Calibre Post Acute, Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement an effective training program for the Developmental Disability Caregivers (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) for 3 (DDC #1, DDC #2, and DDC #3) of 3 (DDC #1, DDC #2, and DDC #3) DDC's who provided care for R #89. If the DDC staff are not trained, then they could likely not have the knowledge to safely care for residents in the facility. The findings are: A. Record review of R #89's admission Record, no date revealed the following: 1. R #89 was admitted to the facility on [DATE]. 2. R #89 had a diagnosis of unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). B. Record review of R #89's progress notes revealed the following: 1. On 02/05/26 at 11:47 PM, R #89's DDC (the record did not specify which DDC) was at his bedside. 2. On 02/06/26 at 12:53 AM, R #89's DDC was present (the record did not specify which DDC). 3. On 02/06/26 at 5:52 AM, R #89's DDC was present. 4. On 02/06/26 at 9:33 AM, staff documented that at 8:45 AM, the DON and ADON witnessed R #89 with his arms tied to the bed rails. The ADON educated DDC #1 that restraints were not allowed in the facility, and DDC #1 was relieved by DDC #2. C. On 03/03/26 at 12:17 PM, during an interview, the DON stated the following: 1. R #89 would have DDCs who stayed with him around the clock. 2. She understood that the DDCs were supposed to provide R #89 with the same services they provided in his home, such as feeding, redirection, and companionship. D. On 03/03/26 at 12:42 PM, during an interview, ADON #1 stated the following: 1. DDC #2 was with R #89 when he first arrived. 2. DDC #3 relieved DDC #2 on 02/05/26 but he was not sure what time. 3. DDC #1 relieved DDC #3 sometime during the night shift between 02/05/26 and 02/06/26. 4. DDC #2 relieved DDC #1 at approximately 9:30 AM on 02/06/26. E. On 03/03/26 at 12:50 PM, during an interview, the DON confirmed the following: 1. DDC #1, DDC #2, and DDC #3 did not receive any training from the facility regarding facility policies and expectations. 2. She assumed the DDCs' employer required the same training for the DDCs as the facility required for its staff. 3. She was not sure what training DDC #1, DDC #2, or DDC #3 had received. 4. The facility did not provide DDC #1, DDC #2, or DDC #3 any training regarding its policies and expectations before they assisted R #89 in the facility.

Based on record review and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 (R #89) of 2 (R #3 and R #89) residents reviewed for physical restraints (any device used to prevent freedom of movement or action). If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are: A. Record review of R #89's progress note, dated 02/06/26, revealed the following: 1. On 02/06/25 at 8:45 AM, a facility staff member notified the ADON (the documentation did not specify which ADON) and the DON that R #89 was restrained to the bed. 2. The ADON and DON observed R #89's arms restrained to the bed rails. 3. The ADON removed the restraints from R #89's arms. 4. The ADON educated R #89's developmental disability caregiver (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) that the facility does not allow restraints. B. On 03/02/26 at 3:35 PM, during an interview, the DON stated the following: 1. On 02/06/26 at approximately 08:45 AM, she was notified by ADON #1 that a staff member observed R #89 restrained to the bed. 2. ADON #1 and the DON went to R #89's room and saw R #89's arms tied to the bed rails with blankets. 3. ADON #1 removed the restraints from R #89's arms. 4. ADON #1 educated R #89's DDC that he cannot restrain R #89. 5. After this, she interviewed staff to determine whether anyone else had witnessed the incident. 6. LPN #16 told her that on 02/06/26 around 6:30 AM he saw R #89 restrained to the bed and had educated R #89's DDC that he could not restrain R #89. C. On 03/03/26 at 9:00 AM, during an interview, LPN #16 stated the following: 1. On 02/06/26 around 6:30 AM to 7:00 AM, he went into R #89's room he went into R #89's room and observed a sheet tied around R #89's feet. 2. He said R #89's DDC said R #89 was trying to kick the window, so he tied his feet. 3. He untied the sheet from R #89's feet. 4. He educated R #89's DDC that the facility was a restraint free facility and he cannot restrain R #89. 5. R #89's DDC verbalized understanding that he cannot restrain R #89. D. Record review of the incident report submitted to the state agency, dated 02/06/26, revealed the following: 1. On 02/06/26 at 8:45 AM, R #89's arms were restrained by the DDC. 2. R #89's DDC was educated that the facility has a no restraint policy (staff are not allowed to use restraints). 3. Staff did not document that R #89 had been restrained by R #89's DDC on 02/06/26 between 6:30 AM and 7:00 AM. E. Record review of the follow-up report submitted to the state agency, dated 02/09/26, revealed staff did not document that during the investigation the DON was informed that R #89 had also been restrained by R #89's DDC on 02/06/26 between 6:30 AM and 7:00 AM. F. On 03/03/26 at 9:38 AM, during an interview, the Administrator confirmed the following: 1. LPN #16 did not notify administration when he found R #89 restrained by his DDC between 6:30 AM and 7:00 AM. 2. Staff were expected to notify administration immediately of any concerns of abuse 3. The facility did not notify the state agency that R #89 had been restrained in the facility by his DDC on 02/06/26 between 6:30 AM and 7:00 AM. 4. The facility was expected to report all allegations of abuse to the state agency within two (2) hours of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents remained free from physical restraints (any device used to prevent freedom of movement or action) unless staff used them to treat a specific medical condition (indication or characteristic of a medical, physical or psychological condition) as identified through an assessment for 1 (R #89) of 2 (R #3 and R #89) residents reviewed for physical restraints. This deficient practice could likely result in physical restraints being used for punishment or staff convenience; causing injury or unnecessarily restricting residents from freedom, movement, or activity. The findings are: A. Record review of R #89's admission Record, no date, revealed the following: 1. R #89 was admitted to the facility on [DATE]. 2. R #89 had the following diagnoses: a. Unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). b. Depression (serious mood disorder characterized by persistent sadness, loss of interest in activities). c. Anxiety disorder (mental health condition characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life). B. Record review of R #89's progress note, dated 02/06/26, revealed the following: 1. On 02/06/25 at 8:45 AM, a CNA notified the ADON and DON that R #89 was restrained to the bed. 2. The ADON and DON observed R #89's arms restrained to the bed rails. 3. The ADON removed the restraints. 4. The ADON educated R #89's Developmental Disability Caregiver (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) that the facility does not allow restraints. C. On 03/02/26 at 3:15 PM, during an interview, ADON #1 stated the following: 1. On 02/06/26, one of the CNAs notified him that R #89 was tied to the bed. 2. ADON #1 notified the DON and they went to R #89's room. 3. R #89's DDC was lying on R #89's legs and R #89's arms were tied to the bed rails with blankets. 4. He untied the blankets from R #89's arms and assessed R #89 for injury. 5. R #89's DDC told him that he restrained R #89 because R #89 was trying to hit and kick him. R #89 said he was going to break the window. 6. ADON #1 explained to the DDC that the facility was restraint free and he was not allowed to restrain R #89. D. On 03/02/26 at 3:35 PM, during an interview, the DON stated the following: 1. On 02/06/26 at approximately 8:45 AM, she was notified by ADON #1 that a staff member observed R #89 restrained to the bed. 2. When she and ADON #1 arrived to R #89's room, they saw R #89's arms tied to the bed rails. 3. ADON #1 removed the restraints from R #89's arms. 4. ADON #1 told R #89's DDC that he cannot restrain R #89. 5. After this, she interviewed staff to see if anyone else had seen anything. 6. LPN #16 told her that on 02/06/26 around 6:30 AM he was notified that R #89 was restrained to the bed (a separate incident earlier in the morning). E. On 03/03/26 at 9:00 AM, during an interview, LPN #16 stated the following: 1. On 02/06/26 around 6:30 AM to 7:00 AM, he went into R #89's room there was a sheet tied around R #89's feet. 2. He untied the sheet from R #89's feet. 3. He educated R #89's DDC that the facility was a restraint free facility and he cannot restrain R #89. F. On 03/03/26 at 9:59 AM, during an interview, the DON confirmed the following: 1. The facility does not allow residents to be restrained. 2. R #89 should not have been restrained. G. Record review of facility restraint policy, dated 09/30/23, revealed Physical restraints shall only be used for the safety and wellbeing of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for behavioral health concerns when: 1. Staff delayed psychiatric services for R #16 after a psychiatric referral on 12/18/24 and 07/20/25. 2. Staff failed to refer R #16 for recommended therapy services on 03/14/25. 3. Staff did not have an effective process for referring residents to behavioral health services. These deficient practices could likely result in residents not receiving the behavioral or mental health care and assistance needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings are: A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Parkinson's Disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination). b. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances). c. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in the morning, despite having adequate opportunity to sleep). d. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 4. An order dated 12/18/24, to refer R #16 to [Name of psychiatric provider] for evaluation and treatment. 5. An order dated 05/07/25, for behavior monitoring for compulsive behaviors. 6. An order dated 07/20/25, for psych consult due to inappropriate sexual behaviors. C. Record review of R #16's progress notes, multiple dates, revealed the following: 1. On 11/04/24, R #16 was making sexually inappropriate verbal comments towards female staff. 2. On 12/24/24, staff documented that R #16 became frustrated and very upset with staff. R #16 was cussing under his breath and was not easily redirected (a proactive strategy to guide a child away from challenging or undesirable actions toward more positive and acceptable ones before the behavior escalates). 3. On 12/29/24, staff documented R #16 was agitated throughout shift. 4. On 04/08/25, staff documented R #16 had been having inappropriate behaviors toward female staff. 5. On 04/26/25, on the quarterly social services evaluation progress note, staff documented that R #16 continued to have negative sexual behaviors toward female staff. 6. On 04/27/25, staff documented R #16 had sexual behaviors. 7. On 07/11/25, staff documented R #16 had sexual behaviors toward a female resident and female staff member. 8. On 07/20/25, staff documented R #16 had been talking about having sexual relations with staff and residents. Staff notified the on-call provider. The on-call provider ordered a psychiatric referral. 9. On 07/21/25, staff documented R #16 stated he wasn't feeling well due to staff saying he was having sexual behaviors. 10. On 09/14/25, staff documented R #16 was sexually inappropriate with female residents in his room. 11. On 10/06/25, staff documented R #16 had self-harm and the psychiatric provider was notified. D. Record review of R #16's administration record (method for staff to document treatments or behaviors), dated July 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 07/09/25. 2. 07/20/25. E. Record review of R #16's administration record, dated August 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 08/05/25 2. 08/06/25 F. Record review of R #16's administration record, dated September 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 09/08/25 2. 09/14/25 G. Record review of R #16's provider progress notes, multiple dates, revealed the following: 1. On 05/23/25, the provider documented that R #16 had depression and was not followed by psychiatry. 2. On 07/01/25, the provider documented that R #16 had a diagnosis of depression and was not followed by psychiatry. 3. On 08/23/25, the provider documented that R #16 had a diagnosis of depression and was not followed by psychiatry. H. Record review of R #16's Psychiatric Evaluation (a comprehensive assessment of an individual's mental health status conducted by a qualified mental health professional, such as a psychiatrist, psychologist, or social worker), multiple dates, revealed R #16 was seen on: 1. 03/14/25, the psychiatric provider recommended R #16 continue therapy services (resident was not receiving therapy services at that time, see finding I and M). 2. 10/06/25, after an episode of self-harm. I. Record review of R #16's entire medical record, no date, revealed R #16 was not seen for therapy services at the facility. J. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following: 1. R #16 was taking an anti-depressant for a diagnosis of depression. 2. R #16 did not have any non-pharmacological interventions in place for his diagnosis of depression. 3. She was unsure if R #16 was receiving behavioral health services. 4. R #16 frequently exhibited sexual behaviors toward female staff and female residents. 5. Staff were monitoring R #16 for his sexual behaviors toward female staff and female residents. 6. R #16's order to monitor compulsive behaviors was related to sexual behaviors. 7. She was the nurse working when R #16 had an episode of self-harm on 10/06/25. 8. R #16 had never stated suicidal thoughts or showed suicidal behaviors prior to 10/06/25. K. On 10/10/25 at 10:02 AM, during an interview, the SSD stated the following: 1. R #16 had a referral for [Name of psychiatric company] on 12/18/24. 2. R #16 was not seen by the psychiatric provider until 03/14/25. 3. She stated that when a referral is placed for a psychiatric provider, the nurses were expected to verbally notify her, then she sends the referral to the psychiatric provider. 4. R #16 had another referral, dated 07/20/25, for a psychiatric consult due to increased sexual behaviors. 5. R #16 was not seen by the psychiatric provider until 10/06/25. 6. She stated she did not have a method to track when she was verbally notified about psychiatric referrals. L. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. Staff were expected to verbally notify the SSD when a psychiatric referral was ordered. 2. The SSD was expected to send the referral to the psychiatric provider. 3. There was no tracking method to ensure the SSD was notified and the referral was sent to the psychiatric provider. 4. Her expectation was for nursing staff to notify the psychiatric provider if a resident is having increased behaviors. 5. She was unable to determine when the SSD was notified about R #16's referrals on 12/18/24 or 07/20/25. 6. R #16 was seen by the psychiatric provider on 03/14/25 and after his episode of self-harm on 10/06/25. M. On 10/10/25 at 12:20 PM, during an interview, the Medical Records Director confirmed R #16 was not being seen for counseling. N. On 10/10/15 at 12:55 PM, during an interview, the psychiatric nurse practitioner (PNP) confirmed the following: 1. He usually received referrals from the SSD via email. 2. He was unsure when he was notified about R #16's first referral on 12/18/24. 3. He saw R #16 on 03/14/25. 4. He was not notified that a new referral for R #16 was placed on 07/20/25. 5. He was not notified that R #16 had sexual behaviors. 6. If he had been notified about R #16 having sexual behaviors, he would have followed up with him. 7. He saw R #16 after an episode of self-harm on 10/06/25. 8. He confirmed he did not see R #16 between the 03/14/25 and 10/06/25 visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to meet quality of care standards for 1 (R #9) of 3 (R #1, R #2, and R #9) residents reviewed for diabetes (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels) when staff did not obtain finger stick blood glucose levels for R #9 upon return to the facility. This deficient practice could likely result in complications related to diabetes. The findings are: A. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of type 2 diabetes mellitus with hyperglycemia (DM2; chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels). B. Record review of R #9's nursing progress notes revealed the following: 1. R #9 was sent to the hospital on [DATE] due to a fall at the facility. 2. R #9 was admitted to the hospital from [DATE] through 08/31/25. C. Record review of R #9's convalescent care orders (CCO; discharge orders from the hospital for residents entering long-term care facilities), dated 08/31/25, revealed the following: 1. Treatment Orders: For patients with diabetes and accuchecks (routine blood glucose checks ordered for patients) a. Accuchecks before meals and at bedtime (AC and HS; blood glucose checks performed before meals and at bedtime to manage diabetes effectively.)? Was answered Yes. D. Record review of R #9's provider progress notes revealed the following: 1. R #9 was seen by the facility provider on 09/03/25. 2. Under diagnosis, assessment, plan provider documented the following: a. Diabetes mellitus type 2, continue blood sugar checks before meals and at bedtime. E. Record review of R #9's physician's orders revealed no order for accuchecks/blood sugar checks was entered as indicated on the CCO and providers progress note for 09/03/25. F. Record review of R #9's blood sugar summary (vital sign section where staff document blood glucose levels) revealed no blood glucose checks were completed by staff after 08/26/25. G. On 10/16/25 at 2:31 PM, during an interview with the provider, he confirmed he did want R #9 to be on blood glucose checks upon his readmission from the hospital. He was unaware that this order had not been implemented upon R #9's return from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 3 (R #1, R #2 and R #9) of 3 (R #1, R #2 and R #9) residents reviewed for assessment and monitoring when facility staff failed to: 1. Administer medications as ordered for R #1, R #2 and R #9. 2. Contact the provider to notify them when medication was held due to possible adverse effects (unintended effect that is undesirable, unpleasant, or harmful) of medication for R #1, R #2 and R #9. If the facility is not providing care per physician's orders, notifying the provider of changes and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of hypertensive heart disease with heart failure (condition in which high blood pressure has caused significant damage to the heart leading to the heart's inability to pump blood effectively). B. Record review of R #1's physician orders revealed the following: 1. Order dated 12/11/24, for amlodipine (medication used to hypertension by relaxing the heart vessels making it easier for heart to pump blood) 5 mg, give 1 tablet by mouth one time a day for hypertension (high blood pressure). 2. Order dated 12/13/24, for lisinopril (medication used to treat hypertension by relaxing the blood vessels which lowers blood pressure and increases blood flow to the heart) 20 mg, give 1 tablet by mouth one time a day for hypertension. 3. The physician orders did not contain an order to hold medications based on specific parameters (specific predetermined measurements for vital signs [blood pressure] set by physician/provider used to decide whether medication should be given or not). C. Record review of R #1's medication administration record (MAR; a form used to document medication administration) dated June 2025, revealed the following: -amlodipine 1. On 06/23/25 staff documented 5 = hold (do not give medication)/see progress notes. 2. On 06/26/25 staff documented 5. 3. On 06/30/25 staff documented 5. -lisinopril 4. On 06/23/25 staff documented 5. 5. On 06/26/25 staff documented 5. 6. On 06/30/25 staff documented 5. D. Record review of R #1's medication administration record dated July 2025, revealed the following: -amlodipine 1. On 07/02/25 staff documented 4 = vitals outside of parameters for administration (specific predetermined measurements for vital signs [blood pressure] set by provider indicating when medication is to be held) 2. On 07/04/25 staff documented 5. 3. On 07/07/25 staff documented 4. -lisinopril 4. On 07/02/25 staff documented 4. 5. On 07/04/25 staff documented 5. 6. On 07/07/25 staff documented 4. E. Record review of R #1's progress notes for June 2025 revealed the following: 1. Staff did not document they notified the provider regarding holding R #1's BP medication. 2. On 06/23/25 staff documented medication held due to low parameters BP 77/55 heart rate (HR) 96. 3. On 06/26/25 staff documented resident's BP 97/51. 4. On 06/30/25 staff documented This medication is on hold due to resident's BP of 97/52 F. Record review of R #1's progress notes for July 2025 revealed the following: 1. Staff did not document they notified the provider regarding holding R #1's BP medication. 2. On 07/02/25 staff did not document what R #1's BP reading was or why BP medication was held. 3. On 07/04/25 staff documented resident's BP 92/47. 4. On 07/07/25 staff did not document what R #1's BP reading was or why BP medication was held. R #2 G. Record review of R #2's admission record (no date) revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had a diagnosis of hypertensive heart disease without heart failure (condition in which high blood pressure has caused significant damage to the heart but has not yet progressed to affect the heart's ability to pump blood effectively). H. Record review of R #2's physician orders revealed the following: 1. Order dated 11/08/23, for amlodipine 5 mg, give 2 tablets by mouth one time a day for hypertension, hold BP medication of systolic BP (top number of BP reading) is less than 100 or greater than 180 or if diastolic BP (bottom number of BP reading) is less than 50 or greater than 90. I. Record review of R #2's MAR dated June 2025, revealed the following: -amlodipine 1. R #2's blood pressure medication was held 18 out of 30 days in June 2025. 2. On 06/02/25 staff documented 4 but staff did not document R #2's BP reading or HR. 3. On 06/04/25 staff documented 4 BP 90/60, HR 62. 4. On 06/05/25 staff documented 4 BP 89/55, HR 74. 5. On 06/06/25 staff documented 4 BP 117/59, HR 52. 6. On 06/09/25 staff documented 4 BP 108/53, HR 78. 7. On 06/10/25 staff documented 4 BP 102/45, HR 59. 8. On 06/12/25 staff documented 4 BP 101/57, HR 58. 9. On 06/13/25 staff documented 4 BP 83/46, HR 72. 10. On 06/14/25 staff documented 4 BP 87/60 HR 54. 11. On 06/16/25 staff documented 9 = Other/See progress notes but staff did not document R #2's BP reading or HR. 12. On 06/18/25 staff documented 4 BP 95/51 HR 110. 13. On 06/20/25 staff documented 5 BP 97/58, HR 61. 14. On 06/22/25 staff documented 5 but staff did not document R #2's BP reading or HR. 15. On 06/23/25 staff documented 4 BP 118/62, HR 67. 16. On 06/24/25 staff documented 4 BP 100/55, HR 91. 17. On 06/27/25 staff documented 4 but staff did not document R #2's BP reading or HR. 18. On 06/28/25 staff documented 4 but staff did not document R #2's BP reading or HR. 19. On 06/29/25 staff documented 4 but staff did not document R #2's BP reading or HR. J. Record review of R #2's MAR dated July 2025, revealed the following: -amlodipine 1. R #2's blood pressure medication was held 19 out of 31 days in July 2025. 2. On 07/01/25 staff documented 5 BP 99/52, HR 47. 3. On 07/02/25 staff documented 4 but staff did not document R #2's BP reading or HR. 4. On 07/03/25 staff documented 5 but staff did not document R #2's BP reading or HR. 5. On 07/04/25 staff documented 5 BP 104/59, HR 47. 6. On 07/07/25 staff documented 4 but staff did not document R #2's BP reading or HR. 7. On 07/08/25 staff documented 4 but staff did not document R #2's BP reading or HR. 8. On 07/12/25 staff documented 4 but staff did not document R #2's BP reading or HR. 9. On 07/13/25 staff documented 4 BP 103/87, HR 76. 10. On 07/14/25 staff documented 9 but staff did not document R #2's BP reading or HR. 11. On 07/16/25 staff documented 4 but staff did not document R #2's BP reading or HR. 12. On 07/18/25 staff documented 5 but staff did not document R #2's BP reading or HR. 13. On 07/19/25 staff documented 5 BP 94/61, HR 59. 14. On 07/21/25 staff documented 4 but staff did not document R #2's BP reading or HR. 15. On 07/22/25 staff documented 4 but staff did not document R #2's BP reading or HR. 16. On 07/23/25 staff documented 4 BP 105/59, HR 54. 17. On 07/25/25 staff documented 4 BP 99/50, HR 69. 18. On 07/27/25 staff documented 4 BP 89/59, HR 61. 19. On 07/30/25 staff documented 4 BP 97/51, HR 77. 20. On 07/31/25 staff documented 4 BP 98/42, HR 54. K. Record review of R #2s progress notes for June 2025 revealed the following: 1. Staff did not document they notified the provider regarding holding R #2's amlodipine for several days. 2. On 06/02/25 staff did not document R #2's blood pressure or the reason the amlodipine was held. 3. On 06/05/25 staff documented hold medication per nurse, BP and HR low. 4. On 06/06/25 and 06/09/25 staff did not document regarding holding amlodipine even though the documented BP readings on the MAR were within the parameters to give the medication. 5. On 06/12/25 staff documented hold medication BP was low, staff did not document communication to the provider to determine the need to hold medication even though the documented BP reading was within the parameters to give. 6. On 06/13/25 staff did not document any communication to the provider regarding significantly low BP of 83/46. 7. On 06/14/25 staff documented amlodipine held due to low parameters. No documentation that the provider was informed that R #2's BP remained low at 87/60. 8. On 06/16/25 staff did not document R #2's BP reading and documented patient had an appointment. No documentation that provider was notified that R #2 missed his medication due to being at an appointment. 9. On 06/22/25 staff documented resident's BP 99/56, HR 53. 10. On 06/23/25 and 06/24/25 staff did not document regarding holding amlodipine even though the documented BP readings on the MAR were within the parameters to give the medication. 11. On 06/27/25, 06/28/25 and 06/29/25 staff did not document R #2's BP readings or the reason that amlodipine was held. L. Record review of R #2's progress notes for July 2025 revealed the following: 1. Staff did not document that they notified the provider regarding holding R #2's medication for several days. 2. On 07/02/25 staff did not document what R #2's blood pressure reading was or why amlodipine was held. 3. On 07/03/25 staff documented resident's BP 99/54. 4. On 07/04/25 staff documented amlodipine is on hold due to resident's pulse (Heart rate/HR) of 47. Documentation did not include whether the provider was consulted or notified of low HR since R #2's amlodipine order does not have HR parameters indicating when to hold the medication. 5. On 07/07/25, 07/08/25 and 07/12/25 staff did not document R #2's BP or the reason why amlodipine was held. 6. On 07/13/25 staff did not document regarding holding amlodipine even though the documented BP reading on the MAR was within the parameters to give the medication. 7. On 07/14/25 staff did not document R #2's BP reading and documented resident is out of facility on transport, reported to charge nurse. No documentation that provider was notified that R #2 missed his medication due to being at an appointment. 8. On 07/16/25 staff did not document R #2's BP reading or the reason why amlodipine was held. 9. On 07/18/25 staff documented resident's BP 95/55, HR 63. 10. On 07/21/25 and 07/22/25 staff did not document R #2's BP or the reason why amlodipine was held. 11. On 07/23/25 staff documented BP and HR low, nurse notified staff did not document why amlodipine was held even though the documented BP reading on the MAR was within the parameters to give the medication. M. Record review of American Heart Association Low blood pressure-When blood pressure is too low last reviewed 05/06/24.www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low revealed the following: 1. Low blood pressure occurs when blood pressure is less than 90/60. 2. Low blood pressure can happen with diuretics (medications that help the body eliminate excess fluid by increasing urine production) and other drugs used to treat high blood pressure. R #9 N. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of type 2 diabetes mellitus with hyperglycemia (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels). O. Record review of R #9's physician orders revealed the following: 1. Order dated 08/28/25, for insulin glargine (medication used to improve and maintain blood sugar levels over an extended period of time) inject 28 units one time a day for diabetes mellitus type 2 (DM-2) 2. Order dated 08/22/25, for Humulin regular insulin (insulin that works to help lower blood sugar levels within 30 minutes of injection) inject as per sliding scale (insulin dosages that are adjusted based on the patient's current blood sugar level) before meals and at bedtime as follows: a. If BS level is 0-80 and conscious give 4 ounces of juice, if unconscious give glucagon (emergency medication used to treat severe low blood sugar in diabetes patients) 1 mg intramuscularly, notify doctor. b. If BS level is 81-199, no coverage (no insulin given). c. If BS level is 200-250 give 2 units. d. If BS level is 251-300 give 4 units. e. If BS level is 301-350 give 6 units. f. If BS level is 351-400 give 8 units. g. If BS level is 401 or greater give 10 units and notify doctor. P. Record review of R #9's MAR dated August 2025, revealed the following: -insulin glargine 1. On 08/20/25 staff documented 13 medication not available. 2. On 08/21/25 staff documented 5. 3. On 08/25/25 staff documented 5. 4. On 08/26/25 staff documented 6 = hospitalized -Humulin 5. On 08/23/25 at 630 AM staff documented 4 BS 70. 6. On 08/24/25 at 630 AM staff documented 4 BS 80. 7. On 08/24/25 at 1130 AM staff documented 9, staff did not document BS level. 8. On 08/24/25 at 430 PM staff documented 4 BS 70. 9. On 08/25/25 at 430 PM staff documented 4 BS 65. 10. On 08/25/25 at 830 PM staff documented 4 BS 57. 11. On 08/26/25 at 1130 AM staff documented 4 BS 62. Q. Record review of Diabetic Management Policy dated 03/19/24 revealed the following: 1. ACUTE COMPLICATION MANAGEMENT: HYPOGLYCEMIA - Low Blood Sugar Levels a. If the BG (blood glucose/BS) level is below 70 mg/dl or other physician directed low parameter, and the resident can swallow, or the resident is tube fed: Give fast acting source of sugar and notify MD. b. Reassess the BG level in 15 minutes and document the results of the BG on the MAR. c. If the BG level remains below 70 mg/dl or other physician directed low parameter give: Additional source of sugar (e.g., another 4 ounces of orange juice or administer glucose gel. d. Recheck blood glucose in 15 minutes and document the results. e. Notify the physician of the episode. R. Record review of R #9's progress notes for August 2025 revealed the following: 1. On 08/21/25 staff did not document R #9's BS level or the reason why insulin glargine was held. 2. On 08/25/25 for insulin glargine, staff documented blood glucose low. Staff did not consult the provider regarding holding the medication since the medication does not have hold parameters. 3. On 08/23/25, 08/24/25, 08/25/25 and 08/26/25 staff did not document that they gave juice, glucagon, rechecked the BS level or notified the provider of R #9's BS levels of 80 or less. S. On 10/17/25 at 11:00 AM, during an interview, the DON confirmed the following: 1. Staff did not contact the provider to notify them of R #1's and R #2's BP medications being held. 2. R #1's amlodipine and lisinopril orders did not have parameters indicating when the medications should be held. 3. R #2's amlodipine was held outside of set parameters. 4. R #9's insulin glargine was held, and the order did not have parameters indicating when to hold the medication. 5. Staff did not follow R #9's Humulin insulin order or the facility policy regarding low blood sugars. 6. Her expectation is that if staff have concerns regarding administering medications, they contact the provider, document the conversation held with provider and enter a new order as needed depending on what the provider's decision is regarding the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and blood sugar) and that medication was not given for 3 (R #1, R #2, and R #9) of 3 (R #1, R #2, and R #9) residents reviewed for assessment and monitoring when staff failed to notify the provider that: 1. R #1 and R #2's blood pressure was low. 2. R #9's blood sugar was low. 3. Medication was held (not given) for R #1, R #2 and R #3. These deficient practices could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: R #1A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of hypertensive heart disease with heart failure (condition in which high blood pressure has caused significant damage to the heart leading to the heart's inability to pump blood effectively). B. Record review of R #1's physician orders revealed the following: 1. Order dated 12/11/24, for amlodipine (medication used to hypertension by relaxing the heart vessels making it easier for heart to pump blood) 5 mg, give 1 tablet by mouth one time a day for hypertension (high blood pressure). 2. Order dated 12/13/24, for lisinopril (medication used to treat hypertension by relaxing the blood vessels which lowers blood pressure and increases blood flow to the heart) 20 mg, give 1 tablet by mouth one time a day for hypertension. C. Record review of R #1's medical record revealed the following: 1. On 06/23/25 staff documented medication held due to low parameters BP 77/55 heart rate (HR) 96. 2. On 06/26/25 staff documented resident's BP 97/51. 3. On 06/30/25 staff documented This medication is on hold due to resident's BP of 97/52 4. On 07/02/25 staff documented vitals outside of parameters for administration (specific predetermined measurements for vital signs set by physician/provider used to decide whether medication should be given or not). Staff did not document R #1's BP reading. 5. On 07/04/25 staff documented resident's BP 92/47. 6. On 07/07/25 staff documented vitals outside of parameters for administration. Staff did not document R #1's BP reading. 7. Medical record did not contain any documentation that the provider was notified of R #1's low blood pressure or that R #1's medication was held. R #2 D. Record review of R #2's admission record (no date) revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had a diagnosis of hypertensive heart disease without heart failure (condition in which high blood pressure has caused significant damage to the heart but has not yet progressed to affect the heart's ability to pump blood effectively). E. Record review of R #2's physician orders revealed the following: 1. Order dated 11/08/23, for amlodipine 5 mg, give 2 tablets by mouth one time a day for hypertension, hold BP medication of systolic BP (top number of BP reading) is less than 100 or greater than 180 or if diastolic BP (bottom number of BP reading) is less than 50 or greater than 90. F. Record review of R #2's medical record revealed the following: 1. On 06/04/25 staff documented BP 90/60, vitals outside of parameters for administration. 2. On 06/05/25 staff documented BP 89/55, vitals outside of parameters for administration. 3. On 06/10/25 staff documented BP 102/45, vitals outside of parameters for administration. 4. On 06/13/25 staff documented BP 83/46, vitals outside of parameters for administration. 5. On 06/14/25 staff documented BP 87/60, vitals outside of parameters for administration. 6. On 06/18/25 staff documented BP 95/51, vitals outside of parameters for administration. 7. On 06/20/25 staff documented BP 97/58, staff did not document whether medication was held or given. 8. On 07/01/25 staff documented this medication is on hold due to residents bp of 99/52. 9. On 07/19/25 staff documented this medication is on hold due to residents bp of 94/61. 10. On 07/25/25 staff documented BP 99/50, vitals outside of parameters for administration. 11. On 07/27/25 staff documented BP 89/59, vitals outside of parameters for administration. 12. On 07/30/25 staff documented BP 97/51, vitals outside of parameters for administration. 13. On 07/31/25 staff documented BP 98/42, vitals outside of parameters for administration. 14. Medical record did not contain any documentation that the provider was notified of R #2's low blood pressure or that R #2's medication was held. G. Record review of American Heart Association Low blood pressure-When blood pressure is too low last reviewed 05/06/24.www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low revealed the following: 1. Low blood pressure occurs when blood pressure is less than 90/60. 2. Low blood pressure can happen with diuretics (medications that help the body eliminate excess fluid by increasing urine production) and other drugs used to treat high blood pressure. R #9 H. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of type 2 diabetes mellitus with hyperglycemia (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels). I. Record review of R #9's physician orders revealed the following: 1. Order dated 08/28/25, for insulin glargine (medication used to improve and maintain blood sugar levels over an extended period of time) inject 28 units one time a day for diabetes mellitus type 2 (DM-2) 2. Order dated 08/22/25, for Humulin regular insulin (insulin that works to help lower blood sugar levels within 30 minutes of injection) inject as per sliding scale (insulin dosages that are adjusted based on the patient's current blood sugar level) before meals and at bedtime as follows: a. If BS level is 0-80 and conscious give 4 ounces of juice, if unconscious give glucagon (emergency medication used to treat severe low blood sugar in diabetes patients) 1 mg intramuscularly, notify doctor. b. If BS level is 81-199, no coverage (no insulin given). c. If BS level is 200-250 give 2 units. d. If BS level is 251-300 give 4 units. e. If BS level is 301-350 give 6 units. f. If BS level is 351-400 give 8 units. g. If BS level is 401 or greater give 10 units and notify doctor. J. Record review of the facility's Diabetic Management Policy dated 03/19/24 revealed the following: 1. ACUTE COMPLICATION MANAGEMENT: HYPOGLYCEMIA - Low Blood Sugar Levels a. If the BG (blood glucose/BS) level is below 70 mg/dl or other physician directed low parameter, and the resident can swallow, or the resident is tube fed: Give fast acting source of sugar and notify Medical Doctor (MD). b. Reassess the BG level in 15 minutes and document the results of the BG on the MAR. c. If the BG level remains below 70 mg/dl or other physician directed low parameter give: Additional source of sugar (e.g., another 4 ounces of orange juice or administer glucose gel. d. Recheck blood glucose in 15 minutes and document the results. e. Notify the physician of the episode. K. Record review of R #9's medical record revealed the following: 1. On 08/23/25 at 630 AM staff documented BS 70. 2. On 08/24/25 at 630 AM staff documented BS 80. 3. On 08/24/25 at 1130 AM staff documented BS 70. 4. On 08/25/25 at 430 PM staff documented BS 65. 5. On 08/25/25 at 830 PM staff documented BS 57. 6. On 08/26/25 at 1130 AM staff documented BS 62. 7. Medical record did not contain any documentation that the provider was notified of R #9's low blood sugar levels as indicated on R #9's physician's orders and as indicated in the facility's Diabetic Management Policy. L. On 10/17/25 at 11:00 AM, during an interview, the DON confirmed the following: 1. Staff did not contact the provider to notify them of R #1's and R #2's low BP readings and holding BP medications. 2. Staff did not contact the provider to notify them of R #9's blood sugar levels as indicated in the order or the facility's Diabetic Management Policy. 3. Her expectation is that if staff have concerns regarding resident's vital signs and deciding to hold medications, they should contact the provider, document the conversation held with provider and enter a new order as needed depending on what the provider's decision is regarding the medication. 4. Staff should contact the physician as stated on the physician's orders. 5. Staff should follow facility's policy regarding contacting the provider.

