselves. V3 stated she got signatures from the staff, but they would not have signed if they had not attended.
On April 27, 2023, at 12:02 pm V28 stated she signed the updated attendance sheet for R7 and R34. V28 stated she is a member of the interdisciplinary team, but she did not realize she was participating in a care plan meeting at the time they occurred this month.
On April 27, 2023, at 12:40 pm V14 Dietary Manager stated he signed the multi-disciplinary attendance sheets for R7 and R34, but he did not participate in their care plan meetings in January and April of this year. V14 stated V3 handed him a stack of papers and instructed him to sign them.
On April 26, 2023, at 2:55 pm R34 stated he declined to participate in his care plan meetings.
R34's EHR (Electronic Health Record) was reviewed. No documentation was noted regarding R34's IDT (Interdisciplinary Team) care plan meeting.
Review of the Signature of the Multidisciplinary Team sign in documents R34's last IDT meeting occurred on October 20, 2022.
The facility provided an Upcoming Care Plan Meetings at a Glance for April 2023, R7 and R34 were not listed. The facility did not provide an Upcoming Care Plan Meetings at a Glance for January 2023.
The facility policy Care Planning -Interdisciplinary Team revised date September 2013 states the Care Planning / Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a care planning / interdisciplinary team that includes, but is not limited to the resident's attending Physician, Register Nurse who has responsibility for the resident, Dietary Manager / Dietician, Social Services Worker, Activity Director / Coordinator, Therapist, Consultants, Director of Nursing, Charge Nurse, and Nursing Assistant. The resident, their family or legal representative are encouraged to participate in the development of and revision to the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide incontinence care and a bed bath to promote cleanliness and prevent infection. This applies to 2 of 2 residents (R28 and R33) reviewed for ADLs (Activities of Daily Living) in a sample of 19.
The findings include:
1. R28's EMR (Electronic Medical Record) showed R28 was admitted to the facility with diagnoses including lack of coordination, reduced mobility, generalized muscle weakness, legal blindness, and benign prostatic hyperplasia with lower urinary tract symptoms.
R28's MDS (Minimum Data Set) dated April 10, 2023, showed R28 was cognitively intact and was totally dependent on staff for bed mobility, dressing, toileting, and personal hygiene.
On April 25, 2023, at 11:05 AM, R28's room had a strong odor of urine. R28 said he could not remember the last time the staff cleaned him up and he was not too happy about it. V10 (CNA/Certified Nurse Assistant) and V11 (CNA) entered R28's room and began to provide incontinence care for R28. R28's incontinence brief was removed and R28 was turned to the side. R28's incontinence brief was very full and R28's incontinence pad had a large urine stain, with both wet and dry areas, covering 75% of the incontinence pad. V10 wiped R28's buttocks with soapy water, patted it dry, applied cream, and then placed new incontinence brief under R28. V10 did not change gloves or perform hand hygiene when going from dirty care to clean care. R28 was rolled onto his back and V11 fixed incontinence brief on the opposite side and closed the brief. R28 did not receive perineal care during incontinence care. R28 continued to smell of urine.
On April 25, 2023, at 11:15 AM, V10 said she cleaned R28's skin along his stomach fold but did not clean the perineal area and thigh folds.
On April 26, 2023, at 12:15 PM, V2 (DON/Director of Nursing) said the staff should clean the perineal area for male residents when providing incontinence care.
The facility's Perineal Care policy dated November 2022, shows to cleanse the shaft of the penis, cleanse the scrotum, and to clean and dry the bottom of the scrotum and the anal area.
2. R33's EMR showed R33 was admitted to the facility with diagnoses including Parkinson's disease, seizures, dementia, hypertension, and hypothyroidism.
R33's MDS dated [DATE], showed R33 had severe cognitive impairment and was totally dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene.
On April 26, 2023, at 11:47 AM, V12 (CNA) provided a bed bath and incontinence care for R33. V12 gathered two water basins, one with clean water and one with soapy water. V12 placed a washcloth in the soapy water basin and began wiping legs and feet and dipping back into soapy water basin. V12 did not rinse R33 after with clean water before patting her dry. V12 turned R33 away from her and R33's incontinence brief had a large, formed bowel movement. V12 took disposable wipes and wiped as much stool off R33's buttocks. V12 then took the same washcloth from soapy water basin and wiped R33's buttocks and puts washcloth back into soapy water and wiped R33's buttocks again. V12 did not throw away the dirty water and get new soapy water in basin. V12 applied a new incontinence brief under resident without providing perineal care, changing gloves, or performing hand hygiene. V12 puts a new washcloth into the dirty soapy water bucket and began wiping residents' face, arms, and chest.