Based on record review and interview, the facility failed to ensure nursing staff completed mandatory behavioral health training (a form of instruction that provides knowledge and skills to identify, understand, and respond to mental health and substance use challenges, including the promotion of well-being) for 1 (LPN #26) of 4 (LPN #17, LPN #18, LPN #25, and LPN #26) staff sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are: A. Record review of staff training records revealed LPN #26 did not complete the mandatory behavioral health training. B. On 10/14/25 at 12:29 PM, during an interview, the Administrator stated the following: 1. He was unable to find LPN #26's behavioral health training. 2. If LPN #26 did not complete the behavioral health training, he would ensure she completed it that day. 3. All staff were required to complete behavioral health training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances). b. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in the morning, despite having adequate opportunity to sleep). c. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 4. An order dated 11/22/24 for trazadone (antidepressant medication that is also used to treat anxiety and insomnia) 25 mg, once a day for sleep aide. 5. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia. C. Record review of R #16's pharmacist recommendation, dated 07/28/25, revealed the following: 1. R #16 had been taking escitalopram 20 mg once a day since 10/18/24. 2. The pharmacist recommended R #16 be evaluated to decrease the dose of escitalopram. 3. The provider documented resident with good response, maintain current dose. 4. The provider documented disagree with the pharmacist recommendation. 5. The provider did not document a clinical rationale for why R #16 should not have a dose reduction. D. Record review of R #16's entire medical record, no date, revealed the provider did not document a clinical rationale for why a GDR should not be conducted for R #16 for escitalopram 20 mg. E. On 10/09/25 at 2:11 PM, during an interview, the DON confirmed the following: 1. R #16 was taking the same dose of escitalopram and oxcarbazepine since he arrived on 10/17/24. 2. The pharmacist recommended a GDR for escitalopram on 07/28/25 and the provider declined the GDR. 3. R #16's provider did not document a clinical rationale for why a GDR should not be conducted for escitalopram. F. On 10/14/25 at 12:29 PM, during an interview, the Medical Director confirmed the following: 1. A GDR for antidepressant medications should be attempted if a resident was not showing signs of depression. 2. Providers were expected to document a clinical rationale for why a GDR should not be attempted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression when staff failed to: 1. Include what behaviors staff were expected to monitor for related to his diagnosis of depression. 2. Include non-pharmacological interventions for R #16's diagnosis of depression. These deficient practices could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had a diagnosis of major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the escitalopram order in the EMR system that stated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 4. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 5. An order dated 05/07/25, for behavior monitoring for compulsive behaviors. C. Record review of R #16's progress notes, multiple dates, revealed the following: 1. On 11/04/24, R #16 was making sexually inappropriate verbal comments towards female staff. 2. On 12/24/24, staff documented that R #16 became frustrated and very upset with staff. R #16 was cussing under his breath and was not easily redirected (a proactive strategy to guide a child away from challenging or undesirable actions toward more positive and acceptable ones before the behavior escalates). 3. On 12/29/24, staff documented R #16 was agitated throughout shift. 4. On 04/08/25, staff documented that R #16 had been having inappropriate behaviors toward female staff. 5. On 04/26/25, social services progress note, staff documented that R #16 continued to have negative sexual behaviors toward female staff. 6. On 04/27/25, staff documented that R #16 had sexual behaviors. 7. On 07/11/25, staff documented that R #16 had sexual behaviors toward a female resident and female staff member. 8. On 07/20/25, staff documented that R #16 had been talking about having sexual relations with staff and residents. Staff notified the on-call provider. The on-call provider ordered a psychiatric referral. 9. On 07/21/25, staff documented that R #16 stated he wasn't feeling well due to staff saying he was having sexual behaviors. 10. On 09/14/25, staff documented that R #16 was sexually inappropriate with female residents in his room. D. Record review of R #16's care plan, revised on 05/29/25, revealed the following: 1. Staff documented that R #16 behavior should be monitored. 2. Staff did not document what behaviors R #16 should be monitored for related to depression diagnosis or anti-depressant medication. 3. Staff did not document what non-pharmacological interventions staff were expected to implement for R #16's diagnosis of depression. 4. Staff did not document what compulsive behaviors R #16 had that needed to be monitored. 5. Staff did not document what interventions staff were expected to implement when R #16 exhibited compulsive behaviors. 6. Staff did not document that R #16 had sexually inappropriate behaviors with female staff and female residents. E. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following: 1. R #16 was taking an anti-depressant for depression. 2. R #16 had a black box warning for escitalopram and trazadone orders that indicated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. R #16 was not monitored for suicidal thoughts or suicidal behaviors. 4. R #16 was not monitored for depression symptoms. 5. R #16 did not have any non-pharmacological interventions in place for his diagnosis of depression. 6. R #16 was being monitored for inappropriate sexual behaviors toward female staff and female residents. F. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. R #16's order for escitalopram had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 2. R #16's care plan did not include any specific behaviors related to depression that staff should monitor for. 3. R #16's care plan did not include any non-pharmacological interventions for his diagnosis of depression. 4. R #16's care plan did not include for staff to monitor R #16 for worsening depression or emergence of suicidal thoughts or suicidal behaviors. 5. Staff should include what interventions are in place to treat depression on the care plan. 6. Staff should include what behaviors residents were being monitored for on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. They are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary and had adequate monitoring for 2 (R #16 and R #24) of 3 (R #16, R #24, and R #25) residents reviewed for depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) treatment, when staff failed to: 1. Ensure a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #16. 2. Adequately monitor for adverse side effects (unwanted, harmful, or abnormal result) of psychotropic medication for R #16 and R #24. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side. The findings are:
Gradual Dose Reduction
A. Record review of R #16's admission documents, no date, revealed the following:
1. R #16 was admitted to the facility on [DATE].
2. R #16 had the following diagnoses:
a. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances).
b. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in the morning, despite having adequate opportunity to sleep).
c. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime).
B. Record review of R #16's physician orders, multiple dates, revealed the following:
1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression.
2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25.
3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression.
4. An order dated 11/22/24 for trazadone (antidepressant medication that is also used to treat anxiety and insomnia) 25 mg, once a day for sleep aide.
5. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia.
C. Record review of R #16's PHQ-9 (a comprehensive, nine-question questionnaire that covers a wider range of depressive symptoms) assessment, multiple dates, revealed the following assessment scores (the PHQ-9 scoring ranges from 0 being no depression symptoms to 27 being severe depression symptoms):
1. On 10/17/24, R #16's score was 0.
2. On 12/29/24, R #16's score was 0.
3. On 01/24/25, R #16's score was 0.
4. On 04/26/25, R #16's score was 0.
5. On 07/28/25, R #16's score was 0.
D. Record review of R #16's pharmacist recommendation dated 07/28/25, revealed the following:
1. R #16 had been taking escitalopram 20 mg once a day since 10/18/24.
2. The pharmacist recommended R #16 be evaluated to decrease the dose of escitalopram.
3. The provider selected resident with good response, maintain current dose.
4. The provider selected disagree with the pharmacist recommendation.
5. The provider did not document a clinical rationale for why R #16 should not have a dose reduction.
E. Record review of R #16's entire medical record, no date, revealed the provider did not document a clinical rationale for why a GDR had not been conducted for R #16 for escitalopram 20 mg, oxcarbazepine 300mg, or trazadone 25 mg.
F. On 10/09/25 at 2:04 PM, during an interview, LPN #16 stated R #16 did not have any symptoms of depression.
G. On 10/09/25 at 3:32 PM, during an interview, the SSD confirmed R #16 always scored 0 on the PHQ-9 assessments, indicating he was not depressed.
H. On 10/09/25 at 2:11 PM, during an interview, the DON confirmed the following:
1. R #16 had a diagnosis of MDD and insomnia.
2. R #16 had not shown any signs or symptoms of depression since admission.
3. R #16 was taking the same dose of escitalopram and oxcarbazepine since he arrived on 10/17/24.
4. R #16 was taking the same dose of trazadone since it was ordered on 11/22/24.
5. The provider had not conducted a GDR on escitalopram, oxcarbazepine, or trazadone.
6. The pharmacist recommended a GDR for escitalopram on 07/28/25 and the provider declined the GDR.
7. R #16's provider did not document a clinical rationale for why a GDR should not be conducted for escitalopram.
8. R #16's provider did not document a clinical for why a GDR should not be conducted for oxcarbazepine or trazadone.
Monitoring
R #16
I. Record review of R #16's physician's orders, multiple dates, revealed the following:
1. An order dated 10/17/24, for escitalopram oxalate, 20 mg, once a day for depression.
2. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the escitalopram order in the EMR system that stated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
3. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia.
4. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the trazadone order in the EMR system that stated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
5. An order dated 05/07/25, for behavior monitoring for compulsive behaviors.
J. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following:
1. R #16 had a black box warning for escitalopram and trazadone that indicated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
2. R #16 was not being monitored for suicidal thoughts or suicidal behaviors.
3. R #16 was not being monitored for depression symptoms.
4. Staff must acknowledge black box warnings when they enter an order for a medication that has a black box warning.
5. She had never been instructed what to do when the black box warning pops up, so she just acknowledges them.
6. She did not notify the provider about black box warnings when they popped up.
K. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following:
1. R #16's order for escitalopram had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
2. R #16's order for trazadone had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors.
3. Staff were not monitoring R #16 for suicidal thoughts or suicidal behaviors.
4. Staff were not monitoring R #16 for depression symptoms.
5. Staff were expected to notify the provider if a black box warning pops up.
6. Staff did not document in R #16's medical record whether the provider was notified about the black box warnings.
7. She was not sure if staff were expected to monitor residents for the signs or symptoms that were included in black box warnings.
L. On 10/10/25 at 12:55 PM, during an interview, the Psychiatric Nurse Practitioner (PNP) confirmed the following:
1. He would expect staff to monitor all residents who were taking anti-depressants for worsening of depressive symptoms and suicidal thoughts and behaviors.
2. He was not notified about the black box warning on R #16's escitalopram or trazadone.
3. He would expect residents to be monitored for suicidal thoughts and suicidal behaviors if there was a black box indicating they should be monitored.
R #24
M. Record review of R #24's admission Record, no date, revealed R #24 was admitted on [DATE] with the following diagnoses.
1. Other specified Depressive Episodes (refer to a category that applies to individuals who exhibit symptoms characteristic of a
depressive disorder but do not meet the full criteria for any specific depressive disorder.)
2. Mild Neurocognitive Disorder due to known physiological condition with behavioral disturbance (also known as Mild Cognitive Impairment, is a condition in which individuals demonstrate cognitive impairment with minimal impairment of instrumental activities of daily living.)
3. Major Depressive Disorder recurrent, severe with Psychotic symptoms.
4. Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety.
N. Record review of R #24's physician orders revealed an order dated 07/02/25 for Duloxetine HCI (a selective serotonin and norepinephrine reuptake inhibitor used to treat major depressive disorder, generalized anxiety disorder, and certain types of chronic pain) oral capsule delayed release give 1 capsule by mouth at bedtime for major depressive disorder, recurrent, severe with psychotic symptoms. The black box warning associated with R #24's Duloxetine medication in physicians orders reads as follows:
1. Suicidal thoughts and behavior.
2. Monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.
O. Record review of R #24's MAR, dated 10/01/25-10/31/25 revealed the following behaviors and anti-psychotic interventions monitored for psychosis every shift for use of antipsychotic medication in R #24's MAR as follows:
1. Monitor behaviors of psychosis every shift for use of antipsychotic medication:
a. Yelling,
b. screaming,
c. refusing care,
d. refusing medication,
e. false accusations.
2. Anti-psychotic interventions:
1. allow to express feelings,
2. offer emotional support,
3. redirect resident,
4. two times a day for monitoring.
P. Record review of R #24's entire medical record, no date, revealed R #24 did not have any documentation for monitoring suicidal thoughts and suicidal behaviors for the medication Duloxetine HCI (used to treat major depressive disorder.)
Q. On 10/10/25 at 1:45 PM during an interview with LPN #26 stated, she is documenting the interventions and monitoring R #24's antipsychotic medication in R #24's MAR when she works with R #24. LPN #26 did confirm R #24 is on Duloxetine (antidepressant medication). LPN #26 stated for R #24 there's no documentation regarding suicidal ideations in R #24's MAR. LPN #26 stated if the order in the MAR doesn't state to monitor and provide interventions for suicidal thoughts and suicidal behaviors then the nurses won't document. LPN #26 did confirm that if the medication has a black box warning the nurses are to look at that and it should be put in the MAR to monitor the resident.
R. On 10/10/25 at 1:54 PM during an interview with the DON regarding R #24's antidepressant medication black box warnings; the DON confirmed R #24 had no documentation and was not being monitored for suicidal ideations on the R #24's MAR. The DON stated that suicidal behaviors for the black box warning for Duloxetine has increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients, and R #24 is not in either of these categories. The DON stated that her expectation is that the nurses will assess the residents and keep communication with the physician and inform the CNAs to assist in monitoring residents and for the nurses to document appropriately for each residents' black box warning.
S. On 10/14/25 at 12:29 PM, during an interview, the Medical Director confirmed the following:
1. Oxcarbazepine is an anti-convulsant medication and is not approved to be prescribed for the diagnosis of depression.
2. A GDR for antidepressant medications should be attempted if a resident is not showing signs of depression.
3. Providers are expected to document a clinical rationale for why a GDR should not be attempted.
4. All residents who are being treated with antidepressant medications should be monitored for worsening of depression symptoms and suicidal thoughts or behaviors.
5. If a black box warning indicates that a resident should be monitored for suicidal thoughts or suicidal behaviors, staff should monitor the resident for suicidal thoughts and suicidal behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are:
A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE].
B. Record review of R #16's progress note, dated 05/07/25, revealed the following:
1. R #16 fell.
2. R #16 had a bruise noted to the side of her left eye.
3. R #16 had redness to her forehead, left shoulder, left hip, and both knees.
C. Record review of R #16's quarterly MDS, dated [DATE], revealed staff documented the following:
1. R #16 had one fall with no injury.
2. R #16 had zero falls with injury (except major; skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain).
3. R #16 had zero falls with major injury.
D. On 06/16/25 at 3:47 PM, during an interview, the MDS coordinator confirmed the following:
1. R #16 fell on [DATE].
2. R #16 had bruising to her left eye and redness to her forehead, left shoulder, left hip, and both knees.
3. On R #16's quarterly MDS assessment, staff documented that R #16 had one fall without injury.
4. R #16's quarterly MDS assessment was inaccurate, and staff should have documented that R #16 had one fall with injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure care plan revisions occurred for 3 (R #8, R #17, and R #25) of 3 (R #8, R #17, and R #25) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
R #8
A. On 06/16/25 at 10:03 AM, during an observation of R #8's room the smell of urine became extremely strong. R #8 sat on his bed with nothing on only a brief. The brief appeared to be extremely soiled and was dark in color. The mattress did not have any sheets.
B. On 06/17/25 at 8:50 AM, during an interview, the ADON said that R #8 will go days without letting anyone change his brief. The ADON said that R #8 will kick, throw things, and cuss at staff if he doesn't want to be changed. The ADON said that R #8 does not like sheets on his bed. The ADON further stated R #8 will take the sheets off his bed if they put them on. The ADON said that they are not able to shower R #8. The ADON said that when the resident is compliant with care, staff will do as much as they can for him. The DON said staff will reproach R #8 several times throughout the day to see if R #8 will allow them to change him, shower him, and put sheets on the resident's bed. The ADON said that they have changed R #8's mattress several times due to the smell. The ADON said that staff have to continue to ask the resident throughout the day if he will let them provide any care for him. The ADON said that R #8 will sometime let staff provide care if you offer him a Diet Dr. Pepper and chips.
C. Record review of R #8's care plan, dated 04/10/25, did not contain the following documentation:
1. R #8's occasional compliance with care when Diet Dr. Pepper or chips are offered.
2. Interventions for care and refusals.
3. Interventions for changing R #8's sheets and refusals of allowing sheets on his bed.
4. Interventions for refusals of showering/bathing for R #8.
5. When and how often R #8's mattress should be changed.
D. On 06/17/25 at 2:24 PM, during an interview, the DON said that she would expect staff to document when R #8 refuses to have sheets on his bed. The DON said Dr. Pepper and chips don't always work with the resident, but that it is used as an intervention. The DON confirmed the drink and chips intervention was not documented. The DON confirmed the interventions for R #8 were documented by the previous staff and have not been updated since 11/15/24. The DON said her expectation was that the care plan be updated and that interventions for refusal of care should be documented.
R #17
E. Record review of R #17's admission documents, no date, revealed the following:
1. R #17 was admitted to the facility on [DATE].
2. R #17 had the following diagnoses:
a. Muscle weakness.
b. Lack of coordination.
c. Abnormalities of gait and mobility.
d. Difficulty in walking.
F. Record review of R #18's progress note, dated 04/07/25, revealed the following:
1. R #17 had a fall on 04/05/25.
2. R #17 fell due to weakness and imbalance.
3. The intervention put in place due to R #17's fall was for R #17 to participate in the restorative program (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible).
G. Record review of R #17's care plan, revised 12/30/24, revealed staff did not revise R #17's care plan to include that she was participating in the restorative program.
H. On 06/17/25 at 1:39 PM, during a joint interview, the DON and MDS Director confirmed the following:
1. R #17 fell on [DATE].
2. R #17 was participating in the restorative program to improve her weakness and balance.
3. Staff did not revise R #17's care plan to include that she was participating in the restorative program.
4. Staff should have revised R #17's care plan to include the restorative program as an intervention to prevent falls.
R #25
I. Record review of R #25's admission documents, no date, revealed she was admitted to the facility on [DATE].
J. Record review of R #25's physician orders, multiple dates revealed the following:
1. An order dated 07/19/24 regular diet, regular texture, regular/thin consistency
2. An order dated 06/17/25 enteral feed five times a day isosource 1.5 250ml of formula (a specialized liquid nutritional supplement designed to provide essential nutrients to individuals who may have difficulty meeting their nutritional needs through regular food intake) at each feeding as tolerated.
3. An order dated 06/11/24 Amiodarone HCI oral tablet 200 mg give 200 mg via gastrostomy tube (G-tube a tube inserted through the belly that brings nutrition directly to the stomach) at bedtime for arrythmia (irregular heart beat).
4. An order dated 06/11/24 Levothyroxine sodium oral tablet 112 mcg give 1 tablet via G-tube one time a day for hypothyroidism (thyroid gland doesn't make and release enough hormone into your bloodstream).
K. Record review of R #25's care plan, dated 04/17/25, revealed R #25 is to only have female staff for direct care on resident. No specific details in care plan interventions.
L. On 06/18/25 at 9:55 AM, during an interview, the DON confirmed R #25's care plan does not justify if a male staff member is to feed and administer medication to R #25, and what plan to follow to ensure resident is fed and medications are given per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #25) of 3 (R #18, R #25, and R #26) residents reviewed for neglect, when staff failed to administer R #25's heart rhythm and thyroid medication as ordered by the physician. This deficient practice could likely lead to the residents medical conditions worsening and having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are:
A. Record review of R #25's face sheet, no date, revealed the following:
1. R #25 was admitted to the facility on [DATE].
2. R #25 diagnoses include the following:
a. Gastrostomy status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage).
b. Epilepsy, unspecified, intractable, with status epilepticus (a potentially life-threatening state in which a person experiences an abnormally prolonged seizure (any seizure lasting longer than five minutes) or does not fully regain consciousness between seizures).
c. Hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure).
d. Paroxysmal arterial fibrillation (a type of irregular heartbeat).
e. Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by the buildup of plaque fats, cholesterol, and other substances in the arteries, leading to narrowed arteries and reduced blood flow).
f. Chronic systolic (congestive) heart failure (systolic heart failure, the left ventricle of your heart, which pumps most of the blood, has become weak).
g. Cardiomegaly (an enlarged heart is an indicator of a condition that puts a strain on your heart).
h. Hypothyroidism, unspecified (thyroid gland doesn't make and release enough hormone into your bloodstream).
B. Record review of R #25's physician orders, multiple dates revealed the following:
1. An order dated 07/19/24 regular diet, regular texture, regular/thin consistency
2. An order dated 06/17/25 enteral feed five times a day isosource 1.5 250 ml of formula (a specialized liquid nutritional supplement designed to provide essential nutrients to individuals who may have difficulty meeting their nutritional needs through regular food intake) at each feeding as tolerated at each feeding as tolerated.
3. An order dated 06/11/24 Amiodarone HCI oral tablet 200 mg give 200 mg via gastrostomy tube (G-tube a tube inserted through the belly that brings nutrition directly to the stomach) at bedtime for arrythmia (irregular heart beat).
4. An order dated 06/11/24 Levothyroxine sodium oral tablet 112 mcg give 1 tablet via G-tube one time a day for hypothyroidism.
C. Record review of R #25's MAR dated May 2025, revealed staff documented the following:
1. On 06/14/25 for amiodarone dose scheduled for Hour of Sleep (HS) administration, staff documented code 9; (other/see progress note effective) on order.
2. On 06/14/25 for levothyroxine dose scheduled for 0500 administration, staff documented code 13; (medication not available effective) none in med dispenser.
3. On 06/15/25 for levothyroxine dose scheduled for 0500 administration, staff documented code 13; (medication not available effective) medication on order.
D. Record review of R #25's progress notes for 06/14/25 and 06/15/25, revealed staff did not notify the physician of the following:
1. R #25's amiodarone medication not available on 06/14/25 and 06/15/25.
2. R #25's levothyroxine medication not available on 06/14/25 and 06/15/25.
E. Record review of R #25's progress notes on 06/14/25 and 06/15/25 dates revealed the provider was not notified of medication not given to R #25.
F. On 06/18/25 at 8:35 AM, during an interview with Licensed Vocational Nurse (LVN) #26, stated he was the nurse assigned to R #25. LVN #26 stated he doesn't give R #25 her medications or G-tube feedings due to R #25 not wanting males to work with her. LVN #26 stated he didn't know if R #25 received her meds or G-tube feeding on 06/18/25. LVN #26 stated to ask the nurse on the northside hallway if she has but they haven't requested the meds, so LVN #26 didn't think R #25 received her medication or G-tube feeding on 06/18/25. LVN #26 stated that anytime there's medications not available the physician is to be notified that the medication was not available and when the medication was not administered to R #25.
G. On 06/18/25 at 9:50 AM during an interview with RN #27, she stated she fed R #25 through her G-tube and gave her medication at 9:42 AM on 06/18/25. RN #27 stated the order to feed R #25 is five times a day. RN #27 stated the times are scheduled and reference the MAR. The 10:00 AM the feeding was done, and RN #27 was not sure who fed resident at 8:00 AM feeding. RN #27 stated she documented in the MAR because she gave meds and feeding to R #25.
H. On 06/18/25 at 9:55 am, during an interview with the DON confirm the following:
1. An order to feed R #25 five times a day.
2. R #25 prefers females' staff to care for her.
3. Resident is expected to advocate for herself.
4. LVN #26 documented in R #25's MAR that he is doing R #25's medication administration and G-tube feedings and LVN #26 is overseeing her care when LVN #26 is not. This is not clear
5. Staff are expected to notify the provider if a resident refuses medication or if medication is not available.
6. Male staff working with R #25 are expected to follow up by asking female nurse if she administered R #25 medication and G-tube feeding.
7. Staff are expected to follow the order, notify the provider, and family of any changes with resident care.
8. Staff are expected to document all contact with the provider in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #8, R #17, and R #25 ) of 3 (R #8, R #17, and R #25) residents reviewed for documentation accuracy when staff failed to do the following:
1. Document attempts to change R #8's brief.
2. Document attempts to shower/bathe R #8.
3. Document attempts to put sheets on R #8's mattress.
4. Document changing R #8's mattress.
5. Document R #17's fall on 04/05/25.
6. Document unavailable medication for R #25.
These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are:
R #8
A. On 06/16/25 at 10:00 AM, during a walk through of the facility, there was a strong smell of urine starting at room [ROOM NUMBER].
B. On 06/16/25 at 10:02 AM, during an interview, ADON #1 confirmed the smell of urine and indicated that it was coming from R #8's room.
C. On 06/16/25 at 10:03 AM, during an observation of R #8's room the smell of urine became extremely strong. R #8 sat on his bed with nothing on, only a brief. The brief appeared to be extremely soiled and was dark in color. There were no sheets on R #8's mattress.
D. On 06/17/25 at 8:50 AM, during an interview, the ADON said R #8 will go days without letting anyone change his brief. The ADON said R #8 will kick, throw things, and cuss at staff if he doesn't want to be changed. The ADON said R #8 does not like sheets on his bed. The ADON said R #8 will take the sheets off his bed if they put them on. The ADON said they are not able to shower R #8. The ADON said that when the resident is compliant with care, staff will do as much as they can for him. The DON said staff will reproach R #8 several times throughout the day to see if R #8 will allow them to change him, shower him, and put sheets on the resident's bed. The ADON said they have changed R #8's mattress several times due to the smell. The ADON said staff have to continue to ask the resident throughout the day if he will let them provide any care for him.
E. Record review of R #8's medical record, no date, revealed the records did not contain documentation of the following:
1. The refusals to change R #8's brief throughout the day.
2. The reproach to shower/bathe R #8.
3. The attempts to put sheets on R #8's bed.
4. The changes of R #8's mattress.
F. On 06/18/25 at 9:16 AM, during an interview, the ADON confirmed staff do not document all the attempts to shower/bathe, brief changes, and attempts to put sheets on R #8's bed. The ADON confirmed there was no documentation of the times that R #8's mattress has been changed.
R #17
G. Record review of R #17's admission documents, no date, revealed the following:
1. R #17 was admitted to the facility on [DATE].
2. R #17 had the following diagnoses:
a. Muscle weakness.
b. Lack of coordination.
c. Abnormalities of gait and mobility.
d. Difficulty in walking.
H. Record review of R #17's progress note, dated 04/07/25, revealed the following:
1. R #17 had a fall on 04/05/25.
2. R #17 fell due to weakness and imbalance.
I. Record review of R #17's entire medical record, no date, revealed staff did not document the following:
1. R #17's fall on 04/05/25.
2. Assessment data related to R #17 after her fall on 04/05/25.
J. On 06/17/25 at 1:39 PM, during an interview, the DON confirmed the following:
1. R #17 fell on [DATE].
2. Staff did not document in R #17's medical record that she fell on [DATE].
3. Staff did not document an assessment of R #17 after she fell on [DATE].
4. Staff did not document whether R #17's provider or R #17's family were notified after she fell on [DATE].
5. Staff were expected to document when a resident falls, an assessment of the resident after the fall, provider notification and provider response, and notification of the resident's family.
R #25
K. Record review of R #25's face sheet, no date, revealed the following:
1. R #25 was admitted to the facility on [DATE].
2. R #25 diagnoses included the following:
a. Hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure).
b. Paroxysmal atrial fibrillation (a type of irregular heartbeat).
c. Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by the buildup of plaque fats, cholesterol, and other substances in the arteries, leading to narrowed arteries and reduced blood flow).
d. Chronic systolic (congestive) heart failure (systolic heart failure, the left ventricle of your heart, which pumps most of the blood, has become weak).
e. Cardiomegaly (an enlarged heart is an indicator of a condition that puts a strain on your heart).
f. Hypothyroidism, unspecified (thyroid gland doesn't make and release enough hormone into your bloodstream).
L. Record review of R #25's physician orders, dated 6/11/24, revealed the following:
1. An order for amiodarone HCI oral tablet 200 mg give 200 mg via gastrostomy tube (G-tube a tube inserted through the belly that brings nutrition directly to the stomach) at bedtime for arrythmia (irregular heartbeat).
2. An order for Levothyroxine sodium oral tablet 112 mcg give 1 tablet via G-tube one time a day for hypothyroidism (thyroid gland doesn't make and release enough hormone into your bloodstream).
M. Record review of R #25's MA dated June 2025, revealed the following:
1. Staff documented R #25's amiodarone code 9; (other see progress note effective) medication not available on 06/14/25 and 6/15/25.
2. Staff documented R #25's levothyroxine medication code 13; (medication not available effective) on 06/14/25 and 6/15/25.
N. Record review of R #25's progress notes for 06/14/25 and 06/15/25 revealed staff did not notify the physician of the following medications not available:
1. R #25's amiodarone medication not available on the following date:
a. 06/14/25,
b. 06/15/25.
2. R #25's levothyroxine medication not available on the following dates:
a. 06/14/25,
b. 06/15/25.
O. On 06/18/25 at 9:55 am, during an interview with the DON confirm staff are expected to notify the provider if medication is not available.

Based on record review and interview, the facility failed to provide behavioral health training (training that helps staff recognize and respond to various behavioral and mental health issues that residents may present with) for 3 (CNA #8, CNA #9 and ADON #1) of 3 (CNA #8, CNA #9 and ADON #1) staff sampled for training. This deficient practice could likely result in residents not receiving the services necessary to attain or maintain their physical, mental, and psychosocial (involving both psychological and social aspects) well-being. The findings are:
A. Record review of the facility's assessment dated 2024-2025, revealed the facility has 20 residents with behavioral health needs and 30 residents with mental illness diagnoses.
B. Record review of staff training records revealed the following:
1. CNA #8 did not complete training for behavioral health.
2. CNA #9 did not complete training for behavioral health.
3. ADON #1 did not complete training for behavioral health.
C. On 06/18/25 at 11:46 AM, during an interview, Human Resources confirmed CNA #8, CNA #9, and ADON #1 did not complete a training titled behavioral health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to notify the provider of missed medication doses for 1 (R #25) of 3 (R #18, R #25 and R #26) residents reviewed for medications not available when staff failed to:
1. Notify the provider of the missed dose of Amiodarone (medication used to treat affects the rhythm of your heartbeats. It is used to help keep the heart beating normally in people with life-threatening heart rhythm disorders of the ventricles) on 06/14/25 and 06/15/25.
2. Notify the provider of the missed dose of Levothyroxine (medication used to treat hypothyroidism underactive thyroid; a condition where the thyroid gland does not produce enough thyroid hormone) on 6/14/25 and 6/15/25.
These deficient practices could likely result in residents not receiving the necessary care or worsening medical conditions due to lack of treatment. The findings are:
A. Record review of R #25's face sheet, no date, revealed the following:
1. R #25 was admitted to the facility on [DATE].
2. R #25 diagnoses include the following:
a. Hypertensive heart disease with heart failure (a long-term condition that develops over many years in people who have high blood pressure).
b. Paroxysmal arterial fibrillation (a type of irregular heartbeat).
c. Atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by the buildup of plaque (fats, cholesterol, and other substances) in the arteries, leading to narrowed arteries and reduced blood flow).
d. Chronic systolic (congestive) heart failure (systolic heart failure, the left ventricle of your heart, which pumps most of the blood, has become weak).
e. Cardiomegaly (an enlarged heart, is an indicator of a condition that puts a strain on your heart).
f. Hypothyroidism, unspecified (thyroid gland doesn't make and release enough hormone into your bloodstream).
B. Record review of R #25's physician orders, dated 06/11/24, revealed the following:
1. An order for amiodarone HCI oral tablet 200 mg give 200 mg via G-tube at bedtime for arrythmia.
2. An order for Levothyroxine sodium oral tablet 112 mcg give 1 tablet via G-tube one time a day for hypothyroidism.
C. Record review of R #25's MAR, dated June 2025, revealed the following:
1. Staff documented R #25's amiodarone code 9; (other see progress note effective) medication not available on the following dates:
a. 06/14/25,
b. 06/15/25.
2. Staff documented R #25's levothyroxine medication code 13; (medication not available effective) on the following dates:
a. 06/14/25,
b. 06/15/25.
D. Record review of R #25's progress notes for 06/14/25 and 06/15/25, revealed staff did not notify the physician of the following:
1. R #25's amiodarone medication not available on 06/14/25 and 06/15/25.
2. R #25's levothyroxine medication not available on 06/14/25 and 06/15/25.
E. On 06/17/25 at 9:13 am, during an interview, Licensed Vocational Nurse (LVN) #26, stated the following:
1. Confirmed R #25's order for amiodarone HCI oral tablet 200 mg give 200 mg via G-tube at bedtime for arrythmia.
2. Confirmed R #25's order for Levothyroxine sodium oral tablet 112 mcg give 1 tablet via G-tube one time a day for hypothyroidism.
F. On 06/18/25 at 9:55 am, during an interview, the DON confirm the following:
1. Staff are expected to notify the provider if a resident refuses medication or if medication is not available.
2. Staff are expected to document all contact with the provider in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #3) of 1 (R #3) resident reviewed for baseline care plans.
This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:
A. Record review of R #3's admission Record, no date, revealed R #3 was admitted into the facility on [DATE].
B. Record review of R #3's baseline care plan dated 01/27/25 revealed the plan was created on 01/27/25 (not within 48 hours of admission).
C. On 02/20/25 at 12:47 PM, during an interview with the MDS Nurse, he confirmed the following:
1. The baseline care plan should be created upon admission by the admitting nurse.
2. R #3's baseline care plan was created on 01/27/25.
3. R #3's baseline care plan was not completed within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide activities of daily living (ADL) assistance for 4 (R #8, R #10, R #11, and R #24) of 5 (R #8, R #10, R #11, R #24, and R #25) residents reviewed for ADL care when staff failed to:
1. Assist R #8 and R #11 with toileting.
2. Assist R #10 with ADL care.
3. Assist R #24 with brushing his teeth and showering.
These deficient practices caused R #8 and R #25 psychological distress, and feeling embarrassed. The findings are:
R #8
A. On 02/18/25 at 8:41 AM, during an interview with CNA #8, he stated on 02/16/25, in the morning, there were only two (2) CNA's working on the South Unit. CNA #8 said there was 58 residents on the South Unit that day. CNA #8 said R #8 was assisted to the bathroom by the LPN #8 and Activity Director (AD) and was left on the toilet for approximately an hour. CNA #8 said he was assisting another resident when R #8 was taken to the bathroom at 11:00 am. CNA #8 said that when he finished, he noticed R #8's call light was still on. CNA #8 said that when he went to her room at approximately 12:00 PM, R #8 was still on the toilet in her bathroom waiting for assistance.
B. On 02/18/25 at 9:42 AM, during an interview with R #8, she said on 02/16/25, at 11:00 AM, she was assisted to the bathroom. R #8 said she is assisted with the Sara lift (a patient-assisting device that helps patients stand up and move around) and it takes two people to help her. R #8 said when she finished in the bathroom, she turned on the call light. R #8 said it was a little before 12:00 PM, before CNA #8 was able to get her off the toilet. R #8 said she was upset and crying. R #8 said she felt like no one cared. R #8 said it takes 15 minutes to an hour for her call light to be answered. R #8 said that there is usually only one CNA on her hall. R #8 said that when she needs assistance getting out of bed or to the bathroom, she has to wait longer because the CNA assigned to her hall has to find someone to help.
C. Record review of R #8's care plan dated 08/12/24, revealed R #8 needs assistance with ADL's.
D. Record review of R #8's Quarterly MDS dated [DATE], revealed R #8 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting.
E. On 02/18/25 at 2:49 PM, during an interview, AD #8 said on 02/16/25, she assisted LPN #8 transfer R #8 to the toilet. AD said she was finishing an activity with residents and was asked to assist at 11:00 AM. AD #8 said that there were only two CNA's on the South Unit and there were a lot of call lights on. AD #8 said she tries to help when she sees call lights, but she does not work the floor.
F. On 02/19/25 at 10:50 AM, during an interview, CNA #10 said there are a lot of residents on the South Unit that are two people assist. CNA #10 said that on 02/16/25 there was only 2 CNA's and they weren't able to do showers, vital signs, or any documentation. CNA #10 said residents end up wetting themselves and have bowel movements because they can't get to them in time.
R #10
G. On 02/17/25 at 2:43 PM, during an interview, R #10 said she usually waits 45 minutes to get assistance. R #10 said she is a two person assist because she needs the hoyer lift (a mechanical device that helps move people with limited mobility). R #10 said there are a lot of residents on the South Unit that need the hoyer lift. R #10 said there are only 3 CNA's scheduled on the South Unit. R #10 said that sometimes there are only 2 CNA's for the entire unit. R #10 said that when she needs help, the CNA has to try and find someone to help them. R #10 said they come in and turn off the light and tell her they need to find someone to help and then don't come back for 30 to 45 minutes.
H. Record review of R #10's care plan dated 11/12/24, revealed R #10 requires assistance to meet basic ADL needs.
I. Record review of R #10's Quarterly MDS dated [DATE], revealed R #10 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene.
R #11
J. On 02/19/25 at 10:55 AM, during an interview with CNA #11, she said there is not enough staff. CNA #10 said residents are having accidents and wetting themselves because they can't get to them in time. CNA #11 said R #11 needs assistance to get to the bathroom and he has had accidents because he can't wait.
K. On 02/19/25 at 10:58 AM, during an interview, R #11 said has had to wait 30 minutes to an hour to get help because staff don't answer the call lights. R #11 said he has had quite a few accidents. R #11 said he needs help to go to the bathroom.
L. Record review of R #11's care plan dated 11/19/24, revealed R #11 requires assistance to meet ADL needs.
M. Record review of R #11's Quarterly MDS dated [DATE], revealed R #11 is partial/moderate assistance (helper does less that half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Assistance with Oral Care
N. Record review of R #24's Face Sheet revealed the following diagnosis of a Traumatic Brain Injury and was admitted to the facility in 2009.
O. On 02/17/25 at 9:08 AM, during an interview, R #24's family member (FM) stated staff do not brush R #24's teeth daily after meals. R #24 is not interviewable.
P. Record review of R #24's Quarterly MDS dated [DATE], revealed R #24 requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort).
Q. Record review of R #24's care plan dated 12/03/24, revealed R #24 requires substantial/maximal assistance.
R. Record review of R #24's ADL sheet, dated December 2024, revealed the following:
1. On 12/11/24, staff did not document that R#24 received oral care after each meal.
2. On 12/22/24, staff did not document that R#24 received oral care after each meal.
3. On 12/29/24, staff did not document that R#24 received oral care after each meal.
S. Record review of R #24's ADL sheet, dated January 2025, revealed the following:
1. On 01/01/25, staff did not document that R#24 received oral care after each meal.
2. On 01/03/25, staff did not document that R#24 received oral care after each meal.
3. On 01/05/25, staff did not document that R#24 received oral care after each meal.
4. On 01/06/25, staff did not document that R#24 received oral care after each meal.
5. On 01/07/25, staff did not document that R#24 received oral care after each meal.
6. On 01/09/25, staff did not document that R#24 received oral care after each meal.
7. On 01/12/25, staff did not document that R#24 received oral care after each meal.
8. On 01/17/25, staff did not document that R#24 received oral care after each meal.
9. On 01/19/25, staff did not document that R#24 received oral care after each meal.
10. On 01/26/25, staff did not document that R#24 received oral care after each meal.
11. On 01/28/25, staff did not document that R#24 received oral care after each meal.
12. On 01/31/25, staff did not document that R#24 received oral care after each meal.
T. Record review of R #24's ADL sheet, dated February 2025, revealed the following:
1. On 02/02/25, staff did not document that R#24 received oral care for all shifts.
2. On 02/03/25, staff did not document that R#24 received oral care for all shifts.
3. On 02/04/25, staff did not document that R#24 received oral care for all shifts.
4. On 02/06/25, staff did not document that R#24 received oral care for all shifts.
5. On 02/07/25, staff did not document that R#24 received oral care for all shifts.
6. On 02/09/25, staff did not document that R#24 received oral care for all shifts.
7. On 02/10/25, staff did not document that R#24 received oral care for all shifts.
8. On 02/13/25, staff did not document that R#24 received oral care for all shifts.
9. On 02/14/25, staff did not document that R#24 received oral care for all shifts.
10. On 02/17/25, staff did not document that R#24 received oral care for all shifts.
11. On 02/18/25, staff did not document that R#24 received oral care for all shifts.
12. On 02/19/25, staff did not document that R#24 received oral care for all shifts.
U. On 02/18/25 at 10:51 AM, during an interview with the CNA #9, he stated R #24 requires total assistance for oral hygiene. CNA #9 confirmed R #24 is scheduled for oral hygiene after meals. CNA #9 also stated R #24 can't do oral hygiene himself. CNA #9 confirmed he did not complete oral hygiene yet, as of the time of the interview.
V. On 02/18/25 at 11:12 AM, during an interview with LPN #8, she confirmed R #24 receives oral hygiene daily, and R #24 can't complete oral hygiene alone. LPN #8 stated R #24's oral hygiene is done after every meal, and the CNAs are assigned to do it.
R #24
W. On 02/17/25 at 9:08 AM, during an interview with FM #24, she stated, R #24 is scheduled to get showered three times a week. FM #24 stated R #24 goes days without a shower, and R #24 had a noticeable smell. R #24 stated that she feels the R #24 is not getting showered due to the facility being short staffed. FM #24 confirmed she reported to the Administrator that the staff are not following the shower schedule because she felt they were short of staff.
X. Record review of R #24's Quarterly MDS for ADL-bathing dated 01/23/25, revealed R #24 required substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
Y. Record review of R #24's care plan dated 12/03/24 for ADL-bathing revealed R #24 requires substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
Z. Record review of R #24's shower schedule no date revealed R #24 shower nights are Mondays, Wednesdays, and Fridays.
AA. Record review of R #24's ADL documentation survey report for December 2024, revealed staff did not document showers were done for R #24 on the following dates:
1. On 12/02/24, staff documented NA (not applicable) R #24 did not receive a shower day shift and no documentation for night shift.
2. On 12/04/24, staff documented NA, R#24 did not receive a shower for all shifts.
3. On 12/06/24, staff documented NA for night shift R #24 did not receive a shower.
4. On 12/09/24, staff documented NA, R #24 did not receive a shower for all shifts.
5. On 12/11/24, staff did not document R #24 did not receive a shower for all shifts.
6. On 12/13/24, staff documented NA for night shift R #24 did not receive a shower.
7. On 12/16/24, staff documented NA for day shift R #24 did not receive a shower and no documentation for night shift.
8. On 12/18/24, staff documented NA staff documented NA (not applicable) R #24 did not receive a shower for all shifts.
9. On 12/25/24, staff documented NA, R #24 did not receive a shower for all shifts.
10. On 12/27/24, staff documented NA, R #24 did not receive a shower for night shift.
11. On 12/30/24, staff documented NA, R #24 did not receive a shower for all shifts.
BB. Record review of R #24's ADL documentation survey report dated January 2025 revealed the following:
1. On 01/08/25, staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift.
2. On 01/20/25, staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift.
3. On 01/24/25, staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift.
CC. Record review of R #24's ADL, documentation survey report dated February 2025, revealed the following:
1. On 02/05/25, staff documented NA, R #24 did not receive a shower for night shift.
2. On 02/12/25, staff documented NA, R #24 did not receive a shower for night shift.
3. On 02/14/25, staff did not document that R #24 received a shower for all shifts.
4. On 02/17/25, staff did not document that R #24 received a shower for all shifts.
5. On 02/19/25, staff did not document that R #24 received a shower for all shifts.
DD. On 02/20/25 at 12:26 PM, during an interview, CNA #28 stated she follows the shower schedule but when the facility is short staffed, sometimes shower don't happen. CNA #28 further stated that if there is enough staff the resident who missed a shower will get a shower on next day if possible.
EE. On 02/20/25 at 12:36 PM, during an interview, CNA #8 stated staff shower residents as scheduled for the most part. CNA #8 continued to stated that when the facility is short staffed, the CNAs are not able to complete showers. CNA #8 stated sometimes on the following day it's already too busy and CNAs don't have time to make up showers.
FF. On 02/20/25 at 2:25 PM, during an interview the ADON did not confirm or deny the missed showers for R #24 for the month of February on the ADL sheet, when asked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure wound care orders were obtained and implemented for 1 (R #3) of 1 (R #3) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). This deficient practice could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers. The findings are:
A. Record review of R #3's admission Record (no date) revealed R #3 was admitted to the facility on [DATE].
B. Record review R #3's admit data collection (assessment completed by nursing staff upon admission) dated 01/24/25 revealed the following:
1. Stage II (shallow, open ulcer with a red-pink wound bed, without slough [non-viable tissue composed of dead cells accumulating on the wound surface. Can appear as a moist, yellow, tan, or white layer and is often fibrous or stringy in texture]) pressure injury to sacrum (area of spinal column just above the coccyx [tailbone, is a small triangle-shaped bone at the end of the spinal column]).
C. Record review of R #3's provider progress note dated 01/27/25 revealed the following:
1. Skin-pink warm and dry, patient with stage III (full thickness tissue loss, deep wounds that extend beyond the first two layers of the skin and may reveal subcutaneous (fatty) tissue, muscle, tendon, or even bone) pressure ulcer to coccyx.
2. Wound care nurse evaluated today.
D. Record review of R #3's physician's orders revealed an order date 01/27/25, wound care - cleanse site with normal saline (mixture of sodium chloride and water used to cleanse wounds), pat dry, apply calcium alginate (highly absorbent, biodegradable dressing made from seaweed that absorbs drainage and forms a gel), MediHoney (antibacterial wound gel made from honey) to wound bed cover with foam dressing (highly absorbent dressing that provides cushioning and protection). Change every other day and as needed.
E. Record review of R #3's Treatment Administration Record (TAR, electronic document where facility staff document wound care was completed) for January 2025 revealed facility staff did not have orders in place for treatment of R #3's pressure ulcer for January 24 through January 26, 2025.
F. Record review of R #3's TAR for January 2025 revealed facility staff did not have orders in place for treatment of R #3's pressure ulcer until 01/27/25.
G. Record review of R #3's Nursing Progress Notes dated 01/24/25 through 01/26/25 revealed staff did not consult with the facility provider to obtain wound care orders until 01/27/25.
H. On 02/19/25 at 4:37 PM, an interview with LPN #1, revealed the following:
1. Nursing staff that complete the admission and note that residents have a wound are responsible for obtaining orders if there are no current orders.
2. Wound care was not started on R #3 until 01/27/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to receive medication needed for treatment of an illness for 1 (R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for quality of care. Failure to follow physician orders could likely lead to facility staff and physician being unaware of changes in resident's condition and could likely lead to worsening of resident's condition. The findings are:
A. Record review of R #4's admission record (no date) revealed R #4 was admitted to the facility on [DATE].
B. Record review of R #4's change in condition evaluation dated 02/10/25 revealed R #4 presented with generalized weakness, altered mental status (change in awareness, movement and behaviors that stems from illnesses, disorders and injuries affecting your brain) and had an elevated temperature. She was tested for Covid-19 (coronavirus disease; acute disease in humans which is characterized mainly by fever and cough and can progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) and the results were positive.
C. Record review of R #4's nursing progress note dated 02/10/25 at 5:04 PM revealed the following:
1. Provider was notified of the positive Covid-19 results.
2. Provider ordered antiviral medication (medication used to treat Covid -19) for R #4.
D. Record review of R #4's physician's orders revealed an order dated 02/10/25, for Molnupiravir (antiviral medication for the treatment of mild-to-moderate COVID-19), give 800 mg by mouth two times a day for Covid for five days.
E. Record review of R #4's Medication Administration Record (MAR) for February 2025, revealed the following:
1. On 02/10/25, for Molnupiravir bedtime dose staff documented medication was not given, see progress notes.
2. On 02/11/25, for Molnupiravir bedtime dose staff documented medication was not given, see progress notes.
3. On 02/12/25, for Molnupiravir bedtime dose staff documented medication was not given, see progress notes.
4. On 02/13/25, for Molnupiravir bedtime dose staff documented medication was not given, see progress notes.
5. On 02/11/25, for Molnupiravir morning dose staff documented medication not available.
6. On 02/12/25, for Molnupiravir morning dose staff documented medication not available.
7. On 02/13/25, for Molnupiravir morning dose staff documented medication not available.
F. Record review of R #4's orders administration notes (staff notes regarding the administration of medication) for Molnupiravir revealed the following:
1. On 02/10/25 staff did not document why R #4 did not receive the medication.
2. On 02/11/25 at 3:07 PM, staff documented that the pharmacy is waiting for approval from the DON to bill the facility for medication.
3. On 02/12/25 at 3:49 AM, staff documented that the medication is pending delivery from the pharmacy.
4. On 02/13/25 at 7:18 PM, staff documented that the medication is pending delivery from the pharmacy
G. On 02/20/25 at 10:57 AM, during an interview, LPN #2, stated the following:
1. On 02/11/25, she informed the ADON that she called the pharmacy and the pharmacy told her they required approval from the facility DON to bill the facility for R #4's Molnupiravir.
2. LPN #2 did not contact the physician to advise her that R #4 had not received the Molnupiravir.
H. On 02/20/25 at 11:39 AM, during an interview with physician #1, she stated that her expectation is for facility staff to contact her and inform her that R #4 had not received the Molnupiravir.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 5 (R #8, R #10, R #11, R #25, and R #26) of 6 (R #8, R #10, R #11, R #24, R #25, and R #26) residents reviewed for staffing when staff failed to:
1. To transfer R #8.
2. Change R #10's brief.
3. To assist R #11 to the toilet as needed.
4. Assist R #24 with oral care and showers.
5. Change R #25's brief after 30 minutes or longer.
This deficient practice caused R #25 psychological distress, feeling embarrassed and crying when discussing how she was left soiled when she has to wait to be changed. The findings are:
A. Record review of R #25's admission Record, (Face Sheet) no date revealed the following:
1. admission date 01/17/24.
2. Diagnosis of Chronic Kidney Disease, Stage 4 (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood. Severe).
B. Record review of R #25 physician orders revealed on 12/11/24, Torsemide Oral Tablet (Diuretic medicine that helps to remove excess water and sodium from the body through urine) 10 mg.
C. Record review of R #25's MDS assessment dated [DATE], revealed R #25 is Dependent- (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity.)
D. On 02/18/25 at 9:33 AM, during an interview and observation with R #25, revealed R #25 was visibly in distress, head down with tears running down her face when discussing staffing. R #25 stated the facility is short staffed and she feels like they save her until they are done with all the other residents. R #25 stated staff take a long to answer the call lights. R #25 further stated when there is a storage of staff CNAs can take 30 minutes or longer to answer call lights. R #25 stated for the shift from 6:00 AM and 4:00 PM (day shift) is when there is staff shortage. R #25 stated the facility needs more help to answer the call lights faster. R #25 stated that when CNAs come they turn the call lights off and say they are short staffed, and she will need to wait. R #25 stated she feels embarrassed because she's left wet to wait for assistance for a long time.
E. On 02/18/25 at 11:28 AM, during an observation by another resident's room, R #25 called out in hallway to surveyor, and R #25 stated I need help, I need to be changed. R #25 stated she had been waiting 25 minutes.
F. On 02/19/25 at 1:52 PM, during an interview CNA #10 confirmed there is a lot of residents who use the Hoyer lift (a mechanical device that helps move people with limited mobility). and two people are always needed for safety. CNA #10 confirmed the residents complain that call lights are not being answered on time due to needing two staff to assist the residents with the hoyer lift, leaving the unit without CNAs.
G. On 02/18/25 at 10:12 am, during an interview with the ADON, she stated her expectation is that the call lights be answered within five minutes after the call light is activated. The ADON said if there is a resident that needs a two person assist that it will take a little longer to answer other call lights. The ADON said that she is not aware of any residents that have waited 15-30 minutes or longer for assistance.
R #8
H. On 02/18/25 at 8:41 AM, during an interview with CNA #8, he stated that on 02/16/25, in the morning, there were only two (2) CNA's working on the South Unit. CNA #8 said that there were 58 residents on the South Unit that day. CNA #8 said R #8 was assisted to the bathroom by the LPN #8 and Activity Director (AD) around 11:00 AM and was left on the toilet for approximately an hour. CNA #8 said he assisted another resident when he saw R #8 being assisted to the bathroom. CNA #8 said when he finished assisting another resident, he noticed R #8's call light was still on. CNA #8 said he went to R #8's room at 12:00 PM (02/16/25), R #8 was still on the toilet in her bathroom waiting for assistance.
I. On 02/18/25 at 9:42 AM, during an interview, R #8 stated on 02/16/25, at 11:00 AM, she was assisted to the bathroom. R #8 said she was assisted with the Sara lift (a patient-assisting device that helps patients stand up and move around) and requires two people to help her. R #8 said when she finished in the bathroom, she turned on the call light. R #8 said it was a little before 12:00 PM, before CNA #8 was able to get her off the toilet. R #8 said she was upset and cried. R #8 further stated she felt like no one cared. R #8 said it takes 15 minutes to an hour for her call light to be answered. R #8 said that there is usually only one (1) CNA on her hall. R #8 said when she needs assistance getting out of bed or to the bathroom, she has to wait longer because the CNA assigned to her hall has to find someone to help.
J. On 02/18/25 at 2:49 PM, during an interview, AD #8 stated on 02/16/25, she assisted LPN #8 transfer R #8 on the toilet. AD said she finished an activity with the residents and was asked to assist at approximately 11:00 AM. AD #8 stated there were only two CNA's on the South Unit and there were a lot of call lights on. AD #8 said she tried to help when she sees call lights, but she does not work the floor.
K. On 02/19/25 at 10:50 AM, during an interview, CNA #10 said there are a lot of residents on the South Unit that are two people assist. CNA #10 said on 02/16/25 there was only two (2) CNA's and they were not able to complete showers, take vital signs, or complete any documentation. CNA #10 said the residents end up wetting themselves and have bowel movements because they can not get to them in time.
L. On 02/18/25 at 10:12 am, during an interview ADON stated that it is not acceptable for a resident to be left on the toilet for an hour.
R #10
M. On 02/17/25 at 2:43 PM, during an interview, R #10 said she usually waits 45 minutes to get assistance. R #10 said she is a two person assist because she needs the hoyer lift. R #10 said there are a lot of residents on the South Unit that need the hoyer lift. R #10 said that there are only three (3) CNA's scheduled on the South Unit. R #10 said sometimes there are only two (2) CNA's for the entire unit. R #10 said when she needs help, the CNA has to try and find someone to help them. R #10 said they come in and turn off the light and tell her they need to find someone to help and then don't come back for 30 to 45 minutes.
R #11
N. On 02/19/25 at 10:55 AM, during an interview with CNA #11, she said there is not enough staff. CNA #10 said residents are having accidents and wetting themselves because they can't get to them in time. CNA #11 said R #11 needs assistance to get to the bathroom and he has had accidents because he can't wait.
O. On 02/19/25 at 10:58 AM, during an interview, R #11 said he has had to wait 30 minutes to an hour to get help because staff don't answer the call lights. R #11 said he has had quite a few accidents. R #11 said he needs help to go to the bathroom.
P. Record review of the transfer list dated 02/14/25 revealed the following:
1. There are 17 residents on the South Unit that require the assistance of two staff members due to hoyer lift.
2. There are seven residents on the South Unit that require the assistance of two staff members due to Sara lift.
3. There are five residents on the North Unit that require the assistance of two staff members due to hoyer lift.
4. There are two residents on the North Unit that require the assistance of two staff members due to Sara lift.
R #24
Q. On 02/17/25 at 9:08 AM, during an interview with R #24's sister stated staff do not brush R #24 teeth daily. R #24's sister stated that there is not enough staff. FM #24 she stated, R #24 is scheduled to get showered three times a week. FM #24 stated R #24 goes days without a shower, and R #24 had a noticeable smell. R #24 stated that she feels the R #24 is not getting showered due to the facility being short staffed. FM #24 confirmed she reported to the Administrator that the staff are not following the shower schedule because she felt they were short of staff.
R. Record review of R #24's Quarterly Minimum Data Set (MDS) dated [DATE], revealed R #24 requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). For ADL-bathing, R #24 requires substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
S. Record review of R #24's care plan dated 12/03/24, revealed R #24 requires substantial/maximal assistance. ADL-bathing revealed R #24 requires substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
T. Record review of R #24's ADL sheet for December 2024, revealed the following:
1. On 12/11/24, R #24 did not receive any oral care.
2. On 12/22/24, R #24 did not receive any oral care.
3. On 12/29/24, R #24 did not receive any oral care.
U. Record review of R #24's ADL sheet for January 2025, revealed the following:
1. On 01/01/25, R #24 did not receive any oral care.
2. On On 01/03/25, R #24 did not receive any oral care.
3. On 01/05/25, R #24 did not receive any oral care.
4. On 01/06/25, R #24 did not receive any oral care.
5. On 01/07/25, R #24 did not receive any oral care.
6. On 01/09/25, R #24 did not receive any oral care.
7. On 01/12/25, R #24 did not receive any oral care.
8. On 01/17/25, R #24 did not receive any oral care.
9. On 01/19/25, R #24 did not receive any oral care.
10. On 01/26/25, R #24 did not receive any oral care.
11. On 01/28/25, R #24 did not receive any oral care.
12. On 01/31/25,R #24 did not receive any oral care.
V. Record review of R #24's ADL sheet for February 2025, revealed the following:
1. On 02/02/25, R #24 did not receive any oral care.
2. On 02/03/25, R #24 did not receive any oral care.
3. On 02/04/25, R #24 did not receive any oral care.
4. On 02/06/25, R #24 did not receive any oral care.
5. On 02/07/25, R #24 did not receive any oral care.
6. On 02/09/25, R #24 did not receive any oral care.
7. On 02/10/25, R #24 did not receive any oral care.
8. On 02/13/25, R #24 did not receive any oral care.
9. On 02/14/25, R #24 did not receive any oral care.
10. On 02/17/25, R #24 did not receive any oral care.
11. On 02/18/25, R #24 did not receive any oral care.
12. On 02/19/25, R #24 did not receive any oral care.
W. On 02/18/25 at 10:51 AM, during an interview, CNA #9 stated R #24 requires total assistance for oral hygiene. CNA #9 confirmed R #24 is scheduled for oral hygiene after meals. CNA #9 confirmed R #24 need assistance because R #24 is unable do oral hygiene himself. CNA #9 confirmed he did not complete oral hygiene for R #24 on 02/18/25.
X. Record review of R #24's shower schedule revealed R #24 shower days are Mondays, Wednesdays, and Fridays.
Y. Record review of R #24's ADL documentation survey report for December 2024, revealed staff did not document showers were done for R #24 on the following dates:
1. On 12/02/24, Staff documented NA (not applicable) R #24 did not receive a shower day shift and no documentation for night shift.
2. On 12/04/24, Staff documented NA, R#24 did not receive a shower for all shifts.
3. On 12/06/24, Staff documented NA for night shift R #24 did not receive a shower.
4. On 12/09/24, Staff documented NA, R #24 did not receive a shower for all shifts.
5. On 12/11/24, Staff did not document R #24 did not receive a shower for all shifts.
6. On 12/13/24, Staff documented NA for night shift R #24 did not receive a shower.
7. On 12/16/24, Staff documented NA for day shift R #24 did not receive a shower and no documentation for night shift.
8. On 12/18/24, Staff documented NA, staff documented NA (not applicable) R #24 did not receive a shower for all shifts.
9. On 12/25/24, Staff documented NA, R #24 did not receive a shower for all shifts.
10. On 12/27/24, Staff documented NA, R #24 did not receive a shower for night shift.
11. On 12/30/24, Staff documented NA, R #24 did not receive a shower for all shifts.
Z. Record review of R #24's ADL documentation survey report dated January 2025 revealed the following:
1. On 01/08/25, Staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift.
2. On 01/20/25, Staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift.
3. On 01/24/25, Staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift.
AA. Record review of R #24's ADL, documentation survey report dated February 2025, revealed the following:
1. On 02/05/25, Staff documented NA, R #24 did not receive a shower for night shift.
2. On 02/12/25, Staff documented NA, R #24 did not receive a shower for night shift.
3. On 02/14/25, Staff did not document that R #24 received a shower for all shifts.
4. On 02/17/25, Staff did not document that R #24 received a shower for all shifts.
5. On 02/19/25, Staff did not document that R #24 received a shower for all shifts.
BB. On 02/20/25 at 12:26 PM, during an interview, CNA #28 stated she follows the shower schedule but when the facility is short staffed, sometimes shower don't happen. CNA #28 further stated that if there is enough staff the resident who missed a shower will get a shower on next day if possible.
CC. On 02/20/25 at 12:36 PM, during an interview, CNA #8 stated showers happen as scheduled for the most part but, when the facility is short staffed, the CNAs don't do showers. Sometimes the next day it's already too busy and CNAs don't have time to make up showers.
DD. On 02/14/25 at 3:01 PM, during an observation of the North Unit, there were 46 residents and two CNA's working the unit.
EE. On 02/14/25 at 3:10 PM, during an observation of the South Unit, there were 56 residents and two CNA's working the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure nursing staff demonstrated competency in the skills and techniques necessary to safely change a suprapubic catheter (a thin flexible tube inserted directly into the bladder through a small incision in the lower abdomen, just above the pubic bone. It is used to drain urine from the bladder when a person is unable to urinate normally) for residents for 1 (ADON) of 1 (ADON) employees sampled for training and competency. This deficient practice could likely result in nurses working with residents without adequate knowledge and skills to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are:
A. Record review of R #17's admission record, no date, revealed the following:
1. R #17 was admitted to the facility on [DATE].
2. R #17 had the following diagnoses:
a. Acute Cystitis with Hematuria [a condition where someone experiences an inflammation of the bladder (acute cystitis) ac companied by blood in the urine (hematuria)].
b. Need for assistance with personal care.
c. Obstructive and Reflux Uropathy (obstructive uropathy occurs when the urine can't drain normally, reflux occurs when urine flows backward into the upper urinary tract).
B. Record review of R #17's nursing progress note, dated 01/12/25, revealed the following:
1. R #17 had bright red blood in his brief (disposable diapers designed for adults who have incontinence or limited mobility).
2. The doctor was in the facility and gave orders to send R #17 to the Emergency Room.
C. Record review of R #17's provider progress note, dated 01/12/25, revealed the following:
1. R #17's suprapubic catheter was changed by the nurse.
2. The nurse reported to the provider that there was no drainage from R #17's catheter after she changed it.
3. The nurse reported that there was blood and no urine drainage when she flushed the catheter.
4. R #17 had blood coming out of his urethra (the hollow tube that lets urine, a waste product, leave the body).
5. R #17 had decreased urine output.
6. R #17 reported bladder pain.
7. The provider gave orders to send R #17 to the emergency room.
D. Record review of R #17's hospital records, dated 01/12/25 through 01/13/25, revealed the following:
1. R #17's suprapubic catheter had been replaced by the staff at the skilled nursing facility and R #17 began to experience suprapubic (area above the pubis, which is the bony structure at the front of the pelvis) pain and blood from his urethra.
2. R #17's computed tomography (CT) scan revealed that the suprapubic catheter balloon was inflated in R #17's prostate.
3. The urologist (a surgeon who specializes in the urinary tract, reproductive system, and adrenal glands) recommended replacement of the suprapubic catheter.
4. R #17 was admitted to the hospital for observation.
5. R #17 was discharged from the hospital on [DATE].
E. Record review of R #17's progress note, dated 01/13/25, revealed the following:
1. R #17 returned to the facility.
2. R #17 had a diagnosis of a displaced supra pubic catheter.
3. R #17 denied pain or discomfort.
F. On 02/18/25 at 3:25 PM, during an interview, the ADON stated the following:
1. On 01/12/25, R #17's family member requested for her to flush (pushing saline (salty water) through a catheter inserted in the bladder to prevent a build-up of mucus within the bladder) R #17's supra pubic catheter.
2. R #17's catheter was dirty so she decided it needed to be replaced.
3. R #17 had blood in his brief approximately three to four hours after the catheter was changed.
4. She notified the provider after she noticed blood in R #17's brief.
5. The provider assessed R #17 and ordered for him to be sent to the hospital.
6. R #17 returned to the facility the next day.
7. R #17 did not have any complications after returning from the hospital.
8. She stated that she completed several competencies with the previous ADON when she started in December 2024 (she was unable to state which competencies she completed).
9. She could not remember if she completed a competency regarding suprapubic catheter changes.
G. Record review of the ADON's Licensed Nurse Competency forms, dated 12/24/24, revealed the following:
1. The ADON's hire date was 12/19/24.
2. The assessment method for the competency of Urinary catheterization was documented as oral (a type of examination where a person is questioned verbally).
3. There was no documentation that the competency included a skills check off (a supervised assessment of a person's ability to perform a skill or procedure).
4. There was no date for the completion of the basic nursing skills competencies.
5. There were no initials from the educator indicating that the competencies were completed.
H. On 02/19/25 at 9:19 AM, during an interview with the Nurse Educator (NE), the following was confirmed:
1. The basic nursing skills competencies that are completed by nursing staff are verbal competencies and the nurses tell her what they would do for each skill.
2. She does not complete a step-by-step check-off for each of the competencies.
3. She does not observe a return demonstration for the staff to demonstrate competency for each basic nursing skill.
4. She stated that she completed an in-service regarding catheter changes and suprapubic catheter changes after R #17 returned from the hospital on [DATE] (she did not remember the date).
5. She did not observe the ADON perform a return demonstration of replacing a urinary catheter or a suprapubic catheter.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 98 residents in the facility (residents were identified on the resident matrix provided by the DON on 02/13/25) who eat food prepared in the kitchen when staff failed to:
1. Keep the deep freezer and kitchen floors clean.
2. Keep the stoves and surrounding areas clean from oil.
3. Maintain the quality of the oil (fresh) in the deep fryer.
4. Perform hand hygiene prior to assisting R #24 with meal.
These deficient practices could likely lead to foodborne illnesses. The findings are:
A. On 02/14/25 at 11:16 AM, during an observation of the kitchen revealed the following:
1. The floors in the deep freezer and kitchen had food particles/paper, spilled liquid, and were sticky.
2. The oil in the deep fryer was dark and smokey and had food particles floating on top of the oil.
3. The floor under and the appliances next to the deep fryer were covered in oil.
4. Coffee spilled on the floor.
5. Jelly in the refrigerator was not covered.
6. A straw, and cup lids on the floor around the trash cans by the dishwasher.
7. A blanket on the floor under a sink that appeared wet and dirty.
8. The drain on the floor was backed up with food particles and paper trash.
B. On 02/14/25 at 11:24, during an interview, the Kitchen Manager (KM) confirmed that there were crumbs in the deep fryer, and the deep fryer, appliances and floor had a build up of oil and crumbs. The KM confirmed the jelly was not covered and the walk in floor was not clean. The KM also confirmed a blanket was on the floor under the sink and said the blanket was to clean up a leak. The KM confirmed straws and lids on the floor in the dishwasher area.
C. On 02/14/25 at 12:10 PM, during an observation of the Assisted Dining Room revealed the following:
1. R #24 was sitting at a table in the dining room with his meal in front of him, CNA #29 assisted R #24.
2. CNA #29 adjusted R #24's feet on the footrest and the brake on the wheelchair.
3. CNA #29 did not perform hand hygiene before she resumed assisting R #24.
D. On 02/14/25 at 12:10 PM, during an interview CNA #29 she confirmed she did perform hand hygiene prior to resuming assistance to R #24 after adjusting R #24's feet on the footrests and brake on wheelchair. CNA #29 confirmed that she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #17 and R #18) of 2 (R #17 and R #18) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are:
R #17
A. Record review of R #17's admission record, no date, revealed the following:
1. R #17 was admitted to the facility on [DATE].
2. R #17 had the following diagnoses:
a. Acute Cystitis with Hematuria [a condition where someone experiences an inflammation of the bladder (acute cystitis) accompanied by blood in the urine (hematuria)].
b. Need for assistance with personal care.
c. Obstructive and Reflux Uropathy (obstructive uropathy occurs when the urine can't drain normally, reflux occurs when urine flows backward into the upper urinary tract).
B. Record review of R #17's progress note, dated 01/12/25, revealed the following:
1. R #17 had bright red blood in his brief (disposable diapers designed for adults who have incontinence or limited mobility).
2. The doctor was in the facility and gave orders to send R #17 to the Emergency Room.
C. Record review of R #17's provider progress note, dated 01/12/25, revealed the following:
1. R #17's suprapubic catheter lower abdomen, just above the pubic bone. (It is used to drain urine from the bladder when a person is unable to urinate normally) was changed by the nurse.
2. The nurse reported to the provider that there was no drainage from R #17's catheter after she changed it.
3. The nurse reported that there was blood and no urine drainage when she flushed the catheter.
4. R #17 had blood coming out of his urethra (the hollow tube that lets urine, a waste product, leave the body).
5. R #17 had decreased urine output.
6. R #17 was reporting bladder pain.
7. The provider gave orders to send R #17 to the emergency room.
D. Record review of R #17's entire medical record, no date, revealed the record did not contain any documentation of the following:
1. R #17's suprapubic catheter was changed on 01/12/25.
2. Urine output at the time of the suprapubic catheter change.
3. An assessment of how R #17 tolerated the suprapubic catheter change.
E. On 02/18/25 at 3:25 PM, during an interview with the ADON, stated the following:
1. On 01/12/25, R #17's family member requested for her to flush (pushing saline (salty water) through a catheter inserted in the bladder to prevent a build-up of mucus within the bladder) R #17's supra pubic catheter.
2. R #17's catheter was dirty so she decided it needed to be replaced.
3. R #17 had blood in his brief approximately three to four hours after the catheter was changed.
4. She notified the provider after she noticed blood in R #17's brief.
5. The provider assessed R #17 and ordered for him to be sent to the hospital.
6. R #17 returned to the facility the next day.
7. She confirmed there was no documentation in the medical record of R #17's suprapubic catheter was changed on 01/12/25.
8. She confirmed the medical record did not contain documentation regarding R #17's urine output at the time of the suprapubic catheter change or how R #17 tolerated the suprapubic catheter change.
9. She confirmed staff are expected to document any procedure that is performed.
10. She confirmed staff are expected to document any concerns that are identified and when they notified the provider and any orders from the provider.
F. Record review of the facility's Indwelling (foley) Catheter Removal policy, revised August 2022, revealed the following:
1. Document the following in the resident's medical record:
a. The date and time the procedure was performed.
b. The name and title of the individual(s) who performed the procedure.
c. All assessment data (e.g., urine amount, color, clarity, etc.) obtained during the procedure.
d. The time and amount of first void after catheter removal.
e. How the resident tolerated the procedure .
R #18
G. Record review of R #18's admission record, no date, revealed the following:
1. R #18 was admitted to the facility on [DATE].
2. R #18 had the following diagnoses:
a. Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause airflow obstruction and breathing problems).
b. Type 2 Diabetes Mellitus with Hyperglycemia (a chronic condition where the body does not use insulin properly or does not produce enough insulin, leading to high blood sugar levels (hyperglycemia).
c. Cirrhosis of Liver (a chronic liver disease characterized by the permanent scarring of the liver tissue).
d. Peripheral Vascular Disease (a condition that affects the blood vessels outside of the heart and brain).
e. Diastolic (Congestive) Heart Failure (occurs when the left ventricle of the heart stiffens and can't relax normally).
f. Hypertensive Heart Disease with Heart Failure (condition that occurs when chronic high blood pressure leads to heart damage and heart failure).
g. Personal History of Other Venous Thrombosis and Embolism (refers to a previous occurrence of blood clots in the veins, other than deep vein thrombosis (DVT) and pulmonary embolism (PE)).
h. Personal History of Nicotine Dependence (current pattern of using nicotine-containing products).
i. Reduced Mobility (the inability to move around freely and without pain).
H. Record review of R #18's nursing progress note, dated 02/14/25 at 6:32 AM, revealed the following:
1. The night nurse notified the day shift nurse R #18 was having trouble breathing.
2. R #18 was assessed by the day shift nurse and the following was identified:
a. R #18 used a non-rebreather (an oxygen mask that delivers high concentrations of oxygen. It's for emergency situations when a person needs oxygen quickly) at 15 Liters of oxygen per minute (LPM).
b. R #18 had difficulty breathing.
c. R #18 refused to be transferred to the hospital.
d. R #18 was educated about his status and continued to refuse to be transferred to the hospital.
e. The provider was aware of the situation.
f. The day shift nurse notified the DON and ADON about R #18's difficulty breathing and refusal to go to the hospital.
I. On 02/20/25 at 10:18 AM, during an interview, LPN #16 stated the following:
1. He was the day shift nurse that worked with R #18 on 02/14/25.
2. LPN #17 was the night shift nurse that worked with R #18 on the evening of 02/13/25 to the morning of 02/14/25.
3. LPN #17 gave him the following report regarding R #18:
a. R #18 had difficulty breathing.
b. She had received orders for a chest X-ray (CXR, an imaging test that uses electromagnetic radiation to create detailed images of the internal structures of the chest, including the lungs, heart, and ribs) for R #18.
4. He was unsure how long R #18 had been having trouble breathing prior to his arrival.
5. He gave R #18 a breathing treatment and R #18's breathing started to improve.
6. He was able to get R #18 off the non-rebreather and on a nasal cannula (a device that gives additional oxygen through the nose) at 4 LPM of oxygen.
7. The results of R #18's CXR showed that he had left lower lobe atelectasis (a condition where part or all of a lung collapses, leading to a decrease in gas exchange).
8. He contacted the provider with the results of the CXR and received orders for scheduled nebulizer treatments and Levoquin (an antibiotic medication that treats bacterial infections).
9. He reassessed R #18 oxygen saturation and effort of breathing approximately every 2 hours after he started his shift.
10. R #18 started yelling that he was having trouble breathing and he notified the DON and ADON that he was sending him to the hospital.
11. R #18 continued to refuse to go to the hospital, but he called 911 anyway because R #18's breathing status was so bad.
J. On 02/20/24 at 11:58, during an interview, Advanced Practice Nurse (APN) #16 stated the following:
1. Between the hours of 7 PM and 7 AM, staff contact the on-call service for any concerns regarding residents.
2. On 02//14/25 at 5:50 AM, staff messaged on-call with the following information regarding R #18
a. Staff had given R #18 a duo-nebulizer treatment 20 minutes prior to contacting on-call.
b. R #18 was on a non-rebreather mask at 15 LPM of oxygen and had an oxygen saturation in the high 70's (normal is 95% to 100%).
c. R #18 refused to go to the hospital.
3. On-call gave the following orders:
a. Give another DuoNeb to be given right away.
b. Serial (scheduled) DuoNebs (did not state the frequency).
c. Stat (latin word meaning immediately) CXR.
K. Record review of R #18's entire medical record, no date, revealed staff did not document the following:
1. When R #18 started having trouble breathing.
2. Assessment of R #18 breathing status prior to 6:32 AM on 02/14/25.
3. Oxygen saturations and lung sounds of R #18 throughout the day on 02/14/25.
4. When the on-call provider was contacted and any orders that were received for R #18 prior to 06:32 AM.
5. Administration of DuoNeb treatments.
L. On 02/20/25 at 10:07 AM, during an interview with the ADON, the following was confirmed:
1. Staff were expected to document all resident assessments.
2. Staff were expected to document all contact with providers.
3. Staff were expected to document any orders received from providers.
4. Staff were expected to document all treatments that were given to residents.