On April 26, 2023, at 12:15 PM, V2 said the staff are supposed to clean the entire perineal care even if the resident only had a bowel movement. V2 said the staff should use clean water to rinse after using soapy water. V2 also said the staff should get new, clean water after using the water to clean the resident after having a bowel movement. V2 also said the staff should be changing their gloves and performing hand hygiene when going from dirty to clean during incontinence care.
The facility's Bed Baths policy, dated November 2022, shows to expose the back and buttocks and wash, rinse and dry the area, change the bath water in the basin, obtain a clean washcloth, perform hand hygiene, and don new gloves. For females, expose the perineal area washing the pubic area with downward strokes from the front to the back.
The facility's Hand Hygiene policy, dated May 2022, shows the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene should also be used when, during resident care, moving from a contaminated body site to a clean body site, and after assistance with personal body functions (e.g., elimination, hair grooming, smoking).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to communicate pertinent clinical information with the dialysis provider, failed to document a post dialysis assessment, failed to ensure necessary precautions to protect the access site, and failed to document adherence with fluid restriction for 1 of 1 resident (R49) reviewed for dialysis in a sample of 19.
Findings include:
According to the face sheet R49 had diagnoses including end stage renal disease, atrial fibrillation, and cerebral infarction. The Minimum Data Set (MDS) dated [DATE] showed R49's cognition was moderately impaired and required limited assistance with activities of daily living (ADLs). R49 walks with a cane and was able to feed himself.
The Physician Order Sheet (POS) shows R49 received hemodialysis treatment three times per week. An order dated 3/23/23 showed R49 was on one liter fluid restriction.
On 4/26/2023 at 12:17 PM, V16 (Registered Nurse/RN dialysis center) stated communication between the nursing home and dialysis center would be written exchange of clinical information. The dialysis center expects to receive information regarding the resident's vital signs, medication given that day, new medication ordered, any new change in condition and any abnormal labs be sent with the resident to the dialysis center. After treatment the dialysis center would document the resident's vital signs, weights, amount of fluid removed, any medication administered, and any change in condition on the communication form received from the facility. V16 stated the communication between the facility and dialysis center for R49 has been inconsistent. V16 said R49 had an arteriovenous fistula (AV fistula) in the left upper arm for dialysis access.
On 4/26/23 at 4:00 PM, V18 (RN) stated R49 usually returns from dialysis around 8:30 PM on Mondays, Wednesdays and Fridays. V18 could not provide any documentation of clinical information received from the dialysis center. V18 said if they receive any documents, they would be placed in the basket at the nurses station to be scanned into the electronic medical record. V18 stated upon return from dialysis the nurse should document the resident assessment in the progress notes in the Electronic Health Record (EHR).
During April 2023 R49's nursing progress notes had only one post dialysis resident assessment dated [DATE]. No dialysis communication forms were found in the EHR. After multiple requests, the facility did not provide any post dialysis communication documentation for R49.
On 04/26/2023 at 04:05 PM, V6 (RN) stated she only sends R49's transfer sheet to dialysis, but not a communication form.
R49's care plan for dialysis treatment did not include interventions to protect the AV fistula by not taking blood pressure or blood draws on the arm with the fistula. No cautionary sign was observed in R49's room. No cautionary alert was noted in the EHR. R49's care plan erroneously identifies the AV fistula on the left lower arm, it is located in the left upper arm.
R49's April 2023 Medication Administration Record (MAR) did not have documentation of assessment for AV fistula bruit and thrill.
R49's care plan does not indicate the amount of fluids served from dietary or given by nursing to establish a plan to adhere to the fluid restriction.
On 4/26/23 and 4/27/23, R49 had a water pitcher filled with 900 milliliters (mls) of water, a half full twelve ounce bottle of coca cola, and eight ounce cup of ice on the over the bed table.
On 4/26/23 at 12:35 PM R49 was served coffee with cream in eight ounce cup with three ounces gone, eight ounce glass of red juice was empty, eight ounce cup of white liquid with six ounces gone, eight ounce glass of water with three ounces gone, a total of 690 mls consumed at the end of the meal. On 4/27/23 at 9:05 am R49 was served eight ounce cup of coffee with four ounces gone, four ounces of apple juice and eight ounces of water not consumed, a total of 120 mls consumed by the end of the meal.
There is no documentation of liquid intake to verify adherence to the fluid restriction order.
The facility's Hemodialysis policy dated 3/2023 includes there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing and dialysis staff. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment center to observe for bleeding and other complications. The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access is located. The nurse will ensure that the dialysis access site is checked before and after dialysis treatment every shift for patency by auscultating for bruit and palpating for a thrill.