THIS IS A REPEAT DEFICIENCY FROM 11/06/24
Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for physician's orders, when staff did not administer R #3's blood pressure medication as ordered by the physician. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are:
A. Record review of R #3's Physician orders revealed the following:
1. Order date 01/24/25: carvedilol (medication used to treat high blood pressure) 25 mg, give via percutaneous endoscopic gastrostomy (PEG tube; to surgically insert a feeding tube into a patient's stomach bypassing the mouth and esophagus) one time a day for hypertension (high blood pressure)
2. Order date 01/24/25: hydralazine (medication used to treat high blood pressure) 50 mg, via PEG-Tube three times a day for hypertension.
3. Order date 01/24/25: guanfacine (medication used to treat high blood pressure) 2 mg, via PEG-Tube one time a day for hypertension.
B. Record review of R #3's Medication Administration Record (MAR) for January 2025 revealed the following:
1. On 01/26/25, guanfacine was not given and staff documented vitals (vital signs; blood pressure, heart rate, temperature) outside of parameters (set number range indicated by physician) for administration.
2. On 01/26/25, hydralazine was not given and staff documented see progress notes.
3. On 01/27/25, hydralazine was not given and staff documented see progress notes
4. On 01/26/25, carvedilol was not given and staff documented see progress notes.
5. On 01/27/25, carvedilol was not given and staff documented see progress notes
C. Record review of R #3's nurse progress notes revealed the following:
1. On 01/26/25 staff did not document R #3's vital signs and why guanfacine was not given (see finding B. 1.).
2. On 01/26/25 at 11:13 AM, staff documented: hydralazine was not given due to low blood pressure.
3. On 01/26/25 at 11:16 AM, staff documented: carvedilol was not given due to low blood pressure.
4. On 01/26/25 at 1:10 PM, staff documented: hydralazine was not given due to low blood pressure.
5. On 01/27/25 at 10:09 AM, staff documented: hydralazine was not given due to low blood pressure.
6. On 01/27/25 at 10:09 AM, staff documented: carvedilol was not given due to low blood pressure.
D. On 02/20/25 at 12:15 PM, during an interview, the DON confirmed the following:
1. Staff did not administer R #3's blood pressure medication according to the physicians' orders.
2. R #3's orders for carvedilol, guanfacine and hydralazine did not have parameters in place to determine whether to hold or administer the medications.
3. The expectation was for staff to contact the physician to determine whether the medication should be held or given.
4. The staff should also contact the physician to determine if the order needs to be updated with parameters on when to hold the medication.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions by professional standards of food service safety. This failure could potentially affect all 40 residents on the north unit (residents were identified by the Resident Matrix provided by the Administrator on 10/28/24). When they failed to ensure staff maintain refrigerator temperatures in the nutrition refrigerators.
If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
The findings are:
A. On 11/04/24 at 11:31 AM, during an observation of the nourishment room refrigerator by nurses station on the north unit, the following was revealed:
1. The refrigerator thermometer read 48 degrees Fahrenheit.
2. There was condensation on the back wall inside the refrigerator.
B. Record review of the refrigerator temperature log for the nourishment room by the nurses station on the north unit revealed the following:
1. The log stated refrigerator temperature should be between 36-46 degrees Fahrenheit [foods must be maintained at or below 41 degrees Farenheit].
2. The refrigerator temperatures log was for October 2024.
3. The log did not contain any recording of temperatures for November 2024.
C. On 11/04/24 at 11:31 AM, during an interview with ADON #1, she confirmed the following:
1. The nourishment room refrigerator by nurses station on the north temperature was 48 degrees Fahrenheit.
2. The appropriate temperature should be between 36-46 degrees Fahrenheit [foods must be maintained at or below 41 degrees Fahrenheit].
3. Night shift nurses are expected to check the refrigerator temperature every evening.
4. Staff did not check the temperature for the refrigerator after 10/31/24.
5. There was condensation on the back wall inside of the refrigerator.
D. On 11/06/24 at 1:27 PM, during an interview with the DON, she confirmed the staff are expected to write down the temperatures daily and fix the refrigerator if the temperature is out of range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and the resident's representative of a transfer in writing for 1 (R #77) of 2 (R #77 and R #94) residents sampled for hospitalizations when they failed to:
1. Notify the resident or the resident's representative of the transfers to the hospital in writing and in a language and manner they understand.
2. Contents of the notice include the following:
-The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form.
-Statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.
3. Send a written copy of the Transfer Notices to the Ombudsman.
These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, and their rights to advocate and make informed decision regarding their healthcare. The findings are:
A. On 10/28/24 at 3:28 PM, during an interview with R #77's representative, she stated the following:
1. R #77 was transferred to the hospital, three times since admission, one time was on 10/27/24.
2. She could not remember the dates of the other two hospital transfers.
3. Staff did not give R #77 or her representative paperwork before R #77 was transferred to the hospital (all three times) or when R #77 returned to the facility.
B. Record review of R #77's progress note, dated 09/23/24, revealed R #77 was transferred to the hospital on [DATE].
C. Record review of R #77's transfer notice, dated 09/23/24, revealed the following:
1. Staff did not document that a copy of the transfer notice was provided to the resident or their representative.
2. Staff did not document the name, phone number, or address (mailing and email) of the Office of the State Long-Term Care Ombudsman.
3. Staff did not document a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.
4. Staff did not document that a written copy of the Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman.
D. Record review of R #77's progress note dated 09/25/24, revealed R #77 was transferred to the hospital on [DATE].
E. Record review of R #77's transfer notice, dated 09/25/24, revealed the following:
1. Staff did not document that a copy of the transfer notice was provided to the resident or their representative.
2. Staff did not document the name, phone number, or address (mailing and email) of the Office of the State Long-Term Care Ombudsman.
3. Staff did not document a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.
4. Staff did not document that a written copy of the Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman.
F. Record review of R #77's progress note, dated 10/28/24, revealed R #77 was transferred to the hospital on [DATE].
G. Record review of R #77's entire medical record, revealed that the medical record did not have a transfer notification when the resident was transferred to the hospital on [DATE]
H. On 11/06/24 at 9:27 AM, during an interview with LPN #16, stated the following:
1. Nursing staff are expected to complete a transfer notice prior to sending a resident to the hospital.
2. Staff give the transfer notice to the paramedics along with other documentation.
3. Staff do not give a copy of the transfer notice to the resident or their representative.
4. She confirmed that the transfer notices does not have information for how to contact the Office of the State Long-Term Care Ombudsman.
5. She confirmed that the transfer notices does not have a statement of the resident's appeal rights.
6. She confirmed staff did not complete a transfer notice for R #77's transfer to the hospital on [DATE].
I. On 11/06/24 at 12:05 PM, during an interview with the Social Services Director, stated the following:
1. Nurses are expected to complete transfer notifications at the time of a resident's transfer to the hospital or another facility.
2. She sends a report weekly to the Ombudsman that includes who was transferred from the facility.
3. She does not send a written copy of the transfer notice to the Ombudsman.
4. She confirmed that the facility transfer notices does not include information for how the resident or their representative can appeal a transfer.
5. She confirmed that the facility transfer notices does not include information for how the resident or their representative can contact the Ombudsman.
J. On 11/06/24 at 1:03 PM, during an interview with the DON, stated the following:
1. Staff are not expected to give a transfer notice to the resident or their representative prior to being transferred to the hospital.
2. Staff are expected to contact the resident's POA to notify about the resident being transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #77 and R #94) of 2 (R #77 and R #94) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are:
R #77
A. On 10/28/24 at 3:28 PM, during an interview with R #77's family member (resident representative), she stated the following :
1. R #77 was transferred to the hospital three times since admission, one time was on 10/27/24.
2. She could not remember the dates of the other two hospital transfers.
3. Staff did not give R #77 or her representative a bed hold policy notification before R #77 was transferred to the hospital (all three times) or when R #77 returned to the facility.
B. Record review of R #77's progress note, dated 09/23/24, revealed R #77 was transferred to the hospital on [DATE].
C. Record review of R #77's bed hold notice, dated 09/23/24, revealed the following:
1. Staff did not document how many days a bed would be held for the resident.
2. Staff documented on the resident signature line that R #77's daughter was notified about the bed hold notice.
3. Staff did not document that the written Bed Hold Notification was provided to the resident.
4. Staff did not document that the written Bed Hold Notification form was provided to the resident's representative.
D. Record review of R #77's progress note, dated 09/25/24, revealed R #77 was transferred to the hospital on [DATE].
E. Record review of R #77's bed hold notice, dated 09/25/24, revealed the following:
1. Staff did not document who was notified about the Bed Hold Notification.
2. The form was blank on the resident signature line.
3. Staff did not document that the written Bed Hold Notification was provided to the resident.
4. Staff did not document that the written Bed Hold Notification form was provided to the resident's family.
F. Record review of R #77's progress note, dated 10/28/24, revealed R #77 was transferred to the hospital on [DATE].
G. Record review of R #77's entire medical record, revealed the medical record did not have a Bed Hold Notification when R #77 was transferred to the hospital on [DATE].
H. On 11/06/24 at 9:27 AM, during an interview with LPN #16, the following was stated:
1. Nurses complete a Bed Hold Policy Notification when a resident is transferred to the hospital.
2. If the resident is alert at the time of transfer, the nurses discuss the Bed Hold Policy and will have them sign the Bed Hold Policy Notification
3. If the resident is unable to sign the Bed Hold Policy Notification at the time of transfer, the nurses give the Bed Hold Policy Notification to Social Services to contact the resident's family within 24 hours.
4. LPN #16 confirmed staff did not complete a Bed Hold Policy Notification for R #77 prior to her transfer to the hospital on [DATE].
I. On 11/06/24 at 12:05 PM, during an interview with the Social Services Director, the following was confirmed:
1. Nurses complete Bed Hold Notifications prior to residents being transferred to the hospital.
2. The nurses have the resident or the resident representative sign the Bed Hold Policy Notification at the time of the transfer.
3. If the resident is unable to sign and a resident representative is not present at the time of transfer, the nurses call the resident's representative to notify them about the Bed Hold Policy.
4. The nurses send a copy of the Bed Hold Policy with the resident at the time of the transfer.
5. She does not contact the resident's family to sign the Bed Hold Policy Notification.
6. She does not send a copy of the Bed Hold Policy Notification to the resident's representative.
7. She confirmed R #77's Bed Hold Policy Notification, dated 09/23/24, staff did not document the number of bed hold days R #77 had remaining.
8. She confirmed R #77's Bed Hold Policy Notification, dated 09/25/24, the resident or their representative did not sign the form.
9. She confirmed staff did not complete a Bed Hold Policy Notification for R #77's transfer to the hospital on [DATE].
J. On 11/06/24 at 1:03 PM, during an interview with the DON, stated that nursing staff would not be expected to give a Bed Hold Policy Notification to the resident or their representative prior to being transferred to the hospital (contradicting finding H and finding I).
R #94
K. Record review of R #94's Discharge summary revealed R #94 was transferred to the hospital on [DATE] due to hardware exposure (a situation where orthopedic hardware, such as screws, plates, or replacement joints, is exposed).
L. Record review of R # 94's bed hold notice and authorization dated 08/05/24, revealed the following:
1. The number of days the bed would be held was not documented.
2. The date that notice was provided to the resident or resident representative was not documented.
M. On 11/05/24 at 1:02 PM, during an interview, the DON said that the bed-hold notice should have the days that the bed will be held so that the residents know how many days they have and it should be documented when it was provided to the resident or resident representative.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff that reflects a resident's functional capabilities) was completed for 2 (R #82 and R #88) of 3 (R #5, R #82, and R #88) residents reviewed for resident assessments. This deficient practice could likely result in in the facility receiving monies they are not entitled to and possible delays in transitions to a new setting. The findings are:
R #82
A. Record review of R #82's medical record revealed a discharge date of 07/02/24.
B. Record review of R #82's medical record revealed staff did not complete a Discharge MDS assessment until 11/01/24.
C. On 011/06/24 at 4:10 PM, during interview, MDS Coordinator #1 confirmed R #82's Discharge MDS assessment was not completed upon discharge.
R #88
D. Record review of R #88's medical record revealed a discharge date of 06/06/24.
E. Record review of R #88's medical record revealed staff did not complete a Discharge MDS assessment until 11/01/24.
F. On 011/06/24 at 4:10 PM, during interview, MDS Coordinator #1 confirmed R #88's Discharge MDS assessment was not completed upon discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) was accurate for 5 (R #33, R #36, R #48, R #84, and R #85) of 6 (R #5, R #33, R #36, R #48, R #84, and R #85) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are:
R #33
A. Record review of R #33's admission record, no date, revealed the following:
1. R #33 was admitted to the facility on [DATE].
2. R #33 had the following diagnoses:
a. Type 2 diabetes mellitus (a long-term condition in which the body is unable to make enough insulin to control blood sugar).
b. Difficulty in walking.
c. Muscle weakness.
d. Peripheral vascular disease (a chronic condition that occurs when blood vessels outside of the heart and brain narrow or become blocked).
e. Edema (swelling caused by too much fluid trapped in the body's tissues).
B. Record review of R #33's progress note, dated 10/03/24, revealed R #33 had a partial avulsed right great (largest toe) toenail (a common treatment for ingrown toenails that are painful or recur often) and a wound to the right heel (identified in finding C as a diabetic ulcer).
C. Record review of R #33's physician's order, multiple dates, revealed the following:
1. Order dated 10/03/24 and discontinued on 10/29/24, for wound care for an ulceration (open sore that can develop on the skin) to R #33's right heel.
2. Order dated 10/03/24 and discontinued on 10/29/24, for wound care to R #33's right great toe.
3. New wound care orders dated 10/29/24, for the diabetic ulcer to R #33's right heel.
D. Record review of R #33's quarterly Minimum Data Set assessment dated [DATE], revealed the following:
1. Section M1040: Other Ulcers, Wounds and Skin Problems.
a. Staff did not document that R #33 had any diabetic foot ulcers to the right heel.
b. Staff did not document that R #33 had any other open lesions on the foot (including the wound to the right great toe).
2. Section N0350: Insulin (injectable medication that helps control blood sugar levels in people with diabetes). Staff documented that R #33 received insulin seven times in the last seven days.
3. Section N0415: High-Risk Drug Classes (Medications that can cause significant harm to residents if used incorrectly). Staff did not document that resident received high-risk medication insulin.
E. On 11/05/24 at 1:12 PM, during an interview with MDS Coordinator # 2, the following was confirmed:
1. R #33 had a diabetic ulcer to her right heel.
2. R #33 had a wound to her right great toe.
3. R #33's Quarterly MDS Assessment, dated 10/20/24, did not include R #33's wound on her right heel and her wound on her right great toe.
4. The MDS Assessment should have included the wounds to R #33's right heel and right great toe.
F. On 11/05/24 at 1:50 PM, during an interview MDS Coordinator #1, she confirmed section N0415 of the MDS assessment should have been updated to document R #33 was on insulin which is considered a high-risk medication.
R #36
G. On 10/29/24 at 9:06 AM, during an interview, R #36 said the facility does not give her the food she is supposed to eat because she is a diabetic.
H. Record review of R #36's physician orders dated 09/28/24, revealed R #36 had an order for Humalog Injection Solution (a fast-acting insulin) 100 unit/ML.
I. Record review of R #36's medical record, no date, revealed R #36 did not have a diagnosis of diabetes.
J. Record review of R #36's MDS assessment dated [DATE], revealed R #36 did not have a diagnosis of diabetes, or a diabetic meal/ preference.
K. On 10/31/24 at 10:24 AM, during an interview, LPN #8 confirmed R #36 was a diabetic and had an order for insulin.
L. On 10/31/24 at 11:47 AM, during an interview, the DON said R #36 is a diabetic. The DON confirmed that R #36 was taking insulin. The DON confirmed that R #36's quarterly MDS dated [DATE] does not document that she is a diabetic. The DON confirmed that the MDS should document R #36's current diagnosis to ensure she is receiving the care she needs.
R #48
M. Record review of R #48's admission record, no date, revealed the following:
1. R #48 was admitted to the facility on [DATE].
2. R #33 had the following diagnoses:
a. Hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death) affecting right dominant side (side of the body that is more active).
b. Hypertensive heart disease (complication of high blood pressure that affect the heart) with heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
N. Record review of R #48's physician's orders revealed the following:
1. Order dated 12/21/23; Eliquis Oral Tablet (anticoagulant medication used to help prevent blood clots from forming), give 5 mg by mouth two times a day for atrial fibrillation (condition in which the heart beats rapidly irregularly reducing the ability to pump blood properly increasing the chance of blood clot formation).
2. Order dated 03/11/24; Miralax oral powder (laxative medication which softens stool and may naturally stimulate the colon [tube shaped organ in the digestive system that removes waste from the body] to contract) 17 grams/scoop, give 1 scoop by mouth in the morning for constipation (condition in which a person has uncomfortable or infrequent bowel movements).
3. Order dated 04/04/24; Lactulose Oral Solution (laxative medication used to treat chronic constipation), give 30 ml by mouth two times a day for constipation.
4. Order dated 04/12/24; Fleet Enema (liquid laxative solution inserted directly into the rectum to help induce a bowel movement) insert 1 application rectally every 24 hours as needed for Constipation.
5. Order dated 07/05/24; Sennosides-Docusate Sodium Oral Tablet (combination medication of stimulant laxative and stool softener used to treat constipation) 8.6-50 mg, give 1 tablet by mouth two times a day for constipation.
O. Record review of R #48's Annual Minimum Data Set assessment dated [DATE], revealed the following:
1. Section H0600: Bowel Patterns, staff documented No to the question was constipation present.
P. Record review of R #48's Quarterly Minimum Data Set assessment dated [DATE], revealed Section N0415 High-Risk Drug Classes (medications that can cause significant harm to residents if used incorrectly), staff did not document that R #48 was taking an anticoagulant which is a high-risk medication.
Q. On 11/05/24 at 1:53 PM, during an interview with MDS Coordinator # 1, the following was confirmed:
1. R #48 takes multiple medications to treat constipation.
2 Section H0600 was inaccurate and should have been answered Yes because R #48 was routinely receiving medications to treat constipation.
R. On 11/06/24 at 1:38 PM, during an interview with MDS Coordinator # 2, the following was confirmed:
1. R #48 does take an anticoagulant medication daily.
2. Staff did not document that resident was receiving an anticoagulant which is a high-risk medication.
R #84
S. On 10/28/24 at 1:50 PM, during an interview with R #84, stated the following:
1. He told staff that he had broken teeth on the top and bottom of his right side of his mouth.
2. Staff scheduled a dental appointment for him, but it was on the day his parents visit him.
3. He was unsure if staff had rescheduled his dental appointment.
T. Record review of R #84's admission record, no date, revealed the following:
1. R #84 was admitted to the facility on [DATE].
2. R #84 had the following diagnoses:
a. Multiple sclerosis (a chronic disease that affects the central nervous system, including the brain and spinal cord)
b. Need for assistance with personal care
c. Muscle weakness
U. Record review of R #84's physician progress note, dated 08/20/24, revealed the following:
1. R #84 reported a broken lower molar to the provider.
2. The provider documented that they would refer R #84 to the dentist.
V. Record review of R #84's nursing progress notes, multiple dates, revealed R #84 received ordered as needed Acetaminophen (medication that can treat minor aches and pains) for tooth pain on the following dates:
-08/23/24,
-08/25/24,
-08/29/24,
-08/30/24,
-09/02/24,
-09/06/24,
-09/10/24,
-09/13/24,
-09/15/24,
-09/22/24,
-09/23/24,
-09/24/24,
-09/26/24,
-10/05/24,
-10/06/24,
-10/11/24,
-10/16/24,
-10/17/24,
-10/19/24,
-10/20/24,
-10/23/24,
-10/25/24,
-10/27/24,
-10/28/24,
-10/29/24,
-10/30/24,
-11/03/24.
W. Record review of R #84's Quarterly MDS assessment Section L0200: Dental, dated 10/21/24, revealed staff did not document R #84 had mouth or facial pain.
X. On 11/05/24 at 1:19 PM, during an interview with MDS Coordinator # 2, she confirmed the following:
1. R #84 received pain medication multiple times for dental pain during the time of the MDS Assessment.
2. Staff did not document on R #84's Quarterly MDS Assessment, dated 10/21/24, R #84 had mouth or facial pain.
3. Staff should have documented that R #84 had mouth or facial pain on the Quarterly MDS Assessment, dated 10/21/24.
R #85
Y. On 10/28/24 at 1:12 PM, during an observation and interview with R #85, the following was revealed:
1. A foley catheter (a flexible tube that drains urine from the bladder into a collection bag) collection bag hung from R #85's bed.
2. R #85 stated, she had the foley catheter for about three months.
3. R #85 stated, she asked the doctor if they could remove her foley catheter.
4. She stated the doctor told her they could remove her foley catheter when she was more active.
Z. Record review of R #85's admission record, no date, revealed the following:
1. R #85 was admitted to the facility on [DATE].
2. R #85 had the following diagnoses:
a. Urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, uretha, and kidneys)
b. Bladder disorder, unspecified (urinary bladder disease includes urinary bladder inflammation such as cystitis, bladder rupture and bladder obstruction)
AA. Record review of R #85's physician's order, dated 09/03/24, revealed an order to clamp R #85's foley catheter for 15 minutes every 4 hours for a total of 24 hours for bladder training (a behavioral technique that can help people regain bladder control), then remove the foley catheter.
BB. Record review of R #85's Treatment Administration Record, dated September 2024, revealed the following:
1. On 09/03/24 at 4:00 PM, staff documented, staff completed the clamp and release of R #85's foley catheter for bladder training.
2. On 09/03/24 at 8:00 PM, staff documented, staff completed the clamp and release of R #85's foley catheter for bladder training.
3. On 09/04/24 at 12:00 AM, staff documented, staff completed the clamp and release of R #85's foley catheter for bladder training.
4. On 09/04/24 at 4:00 AM, staff documented, staff completed the clamp and release of R #85's foley catheter for bladder training.
5. On 09/04/24 at 8:00 AM, staff documented staff completed the clamp and release of R #85's foley catheter for bladder training.
6. On 09/04/24 at 12:00 PM, staff documented staff completed the clamp and release of R #85's foley catheter for bladder training.
CC. Record review of R #85's admission MDS Assessment, Section H0200: Urinary Toileting Program, dated 09/05/24, revealed staff documented R #85 had not had a trial of a toileting program since admission to the facility.
DD. On 11/05/24 at 1:07 PM, during an interview with MDS Coordinator #2, the following was confirmed:
1. R #85 had an order dated 09/03/24, for bladder training.
2. On R #85's admission MDS assessment dated [DATE], staff documented R #85 did not have a trial in a toileting program.
3. Staff should have documented R #85 participated in a toileting program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #48 and R #77) of 6 (R #5, R #41, R #48, R #60, R #77 and R #81) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are:
R #48
A. Record review of R #48's admission record, no date, revealed the following:
1. R #48 was admitted to the facility on [DATE].
2. Diagnosis of hypertensive heart disease with heart failure (condition that occurs when chronic high blood pressure damages the heart and prevents the heart from pumping blood effectively to the rest of the body).
B. Record review of R #48's physician's orders revealed:
1. Order dated 12/21/23; Furosemide (diuretic medication used to treat fluid retention and swelling) oral tablet, give 40 mg by mouth one time a day for congestive heart failure (CHF; chronic condition in which the heart does not pump blood as well as it should which can cause fluid retention, shortness of breath and swelling of legs)
C. Record review of R #48's Quarterly Minimum Data Set (MDS, federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes), dated 09/19/24, revealed section N0415 High-Risk Drug Classes (medications that can cause significant harm to residents if used incorrectly), staff documented R #48 took furosemide which is a high-risk medication.
D. Record review of R #48's care plan, dated 05/29/24, revealed staff did not document that R #48 had a diagnosis of heart failure and was taking the high-risk medication furosemide.
E. On 11/05/24 at 2:03 PM, during an interview with MDS Coordinator #2, she confirmed R #48's care plan dated 05/29/24 did not include hypertensive heart disease with heart failure and R #48 took high risk medication furosemide.
R #77
F. Record review of R #77's admission Record, no date, revealed the following:
1. R #77 was admitted to the facility on [DATE].
2. R #77 had the following diagnoses:
a. Metabolic encephalopathy (a group of neurological disorders that occur when the brain is affected by a chemical imbalance in the blood).
b. Type 2 diabetes mellitus (a long-term condition in which the body is unable to make enough insulin to control blood sugar) with hyperglycemia (high blood sugar).
c. Acute kidney failure (a sudden decline in kidney function that occurs within a week).
G. Record review of R #77's progress note, dated 09/19/24, revealed R #77 arrived at the facility with a foley catheter (a flexible tube that drains urine from the bladder into a collection bag).
H. Record review of R #77's physician order, dated 09/22/24, revealed an order to change foley catheter monthly for history of urinary retention (a condition that makes it difficult or impossible to empty the bladder) and chronic (long term) foley catheter use since 06/2023.
I. Record review of R #77's admission Minimum Data Set Assessment, dated 10/09/24, revealed R #77 had an foley catheter (medical device that drains urine from the bladder).
J. Record review of R #77's care plan, dated 10/02/24, revealed staff did not document that R #77 had a diagnosis of urinary retention and R #77 had a foley catheter.
K. On 11/05/24 at 1:16 PM, during an interview with MDS Coordinator #2, she confirmed the following:
1. R #77's care plan did not include R #77 had urinary retention and a foley catheter.
2. Staff should have documented on R #77's care plan that she had a foley catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for 6 (R #26, R #28, R #46, R #59, R #64, and R #85) of 6 (R #26, R #28, R #46, R #59, R #64, and R #85) residents reviewed for care plans when they failed to:
1. Have an Interdisciplinary Team Meeting (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) within seven days after the completion of the admission Minimum Data Set assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) for R #85.
2. Revise the care plan with the most current resident information for R #26, R #28, R #46, R #59, and R #64.
These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
Care Plan Timing
R #85
A. Record review of R #85's admission record, no date, revealed R #85 was admitted to the facility on [DATE].
B. On 10/28/24 at 1:10 PM, during an interview with R #85, she revealed she had not been invited to a care plan meeting since she was first admitted to the facility.
C. Record review of R #85's admission MDS assessment, dated 09/03/24, revealed staff completed R #85's admission MDS Assessment on 09/05/24.
D. Record review of R #85's progress notes, dated 08/27/24 through 11/05/24, revealed the following:
1. R #85 had an IDT meeting on 08/28/24.
2. Staff did not complete an IDT meeting after R #85's admission MDS assessment was completed on 09/05/24.
Care Plan Revisions
R #26
E. Record review of R #26's admission documents, no date, revealed the following:
1. R #26 was admitted to the facility on [DATE].
2. R #26 had a diagnosis of Depression (a mental health condition that can affect anyone, causing a persistent low mood and loss of interest in activities).
F. Record review of R #26's physician's orders, multiple dates, revealed the following:
1. An order, dated 08/19/24, for Prozac (an antidepressant medication used to treat depression, obsessive-compulsive disorder (OCD), bulimia nervosa, and panic disorder) 20 mg, give 2 tablets by mouth once a day for depression.
2. An order dated 08/21/24 and discontinued 10/21/24, for Olanzapine (an antipsychotic medication used to treat mental disorders, including schizophrenia and bipolar disorder) 2.5 milligrams (mg, unit of measure), give one tablet at bed time for Major Depressive Disorder (MDD, a serious mental health condition that involves a persistent low mood and loss of interest in activities).
3. An order, dated 10/22/24, for Olanzapine 2.5 mg, give 2 tablets one time a day for MDD related to depression.
G. Record review of R #26's care plan, dated 06/18/24, revealed the following:
1. Staff documented that R #26 feels sad.
2. Staff did not revise R #26's care plan to include that R #26 had a diagnosis of Depression.
3. Staff did not revise R 26's care plan to include that R #26 takes antidepressant medication.
4. Staff did not revise R #26's care plan to include that R #26 takes antipsychotic medication.
H. On 11/05/24 at 1:25 PM, during an interview with MDS Coordinator #2, the following was confirmed:
1. R #26 had a diagnosis of depression.
2. R #26 had orders for antidepressant medication.
3. R #26 had orders for antipsychotic medications.
4. Staff did not document in R #26's care plan that R #26 had a diagnosis of depression or that R #26 had orders for antidepressant and antipsychotic medication.
5. Staff should have documented R #26's diagnosis of depression and orders for antidepressant and antipsychotic medication in R #26's care plan.
R #28
I. On 10/29/24 at 2:17 PM, during an interview, R #28 said that she did not like the food at the facility and that is why her family decided she needed a feeding tube (flexible plastic tubes through which liquid nutrition travels through your gastrointestinal (GI) tract).
J. Record review of R #28's physician's orders dated 06/12/24 revealed enteral feed (a method of providing nutrients and fluids to a patient through their digestive system) Isosource 250 ml of formula four times a day as tolerated.
K. Record review or R #28's progress note dated 09/28/24, revealed R #28 refused her Isosource 250 ml feeding for the evening.
L. On 11/05/24 at 12:56 PM, during an interview, the DON said that R #28's refusals should be documented on the care plan for continuity of care. The DON confirmed that R #28's refusals were not care planned for.
R #46
M. Record review of R #46's admission documents, no date, revealed R #46 was admitted to the facility on [DATE].
N. Record review of the facility list of residents that smoke, no date, revealed R #46 was a smoker.
O. On 10/29/24 at 1:00 PM, during an interview with R #46, he revealed the following:
1. He goes outside to smoke twice a day.
2. He smoked without supervision.
P. Record review of R #46's care plan, dated 10/07/24, revealed the following:
1. Staff did not document that R #46 was a smoker.
2. Staff did not document interventions in place to ensure R #46 was safe when smoking.
Q. On 11/04/24 at 8:51 AM, during in interview with the Activities Director, the following was revealed:
1. Residents who are cognitive are able to smoke on their own.
2. The nurse completes the smoking assessments to determine the safety of residents to smoke independently.
3. If someone requires assistance, the nurses notify her and her or one of the activities staff will go with the resident to smoke.
4. Resident smoking equipment is stored in lock boxes that she keeps in her office.
5. Residents have specified smoke break times.
6. R #46 was independent with smoking.
7. Staff did not document on R #46's care plan that he smoked or any interventions in place to keep him safe.
R #59
R. On 10/28/24 at 3:56 PM, during an interview, R #59's daughter said R #59 goes to the bathroom on her own, but sometimes has an accident.
S. Record review of R #59's MDS assessment dated [DATE], revealed R #59 was occasionally incontinent (having trouble controlling your bladder or bowels occasionally or mildly).
T. Record review of R 59's care plan dated 08/07/24, revealed R #59 is continent of bowel and bladder.
U. On 11/05/24 at 12:49 PM, during an interview, the DON confirmed R #59's occasional incontinence was not care planned for. The DON said that R #59's care plan should document the resident's current condition so that her care is consistent with R #59's needs.
R #64
V. Record review of R #64's admission documents, no date, revealed R #6 was admitted to the facility on [DATE].
W. Record review of the facility list of residents that smoke, no date, revealed R #64 was a smoker.
X. On 10/28/24 at 2:57 PM, during an interview with R #64, the following was revealed:
1. He had an incident where he was smoking a cigarette in his room at night.
2. The facility took his smoking supplies away.
3. He used to be able to smoke whenever he wanted.
4. The facility has set specific times for smoking.
5. The facility has started locking up smoking equipment and only lets them have them at the set times.
Y. Record review of R #64's progress note, dated 09/07/24, revealed the following:
1. R #64 was found smoking in his room while using oxygen on 09/06/24.
2. Staff found two lighters, five vape pens, and three empty packs of cigarettes.
Z. Record review of R #64's care plan, dated 01/26/24, revealed the following:
1. R #64 was able to keep his cigarettes and lighter in his room.
2. R #64 was able to smoke independently.
3. R #64's care plan was not revised to include the incident of resident smoking in his room on 09/06/24.
4. R #64's care plan was not revised to include that the facility had set smoking times.
5. R #64's care plan was not revised to include that R #64's smoking supplies were being secured
by staff in a lockbox.
AA. On 11/05/24 at 1:21 PM, during an interview with MDS Coordinator # 2, the following was confirmed:
1. R #64 was caught smoking in his room on 09/06/24.
2. R #64's care plan was not revised to include the incident that occurred on 09/06/24.
3. R #64's care plan was not revised to include that the facility secures his smoking supplies in lockboxes.
4. Staff should have revised R #64's care plan to include the incident that occurred on 09/06/24.
5. Staff should have revised R #64's care plan to include that the facility was securing his smoking supplies.
BB. On 11/06/24 at 1:06 PM, during an interview with the DON, she confirmed the following:
1. Staff were expected to document on the resident's care plan that they were a smoker.
2. Staff were expected to document any interventions in place to keep them safe while smoking.

Based on record review and interview, the facility failed to provide services that meet professional standards of practice for 1 (R #81) of 5 (R #52, R #59, R #60, R #81 and R #251) residents reviewed for physician's orders when staff failed to:
1. Obtain a Dexcom (continuous glucose monitoring system that tracks glucose levels in the body, without requiring fingersticks [use of lancet to draw blood from the finger]) as ordered by the physician.
2. Ensure R #81 received weekly Trulicity (injectable medication used to treat diabetes by assisting the body to use the insulin it is already making) injections.
These deficient practices could likely result in worsening of medical conditions. The findings are:
A. On 10/29/24 at 09:27 AM, during an interview, R #81 stated she had not had her Dexcom to monitor her sugar levels in two months. She stated she now must get a fingerstick to check her glucose levels four times a day.
B. Record review of R #81's physician's orders revealed the following:
1. Order dated 03/30/24; Trulicity Solution 3 mg/0.5 ml, inject 3 mg subcutaneously (under the skin) one time a day every Sunday for diabetes mellitus type 2 (condition in which the body can't use sugar properly, leading to high blood sugar levels).
2. Order dated 05/14/24; Dexcom sensor, apply to right arm topically before meals and at bedtime for diabetes mellitus.
C. Record review of R # 81's medication administration record (MAR; form used to document administration of medication and treatments) for July 2024, revealed:
1. Dexcom was marked as not administered, see progress notes on the following dates 07/03/24, 07/04/24, 07/08/24, 07/09/24, 07/13/24, 07/17/24, 07/18/24, 07/20/24, 07/21/24, 07/22/24, 07/23/24, 07/26/24, 07/27/24, 07/28/24, 07/29/24, and 07/31/24.
2. Trulicity was marked as not administered, see progress notes on the following dates 07/14/24 and 07/28/24.
D. Record review of R # 81's MAR for August 2024, revealed the following:
1. Dexcom was marked as not administered, see progress notes on the following dates 08/01/24 through 08/17/24 and 08/19/24.
2. Trulicity was marked as not administered, see progress notes on the following dates 08/04/24, 08/11/24, 08/18/24, and 08/25/24.
E. Record review of R # 81's MAR for September 2024, revealed the following:
1. Dexcom was marked as not administered, see progress notes on the following dates 09/05/24 and 09/06/24.
2. Trulicity was marked as not administered, see progress notes on the following dates 09/01/24, 09/08/24, 09/15/24, 09/22/24 and 09/29/24.
F. Record review of R # 81's MAR for October 2024, revealed the following:
1. Dexcom was marked as not administered, see progress notes on the following dates 10/02/24 through 10/30/24.
2. Trulicity was marked as not administered, see progress notes on the following dates 10/06/24, 10/13/24, 10/20/25, and 10/27/24.
G. Record review of R # 81's progress notes from July 2024 through October 2024, revealed the following:
1. 07/03/24 and 07/04/24 nursing staff documented, Dexcom not available.
2. 07/08/24 nursing staff documented, Dexcom not available.
3. 07/09/24 nursing staff documented, Dexcom supplies on order.
4. 07/17/24 through 07/19/24 nursing staff documented, Dexcom not available.
5. 07/20/24 and 07/21/24 nursing staff documented, Dexcom not in place.
6. 08/07/24 and 08/08/24 nursing staff documented, Dexcom unavailable.
7. 08/09/24 nursing staff documented contacted pharmacy regarding Dexcom device, per pharmacy insurance approval still pending. If approved will be delivered 08/09/24.
8. 08/10/24 through 08/13/24 nursing staff documented, Dexcom unavailable.
9. 09/05/24 staff documented Dexcom pending pharmacy.
10. 10/02/24 and 10/03/24 staff documented Dexcom unavailable, ordered from pharmacy.
11. 10/07/24 staff documented Dexcom unavailable, ordered from pharmacy, checked with fingerstick.
12. 10/08/24, 10/11/24 through 10/17/24 staff documented Dexcom not available, assessed with Accu-Check (fingerstick device used to check blood glucose levels).
13. 10/21/24, 10/22/24,10/24/24 and 10/25/24 through 10/27/24 staff documented Dexcom not available, assessed with Accu-Check.
14. Staff did not document further communication with the pharmacy regarding the Dexcom device being unavailable after 08/09/24.
15. Staff did not document any communication with the physician regarding the physician's order for the Dexcom being unavailable.
H. Record review of R # 81's progress notes from July 2024 through October 2024, revealed:
1. 07/28/24 nursing staff documented, Trulicity not available.
2. 08/04/24 nursing staff documented, Trulicity not available.
3. 08/25/24 nursing staff documented, Trulicity not available from pharmacy.
4. 09/01/24 nursing staff documented, Trulicity not administered, unavailable.
5. 09/08/24 nursing staff documented, Trulicity not available.
6. 09/15/24 nursing staff documented, Trulicity not administered, unavailable.
7. 09/22/24 nursing staff documented, Trulicity not available.
8. 09/29/24 nursing staff documented, Trulicity not available.
9. 10/06/24 nursing staff documented, Trulicity not available.
10. 10/13/24 nursing staff documented, Trulicity unavailable.
11. 10/20/24 nursing staff documented, Trulicity unavailable.
11. 10/27/24 nursing staff documented, Trulicity not administered, unavailable.
I. On 11/06/24 at 2:08 PM, during an interview with the DON, she stated the following:
1. Staff did not document any attempts to notify the physician regarding R #81's Dexcom being unavailable for several months or that R #81 missed several doses of Trulicity.
2. Her expectation is that staff would contact the physician to notify them that R #81's physician's orders were not followed due to the Dexcom and Trulicity not being available.

Based on record review and interview, the facility failed to provide quality of care for 1 (R #36) of 1 (R #36) resident reviewed for diabetes (chronic condition that happens from persistently high blood sugar levels) when staff did not check blood glucose levels (the process of checking your blood sugar level to ensure they are within a healthy range) and administer diabetic medications. This deficient practice could likely result in R #36 having a higher risk of developing long-term health problems and a higher risk of diabetic ketoacidosis (DKA; a serious complication of diabetes that can be life-threatening. Occurs when blood sugar is very high, and ketones [acids your body makes when it's using fat instead of sugar for energy] build up in the body, causing symptoms of increased thirst, frequent urination, weakness and fatigue). The findings are:
A. Record review of R #36's medical record dated 01/18/24, revealed R #36 was referred to hospice.
B. Record review of R #36's medical record revealed the record did not contain any documentation R #6 was admitted to hospice.
C. Record review of the R #36's Hospice Benefit Revocation form dated 01/30/24 revealed R #36 was admitted to hospice on 01/23/24. R #36 revoked hospice services on 01/30/24 and was discharged from hospice.
D. Record review of R #36's physician's orders revealed the following:
1. A prescription for Humalog (a type of insulin used to treat diabetes by controlling blood sugar levels) 100 unit/ml to be injected per sliding scale start date 12/10/23 and discontinue date 01/23/24.
2. A prescription for Metformin (used to help lower blood sugar levels in people with type 2 diabetes) tablet 1000 mg start date 12/10/23 and discontinue date 01/23/24.
3. A prescription for Humalog 100 unit/ml to be injected per sliding scale reorder start date 09/28/24.
E. Record review of R #36's progress note dated 09/27/24, revealed the following:
1. Change in condition completed for R #36 due to abnormal vital signs (measurements that fall outside of the normal range for a person's body). LPN # 8 documented that he obtained a blood glucose level (BGL) on R #36 due to history of diabetes.
2. R #36's BGL (Blood glucose level) was 480 (blood glucose level that requires immediate medical attention). LPN #8 contacted physician.
3. R #36's physician recommended one dose of 10 units of Lispro (fast-acting type of insulin).
4. R #36's physician to decide treatment as it is unusual that R #36 is no longer being treated or evaluated for diabetes.
F. Record review of R #36's medical record, no date, revealed R #36's blood glucose levels were not checked from 01/23/24 to 09/27/24.
G. On 11/01/24 at 2:35 PM, during an interview, MDS Coordinator (MDS) #1 said that when R #36 was admitted to hospice on 01/23/24, her insulin was discontinued at that time. MDS #1 said that R #36 was on hospice for seven days, and that R #36's daughter revoked hospice on 01/30/24. MDS #1 confirmed R #36 should have been put back on her insulin when she came off of hospice.
H. On 11/05/24 at 1:17 PM, during an interview, the DON said she does not know why R #36 longer had a diagnosis of diabetes. The DON confirmed that R #36 was on hospice for seven days and at that time her insulin was discontinued. The DON confirmed that R #36 did not get BGL checked or insulin from 01/23/24 to 09/27/24. The DON said she did not know why R #36 was not reevaluated after hospice was revoked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to keep residents free from accidents for 2 (R #46 and R #64) of 2 (R #46 and R#64) residents reviewed for smoking, when staff failed to complete smoking evaluations to determine resident safety while smoking.
This deficient practice could likely result in residents being at risk of serious harm or injury.
The findings are:
R #46
A. Record review of R #46's admission documents, no date, revealed R #46 was admitted to the facility on [DATE].
B. Record review of the facility's list of residents that smoke, no date, revealed R #46 was a smoker.
C. On 10/29/24 at 1:00 PM, during an interview with R #46, he revealed the following:
1. He goes outside to smoke twice a day.
2. He smokes without supervision.
D. Record review of R #46's smoking evaluation, dated 10/07/24, revealed the following:
1. R #46 may not smoke independently pending review by the interdisciplinary team.
2. R #46 stated he will not be smoking during stay.
E. On 11/04/24 at 8:51 AM, during an interview with the Activities Director, the following was confirmed:
1. R #46 was allowed to smoke without supervision (she was unable to determine when R #46 decided he was going to smoke at the facility).
2. R #46's smoking evaluation indicated that he was not allowed to smoke independently.
3. R #46's smoking evaluation indicated that he would not be smoking at the facility.
4. R #46 had initially stated that he would not be smoking, but a few days later, his family brought him smoking supplies.
5. Nursing staff completes smoking evaluations on all residents who smoke.
6. Nursing staff complete smoking evaluations quarterly or if something occurs that would indicate that the resident's ability to smoke safely has changed.
7. Nursing staff did not complete another smoking evaluation on R #46 after he decided he wanted to smoke.
F. On 11/05/24 at 1:17 PM, during an interview with MDS Coordinator #2, the following was revealed:
1. R #46 was not reevaluated for smoking safety after he decided he wanted to smoke.
2. Nursing staff should have completed another smoking evaluation on R #46 after he decided that he was going to smoke.
G. On 11/06/24 at 1:06 PM, during an interview with the DON, she confirmed that nursing staff would be expected to complete a smoking risk evaluation on a resident who decides to smoke while they are a resident at the facility.
R #64
H. Record review of R #64's admission documents, no date, revealed R #6 was admitted to the facility on [DATE].
I. Record review of the facility's list of residents that smoke, no date, revealed R #64 was a smoker.
J. On 10/28/24 at 2:57 PM, during an interview with R #64, the following was revealed:
1. He had an incident where he was smoking a cigarette in his room at night.
2. The facility took his smoking supplies away.
3. He used to be able to smoke whenever he wanted.
4. The facility had set specific times for smoking.
5. The facility had started locking up smoking equipment and only lets them have them at the set times.
K. Record review of R #64's progress note, dated 09/07/24, revealed the following:
1. R #64 was found smoking in his room while using oxygen on 09/06/24.
2. Staff found two lighters, five vape pens, and three empty packs of cigarettes.
L. Record review of R #64's smoking evaluation, dated 07/21/24, revealed the following:
1. R #64 was safe to smoke independently.
2. R #64 was able to keep cigarette and lighting materials.
3. Facility staff did not complete another smoking evaluation after R #64 was found smoking in his room on 09/06/24.
M. Record review of R #64's care plan, dated 01/26/24, revealed the following:
1. R #64 was able to keep his cigarettes and lighter in his room.
2. R #64 was able to smoke independently.
N. On 11/05/24 at 1:21 PM, during an interview with LPN #16, the following was confirmed:
1. R #64 was caught smoking in his room on 09/06/24.
2. Staff did not complete another smoking evaluation after R #64's incident on 09/06/24.
3. Staff should have completed another smoking evaluation after R #64's incident on 09/06/24.
O. On 11/06/24 at 1:14 PM, during an interview with the DON, the following was confirmed:
1. R #64 was caught smoking in his room on 09/06/24.
2. R #64 used oxygen.
3. She considered R #64 smoking in his room a behavior.
4. R #64 was reeducated on smoking safety and had not had any other incidents since 09/06/24.
5. Staff would not be expected to reevaluate R #64's smoking safety after the behavior of smoking in his room (contradicting LPN #16's statement in finding N).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record review, the facility failed to ensure a resident who entered the facility with an indwelling Foley catheter [a tube inserted through the urethra (the tube through which urine leaves the body) and into the bladder to drain urine] received appropriate treatment for 2 (R #77 and R #85) of 2 (R #77 and R #85) residents reviewed for urinary catheter care, when they failed to:
1. Assess R #77 for urinary retention (a condition that occurs when a person is unable to empty their bladder, either partially or completely) after the removal of her foley catheter.
2. Remove R #85's Foley catheter after the completion of bladder training (a behavioral technique that can help people regain bladder control.)
These deficient practices could likely result in residents being susceptible (likely to be influenced) to infection due to the use of a Foley catheter or urinary retention after the removal of a Foley catheter. The findings are:
R #77
A. On 10/28/24 at 3:17 PM, during an interview, R #77's family member stated the following:
1. LPN #17 removed R #77's Foley catheter on 10/27/24.
2. Staff did not check on R #77 for 11 hours after the removal of the Foley catheter.
3. R #77 felt like her bladder was full, and she experienced pain.
4. R #77 was sent to the hospital on [DATE].
5. The hospital staff placed a catheter into R #77's bladder on 10/27/24, and R #77 had 800 milliliters (ml; unit of measure) of urine output.
6. R #77 returned to the facility on [DATE] and did not have a Foley catheter when she returned.
7. R #77 was able to urinate a little after she returned from the hospital.
B. Record review of R #77's physician's order, dated 10/22/24, revealed an order for bladder training every four hours and foley catheter removal by 10/23/24.
C. Record review of R #77's Treatment Administration Record (TAR), dated October 2024, revealed staff documented the following:
1. On 10/22/24 at 4:00 PM, staff completed the clamp and release of R #77's foley catheter for bladder training.
2. On 10/22/24 at 8:00 PM, staff completed the clamp and release of R #77's foley catheter for bladder training.
3. On 10/23/24 12:00 AM, staff completed the clamp and release of R #77's foley catheter for bladder training.
4. On 10/23/24 4:00 AM, staff completed the clamp and release of R #77's foley catheter for bladder training.
5. On 10/23/24 at 8:00 AM, staff completed the clamp and release of R #77's foley catheter for bladder training.
6. On 10/23/24 12:00 PM, staff completed the clamp and release of R #77's foley catheter for bladder training.
D. Record review of R #77's nursing progress note, dated 10/27/24, revealed the following:
1. Staff documented at 9:48 AM:
a. R #77 tolerated bladder training without complaint of pain or discomfort (See Finding C, Resident completed bladder training on 10/23/24).
b. Staff removed R #77's foley catheter after she ate breakfast.
c. R #77's family reported R #77 had pain to her perineal area (the area between the genitals and the anus.)
d. Staff educated R #77 and her family about prolonged Foley use and doctor's orders.
e. Staff would monitor R #77 to ensure she urinated.
2. Staff documented at 4:18 PM:
a. R #77 had one wet brief since the Foley catheter removal. Staff did not document the time of the wet brief or the amount of urine that was voided.
b. Staff educated R #77 that she needed to get out of bed and empty her bladder by bearing down (push with steady pressure.)
E. Record review of progress note, dated 10/28/24, revealed the following:
1. R #77 reported pain to lower abdomen and perineal area.
2. R #77's family told staff that R #77 had not urinated since 9 AM.
3. R #77's family member told staff she wanted R #77 to go to the hospital.
4. R #77 returned from the hospital on [DATE] with documentation for urinary retention, constipation (a bowel dysfunction that makes it difficult or infrequent to have a bowel movement), and urinary tract infection (UTI, bacterial infection that affects the urinary tract).
F. Record review of R #77's hospital records, dated 10/27/24, revealed the following:
1. R #77 arrived at the hospital on [DATE] at 7:33 PM.
2. R #77 reported abdominal pain.
3. R #77 was diagnosed with the following:
a. Urinary retention
b. Constipation
c. UTI
4. R #77 had orders for:
a. Bactrim (antibiotic used to treat UTI).
b. Miralax (medication used to treat constipation).
c. Colace (medication used to treat constipation).
G. Record review of R #77's medical record, no date, revealed the following:
1. Staff did not document an assessment of R #77 for urinary retention on 10/27/24 between 9:48 AM and 4:16 PM.
2. Staff did not document assessment of R #77 for urinary retention on 10/27/24 between 4:16 PM and R #77's transfer to the hospital.
H. On 11/05/24 at 9:47 AM, during an interview, LPN #17 stated the following:
1. R #77 completed bladder training on 10/27/24.
2. After the completion of bladder training on 10/27/24, LPN #17 removed R #77's foley catheter.
3. R #77 denied pain after the removal of her Foley catheter.
4. R #77 reported pain to her perineal area when her family arrived on 10/27/24 (he was unsure of the time).
5. He had another nurse assess R #77, but he was unsure which nurse.
6. He stated staff should assess residents for urinary retention hourly after the removal of a Foley catheter.
7. He stated that on 10/27/24, he went in to assess R #77, and her family member was changing her (he was unsure of the time).
8. He checked R #77's brief, and it was heavy with urine.
9. When R #77's family was present, they did not allow staff to assist with R #77's care unless they requested help.
I. On 11/05/24 at 10:39 AM, during an interview with ADON #2, he stated staff should assess a resident at least every four hours for 24 hours after staff removed a Foley catheter to ensure the resident did not retain urine.
J. On 11/05/24 at 10:42 AM, during an interview with the DON, she stated the following:
1. R #77's Foley catheter was removed on 10/27/24.
2. She was unable to determine if staff assessed R #77 for urinary retention between the time staff removed the resident's Foley catheter in the morning and the time staff wrote the resident's progress note on 10/27/24 at 4:16 PM.
3. R #77 was transferred to the hospital on the evening of 10/27/24.
4. R #77 returned to the facility with diagnoses of urinary retention, constipation, and urinary tract infection.
K. Record review of the facility's Indwelling (Foley) Catheter Removal policy, revised August 2022, revealed the following:
1. Steps in the Procedure:
a. Assist the resident into the supine position (a position where a person lies on their back with their face and torso facing up.)
b. Place a waterproof pad under the resident.
2. Document the following in the resident's medical record:
a. The date and time the procedure was performed.
b. The name and title of the individual(s) who performed the procedure.
c. All assessment data (e.g., urine amount, color, clarity, etc.) obtained during the procedure.
d. The time and amount of first void after catheter removal.
e. How the resident tolerated the procedure.
R #85
L. On 10/28/24 at 1:12 PM, during an observation and interview with R #85, the following was revealed:
1. A Foley catheter collection bag (also called a drainage bag; a device connected to the catheter tubing and collects urine) hung on R #85's bed frame.
2. R #85 stated she had the Foley catheter for about three months.
3. R #85 stated she asked the doctor if they could remove her Foley catheter.
4. The doctor told R #85 they could remove her Foley catheter when she was more active.
M. Record review of R #85's admission record, no date, revealed the following:
1. R #85 was admitted to the facility on [DATE].
2. R #85 had the following diagnoses:
a. Urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, uretha, and kidneys).
b. Bladder disorder, unspecified (a urinary bladder disease includes urinary bladder inflammation such as cystitis, bladder rupture, and bladder obstruction.)
N. Record review of R #85's physician's order, dated 09/03/24, revealed an order to clamp R #85's Foley catheter for 15 minutes every 4 hours for a total of 24 hours for bladder training then remove the foley catheter.
O. Record review of R #85's Treatment Administration Record (TAR), dated September 2024, revealed staff documented the following:
1. On 09/03/24 at 4:00 PM, they completed the clamp and release of R #85's foley catheter for bladder training.
2. On 09/03/24 at 8:00 PM, they completed the clamp and release of R #85's foley catheter for bladder training.
3. On 09/04/24 at 12:00 AM, they completed the clamp and release of R #85's foley catheter for bladder training.
4. On 09/04/24 at 4:00 AM, they completed the clamp and release of R #85's foley catheter for bladder training.
5. On 09/04/24 at 8:00 AM, they completed the clamp and release of R #85's foley catheter for bladder training.
6. On 09/04/24 at 12:00 PM, they completed the clamp and release of R #85's foley catheter for bladder training.
P. Record review of R #85's progress notes, dated 08/27/24 through 11/05/24, revealed staff did not document R #85's Foley catheter was removed, any information pertaining to the procedure, or assessment of R #85 for urinary retention after the removal of the Foley catheter.
Q. Record review of R #85's medical record revealed staff did not document any orders for the placement of a foley catheter (after the order for removal on 09/03/24).
R. On 11/05/24 at 10:00 AM, during an interview, LPN #17 stated the following:
1. He removed R #85's Foley catheter after bladder training was completed on 09/04/24.
2. He returned to work on a different day (he was unsure what day) and R #77 had a foley catheter in place.
3. He was unsure who re-inserted R #77's foley catheter.
4. He confirmed that he did not document the removal of R #85's foley catheter, how she tolerated the procedure, or that he assessed her for urinary retention after the removal of the catheter.
5. He stated R #85 did not have an order to have a Foley catheter.
S. On 11/05/24 at 10:06 AM, during an interview with R #85, she stated staff did not remove her foley catheter in September 2024 (Contradicting LPN #17's statement in finding R).
T. On 11/05/24 at 10:25 AM, during a joint interview, the DON and ADON #2 the following was confirmed:
1. A resident should not have a foley catheter without a physician's order.
2. R #85 had an order for bladder training and foley catheter removal on 09/03/24.
3. R #85 did not have an order to have a foley catheter after 09/04/24.
4. R #85's medical record did not have documentation that her Foley catheter was removed after the completion of bladder training on 09/04/24.
5. ADON #2 stated that he assessed R #85 on 09/05/24 and that she had a foley catheter in place.
6. The expectation was for staff to follow orders for bladder training and removal of a foley catheter.
7. The expectation was for staff to document the removal of a foley catheter and any assessment information.
8. She was unable to determine if staff removed R #85's foley catheter on 09/04/24.

Based on interview and record review, the facility failed to ensure the licensed nurses (RN's and LPN's) and CNA's are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 5 (CNA #8, CNA #9, LPN #8, LPN #9, and LPN #10) of 5 (CNA #8, CNA #9, LPN #8, LPN #9, and LPN #10) reviewed for competent nursing staff. This could affect all 94 residents in the facility (residents were identified by Resident Matrix provided by the DON on 10/28/24). This deficient practice could likely result in nurses and CNA's working with residents without adequate knowledge to do so; likely resulting in injury or inappropriate care being provided to the residents. The findings are:
A. Record review of LPN #8's personnel files revealed the following:
1. LPN #8 was hired on 10/26/23.
2. Competency evaluation was not completed (the measurement of an individual's knowledge and skills as related to safe, competent performance) for LPN #8.
B. Record review of LPN #9's personnel files revealed the following:
1. LPN #9 was hired on 08/10/23.
2. Competency evaluation was not completed for LPN #9.
C. Record review of LPN #10's personnel files revealed the following:
1. LPN #10 was hired on 07/18/24.
2. Competency evaluation was not completed for LPN #10.
D. Record review of CNA #8's personnel files revealed the following:
1. CNA #8 was hired on 09/20/23.
2. Competency evaluation was not completed for CNA #8.
E. Record review of CNA #10's personnel files revealed the following:
1. CNA #10 was hired on 01/16/18.
2. Competency evaluation was not completed for CNA #10.
F. On 11/06/24 at 11:24 AM, during an interview, the DON confirmed LPN #8, LPN #9, LPN #10, CNA #8, and CNA #9 did not have a competency evaluation. The DON said that competencies should be done upon hire, before working the floor, and annually after that. The DON said that all nursing staff and CNA's should complete competency evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #251) of 5 (R #52, R #59, R #60, R #81 and R #251) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved or worsening of medical issues. The findings are:
A. Record review of R #251's admission record (no date) revealed R #251 was admitted [DATE].
B. On 11/04/24 at 8:46 AM, during observation of medication pass by LPN #1, revealed the following:
1. LPN #1 stated he would not administer medications to R #251 because the medications were not available.
2. LPN #1 stated R #251's medications were on order from the pharmacy, since she was a new admission (admission within the last 30 days) she gets partial fills (less than 30-day supply) from the pharmacy.
C. Record review of R #251's Physician's orders revealed the following:
1. Order date 10/23/24; iron (medication used to treat or prevent low levels of iron such as those caused by anemia [low number of red blood cells that can affect your oxygen supply and cause various symptoms]) 27 tablet, give 240 mg by mouth one time a day for anemia.
2. Order date 10/23/24; pantoprazole (medication that reduces the amount of acid produced in the stomach) tablet, give 40 mg by mouth two times a day for gastroesophageal reflux disease (GERD; condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus).
3. Order date 10/23/24; atorvastatin (medication that reduces the amount of acid produced in the stomach) tablet, give 10 mg by mouth one time a day for high-density lipoprotein cholesterol (HDL; cholesterol in the blood).
D. Record review of R #251's medication administration record (MAR; form used to documentation medication administration) for October 2024 revealed the following:
1. 10/23/24 pantoprazole was marked as not administered, see progress notes.
2. 10/24/24 iron was marked as not administered, see progress notes.
E. Record review of R #251's MAR for November 2024 revealed the following:
1. 11/01/24 through 11/05/24 pantoprazole was marked as not administered, see progress notes.
1. 11/04/24 atorvastatin was marked as not administered, see progress notes.
2. 11/06/24 iron was marked as not administered, see progress notes.
F. On 11/06/24 at 1:00 PM, during an interview, with CMA #1 the following was revealed:
1. R #251's pantoprazole and iron were still on order from the pharmacy.
2. The pharmacy often delivers partial fills, sometimes it will be a 3-day supply or a 7-day supply.
G. Record review of R #251's progress notes for October and November 2024 revealed the following:
1. 10/23/24 staff did not document the reason R #251 did not receive her pantoprazole.
2. 10/24/24 and 11/06/24 staff documented iron was on order.
3. 11/01/24, 11/02/24, 11/04/24, 11/05/24 and 11/06/24 staff documented pantoprazole was on order.
4. 11/04/24 staff did not document the reason R #251 did not receive her atorvastatin.
H. On 11/06/24 at 2:08 PM, during an interview with the DON, she stated the following:
1. R #251 was a new admission to the facility and had missed doses of her medications.
2. The facility has had problems with receiving medications from the facility contract pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was medically necessary for 3 (R #5, R #26 and R #48) of 5 (R #5, R #26, R #31, R #33 and R #48) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason or when no longer necessary, placing these residents at a higher risk of adverse side effects (unwanted, harmful, or abnormal result) when the facility failed to:
1. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) and failed to document clinical rationale to continue psychotropic medications for R #5 and R #48.
2. Ensure that antipsychotic for R # 26 was prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior).
R #5
A. Record review of R #5's admission record, no date, revealed the following:
1. R #5 was admitted to the facility on [DATE].
2. R #5 diagnoses include major depressive disorder, single episode, severe without psychotic features (single occurrence of feelings of low mood and loss of interest in activities without having delusions or hallucinations).
B. Record review of R #5's pharmacy note to attending physician/prescriber dated 06/14/24 revealed:
1. R #5 has been taking sertraline (antidepressant medication often used to treat depression) 25 mg at bedtime for depression since 12/02/21, please evaluate the current dose and consider dose reduction.
2. The form was marked agree and signed but not dated by the medical director.
3. The form was marked see physician progress notes for clinical rationale.
C. Record review of R #5's physician's orders revealed the following:
1. Order start date 12/02/21 and discontinued 07/12/24; sertraline 25 mg give 1 tablet by mouth at bedtime for depression.
2. Order start date 07/12/24 and discontinued 10/17/24; sertraline 25 mg give 12.5 mg by mouth at bedtime for depression.
3. Order start date 10/17/24; sertraline 25 mg give 1 tablet by mouth at bedtime for depression.
D. Record review of R #5's progress notes from 06/01/24 through 10/29/24 revealed the following:
1. Nursing staff did not document any incidents of sadness, crying, depression or self-isolation.
2. Activities staff documented:
a. 06/15/24 R #5 gave a smile and a thumbs up when activity staff asked if he would like to practice
b. 06/22/24 R #5 gave a thumbs up when I asked him if he would like his hair combed while he was listening to music. He laughed and giggled out loud as I was talking to him.
c. 07/13/24 R #5 give (sic) a thumbs up when asked if he would like to participate in exercising with the ball and passing it. He also
smiled and laughed out loud during the ball pass.
d. 07/20/24 R #5 gave a smile and a thumbs up when staff asked if he would like his hair combed and to listen to music. Resident
laughed out loud while stock (sic) combed his hair.
e. 08/03/24 R #5 was in good mood today During the visit. He gave a thumbs up laughed out loud and smiled
f. 08/23/24 R # 5 was in a pleasant mood. He engaged in conversation and kept eye contact.
g. 09/07/24 offered the resident the choice to listen to several different stations and he chose the station he wanted by nodding yes, smiling and giving a thumbs up.
h. 09/26/24 R #5 smiles and gave a thumbs up
i. 10/05/24 R #5 smiled and used a thumb up to make his choices.
j. 10/11/24 R #5 responded well to visit. He gave a thumbs up for the choices of listening to music and participating in ball toss. He kept eye gazes here and there and smiled as well as laugh out loud
k. 10/12/23 R #5 was given the option to play ball pass with a football or basketball. He chose the football by grabbing it. He smiled and laughed.
l. 10/23/24 R #5 continues to participate actively in small and large group activities
m. 10/26/24 R #5 responded well to visit. He communicated with me by giving a thumbs up and smiling.
3. Social services staff documented:
a. 07/22/24 during the evaluation, (name of R #5), appeared to be very happy, smiling at every question asked. The staff also reported observing no symptoms of depression. A PHQ-9 evaluation (an easy-to-use patient questionnaire for screening, diagnosing, monitoring and measuring the severity of depression; 0-4 no depression) was conducted, which resulted in a score of zero.
b. 10/20/24 during the evaluation, (name of R #5) appeared to be very happy, smiling at every question asked. The staff also reported observing no symptoms of depression. A PHQ-9 evaluation was conducted, which resulted in a score of zero.
E. On 11/06/24 at 2:24 PM, during an interview with the DON, she confirmed that there was no rationale in R #5's medical record from the physician regarding the need for increase.
R #26
F. Record review of R #26's admission documents, no date, revealed the following:
1. R #26 was admitted to the facility on [DATE].
2. R #26 had a diagnosis of Depression (a mental health condition that can affect anyone, causing a persistent low mood and loss of interest in activities).
G. Record review of R #26's physician's orders, multiple dates, revealed the following:
1. An order dated 08/21/24 and discontinued 10/21/24, for Olanzapine (an antipsychotic medication used to treat mental disorders, including schizophrenia and bipolar disorder) 2.5 milligrams (mg, unit of measure), give one tablet at bed time for Major Depressive Disorder (MDD, a serious mental health condition that involves a persistent low mood and loss of interest in activities).
2. An order, dated 10/22/24, for Olanzapine 2.5 mg, give 2 tablets one time a day for MDD related to depression.
H. Record review of R #26's Medical Record revealed the resident did not have a psychiatric diagnosis to indicate the need for an antipsychotic.
I. On 11/05/24 at 1:25 PM, during an interview with MDS Coordinator #2, she confirmed the following:
1. R #26's order for Olanzapine is for the diagnosis of MDD for Depression.
2. Olanzapine is an antipsychotic medication.
3. R #26 did not have an appropriate diagnosis for the use of an antipsychotic medication.
J. On 11/06/24 at 1:21 PM, during an interview with the DON, she confirmed R #26 did not have a psychiatric diagnosis for the antipsychotic medication. The DON stated the physician ordered the antipsychotic medication for R #26's depression.
R #48
K. Record review of R #48's admission record, no date, revealed the following:
1. R #48 was admitted to the facility on [DATE].
2. R #48 diagnoses include schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves).
L. Record review of R #48's pharmacy note to attending physician/prescriber dated 06/14/24 revealed:
1. R #48 has been taking duloxetine (antidepressant medication used to treat depression and anxiety) 60mg once a day for depression since 12/22/23, please evaluate the current dose and consider dose reduction.
2. The form was marked resident with good response, maintain current dose.
3. The form was marked and signed but not dated.
M. Record review of R #48's physician's orders revealed the following:
1. Order date 12/22/23; duloxetine give 60 mg by mouth once a day for depression.
2. Order date 03/14/24; referral to (name of local behavioral health agency) related to diagnosis of schizophrenia.
N. Record review of R #48's medical record revealed:
1. local behavioral health No service form dated 06/04/24: insurance is stating that patient is not meet criteria for ongoing mental health services at this time.
O. Record review of R #48's progress notes from 06/01/24 through 10/30/24 revealed the following:
1. Nursing staff did not document any incidents of sadness, crying, or depression.
2. Activities staff documented:
a. 07/20/24 R #48 spoke about the different types of food he enjoyed as well as the different types of TV shows and movies he liked. He smiled a lot and laughed out loud . Resident responded well to visit and was very pleasant
b. 08/03/24 R #48 was in a good mood and smiled while he talked to me for this visit.
c. 08/17/24 R #48 was in a good mood this afternoon. He smiled and laughed out loud during visit. Resident spoke about how much he enjoyed playing baseball. He spoke about his time on a team.
c. 09/26/24 R #48 responded well to visit. He engaged in conversation and smiled throughout the visit.
3. Social services staff documented:
a. 06/19/24 R #48 has reported an absence of depressive symptoms, is feeling significantly improved, and the staff have observed no negative behaviors this quarter. A PHQ-9 evaluation was administered, yielding a score of zero.
b. 09/18/24 R #48 has reported feelings of depression, disturbed sleep, and loss of energy, and the staff have observed no negative behaviors this quarter. A PHQ-9 evaluation was administered, yielding a score of 7-
mild depression.
P. On 11/06/24 at 2:30 PM, during an interview with the DON, she confirmed, that there was no rationale from the physician in R #48's medical record regarding the GDR recommendation for R #48.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents obtained dental services for 4 (R #41, R #50, R #81, and R #84) of 4 (R #41, R #50, R #81, and R #84) residents sampled for dental services, when:
1. Receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments for R #41 and R #50.
2. Schedule required dental follow-up for R #50 and R # 81.
3. Emergency dental services for R#84.
These deficient practices are likely to cause the resident unnecessary pain, embarrassment over the condition and/or appearance of teeth, and potential dental or oral complications. The findings are:
R #41
A. On 10/29/24 at 11:01 AM, during an interview with R #41's power of attorney, she stated R #41 had been at the facility for over one year and she would like R #41 to go to the dentist for her regular appointments and to have her teeth cleaned.
B. Record review of R #41's admission record revealed R #41 was admitted to the facility on [DATE].
C. Record review of R #41's medical record revealed, R #41 has not had any dental visits.
D. On 11/06/24 at 2:50 PM, during an interview, the health information specialist (HIS; facility staff that obtains, organizes and manages medical records) confirmed R # 41 had not been to the dentist after her admission to the facility.
R #50
E. On 10/29/24 at 2:37 PM, during an interview with R #50, she stated she had not been to the dentist, but would like to go for her annual checkup.
F. Record review of R #50's admission record revealed R #50 was admitted to the facility on [DATE].
G. Record review of R #50's medical record revealed R #50 was seen by a local dentist on 08/30/23 for her regular checkup.
H. Record review of R #50's progress notes revealed the following:
1. On 08/08/24, nursing staff documented, new orders received for R #50 to start metronidazole (antibiotic used to treat gum infections and dental abscesses) 500 mg by mouth, every eight hours for five days. Cefdinir (antibiotic used to treat a wide variety of infections) 300 mg by mouth, twice daily for five days, and chlorhexidine rinse (antiseptic mouthwash), swish and spit twice daily for dental infection. Dental referral received from nurse practitioner and delivered to scheduler/transportation for scheduling.
2. On 08/23/24 social services staff documented, ancillary needs (address dental, visual, auditory and podiatry needs): R #50 requested dental.
I. On 11/06/24 at 2:50 PM, during an interview, HIS confirmed R #50 had not been to the dentist after her last visit on 08/30/23.
R #81
J. On 10/29/24 at 9:41 AM, during an interview with R #81, she stated she had been to the dentist approximately two months ago and was waiting for follow up appointment to have a tooth extracted (removal of tooth).
K. Record review of R #81's medical record revealed the following:
1. R #81 was seen by the dentist on 08/07/24.
2. Dental visit note dated 08/07/24 revealed R #81 was referred to an oral surgeon due to a fractured tooth (cracked tooth) with abscess (pocket of pus in tooth caused by infection).
L. On 11/06/24 at 2:50 PM, during an interview, HIS confirmed R #81 had not been seen by an oral surgeon for her extraction.
R #84
M. On 10/28/24 at 1:50 PM, during an interview with R #84, the following was revealed:
1. He told staff that he had broken teeth on the top and bottom of his right side of his mouth.
2. Staff scheduled an appointment for him, but it was on the day his parents visit him.
3. Staff have not told him if his appointment was rescheduled.
N. Record review of R #84's admission record, no date, revealed the following:
1. R #84 was admitted to the facility on [DATE].
2. R #84 had the following diagnoses:
a. Multiple Sclerosis (a chronic disease that affects the central nervous system, including the brain and spinal cord)
b. Need for Assistance with Personal Care
c. Muscle Weakness
O. Record review of R #84's physician progress note, dated 08/20/24, revealed the following:
1. R #84 reported a broken lower molar to the provider.
2. The provider would refer R #84 to the dentist.
P. Record review of R #84's nursing progress notes, multiple dates, revealed R #84 received ordered as needed Acetaminophen (medication that can treat minor aches and pains) for tooth pain on the following dates:
-08/23/24,
-08/25/24,
-08/29/24,
-08/30/24,
-09/02/24,
-09/06/24,
-09/10/24,
-09/13/24,
-09/15/24,
-09/22/24,
-09/23/24,
-09/24/24,
-09/26/24,
-10/05/24,
-10/06/24,
-10/11/24,
-10/16/24,
-10/17/24,
-10/19/24,
-10/20/24,
-10/23/24,
-10/25/24,
-10/27/24,
-10/28/24,
-10/29/24,
-10/30/24,
-11/03/24.
Q. On 11/04/24 at 10:05 AM, during an interview with the receptionist, the following was revealed:
1. R #84 had an appointment scheduled with the dentist on 10/23/24 but R #84 canceled it.
2. R #84 had an appointment rescheduled with the dentist on 11/11/24.
3. The scheduler was not notified that R #84 needed a dental appointment until 09/19/24.
R. On 11/06/24 at 1:08 PM, during an interview with the DON, the following was confirmed:
1. If a resident reported pain from a broken tooth, staff would be expected to follow the process to get the resident seen by a dentist.
2. The provider documented that she would refer R #84 to the dentist on 08/20/24 due to pain from a broken tooth.
3. She was unable to determine if the provider referred R #84 to the dentist or notified anyone to have a dental appointment scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure call lights worked at all times as intended for Rooms 133 to 152 on the South Unit reviewed for call system functioning. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are:
A. On 10/29/24 at 12:46 PM, during an interview, a resident stated sometimes her call light does not work. The resident said it happens often and she had told staff, but it still happens.
B. On 10/29/24 at 2:21 PM, during an interview, a resident stated her call light does not work half the time. The resident said that she had told staff.
C. On 10/28/24 at 1:28 PM, during an interview, a resident stated her call light does not work sometimes. She said that if a resident's call light gets unplugged, then none of the call lights on the unit will work. She said that it seems to happen mostly at night. The resident stated she is unable to call for help because she can not really yell. She said she had told the maintenance director.
D. On 10/31/24 at 3:43 PM, during an observation, the call light in room [ROOM NUMBER] A was unplugged from the wall. The call light in 137 A did not light up outside the room when it was unplugged. When the call light in 137 A was unplugged, the call light in rooms 133 through 145 did not work.
E. On 10/31/24 at 3:43 PM, during an interview, the Maintenance Director confirmed the call lights for rooms 133 to 145 did not light up when the call light in room [ROOM NUMBER] A was unplugged.
F. On 11/04/24 at 1:31 PM, during an interview, a resident stated her call light does not work at all sometimes. She said that if another resident's call light gets pulled from the plug than the other call light on the unit will not work. The resident aid that she had told staff and that they have given her a cowbell to use when the call light does not work.
G. On 11/04/24 at 2:50 PM, during an observation, the call light in room [ROOM NUMBER] was unplugged from the wall. When the light was unplugged, the light did not light up outside room [ROOM NUMBER]. When the call light in room [ROOM NUMBER] was unplugged, the call lights in rooms 146 through 152 on the South Unit did not work.
H. On 11/04/24 at 2:50 PM, during an interview, ADON #1 confirmed that when the call light in room [ROOM NUMBER] was unplugged, the call lights in rooms 146 through 152 did not work.

Based on record review and interview, the facility failed to ensure the nursing staff have completed the mandatory Effective Communication training for 5 (LPN #8, LPN #9, LPN #10, LPN #11, and CNA #8) of 5 (LPN #8, LPN #9, LPN #10, LPN #11, and CNA #8) staff randomly sampled for staffing. This deficient practice could likely result in staff being unable to inform residents of their total health status and to provide notice of rights and services. The findings are:
A. Record review of LPN #8's Online Training Transcript revealed the Effective Communication training was not completed.
B. Record review of LPN #9's Online Training Transcript revealed revealed the Effective Communication training was not completed.
C. Record review of LPN #10's Online Training Transcript revealed the Effective Communication training was not completed.
D. Record review of LPN #11's Online Training Transcript revealed the Effective Communication training was not completed.
E. Record review of CNA #8's Online Training Transcript revealed the Effective Communication training was not completed.
F. On 11/06/24 at 11:24 AM, during an interview, the DON confirmed that Effective Communication Training has not been completed.

Based on interview and record review, the facility failed include performance reviews as part of their 12 hours of annual training for 1 (CNA #9) of 2 (CNA #8 and CNA #9) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are:
A. Record review of CNA #9's personnel records revealed CNA # 9 date of hire was 01/16/18.
B. Record review of CNA #9's training records revealed the record did not any contain performance evaluations.
C. On 11/06/24 at 11:24 pm, the DON confirmed CNA #9 had been working at the facility for more than a year. The DON confirmed that the performance evaluation for CNA #9 was not completed and the 12 hours of annual training was not done based on the performance evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a thorough investigation regarding allegations of abuse for 1 (R #9) of 3 (R #8, R #9, and R #10) residents reviewed for abuse and neglect. This failure could likely lead to residents' claims of abuse, neglect, or exploitation not being thoroughly investigated and determining the cause. The findings are:
A. Record review of the Incident Report dated 06/08/24, revealed an allegation of abuse of R #9 was reported to the facility on [DATE] by R #9's daughter and son-in-law.
B. Record review of the Facility 5 day Follow Up Report dated 06/12/24, sent to the state agency revealed CNA #11 was sent home pending investigation for the allegations of abuse for R #9. CNA #11 had provided care for R #9 at the time of the incident. Interviews with CNA #11 were not documented. The follow up report did not contain any documentation that R #9's family or other CNA's involved in the incident were interviewed. The Follow Up Report did not contain any documentation of the how the facility determined that the allegations were not substantiated as documented on the report.
C. On 08/23/24 at 8:45 AM, during an interview, the DON said that she was not working at the time of the alleged allegation of abuse of R #9. The DON said that her expectation would be to remove the staff member involved from the situation, get a statement from the staff member and then the staff member would be suspended pending investigation of the allegation. The DON said that she would interview all parties involved with the incident and with knowledge of what happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure resident was assessed for risk of entrapment (state of being stuck or caught on bed rail) from bed rails for 1 (R #25) of 1 (R #25) resident reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are:
R #25
A. Record review of R #25's admission record revealed R #25 was admitted to the facility on [DATE].
B. Record review of R #25's physician orders dated 07/30/24, revealed an ordered per physical therapist (PT) recommendations for a half bed rail for the left side.
C. Record review of R #25's care plan revealed R #25 had bed rails for mobility, positioning and safety.
D. Record review of R #25 MDS assessment dated [DATE] under section P0100, revealed the resident does not have bed rail use.
E. On 08/23/24 at 11:38 AM, during an observation of R #25's bed, the bed had two bilateral half side rails instead of one.
F. On 08/23/24 at 11:59 AM, during an interview with the DON, she stated R #25's bed rails were added to the care plan on 08/15/24, because they are used for mobility, a risk assessment was not completed.
G. On 08/23/24 at 12:06 PM, during a telephone interview with the MDS specialist, she stated R #25's bed rails are not documented on the MDS assessment because they are not considered a restraint.

Based on record review and interview the facility failed to report injuries of unknown source within two hours to the State Agency (SA) for 3 (R #8, R #9, and R #11) of 3 (R #8, R #9, and R #11) residents sampled for abuse and neglect. If the facility fails to report allegations of injuries of unknown source to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury. The findings are:
R #8
A. On 08/22/24 at 10:03 AM, during an interview, R #8 said that on 06/07/24, she was being transferred from her bed to the shower chair. R #8 said that the Hoyer lift (designed to lift and transfer patients from one place to another e.g., from bed to bath, chair to stretcher) tipped over and it hit her in the head.
B. Record review of R #8's progress note dated 06/07/24 revealed R #8 was being transferred with a lift to a shower chair when it tipped over and hit the resident on the head. The progress note revealed that the resident reported pain to her head and three small open wounds were noted to R #8's forehead and top of head. R # 8's provider ordered R #8 to be sent to the emergency room for evaluation.
C. Record review of the incident report dated 06/08/24, revealed R #8's incident occurred on 06/07/24 and was not reported to the State Agency until 06/08/24.
R #9
D. On 08/22/24 at 2:22 PM, during an interview, LPN #11 said that R #9's family had come to visit, and they were changing R #9 to get him ready for bed. LPN #11 said that R #9's son-in-law came to the nurse's station and said that R #9 had marks on him. LPN #11 said she saw abrasions (a place where the surface of something, such as skin, has been rubbed away) and bruises on R #9's back, arms, and head.
E. On 08/22/24 at 3:42 PM, during an interview with R #9's son-in-law, he said that he had visited R #9 on 06/07/24. R #9's son-in-law said that he was getting R #9 dressed for bed and he saw scratches on R #9's back, hand, and head. R #9's son-in-law said he let the nurse know.
F. Record review of the facility's incident report dated 06/10/24, revealed the incident with R #9 happened on 06/08/24 and the incident was not reported to the State Agency until 06/10/24.
R #11
F. On 08/21/24 at 4:14 PM, during an interview, R #11 said that on 06/17/24 she was being transferred from the shower chair to her bed and that the Hoyer Lift tipped over.
G. Record review of the incident report dated 06/21/24, revealed the incident with R #11 happened on 06/17/24 and the incident was not reported to the State Agency until 06/21/24.
H. On 08/23/24 at 11:19 AM, during an interview, the Administrator said his expectation is the incidents with R #8, R #9, and R #11 should have been reported to the state within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a safe, orderly discharge occurred for 1 (R #22) of 1 (R #22) residents reviewed for discharge. This deficient practice could likely cause the resident not to have their needs met outside of the facility, and the resident could decline and be re-hospitalized . The findings are:
A. Record review of the face sheet for R #22 indicated an admission date of 12/07/23.
B. On 01/02/24 at 3:27 PM during an interview with the Administrator, he revealed the following:
1. R #22 smoked what the facility believed was fentanyl in the bathroom of his room on 12/30/23.
2. The Social Services Director (SSD) handled the incident.
2. The staff called the Police to the facility on [DATE], but the Police did not find anything illegal.
3. R #22 discharged from the facility against medical advice (AMA; a term used in health care institutions when a patient leaves a medical institution against the advice of their doctor) on 12/30/23.
C. Record review of R #22's nursing progress notes revealed the following:
1. Note dated 12/29/23 at 3:57 PM: Staff found the resident on his knees rinsing his face with water and not talking clearly. The resident denied taking anything but had pinpoint pupils. The resident also had difficulty keeping his eyes open. Staff contacted the doctor. The doctor gave orders for a urine drug screen and to continue to monitor the resident.
2. Note dated 12/29/23 at 9:30 PM: R #22's roommate told the nurse R #22 possibly smoked fentanyl pills in their shared bathroom in their room. R #22 was moved to a room closer to the nurses station for close monitoring.
3. Note dated 12/30/23 at 4:30 PM: At approximately 3:00 PM, the nurse suspected R #22 was smoking an illegal substance due to smoke coming from the bathroom. R #22 denied smoking anything. Staff called the police to the facility and no substances were found. Staff explained the facility's policy on smoking to R #22, and the resident voiced understanding. The SSD spoke to R #22, and R #22 signed out AMA. Family member, DON, and provider were notified.
F. Record review of R #22's physician progress note, dated 12/26/23, revealed:
1. R #22 did not have a home to discharge to.
2. R #22 continued to require care at a nursing facility for wound care.
3. R #22 required long-term care or in-patient rehabilitation for drug use at discharge.
G. Record review of R #22's Skilled Nursing Note, dated 12/28/23, revealed R #22 had an unsteady gait, required assistance, and had weakness.
H. On 01/03/24 at 08:17 AM, during an interview with the SSD, he revealed the following:
1. On 12/29/23 R #22 left the facility for 45 minutes without permission.
2. The SSD received a call from the nurse in charge on 12/30/23. She stated when R #22 left the restroom, there was smoke that smelled funny. The smoke did not smell like cigarette smoke.
3. Police came to the facility, searched R #22's belongings, and did not find anything illegal.
4. The resident did not admit anything to the SSD and said, It's my addiction. I know what I did. So do what you need to do.
5. SSD explained to the resident he put himself and other residents at risk.
6. SSD told the resident there were two options:
a. The doctor to write an order for discharge, or
b. The resident discharged from the facility AMA.
7. SSD called the physician to get discharge orders.
8. Doctor refused to discharge R #22.
8. SSD told R #22 the only option left was for R #22 to leave the facility AMA.
9. R #22 signed the AMA form.
10. SSD called R #22's Family Member (FM) to tell her about what occurred and the facility had to discharge the resident.
11. The FM told SSD she could not pick up R #22 from the facility. She also stated R #22 could not stay with her.
12. SSD drove R #22 to the FM's house to pick up money. The SSD then drove R #22 to a local motel.
I. On 01/03/24 at 10:10, during an interview with the DON, she confirmed it was not appropriate to tell a resident they had to leave AMA.
J. On 01/04/24 at 9:40, during an interview with the Medical Director, she confirmed staff should only give an AMA form to a resident who was not medically discharged and the resident insisted on leaving the facility after staff discussed all the risks with them.
K. On 01/04/24 at 10:12 AM, during an interview with R #22's FM, she confirmed the following:
1. She received a call from the SSD on 12/30/23.
2. She was told R #22 had to be discharged due to smoking something in the facility.
3. SSD told her R #22 could not stay at the facility any longer.
4. SSD told her R #22 could never come back to the facility again.
3. She told the SSD R #22 would have to go to the street, because she could not pick him up or take him in.
4. The SSD called her back and asked if she would give R #22 money for a hotel.
5. The SSD drove R #22 to the family member's house to pick up money.
6. She gave R #22 $250 for a hotel room and food.
7. The SSD drove R #22 to a local hotel.
L. Record review of R #22's medical record revealed the medical record did not contain the following:
1. Documentation R #22 or R #22's representative gave verbal or written notice of intent to leave the facility.
2. Documentation of discussions with R #22 or his representative about discharge planning and arrangements for post-discharge care.
M. On 01/04/24 at 12:39 PM, during an interview with the administrator, he confirmed a Notice of Medicare Provider Non-Coverage (a document that informs beneficiaries of their discharge when their Medicare covered services are ending) was not issued to R #22.
N. Record review of the facility policy, Transfer or Discharge, Resident-Initiated, revealed the following:
1. A resident's verbal or written notice of intent to leave against medical advice was considered a resident-initiated discharge.
2. The medical record for resident-initiated discharges should contain documentation or evidence of the resident's or resident representative's verbal or written notice or intent to leave the facility.
3. The medical record for resident-initiated discharges should contain documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care per F660, Discharge Planning Process, and F661, Discharge Summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a thorough investigation regarding allegations of abuse for 7 residents that CNA #11 worked with (Residents were identified by the interview with the DON on 08/08/23 at 2:26 PM). This failure could likely lead to residents' claims of abuse, neglect, or exploitation not being thoroughly investigated and determining the cause. The findings are:
A. Record review of the Health Facility Incident Report dated 06/19/23, revealed an allegation of abuse of R #28 was reported to the facility on [DATE] by R #28's daughter.
B. Record review of the Facility 5 day Follow Up report sent to the state agency revealed CNA #11 was terminated for the allegations of abuse for R #28. No other residents were included in the report.
C. On 08/01/23 at 1:42 PM, during an interview with the DON she confirmed that allegation of abuse for R #28 was confirmed. The DON stated that through her investigation of the incident with R #28, 6 other residents were found to have been possibly abused by CNA #11. The DON continued to state that CNA #11 had reportedly been pinching residents and they did not like it being hurt or uncomfortable. The DON confirmed that CNA #11 admitted she was pinching residents. but that it was out of love. The DON confirmed that the additional 6 resident identified were not reported to the State Agency or included in the 5 day follow up report sent to the State agency and they should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 3 (R #3, R #55, and R #89) of 3 (R #3, R #55, and R # 89) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location that the resident was discharged . The findings are:
R #3
A. Record review of R #3's Progress Notes revealed the following: R #3 was transferred to the hospital on [DATE] due to low blood sugar.
B. Record review of R #3's medical record revealed no written Transfer Notice.
R #55
C. Record review of R #55's Progress Notes revealed the following: R #55 was transferred to the hospital on [DATE] due to PEG tube (feeding tube that allows you to receive nutrition directly through your stomach) being dislodged.
D. Record review of R #55's medical record revealed no written Transfer Notice.
R #89
E. Record review of R #89's Face Sheet no date revealed an admission date of 04/29/23.
F. Record review of R #89's Progress Notes revealed R #89 went to the hospital on [DATE].
G. Record review of R #89's medical record revealed no written Notice of Transfer/discharge was found.
H. On 08/01/23 at 12:31 PM, during an interview the DON confirmed that the facility had not been doing the transfer notices.
I. On 08/01/23 at 1:44 PM, during an interview, Social Services stated he only notifies the Ombudsman weekly via email of any unsafe discharges or AMA (Against Medical Advice) discharges. Stated he was not aware he needed to notify the Ombudsman of all transfers and discharges.

Based on interview and record review, the facility failed to have competent staff when the failed to have competencies for 4 (CNA #23, CNA #24, CNA #25, and LPN #5) of 4 (CNA #23, CNA #24, CNA #25, and LPN #5) nursing staff sampled for competency. This deficient practice could likely result in staff working who are not competent to give care to residents. The findings are:
A. Record review of CNA #23's personnel records revealed
1) No CNA competency evaluation completed.
B. Record review of CNA #24's personnel file revealed
1) No CNA competency evaluation completed.
C. Record review of CNA #25's personnel records revealed
1) No CNA competency evaluation completed.
D. Record review of LPN #5's personnel records revealed
1) No Nursing competency evaluation completed.
E. On 08/02/23 at 9:22 AM, during an interview the ADON confirmed that the facility did not have competencies for CNA #23, CNA #24, CNA #25, and LPN #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written information to the resident or resident representative that specifies the bed hold policy at the time of the transfer for 3 (R #3, R #55, and R #89) of 3 (R #3, R #55, and R #89) residents sampled for hospitalizations. This deficient practice could likely result in the resident and/or their representative being unaware of the resident ability to return to their previous room or the next available room upon return from the hospital. The findings are:
R #3
A. Record review of R #3's Progress Notes revealed the following: R #3 was transferred to the hospital on [DATE] due to low blood sugar.
B. Record review of R #3's medical record revealed no written Bed Hold Policy Notice.
R #55
C. Record review of R #55's Progress Notes revealed the following: R #55 was transferred to the hospital on [DATE] due to PEG tube (feeding tube that allows you to receive nutrition directly through your stomach) being dislodged.
D. Record review of R #55's medical record revealed no written Bed Hold Policy Notice.
R #89
E. Record review of R #89's Face Sheet no date revealed an admission date of 04/29/23.
F. Record review of R #89's Progress Notes revealed R #89 went to the hospital on [DATE].
G. Record review of R #89's medical record revealed no Bed Hold Policy Notice was found.
H. On 08/01/23 at 12:31 PM, during an interview the DON confirmed that the facility had not been doing the Bed Hold Policy Notices.

Based on record review and interview the facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurate for 1 (R #55) of 2 (R #55 and R #74) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are:
A. Record review of R #55's physician's orders revealed: Order Date 05/07/23 Cephalexin (antibiotic medication used to treat a wide variety of bacterial infections) Give 10 ml (milliliters) every 6 hours for UTI (Urinary Tract Infection) for 7 Days.
B. Record review of R #55's Quarterly MDS completed 05/22/23 revealed: Section I Active Diagnosis question I2300 Urinary Tract Infection (UTI) (LAST 30 DAYS) was not marked to indicate that R #55 was treated for UTI on 05/07/23 through 05/14/23.
C. On 08/02/23 at 3:13 PM, during an interview, the DON confirmed that R #55 was treated for a UTI on 05/07/23 and the MDS was not accurately completed to include this information.

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 3 (R #34, R #53, and R #74) of 7 (R #8, R #28, R #29, R #34, R #53, R #55, and R #74) residents reviewed for Comprehensive Care Plans. Failure to develop a person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are:
R #34
A. Record review of R #34's Face sheet revealed an admission date of 07/03/23.
B. On 07/28/23 at 11:22 AM, during an interview, R #34 stated that she was changed from short term skilled care to long term care and she didn't know what or when the plan was for her to go home.
C. Record review of R #34's Care Plan dated 07/12/23 revealed no care plan for R #34's transition from short term care to long term care and no discharge plan.
D. On 08/01/23 at 4:07 PM, during an interview with the DON she confirmed that the Care Plan was not developed to include R #34's transition from short term care to long term care and discharge plan.
R #53
E. Record review of R #53's admission Record revealed an admission date of 06/15/23.
F. On 07/27/23 at 10:21 AM, during an observation of R #53's room revealed bed rails on both sides of R #53's bed were observed.
G. Record review of R #53's Care Plan revealed no bed rail interventions in place.
H. On 07/31/23 at 10:46 AM, during an interview with the DON, she confirmed that the care plan should have interventions for the bed rails.
R #74
I. Record review of R #74's admission Record revealed a readmission date of 04/21/23.
J. Record review of R #74's MDS (Minimum Data Set/comprehensive assessment) dated 05/10/23 revealed: Section G functional status, Activities of daily living (ADL; Daily self-care activities that include bathing, grooming, oral care, dressing, eating and toileting)
1. Bed mobility; requires extensive assistance of 2 or more staff.
2. Dressing; requires extensive assistance of 2 or more staff.
3. Eating and drinking; requires extensive assistance of 1 staff.
4. Toilet use; requires extensive assistance of 2 or more staff.
5. Personal hygiene (combing hair, brushing teeth); Is totally dependent (staff fully performs task) and requires 1 staff.
K. On 08/02/23 at 3:06 PM, during an interview, the DON confirmed that R #74's care plan did not include a plan for the assistance he requires to complete his ADL's.

Based on record review and interview, the facility failed to revise the Care Plan for 2 (R #55) of 3 (R #3, R #55 and R #74) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
A. Record review of R #55's Physician's orders revealed:
1. Order date 05/25/23 NPO diet (nothing by mouth) .for Strict Aspiration precautions (practices that help prevent foods or fluids getting into the airway that can lead to trouble breathing or infections such as pneumonia).
2. Order date 06/08/23 cleanse site (wound) with normal saline, pat dry, apply 50/50 (half and half mixture of creams) zinc (topical treatment that may help wounds heal more quickly and prevent infection) and antifungal (topical treatment to treat fungal infections) cream. Apply twice a day and as needed with each incontinence episode; stage 2 pressure ulceration injury (open, shallow, crater-like wound) of sacrum (area at bottom of spine/tailbone).
B. Record review of R #55's Care Plan initiated 02/14/23 revealed:
1. DYSPHAGIA (difficulty swallowing): Resident needs altered texture (meals that have been altered in texture to meet the needs of people with dysphagia) difficult masticating (chewing) needs assistance with eating.
2. Did not include treatment or a plan for stage 2 pressure ulcer of sacrum.
C. On 08/02/23 at 1:54 PM, during an interview, the Wound Care nurse stated that R #55 only had a small pressure ulcer to her sacrum. When asked about the care plan the Wound Care nurse stated that the MDS nurse is the person responsible for updating the care plan.
D. On 08/02/23 at 3:13 PM, during an interview, the DON confirmed that R #55's Care Plan had not been revised to reflect that she had been changed from being able to eat altered texture foods to being NPO and confirmed R #55's care plan was not revised to include the treatment for the Stage 2 pressure ulcer of sacrum.

Based on observation, record review, and interview, the facility failed to have reasonable accommodations for 1 (R #72) of 2 (R #8 and R #72) residents sampled for environment, when they failed to provide R #72 with a mattress to fit her bed. This deficient practice could likely result in the resident being at risk for accidents. The findings are:
A. Record review of R #72's Face sheet no date revealed an admission date of 03/07/23.
B. On 07/28/23 at 8:41 AM, during an interview with R #72 and observation of R #72's room, it was observed that R #72's mattress was too short and did not fit the bed. R #72 stated that the mattress had been like that since she was admitted .
C. On 08/02/23 at 3:57 PM, during an interview with Maintenance Director, he confirmed that the mattress was too short and did not fit the bed.

Based on interview, observation, and record review, the facility failed to ensure that a resident who enters the facility without an indwelling foley catheter (tube that is inserted through the urethra and into the bladder to drain urine) is not catheterized (procedure that involves placing a foley catheter) unless clinical condition demonstrates that catheterization was necessary and was treated appropriately for Urinary Tract Infection (UTI) for 1 (R #55) of 2 (R #55 and R #241) residents reviewed for Urinary Tract Infections and Foley Catheters when they:
1) Failed to document the need for foley catheter insertion.
2) Failed to ensure an appropriate diagnosis for long term use of a foley catheter.
3) Failed to ensure that a resident received all doses of antibiotic to treat UTI
These deficient practices could result in residents being susceptible to infection due to insertion of foley catheter, worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging it's own tissues) The findings are:
A. On 07/28/23 at 3:53 PM, during an observation, R #55 was lying in bed and foley catheter tubing and bag noted to be hanging on bed frame.
B. Record review of R #55's MDS (Minimum Data Set; Comprehensive assessment) dated 05/22/23 revealed: Section I-Active Diagnosis-Genitourinary (relating to the genital and urinary organs)
1) Question I1550 Neurogenic Bladder (disorder of bladder control due to damage to the nervous system that can cause the bladder to be over or underactive) was not check marked.
2) Question I1650 Obstructive Uropathy (condition when urine can't flow due to partial or complete obstruction) was not check marked.
C. Record review of R#55's Electronic Medical Record (EMR) revealed Urinary Tract Infection as the only genitourinary diagnosis.
D. Record review of R #55's Physician's orders revealed:
1) Order date 05/07/23 Cephalexin (antibiotic medication used to treat a wide variety of bacterial infections) Give 10 ml every 6 hours for UTI for 7 Days.
2) Order date 05/09/23 place 16Fr (size of tubing) Foley catheter one time only for urinary retention for 1 day.
E. Record review of R #55's Care Plan initiated 07/06/23 revealed: [Name of R #55] has indwelling catheter, poor fluid intake and immobile.
F. Record review of R #55's progress notes dated from 02/13/23 through 08/02/23 revealed no documentation of any urinary retention or signs and symptoms of UTI (fever, chills, burning or pain with urination, blood in urine).
G. Record review of R #55's Electronic Medical Record (EMR) revealed missed doses for Cephalexin (antibiotic ordered to treat UTI for 7 days) as follows:
1. 05/07/23 at 5:04 PM med on order
2. 05/08/23 at 11:31 PM med not in yet
3. 05/08/23 at 5:06 PM med not here
4. 05/13/23 at 4:47 AM no documentation
5. 05/13/23 at 5:07 PM pending delivery
6. 05/14/23 at 11:14 AM pending pharmacy delivery
H. On 08/02/23 at 3:13 PM, during an interview, the DON confirmed the following:
1) R #55 diagnosis and medical record did not have documentation to support the need for long term use of the foley catheter.
2) Poor oral intake and immobility do not indicate the need for foley catheter.
3) R #55 missed 6 doses of the antibiotic medication ordered to treat her UTI.

Based on record review, and interview the facility failed to provide trauma informed care (care to help prevent furtherance of trauma and promote safety and well-being) to 1 (R #72) of 1 (R #72) resident diagnosed with a trauma incident. Failing to provide care and seek out knowledge of triggers is likely to cause the resident to become secluded (withdrawn), exhibit behaviors, or cause self harm. The findings are:
A. Record review of R #72's Face sheet revealed and admission date of 03/07/23 and admitting diagnosis of Post-Traumatic Stress Disorder (psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event), unspecified.
B. On 07/28/23 at 8:49 am, during an interview R #72 said the facility was not addressing her PTSD and that counseling would be beneficial.
C. Record review of R #72's care plan dated 03/21/23 revealed no care plan related to R #72's PTSD diagnosis.
D. On 07/31/23 at 4:07 PM, during an Interview with DON, she stated that R #72 did not have a current care plan to address PTSD diagnosis. The DON further stated R #72 has not been to a behavioral health specialist to see if she needed any counseling.

Based on observation, record review and interview, the facility failed to ensure that 1 (R #55) of 6 (R #53, R #55, R #69, R #72, R #73, and R #74) residents reviewed for behavioral-emotional health were receiving necessary behavioral health care to meet their needs. This deficient practice could likely result in residents having a decline in their physical, mental, and psychosocial well-being. The findings are:
A. On 07/28/23 at 3:53 PM, during an observation, R #55 was lying in bed was very quiet and had a flat affect (reduced expression and displays of emotion) on her face. Resident was unable to answer questions.
B. On 08/02/23 at 11:36 AM, during an observation of medication administration. R #55 again had a flat affect on her face. RN #1 stated that R #55 has been sad and her daughter doesn't live here.
C. On 08/02/23 at 1:54 PM, during an interview, the Wound Care nurse stated R #55 has declined, she is sad, and her daughter lives out of town.
D. Record review or R #55's Physician's Orders revealed: order date 06/27/23 Referral to Psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) for evaluation due to diagnosis of depression.
E. Record review of R #55's Electronic Medical Record (EMR) revealed that she had not received any psychiatrist consults or services.
F. On 08/03/23 at 12:26 PM, during an interview the Social Services Director stated he did not receive the order to refer R #55 to the Psychiatrist, so he had not completed any referrals for her yet.

Based on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 2 (R #55 and R #241) of 3 (R #55, R #74, and R #241) residents reviewed for pharmacy services when they failed to provide routine and emergency medications to residents. These deficient practices could likely lead to unresolved infections, worsening of infection or uncontrolled pain. The findings are:
R #55
A. Record review of R #55's Physician's orders revealed: Order date 05/07/23 Cephalexin (antibiotic medication used to treat a wide variety of bacterial infections) Give 10 ml (milliliter) every 6 hours for UTI (Urinary Tract Infection) for 7 days.
B. Record review of R #55's Electronic Medical Record (EMR) revealed missed doses for Cephalexin antibiotic as follows:
1) 05/07/23 at 5:04 PM med on order
2) 05/08/23 at 11:31 PM med not in yet
3) 05/08/23 at 5:06 PM med not here
4) 05/13/23 at 4:47 AM no documentation
5) 05/13/23 at 5:07 PM pending delivery
6) 05/14/23 at 11:14 AM pending pharmacy delivery
R#241
C. Record review of R #241's Physician's orders revealed:
1) Order date 01/28/23 Clonidine (medication used to treat high blood pressure) 0.3 MG (medication dosage) give 1 tablet by mouth one time a day.
2) Order date 01/28/23 Isosorbide Mononitrate (medication used to treat high blood pressure)
120 MG give 1 tablet by mouth one time a day.
3) Order date 01/28/23 Plavix (medication that helps prevent blood clots) 75 mg. Give 1 tablet by mouth at bedtime for CAD (Coronary Heart Disease; condition where the major blood vessels supplying the heart are narrowed)
4) Order date 01/28/23 Oxycodone (medication used to help relieve moderate to severe pain) 10 MG. Give 1 tablet by mouth four times a day.
D. Record review of R #241's Electronic Medical Record (EMR) revealed missed doses as follows:
1) 01/28/23 Plavix 75 mg at HS (bedtime) no documentation
2) 01/28/23 Oxycodone 10 mg at HS (bedtime) no documentation
3) 01/29/23 Isosorbide at 8:23 AM no documentation
4) 01/29/23 Clonidine at 9:21 AM no documentation
E. On 08/03/23 at 11:49 AM, during an interview, LPN #2 stated that receiving medications from the pharmacy has been an ongoing issue. They have to wait more than one day especially for antibiotics and pain medications.
F. On 08/03/23 at 11:56 AM, during an interview, the DON confirmed missed doses for R #55 and R #241. The DON stated that they have had an issue with receiving medications from the pharmacy in a timely manner and are currently trying to switch pharmacies.

Based on observation, interview, and record review, the facility failed to properly store medications, when they failed to:
1) Secure medications in a insulin cart on South Unit,
2) Dispose of a loose tablet stored in the medication cart on North Unit, and
3) Keep temperature logs for a medication refrigerator.
This could affect all 95 residents in the facility (Residents were identified by the resident matrix provided by the Administrator on 07/27/23). This deficient practice could result in residents obtaining medications that have no longer effective or that are not prescribed to them resulting in adverse side effects. The findings are:
Insulin Cart
A. On 07/27/23 at 8:30 AM, during an observation of the south unit, the insulin cart was found to be unlocked.
B. On 07/27/23 at 8:32 AM, during interview, Med Tech #11 confirmed that the insulin cart was not locked.
Loose Tablet
C. On 07/28/23 at 2:28 PM, during an in observation of North Unit Medication Cart revealed 1 tablet loose in the medication cart.
D. On 07/28/23 at 2:29 PM, during an interview Med Tech #4 confirmed the loose tablet.
Temperature Log
E. Record review of the medication refrigerator temperature logs revealed the following:
1) June 2023 were blank, and
2) July 2023 were blank.
F. On 07/28/23 at 2:41 PM, during an interview the Infection Preventionist confirmed that June 2023 and July 2023 temperature logs for the medication refrigerator were blank.
G. On 08/02/23 at 8:44 AM, during an interview the DON confirmed that loose medications should not be in the medication carts. The DON also confirmed that staff should be keeping track of the temperatures in the medication refrigerator

Based on interview and record review, the facility failed to obtain laboratory testing for 1 (R #72) of 1 (R #72) residents reviewed for laboratory services. If the facility fails to obtain labs that have been ordered, this could likely cause a delay in chemotherapy (the treatment of disease by the use of chemical substances, especially the treatment of cancer), causing unnecessary harm to the resident. The findings are:
A. On 07/28/23 at 8:50 AM, during an interview with R #72, she stated that she misses appointments because her labs aren't getting done on the days they are supposed to be done.
B. Record review of R #72's Face sheet revealed and admission date of 03/07/23. It also revealed a diagnosis of Malignant Neoplasm of Esophagus (a disease in which malignant cancer cells form in the tissues of the esophagus).
C. Record review of R #72's Physician's orders revealed order date 06/26/23 CBC (complete blood count) with Differential, CMP (Comprehensive Metabolic Panel) one time a day every 14 day(s) for standing order for chemotherapy.
D. Record review of R #72's Lab Results revealed a collection date of 07/13/23.
E. On 07/31/23 at 3:10 PM, during an interview, the DON confirmed that R #72 missed an appointment for chemotherapy because the labs were not drawn on the correct day.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 95 residents in the facility (residents were identified on the resident matrix provided by the Administrator on 07/27/23) who eat food prepared in the kitchen when they failed to:
1. Keep the deep freezer and kitchen floors clean,
2. Wear hairnets in the kitchen
3. Failed to keep the stoves and surrounding areas clean from grease,
4. Maintain the quality of the oil (fresh) in the deep fryer, and
5. Ensure that spices in the kitchen are labeled and dated.
These deficient practices could likely lead to foodborne illnesses. The findings are:
A. On 07/31/23 at 8:31 AM, during an observation of the kitchen the following was observed:
1. The floors in the deep freezer and kitchen had food particles/paper and were sticky, and
2. The Dietary Assistant #1 did not have a hair net on in the kitchen.
B. On 07/31/23 at 8:36 AM, during an interview with the Dietician Manager, he confirmed that the floors were dirty. The Dietary Manager also said that hairnets should be worn at all times in the kitchen.
C. On 07/31/23 at 8:40 AM, during an interview the Dietary Assistant #1 confirmed that she was not wearing a hairnet.
D. On 08/01/23 at 9:57 AM, during an observation of the kitchen it revealed the following:
1. That the oil in the deep fryer was dark and smokey and had food particles floating on top of the grease.
2. The floor under and the appliances next to the deep fryer were covered in oil.
3. There was coffee spilled on the floor.
E. On 08/01/23 at 10:12, during an interview with the Dietary Manager, he confirmed that the oil in the fryer needed to be changed. The Dietary Manager also confirmed that the floors and appliances had oil and coffee on them.
F. On 08/02/23 at 2:05 PM, an observation of the Kitchen revealed the following open items with no expiration or use by date:
1. One container of [NAME] pepper
2. One container of Season salt
3. One container of Ground cinnamon
4. One container of Montreal Steak seasoning
5. One container of Lemon Pepper
6. One container of Taco Blend
7. One container of Mustard seed
8. One container of Thyme
9. One container of Salt
10. One container of Pepper
G. On 08/03/23 at 2:10 PM, during an interview the Dietary Manager confirmed that the spices were not labeled properly.

Based on observation and interview the facility failed to provide a comfortable and homelike environment for 1 (R #8) of 2 (R #8 and R #72) residents sampled for environment, when they failed to match the existing paint from previous repairs. This deficient practice could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are:
A. On 07/27/28 at 9:44 AM, during an observation of R #8's room, the wall had scuff marks at knee height and about a foot wide below the window and the corner of the room from the roof to halfway down the wall was painted a different color then the rest of the room.
B. On 08/02/23 at 2:39 PM, during an interview with the Maintenance Director, he confirmed that there were previous repairs made in R #8's room and the wall was not painted the same as the rest of the room. He also confirmed that there were scuff marks on the wall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that resident's New Mexico Medical Orders For Scope of Treatment (MOST Advance Directives) were completed accurately for 2 (R #3 and R #53) of 5 (R #3, R #8, R #28, R #53 and R #69) reviewed for Advance Directives. When they failed to:
1) Ensure that the resident's wishes were accurately reflected
2) Ensure that the MOST form was signed by the resident or their designated healthcare decision maker.
These deficient practices could likely result in the residents' end-of-life choices not being known. The findings are
R #3
A. Record review of R #3's Electronic Medical Record (EMR) revealed a readmission date of [DATE].
B. Record review of R #3'S MOST form dated [DATE] revealed: Section -EMERGENCY RESPONSE SECTION (when a person has no pulse or is not breathing) Do Not Attempt Resuscitation/DNR was marked.
C. Record review of R #3'S Physician's Orders revealed: Order date [DATE] CPR/Full code (Cardiopulmonary resuscitation and all other life saving measures be performed).
D. On [DATE] at 2:06 PM, during an interview, CMA #1 stated that a resident's code status is on the resident's home page in the computer (EMR), she stated R #3 was a full code.
E. On [DATE] at 2:08 PM, during an interview, LPN #1 stated that a resident's code status is on the resident's home page in the computer (EMR), she stated R #3 was a full code.
F. On [DATE] at 3:06 PM, during an interview, the DON confirmed that R #3's MOST form, physician's order and computer home page did not match, and staff could potentially go against a resident's end of life wishes.
R #53
G. Record review of R #53's face sheet revealed R #53 was admitted into the facility on [DATE]. R #53's Power of Attorney (POA) was R #53's son.
H. Record review of R #53's MDS dated [DATE], revealed a BIMS (Brief Interview for Mental Status mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 15 (13 to 15 suggests the patient is cognitively intact.)
I. Record review of the MOST form dated [DATE], was signed by Physician on [DATE], and Section D indicated it was discussed with patient. The form was signed by R #53's daughter-in-law.
J. On [DATE] at 10:43 AM, during an interview with the DON, she confirmed that the MOST form for R #53 was signed by the R #53's daughter-n-law, and the expectation is that residents' MOST form be signed by the resident or their POA.
K. Record review of the Advance Directives Policy dated [DATE] revealed the following:
1. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) the information may be provided to the resident's legal representative.
2. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials even if his or her legal representative has already been given the information.

Based on record review and interview, the facility failed to care plan hospice/facility care responsibilities for 1 (R #29) of 1 (R #29) residents sampled for hospice. This deficient practice could likely result in residents not receiving the care they need from hospice. The findings are:
A. Record review of R #29's Physicians Orders revealed an order for Hospice dated 06/08/23.
B. Record review of R #29's Care Plan dated 04/12/23 revealed no hospice/facility care responsibilities (The division of care responsibilities (i.e. providing personal care, activities, medication administration .) that the hospice staff and the facility staff will be responsible for providing to R #29).
C. On 08/02/23 at 10:24 AM, during an interview the DON confirmed that the facility had not care planed the hospice/facility care responsibilities R #29.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to report to the State Survey Agency timely for 4 (R #28, R #43, R #53, and R #74) of 5 (R #3, R #28, R #43, R #53, and R #74) residents sampled for abuse and accidents when they failed to report allegations of abuse or serious bodily injury within two hours to the State Agency. If the facility fails to report allegations of abuse or serious bodily injury to the State Agency within two (2) hours, then residents could likely continue to be abused or suffer serious bodily injury. The findings are:
R #28
A. Record review of the Health Facility Incident Report dated 06/19/23, revealed an allegation of abuse of R #28 was reported to the facility on [DATE] by R #28's daughter. The facility reported the allegation to the State Agency on 06/19/23.
B. On 08/01/23 at 1:42 PM, during an interview with the DON, she confirmed the incident of abuse was not reported to the State Agency within two hours of the facility being aware of the allegation of abuse for R #28.
R #43
C. On 07/27/23 at 8:24 AM, during an observation of the front lobby area revealed R #43 yelling that R #13 had hit her.
D. On 07/27/23 at 9:38 AM, during an interview R #43 stated that R #13 hit her in the dining room. R #43 stated that staff got R #13 away from her and they also witnessed the incident.
E. Record review of the facility incident report dated 07/31/23 revealed it was documented that R #43's incident occurred at 7:00 pm on 07/27/23. The incident was sent to the State Agency on 07/31/23 at 12:20 pm.
F. On 08/01/23 at 2:49 PM, during an interview the DON confirmed that the facility had not reported R #43's incident to the State Agency within 2 hours and the time of the incident had occurred in the morning not evening of 07/27/23.
R #53
G. On 07/27/23 at 9:44 AM, during an observation of the R #53's hallway revealed loud talking and weeping coming from R #53's room. When surveyor entered R #53's room, R #53 was crying and upset. R #53's son was talking to her in a verbally abusive manner telling her she was a bold face liar and to shut up. R #53 was visibly upset crying.
H. On 07/27/23 at 9:55 AM, during an interview with the Administrator, surveyor reported the allegation of abuse regarding R #53 being abused by her son, that the surveyor had witness on 07/27/23 at 9:44 AM.
I. Record review of the Health Facility Incident Report dated 07/28/23, revealed that the incident of abuse involving R #53 occurred on 07/27/23. The facility reported the allegation to the State Agency on 07/28/23.
R #74
J. On 07/28/23 at 3:01 PM, during an interview, R #74's Power of Attorney (person designated to make healthcare decisions when patient/resident is unable to) stated R#74's has had falls every month, sometimes more often.
K. Record review of R # 74's Electronic Medical Record (EMR) revealed Neurological Evaluation Flowsheet initiated 03/28/23 at 10:10 AM, with two additional assessments entered at 10:25 AM and 10:40 AM and a note on the flowsheet stating pt (patient) send out to [name of local hospital]
L. Record review of R #74's EMR revealed hospital Consultation Report dated 03/28/23 at 6:24 PM the report revealed:
1. Reason for consult: subdural hematoma (type of bleed that occurs within your skull but outside the actual brain tissue)
2. Chief complaint: frequent falls
3. Subjective: patient found on ground and brought to ER (Emergency Room) where head CT (Computed tomography uses special x-ray equipment to help assess head injuries) reported as showing SDH (subdural hematoma)
4. Recommendations: may need surgery but patient is stable at present
M. Record review of R #74's EMR revealed Critical Care Progress Note dated 04/17/23 at 7:07 AM revealed: Subdural hematoma status post craniotomy (surgery to cut a bony flap from the skull to access the brain) for hematoma evacuation (removal of solid swelling of clotted blood within the tissues) on 03/20/23.
N. On 08/02/23 at 3:32 PM, during an interview, LPN #2 reviewed R #74's EMR and stated there was a neurological evaluation flowsheet for 03/28/23, so R #74 must have fallen.
O. On 08/02/23 at 3:59 PM, during an interview, the Administrator stated he does remember the fall R #74 had but he does not have any documentation that the fall was reported to the State Agency.

Based on interview and record review the facility failed complete 12 hours of annual training that included the performance reviews and the facility assessment for 3 (CNA #26, CNA #27, and CNA #28) of 3 (CNA #26, CNA #27, and CNA #28) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care. The findings are:
A. Record review of CNA #26's personnel records revealed
1) No information from the performance evaluation or facility assessment were included in the trainings.
B. Record review of CNA #27's personnel records revealed
1) No information from the performance evaluation or facility assessment were included in the trainings.
C. Record review of CNA #28's personnel records revealed
1) No information from the performance evaluation or facility assessment were included in the trainings.
D. On 08/02/23 at 9:22 AM, during an interview the ADON confirmed that the facility did not use the performance reviews or the facility assessment for CNA #26's, CNA #27's, and CNA #28's annual trainings.

Based on record review and interview, the facility failed to ensure that each resident received or was offered Pneumococcal (a bacteria that causes pneumonia infection of the respiratory tract) immunization for 1 (R #28) of 5 (R #8, R #16, R #28, R #69 and R #72) residents reviewed for immunizations. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents. The findings are:
A. Record review of R #28's Face sheet revealed an admission date of 03/20/23.
B. Record review of R #28's Medical Record revealed no documentation of the pneumococcal vaccine was given or offered.
C. On 08/03/23 at 9:12 AM, during an interview, the Infection Preventionist confirmed that R #28 had not received or was offered the pneumococcal vaccine.

Based on record review, and interview, the facility failed to ensure there was relevant communication in the resident's record indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for 1 (R #2) of 1 (R #2) residents reviewed for Hospice Services. This deficient practice could likely lead to the resident not receiving the services needed due to lack of collaboration and communication between the facility and hospice provider. The findings are:
A. Record review of R #2's Physicians Orders revealed the following: 02/09/22 Admit to (name of hospice provider)
B. Record Review of R #2's medical record miscellaneous tab revealed no hospice notes for dates of service after 07/26/22.
C. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that all hospice visit notes should be scanned into the miscellaneous tab of the residents medical record but their medical records staff is behind on scanning.

Based on observation, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity for 2 (R #29 and R #41) of 2 (R #29 and R #41) residents randomly sampled, when the facility failed to provide a dignity cover for their Foley catheter bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected in a collecting bag). This deficient practice could likely result in residents becoming depressed, anxious, and lacking self-worth. The findings are:
A. On 08/31/22 at 1:51 PM during an observation of R #41's room revealed catheter bag did not have a dignity cover on catheter bag visible from the entrance of the room.
B. 08/31/22 at 2:15 PM, during an observation of R #29's room revealed catheter bag did not have a dignity cover on his catheter bag which was visible upon entering.
C. On 08/31/22 at 2:25 PM during an interview, LPN #11 confirmed that the catheter bags should have covers.
D. Record review of [name of facility] Resident Right's policy, no date revealed,
The facility will treat you with dignity and respect in full recognition of your individuality.

Based on interview, and record review, the facility failed to provide written notice for room/roommate change for 2 (R #33, and R #45) of 2 (R #33, and R #45) resident sampled for notification of change. This deficient practice could likely cause residents to become anxious and depressed if they are not given written room/roommate change notices. The finding are:
R #33
A. On 09/07/22 at 2:19 PM, during an interview the SW stated that R #33 moved rooms on 07/20/22.
B. Record review of R #33 medical record revealed no documentation of a written notice of room change.
R #45
C. Record review of R #45 medical record revealed no documentation of a written notice of room change.
D. On 09/07/22 at 9:56 AM, during an interview the Social Worker (SW) stated that R #33 and R #45 had become roommates after R #33 had issues with her roommate. The SW also confirmed that no written notification of room/roommate changes occurred for R #33 or R #45. The SW stated he had been only working as the SW for 2 months.

Based on interview, and observation, the facility failed to ensure residents knew where the most recent survey was located and accessible to all residents. This could affect all 57 residents in the facility (residents were identified by the facility census provided by the Administrator on 08/31/22). If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are unable to know how the facility is doing and make decisions accordingly. The findings are:
A. On 09/01/22 at 1:35 PM, during the resident council interview, R #3, R #4, R #13, R #19, R #28, and R #43, revealed:
1. Residents were not aware that they have access to the most recent Survey
2. The residents did not know where the latest survey was located.
B. On 09/01/22 at 3:19 PM, during an interview with Activity Director revealed confirmed that the survey binders were in a location that the residents may not know or reach.
C. On 09/08/22 at 3:59 PM, during an interview, the Administrator confirmed that all residents should have access and knowledge as to the latest Survey Binders.

Based on interview and record review, the facility staff did not demonstrate their response and rationale to grievances/concerns for 6 (R #3, R #4, R #13, R #19, R #28, and R #43) out of 6 (R #3, R #4, R #13, R #19, R #28, and R #43) residents in Resident Council. This deficient practice could result in the issues continuing and resident's rights not being honored. The findings are:
A. On 09/01/22 at 3:00 PM, during an interview with Resident Council members R #3, R #4, R #13, R #19, R #28, and R #43 revealed they did not know how to file a grievance and did not recall the process being reviewed with them upon admission or in any of the resident council meetings.
B. Record review of Resident Council minutes dated, June 2022, July 2022, August 2022 revealed:
1. that the grievance process was not reviewed with the resident's,
2. during the August 2022 meeting the resident's reported: transportation to and from appointments has been an issue and a grievance was filed by staff on behalf of the residents.
3. Old Business refers to concerns from the previous month and does not have the update status for the grievances from the previous meeting and this leaves residents feeling as if their concerns were not being addressed.
C. On 09/01/22 at 03:19 PM during an interview with Activity Director revealed:
1. Grievances are done on behalf of the resident by staff and handed to the head of the department where the concern is reported.
2. and confirmed that residents in the monthly Resident Counsel meetings have brought up concerns regarding the facility van.
D. Record review of [name of facility] Resident Rights policy, no date, revealed:
Grievances
1. You may voice grievances concerning your care without fear of discrimination or reprisal.
2. You may expect prompt efforts for the resolution of grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure residents, or their representatives received a written notice of transfer as soon as practicable for 3 (R #22, R #25, and R #34) of 3 (R #22, R #25 and R #34) residents reviewed for hospitalizations. This deficient practice could likely result in the resident and/or their representative not knowing the reason that the resident was sent to the hospital. The findings are:
R #22
A. Record review of R #22's Progress Notes revealed:
1. R #22 was transferred to the hospital on [DATE].
B. Record review of R #22's Medical Record revealed no documentation of a written notice of transfer was found to be provided to the resident or the resident's guardian/family.
R #25
C. Record review of R #25's Progress Notes revealed the following:
1. R #25 was transferred to the hospital on [DATE].
D. Record review of R #25's medical record revealed no documentation of a transfer notice.
R #34
E. Record review of R #34's Progress Notes revealed:
1. R #34 was transferred to the hospital on [DATE].
F. Record review of R #34's Medical Record revealed no documentation of a written notice of transfer was found to be provided to the resident or the resident's guardian/family.
G. On 09/07/22 at 12:28 PM, during an interview the DON confirmed that the facility was not giving residents the transfer notices.
H. Record review of [name of facility] Resident Rights Policy, no date, revealed: Notice of and reason for transfer or discharge must be provided to you in an understandable manner

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of their bed hold policy indicating the duration that the bed would be held for 3 (R #22, R #25, and R #34) of 3 (R #22, R #25, and R #34) residents reviewed for transfers to hospital. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room upon return from the hospital. The findings are:
R #22
A. Record review of R #22's Progress Notes revealed:
1. R #22 was transferred to the hospital on [DATE].
B. Record review of R #22's Medical Record revealed no written notice of the facilities bed hold policy was found to be provided to the resident or the resident's guardian/family.
R #25
C. Record review of R #25's Progress Notes revealed the following:
1. R #25 was transferred to the hospital on [DATE].
D. Record review of R #25's medical record revealed no documentation of a bed hold policy notice.
R #34
E. Record review of R #34's Progress Notes revealed:
1. R #34 was transferred to the hospital on [DATE].
F. Record review of R #34's Medical Record revealed no written notice of the facilities bed hold policy was found to be provided to the resident or the resident's guardian/family.
G. On 09/07/22 at 12:28 PM, during an interview the DON confirmed the facility was not giving residents the bed hold policy notice.
H. Record review of [name of facility] resident Rights policy, no date, revealed: You (resident) and family must receive a written notice of state and facility bed hold policies before and at time of transfer.

Recite from 06/24/2021
Based on observation, and interview, the facility failed to ensure that food items in the kitchen were labeled and dated. These deficient practices could likely lead to foodborne illnesses that could affect all 57 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 08/31/22).
The findings are:
A. On 08/31/22 at 10:43 AM, an observation of the Kitchen revealed the following items with no name, or expiration/use-by date:
1. an open bag of thickener not labeled or dated
2. An open bag of dry red crushed pepper, not labeled
3. large container of flour with no label or date
4. large Container of rice with no label or date
Refrigerator
5. 3 sandwiches, no label or date
6. 1 container of apple sauce, no date
7. 1 package of cheese, no date or label
8. 1 container of Tuna with no date or label
9. diced onion in a bag, not labeled or dated
B. On 09/07/22 at 03:57 PM, during an interview, the Dietary Manager confirmed that the items out of their original container and open food items should be labeled and dated.

Based on record review, and interview, the facility failed to develop and implement an accurate, effective, person-centered baseline care plan within 48 hours of admission to include Physician's Orders for 1 (R #159) of 1 (R #159) resident reviewed for baseline care plans. This deficient practice could likely lead to residents not receiving the appropriate care, services, and monitoring needed upon admission to the facility. The findings are:
A. Record review of R #159's admission Record revealed an admission date of 08/09/22 with diagnosis of Osteomyelitis (infection in the bone) of right foot and ankle and Type 2 Diabetes Mellitus (condition that results from insufficient production of insulin [hormone produced in the pancreas which regulates the amount of glucose in the blood] causing high blood sugar).
B. Record review of R #159's Physician's Orders revealed
1. Vancomycin HCl Solution (antibiotic medication used to treat many infections commonly used intravenously [medication given through a vein] as a treatment for complicated bone infections) 1250 mg (unit of measurement for the dose of medication) intravenously one time a day for osteomyelitis until 09/09/2022
2. Semglee Solution (man-made form of insulin that is produced in the body that works to lower blood sugar levels) 100 UNIT/ML (unit of measurement indicating the units of insulin in each milliliter) Inject 24 units (dosage of insulin) subcutaneously (given under the skin) at bedtime for diabetes
C. Record review of R #159's Care Plan dated 08/09/22 did not include interventions for Osteomyelitis being treated with intravenous antibiotics or Diabetes Mellitus requiring insulin.
D. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that R #159's baseline care plan did not include interventions (actions to help treat or cure a condition) for Osteomyelitis which required intravenous antibiotics or for Diabetes Mellitus which required insulin management. The DON confirmed that the baseline care plan should include interventions for these diagnoses.

Based on record review and interview, the facility failed to develop and implement an accurate, comprehensive person-centered care plan for 4 (R #21, R #23, R #33, and R #42) of 4 (R #21, R #23, R #33, and R #42) residents reviewed for care plans, when they failed to:
1) Develop a Care Plan for R #21's Enoxaparin Sodium Solution (medication that helps prevent the formation of blood clots given by subcutaneous injection [injection given under the skin] following surgery] and Eliquis (oral [taken by mouth] medication that helps prevent the formation of blood clots after surgery)
2) Develop a Care Plan for R #23's Primary diagnosis of Hepatic Failure (condition in which the liver is unable to perform its normal functions and is unable to rid the body of toxic substances such as ammonia [waste product made by the body during the digestion of protein], the build-up of ammonia can lead to nausea, vomiting, mental disorientation [altered mental state with loss of sense of time, identity, direction and place], confusion [change in mental status in which a person is not able to think with his or her usual level of clarity])
3) Develop a Care Plan for R #33's behaviors towards staff and residents
4) Develop a Care Plan for R #42's wounds to both lower extremities, upper back, right arm, right hip and coccyx (tail bone) and Heparin (medication that helps prevent the formation of blood clots)
These deficient practices could likely lead to residents not receiving the appropriate care and services including the residents preferences to help maintain the highest practicable well-being. The findings are:
R #21
A. Record review of R #21's admission record revealed an admission date of 05/27/22 with diagnosis of Displaced (type of fracture in which a bone breaks into two or more parts and the bones get displaced from their original position) Bimalleolar (type of broken ankle that happens when parts of both the tibia [known as the shinbone, the larger, stronger, and anterior [frontal] of the two bones in the leg between the knee and ankle] and fibula [thinner of the two bones in the leg between the knee and the ankle] are broken) fracture (medical term for a broken bone) of right lower leg.
B. Record review of R #21's Physician's Orders revealed:
1. Enoxaparin Sodium Solution 40MG/0.4ML (medication strength indicating 40 mg of medication is in 0.4 milliliters of solution) Inject 40 milligram (dosage of medication being given) subcutaneously at bedtime for prevent [sic] blood clotting for deep vein thrombosis (medical term for blood clot) prophylaxis (measure taken to maintain health and prevent something from happening) after surgery; Discontinued date 07/22/22
2. Order start date 07/22/22 Eliquis Tablet 5 MG (Apixaban [generic name for Eliquis]) Give 5 mg (dosage of medication) by mouth two times a day for DVT (medical abbreviation for Deep Vein Thrombosis) prophylaxis
C. Record review of R #21's Progress notes revealed Physician's Progress note; Date of service: 06/13/22 cc (abbreviation for chief complaint also known as the primary reason for the visit): patient seen for DVT prophylaxis Assessment/Plan: DVT prophylaxis medication review, patient tolerated, no adverse response noted, continue to monitor for signs or symptoms of bleeding with anticoagulation therapy
D. Record review of R #21's Care Plan dated 05/31/22 did not have a care plan in place for potential side effects for Enoxaparin and Eliquis.
E. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that R #21's Care Plan did not include monitoring for the potential side effect of bleeding related to the medications Enoxaparin or Eliquis.
R #23
F. Record review of R #23's admission record revealed an admission date of 06/09/21 with primary diagnosis of Hepatic failure and coma [state of unconsciousness from which a person cannot be aroused, even by powerful stimuli]) unspecified (not specific) without coma
G. Record review of R #23's Physician's Orders revealed:
1. Lactulose Solution (medication used to help reduce blood ammonia levels that can cause serious neurological symptoms [seizures and coma] in advanced liver disease) 10 GM/15ML (medication strength indicating 10 grams of medication in 15 milliliters of solution) Give 30 ml (dosage of medication being given) by mouth one time a day for Hepatic Encephalopathy (loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage) May mix in with juice or drinks. Discontinued date 07/23/22
2.07/22/22: Send to ER for abdominal pain, altered mental status, nausea and vomiting, hepatic encephalopathy, and acute kidney injury (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days)
3. 07/23/22 Lactulose Solution 10 GM/15ML Give 30 ml by mouth twice a day for Hepatic Encephalopathy May mix in with juice or drinks.
H. Record review of R #23's Care Plan dated 06/17/21 did not include any interventions for diagnosis of hepatic failure.
I. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that R #23's Care Plan did not include interventions for primary diagnosis of hepatic failure. The DON confirmed that this admitting diagnosis should be part of R #23's comprehensive care plan.
R #33
J. Record review of R #33's Nursing Progress Notes revealed the following:
1. 7/17/2022 11:42 Behavior Note
Note Text: Resident was again heard yelling at a resident in her wheelchair that wanders around the halls . She was going down the hallway and resident threatened to hit her with the grabber (device used to grab things). She was yelling at her telling her that she had no business down this hallway because she did not live here. [name of R #33]was turned around and led in the other direction towards her room to avoid further confrontation. [name of R #33] was again reminded that residents had the right to walk or wheel themselves down the hallways. Again, resident threatened to hit her with her grabber if she came near her room again. This nurse attempted to talk to resident about being aggressive with other residents, and she stated again that she would be talking to the administrator.
2. 7/17/2022 09:15 Behavior Note
Note Text: Resident was heard yelling at her roommate from the Nurses station . resident was yelling at her roommate because she said she had stunk up her bathroom . Resident continued to yell at her roommate and this nurse, stating that they were all pigs and she did'nt [sic] want them using her bathroom. Her roommate was asked to leave the room to let resident cool off. 20 minutes later, her roommate was attempting to go back in her room and resident [name of R #33] was standing in the doorway holding her grabber with the long handle, threatening to hit her if she entered the room. She stated that her roommate needed to find somewhere else to live. This nurse spoke with resident again, and explained that her roommate had just as much right to be in her room. Resident threatened to call the police on this nurse and roommate, and stated that she was going to go to the administrator and demand that they move her roommate somewhere else.
3. 6/7/2022 12:41 Social Services Note
Note Text: Staff continue to report that resident is being verbally aggressive. This worker and administrator contacted resident's daughter/POA (power of attorney) to notify her of the situation . POA stated that these behaviors are not new for her mother. She states that her mother has always made accusations towards other residents and staff .
4. 6/3/2022 15:37 Social Services Note Late Entry:
Note Text: This worker and the administrator met with resident to discuss recent behaviors towards staff. Resident was not consistent with her statements. She was accusing male staff of stealing from her, however when asked about specific items and staff, she changed her statement and was focused on an item in her closet that she claimed did not belong to her. The item is on resident's original inventory. Resident denies any behaviors, but she did raise her voice at this worker several times during the conversation. This worker and administrator notified resident that her guardian angel will review her inventory with her. Resident was okay with that.
5. 5/18/2022 06:26 Behavior Note
Note Text: Resident yelling and pointing her finger at this nurse d/t (due to) administering eye drops . Resident was totally out of control yelling to this nurse and pointing her finger like when you are scolding a child. Resident then refused all her medications .
6. 5/8/2022 10:23 Behavior Note
Note Text: Resident was cursing and yelling at CNA when they were in room trying to help her get ready for breakfast. Resident cont. (continued) to tell staff Shut up and do what they are told. Education given to resident by nurse about effective communicating between herself and staff. Education was ineffective.
7. 5/7/2022 08:30 Behavior Note
Note Text: Nurse was called into the room due to resident yelling at CNAs and telling them to shut up. Resident was upset at staff stating that we do not know how to do our jobs . Resident was stating rude comments about her roommate and other residents . Resident stated that she was going to report us staff and nurse explained that that is okay .
K. Record review of R #33's Care Plan revealed no interventions for behaviors towards staff or residents.
L. On 09/07/22 at 9:56 AM, during an interview, the Social Worker (SW) stated that R #33 was having problems with her roommate and staff. The SW confirmed that R #33 can give an attitude, and she was verbally abusive. The SW did confirm this is a know thing with the staff that she has behaviors.
M. On 09/07/22 at 12:34 PM, during an interview the DON confirmed that R #33's Care Plan did not have interventions for behaviors towards staff and residents. The DON confirmed that should have been updated.
R #42
N. Record review of R #42's admission record revealed an admission date of 06/30/22.
O. Record review of R #42's Physician's Orders revealed: Heparin Sodium Solution (medication used to prevent blood from clotting in the heart or blood vessels during and after surgery, and for initial treatment of various heart, lung, or circulatory disorders in which there is an increased risk of blood clotting) 5000 UNIT/ML (unit of measurement indication amount of heparin in 1 milliliter) Inject 1 ml (abbreviation for milliliter; dosage of medication) subcutaneously two times a day for DVT prophylaxis
P. Record review of R #42's Progress notes revealed admission note; 06/30/22: Resident has multiple covered wounds in both lower extremities, upper back, right arm, right hip and coccyx.
Q. Record review of R #42's care plan dated 07/07/22 revealed no interventions in place for use of Heparin and no interventions for R #42's multiple wounds present upon admission.
R. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that R #42's Care Plan did not include interventions for the use of Heparin or for the wounds present on admission. The DON confirmed that all wounds and Heparin should be care planned due to risk for bleeding.

Based on interview, and record review, the facility failed to provide quality of care for 1 (R #33) of 1 (R #33) residents review for food, when the facility changed R #33's dietary order from mechanical soft diet chopped constancy (chopped up foods) to regular consistency (regular whole foods) on 07/26/22 without the Medical Providers approval. This deficient practice could likely result in the resident having the wrong consistency diet and not being able to consume her food. The finding are:
R #33
A. Record review of R #33's Physician's Orders revealed the following:
1. 04/18/22 CCD diet (diabetic diet), Mechanical Soft texture, Thin Liquids consistency liberalized.
B. On 09/07/22 at 2:32 PM, during an interview the Dietary Manager (DM) stated that R #33 is on a diabetic diet regular constancy. The DM stated that R #33 was on a mechanical soft diet but had been upgraded. The DM explained that she had received a note from R #33's dentist saying that R #33 could do a regular diet. The DM stated that she talked to the nurse on duty who was the Infection Preventionist (IP). The DM stated that the IP stated it was ok to put R #33 on a regular consistency diet because R #33's provider was consulted and was ok with it. The DM confirmed that this happened around 07/26/22 and that R #33 had been receiving regular consistency diet since then. The DM also confirmed that R #33's diet order was never changed to regular diet.
C. Record review of the Note from Dental Office no date revealed the following:
a hand written note on a letter head from local dentist office. To whom it may concern, patient is able to have solid food, does not need to be blended or cut up. Thank you! Call if any questions! No signature or name of person who wrote it.
D. Record review of R #33's Meal ticket dated 09/07/22 revealed regular consistency controlled carbohydrates diet.
E. On 09/07/22 at 2:55 PM, during an interview the IP confirmed that the DM did contact her about R #33's note from the dentist stating it was ok for R #33 to have a regular consistency diet. The IP stated that she called the provider about upgrading to regular diet, and he stated it was ok. The IP was unsure if she (herself) had documented the conversation with the provider, but confirmed that she did not change the dietary order. The IP stated that the reason R #33 was on the mechanical soft was because she did not have dentures. The IP stated that R #33 had gotten the dentures at that time.
F. On 09/07/22 at 2:57 PM, during an interview, the DON confirmed that there was no documentation of the conversation with the provider and the IP regarding R #33's diet order.
G. On 09/07/22 at 3:10 PM, during a joint interview, the Nurse Practitioner (NP provider) confirmed that the IP did contact him about R #33's diet order. The NP stated that he did not agree that the Dentist was in a position medically to make changes to R #33's diet order, and wanted another consult with the dentist to ensure R #33's dentures fit properly. The NP continued to state that once that was done Speech Therapy could reevaluate and determine if the diet could be upgraded to regular consistency diet.
H. On 09/07/22 at 3:05 PM, during an interview, the Speech Therapist (ST) stated that R #33 had issues chewing and she was placed on mechanical soft chopped consistency. The ST stated that R #33 did express the want to upgrade to regular consistency, and she tried two times to see if R #33 could be upgraded but R #33 was not able to. The ST stated that R #33 told her that she could not chew the food no matter what. The ST stated that she was unaware that the dentist wanted to upgrade R #33's diet, and confirmed that the dentist would not normally do this. The ST stated that normally the provider of the facility would contact her to she if the resident could be upgraded, and that did not happen with R #33. The ST confirmed that R #33 should still be on mechanical soft chopped consistency diet. The ST confirmed that R #33 not was at a big risk to her health because R #33 problem was mainly chewing issues.

Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and services for 1 (R #42) of 1 (R #42) residents sampled for dialysis. This deficient practice could likely result in residents not receiving the care and monitoring they need after dialysis treatment. The findings are:
A. Record review of R #42's admission record revealed an admission date of 06/30/22 with diagnosis of Dependence on Renal (medical term for kidney) dialysis.
B. Record Review or R #42's Physician's orders revealed: 07/05/22: Dialysis tues (Tuesday), thurs (Thursday), Sat (Saturday)
C. Record review of R #42's progress notes revealed:
1. 07/02/22 Medication Administration Note- away at dialysis
2. 07/07/22 Medication Administration Note-pt (abbreviation for patient) at dialysis
3. 07/09/22 Medication Administration Note-Resident at dialysis
4. 07/14/22 Medication Administration Note-Resident at dialysis
5. 07/16/22 Medication Administration Note-Resident at dialysis
6. 07/19/22 Medication Administration Note-dialysis
7. 07/21/22 Medication Administration Note-Resident out of facility for Dialysis
8. 07/23/22 Medication Administration Note-Resident at dialysis
9. 7/26/22 Medication Administration Note-Resident is away at Dialysis
10. 7/30/22 Medication Administration Note-Resident is at Dialysis
11. 08/02/22 Medication Administration Note-Resident at dialysis
12. 08/04/22 Medication Administration Note-pt at dialysis
13. 08/06/22 Medication Administration Note-Resident currently at dialysis
D. Review of R #42's medical record miscellaneous tab revealed the following:
1. No Dialysis communication forms, were found for 07/02/22, 07/07/22, 07/14/22, 07/16/22, 07/19/22, 07/21/22, 07/23/22, 07/26/22, 07/30/22, 08/02/22 and 08/04/22.
2. Dialysis communication form, revealed the following: Under the heading Dialysis to complete the following dates 07/09/22 and 08/06/22 had no documentation from the dialysis nurse.
E. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that all of R #42's Dialysis forms should be scanned into the miscellaneous tab.

Recite from 06/24/2021
Based on record review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could likely result in resident's not receiving the services that they require to provide the optimal quality of care. The findings are:
A. Record review of the facility schedule for August 2022 revealed no full time RN coverage.
B. On 09/08/22 at 3:59 PM, during an interview, the Administrator confirmed the facility only has 2 RNs, the DON on the weekdays and the MDS on the weekends and they are not assigned to work the floor.

Based on record review, and interview, the facility failed to provide 12 hours of annual training that included the staff performance review and the facility assessment for 3 (CNA #12, CNA #13, and CNA #14) of 3 (CNA #12, CNA #13, and CNA #14) CNAs reviewed for 12 hours of annual training. This deficient practice could likely result in staff not receiving the proper training's for areas needing improvement or for special needs populations they care for. The finding are:
A. Record review of the employee records revealed the following:
1) CNA #12 had not completed training that included the staff performance review or the facility assessment.
2) CNA #13 had not completed training that included the staff performance review or the facility assessment.
3) CNA #14 had not completed training that included the staff performance review or the facility assessment.
B. On 09/08/22 at 4:04 PM, during an interview the ADON confirmed that the facility was not using the performance evaluations or the facility assessment for the 12 hours of annual training's.

Based on record review, and interview, the facility failed to follow pharmacy recommendations for all 58 residents in the facility (residents were identified by the Resident matrix provided by the Administrator on 08/31/22), when they failed to:
1) Receive the pharmacy recommendation for June 2022 for all 58 residents,
2) Follow the pharmacy recommendation to provide rationale (reason why) for R #25's PRN (as needed) Lorazepam (antianxiety) longer than 14 days.
3) Follow Pharmacy recommendation for R #21, to update the directions on the MAR (Medication administration Record) to monitor and report any signs and symptoms of bleeding.
4) Follow Pharmacy recommendation for R #40, to add a standing order for PRN (as needed) Naloxone (generic name for Narcan a medication used for the emergency treatment of known or suspected opioid overdose) to the MAR.
These deficient practices could likely result in resident taking medication longer than needed if pharmacy recommendations are not addressed. The finding are:
June Monthly Review
A. On 09/06/22 at 10:46 AM during an interview, the DON confirmed that the monthly Pharmacy Review for June 2022 was not available (as the facility did not have it).
R#25
B. Record review of R #25's Physicians Orders revealed the following:
1. 7/21/2022 LORazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours as needed for anxiety.
C. Record review of R #25's Care Plan revealed the following:
Resident on psychotropic medication (is any drug that affects brain activities associated with mental processes and behavior) r/t (related to) antianxiety mood disorder and depression
Potential to develop side effect from the medication .
-Monitor for side effects .
-Monitor target behavior and document
-Provide distraction or diversional activities
-Psych consult as needed
D. Record review of R #25's Medication Administration Record (MAR) for September 2022 revealed the following
1. 07/21/2022 LORazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours as needed for anxiety was documented as not given.
E. Record review of R #25's MAR for August 2022 revealed the following:
1. 7/21/2022 LORazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours as needed for anxiety was documented as not given.
F. Record review of R #25's Pharmacy Review for August 2022 revealed the following:
1. PRN psychotropic orders (LORazepam) can not exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order. No documentation from the provider was found.
G. On 09/07/22 at 12:28 PM, during an interview the DON confirmed that the facility did receive the pharmacy recommendations later than usual (within days of pharmacy review) in August 2022, and the facility had not received the provider documentation yet. The DON did confirm that because R #25 did not receive the PRN lorazepam that the medication should have been reevealuated to see if R #25 needed it and discontinued. The DON also confirmed that R #25 should not have had order for PRN lorazepam longer than 14 days without provider rationale.
R #21
H. Record review of R #21's Physicians Orders revealed the following: Eliquis Tablet (oral [taken by mouth] medication that helps prevent the formation of blood clots after surgery and can cause abnormal bleeding) 5 MG (strength of medication) Give 5 mg (dosage of medication) by mouth two times a day for DVT (medical abbreviation for Deep Vein Thrombosis) prophylaxis
I. Record review of R #21's Pharmacy Review dated 08/07/22 revealed the following: The resident has an order for Eliquis. Please update the directions (instructions on MAR for the staff giving medications to follow) to monitor and report any signs or symptoms of bleeding.
R #40
J. Record review of R #40's Physicians Orders revealed the following: traMADol HCL Tablet (medication used to help relieve moderate to moderately severe pain) 50 MG (strength of pain in milligrams) give 25 mg (dosage strength of medication) by mouth two times a day for LLE (abbreviation for left lower extremity) pain.
K. Record review of R #40's Pharmacy review dated 08/07/22 revealed the following: The resident has an order for Tramadol please add the standing order for PRN (as needed) Naloxone to the MAR since Tramaodl is considered an opioid analgesic (pain relievers used for moderate to severe pain that act on the central nervous system [part of the nervous system that consists of the brain and spinal cord].
L. On 09/08/22 at 5:50 PM, during an interview, the DON confirmed that R #21's and R #40's pharmacy recommendations had not been completed.

Based on record review, and interview, the facility failed keep residents free from unnecessary Psychotropic medications for 1 (R #25) of 5 (R #9, R #21, R #22, R #25, R #34) sampled for unnecessary medications, when they failed to:
1) Provide rationale (reason for) for R #25's PRN (as needed) Lorazepam (antianxiety) longer than 14 days, and
2) Provide a correct diagnosis for R #25's antipsychotic (used to treat psychotic symptoms such as hallucinations, and delusions) medication QUEtiapine Fumarate ordered to treat dementia.
This deficient practice could likely result in residents receiving psychotropic medications longer than needed. The findings are:
A. Record review of R #25's Physicians Orders revealed the following:
1. 7/21/2022 LORazepam Tablet 1 MG. Give 1 tablet by mouth every 8 hours as needed for anxiety.
2. 7/20/2022 QUEtiapine Fumarate Tablet 25 MG. Give 25 mg by mouth two times a day for Dementia.
B. Record review of R #25's Care Plan revealed the following:
Resident on psychotropic medication r/t (related to) antianxiety mood disorder and depression. Potential to develop side effect from the medication .
-Monitor for side effects .
-Monitor target behavior and document
-Provide distraction or diversional activities
-Psych consult as needed
C. Record review of R #25's Medication Administration Record (MAR) for September 2022 revealed the following:
1. 7/21/2022 (medication order date) LORazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours as needed for anxiety was documented as not given.
2. 7/20/2022 QUEtiapine Fumarate Tablet 25 MG
Give 25 mg by mouth two times a day for Dementia was documented as given as ordered.
D. Record review of R #25's MAR for August 2022 revealed the following:
1. 7/21/2022 LORazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours as needed for anxiety was documented as not given.
2. 7/20/2022 QUEtiapine Fumarate Tablet 25 MG
Give 25 mg by mouth two times a day for Dementia was documented as given as ordered.
E. On 09/07/22 at 12:28 PM, during an interview the DON confirmed that R #25 should not have been on the PRN Lorazepam longer than 14 days without provider rationale. The DON also confirmed that dementia is not an appropriate diagnosis for R #25's quetiapine fumarate.

Based on observation, and interview, the facility failed to properly label medication for all 5 residents on North unit (residents were identified by the resident matrix provided by the Administrator on 08/31/22), when they failed to label 9 open over-the-counter medications with an open date in the medication cart. This deficient practice could likely result in resident receiving expired medications. The finding are:
A. On 09/08/22 at 9:20 AM, during an observation of the medication cart on north hallway revealed the following over the counter medications open and not dated:
1. Acidophilus (probiotic)
2. Vitamin D3 25 mg
3. Aspirin 81 mg
4. Ferrous Sulfate 325 mg (iron supplement)
5. Loratadine 10 mg (antihistamine)
6. Sodium Chloride tablets (salt) 1 gm
7. Vitamin B-12 500mg
8. Melatonin (sleep aide) 5 mg
9. Vitamin D3 125 MCG
B. On 09/08/22 at 9:22 AM, during an interview the ADON confirmed that the 9 medications were open and not dated.
C. On 09/08/22 at 12:29 PM during an interview the DON confirmed that the 9 open medications should have an open date on them.

Based on observation, and interview, the facility failed to follow proper infection control practices for 13 residents (R #5, R #10, R #12, R #14, R #15, R #16, R #24, R #29, R #32, R #33, R #43, R #52, and R #53) of 13 residents (R #5, R #10, R #12, R #14, R #15, R #16, R #24, R #29, R #32, R #33, R #43, R #52, and R #53) randomly sampled, when 4 staff members failed to wear their masks in resident care areas. This deficient practice could likely result in the spread of infection and could cause residents to become sick from the staff. The findings are:
South Hallway
A. On 09/08/22 at 8:20 AM, during an observation of South Hallway, revealed CNA #9 was wearing a surgical mask underneath her N-95 mask as she walked past R #33.
B. On 09/08/22 at 8:20 AM, during an interview CNA #9 confirmed that she was wearing the surgical mask under the N-95 mask and that she had received training on personal protective equipment (PPE).
C. On 09/08/22 at 9:03 AM, during an interview the DON confirmed that CNA #9 should not be wearing a surgical mask under her N-95 mask in resident care areas because the surgical mask prevents the N-95 mask from sealing.
Main Dining Room
D. On 09/08/22 at 12:34 PM, during an observation of the main dining room, revealed 8 residents and Dietary Staff (DS) #1 sitting in the dining room with her N-95 mask below her nose. CNA #10 was observed sitting next to DS #1 not wearing her N-95 mask with her mouth and nose exposed. CNA #10 identified the resident eating in the dining room as R #5, R #10, R #12, R #16, R #24, R #29, R #32, and R #43.
E. On 09/08/22 at 12:35 PM, during an interview DS #1 stated that she could be without her N-95 mask and eye protection because she was on break.
F. On 09/08/22 at 12:36 PM, during an interview, CNA #10 confirmed that she was not wearing her not wearing her N-95 mask or eye protection. CNA #10 confirmed that she should have been wearing her N-95 mask because residents were in the dining room eating.
Second Dining Room
G. On 09/08/22 at 12:41 PM, during an observation of the Second Dining Room revealed CNA #11 had her N-95 mask pulled down below chin in the dining room with 4 residents also in the dining room. CNA #10 identified the residents eating in the dining room as R #14, R #15, R #52, and R #53.
H. On 09/08/22 at 12:41 PM, during an interview CNA #11 confirmed that she did not have an N-95 mask on. CNA #10 confirmed that she should have had it on because there were resident in the dining room.
I. On 09/08/22 at 12:44 PM, during an interview the Infection Preventionist confirmed that Staff are to wear their N-95 mask in resident care areas.

Based on record review and interview, the facility failed to ensure that all staff were tested two times a week for Covid-19 (virus that causes a variety of respiratory, gastrointestinal, and neurological diseases] which is characterized mainly by fever and cough). At the time of the recertification survey the facility should have been testing staff twice weekly due to facility having a Covid-19 outbreak (when 1 covid-19 positive staff or resident is identified) . This deficient practice could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22) and could likely lead to lack of identifying Covid-19 positive staff or residents and continue the spread of the infection within the facility. The findings are:
A. Record review of staff Covid-19 test results dated 08/19/22 revealed that Staff #1 tested positive for Covid-19. Review of the test results revealed that staff and residents have only been tested on ce weekly.
B. On 09/08/22 at 9:25 AM, during an interview, the IP (Infection Preventionist; the nurse responsible for preventing the spread of infections in a health-care setting) confirmed that they are still testing due to having positive staff members. Per the IP, she started as the IP approximately 08/15/22 and they have been in outbreak for the month of August 2022.
C. On 09/08/22 at 4:45 PM, during an interview, the IP confirmed that she was not aware that the county positivity rate was currently 15% or that she was to conduct testing of staff and residents twice weekly due to having an outbreak.

Based on observation, and interview, the facility failed to maintain repairs on the facility's van that is used to transport residents to and from appointments. This deficient practice could likely affect all 57 residents (resident were identified on the census provided by the Administrator on 08/31/22.) This could lead to resident's being in danger of harm or death if the Facility Van is not operating in a safe manner during a transport.
The findings are:
A. On 09/01/22 at 1:35 PM, during an interview, R #4 revealed that the facility van was having issues with the air conditioner in the back. R #4 reported having to use alternative transportation (through insurance provider) that has not been reliable and very inconvenient.
B. On 09/01/22 at 3:00 PM, during an interview, R #3 revealed that the van only has 1 seatbelt in the back and only 1 resident can be transported at a time.
C. On 09/06/22 at 9:18 AM, during an interview, the Transporter confirmed that the van only has one seatbelt in the back and the air conditioner in the back does not work. The Transporter reported scheduling resident appointments in the morning because of the air conditioner not functioning and called the resident's insurance provider to arrange transportation. He also confirmed that the alternate means of transportation through the insurance is not reliable.
D. On 09/07/22 at 2:07 PM, during an interview, the Maintenance Director confirmed the issues with the van's air conditioner. He revealed that he was asked to provide a repair quote to Corporate and has not received an approval for the repairs.
E. On 09/08/22 at 3:59 PM, during an interview, the Administrator confirmed the maintenance issues with the van.

Based on record review, and interview, the facility failed to provide abuse, neglect, and exploitation training to 3 (LPN #7, LPN #8, and LPN #9) of 3 (LPN #7, LPN #8, and LPN #9) staff members sampled for abuse, neglect, and exploitation training. This deficient practice could likely result in staff not knowing who, what, and when to report things like abuse, neglect and exploitation. The findings are:
A. Record review of the employee records revealed the following:
1) LPN #7 no completed training for abuse, neglect, and exploitation.
2) LPN #8 no completed training for abuse, neglect, and exploitation.
3) LPN #9 no completed training for abuse, neglect, and exploitation.
B. On 09/08/22 at 4:04 PM, during an interview, the ADON confirmed that LPN's have not completed the abuse, neglect, and exploitation training.

Based on record review and staff interview, the facility failed to ensure the facility assessment was accurate and current. This could affect all 57 residents in the facility (residents were identified by census list provided by the Administrator on 08/31/22). This deficient practice could lead to the residents not receiving the care they need to reach their highest well-being. The finding are:
A. Record review of the Facility Assessment revealed: The document is titled Facility Assessment Worksheet was dated 07/29/21.
B. On 09/08/22 at 3:59 PM, during an interview, the Administrator stated that he did not have a revised Facility Assessment.