Every finding on record at Albemarle Health & Rehabilitation Center

Based on observation, interview, record review, document review, and facility policy review, the facility failed to: provide supervision for a resident identified as having exit-seeking behaviors; develop and implement interventions to prevent a resident elopement; ensure the accuracy of elopement risk assessments and timeliness of reassessment upon the identification of exit-seeking behaviors; ensure the facility's protocol for a missing resident (Code Orange) was promptly and correctly implemented when Resident #127 eloped from the facility on 05/11/2025 without staff knowledge; ensure Resident #133, identified by the facility as being at risk for elopement had their admission Record included in the facility's elopement binder; and ensure Resident #133's wander guard was securely attached. These failures affected 2 (Resident #127 and Resident #133) of 4 sampled residents reviewed for accidents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, serious harm, serious impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, F689, Accidents at a scope and severity of J. The IJ began on 05/11/2025 when Resident #127 identified by the facility as having exit-seeking behaviors, eloped from the facility without staff knowledge and the facility failed to timely and correctly implement their missing person protocol. The survey team notified the Administrator, the Staff Development Coordinator/Infection Preventionist (SDC/IP), and the Regional Director of Clinical Services of the IJ and provided the IJ template on 10/23/2025 at 4:40 PM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on 10/23/2025 at 11:20 PM. The IJ was removed on 10/24/2025, after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F689 remained at a lower scope and severity of D, isolated, with the potential for more than minimal harm. Findings included: A facility policy titled, Elopement/Exit-Seeing Behaviors, effective 01/29/2024, revealed The Elopement Risk Tool Assessment will be used to evaluate a patient's risk of elopement/exit seeking behaviors. According to the policy, 1. Upon admission to the center, each patient will be assessed for elopement/exit seeking history and/or behaviors using the Elopement Risk Tool Assessment and 4. If a patient begins demonstrating unsafe and exit seeking behaviors after the initial admission to the center, utilize the Elopement Risk Took Assessment as needed and re-evaluate at least quarterly and update care plan accordingly.1. A facility policy titled, Code Orange, effective 01/23/2020, revealed Immediately upon notification of a missing patient [resident], Code Orange will be activated throughout the Health and Rehabilitation Center. All established search and recover plans will be initiated in full force to locate and secure the patient as quickly as possible. All staff members will be pre-assigned and trained on their duties and responsibilities during this critical event. The policy specified, Code Orange First 15 Minutes Critical Action Plan Notify: Any time a staff member identifies that a patient is missing they must immediately notify the Charge Nurse/or Supervisor. Announce: The Charge Nurse/Supervisor will immediately activate Code Orange by announcing three times the following message on the paging system: Attention All Staff Code Orange Mr./Mrs. (Patient's Name) please come to the Nursing Station. Secure: Pre-assigned staff members will immediately take their pre-assigned posts at all exit doorways. Search: Designated staff members will immediately search the entire premises sweeping all assigned perimeters both inside and outside the Center. Report: Convene in the lobby 15 minutes from the announced code to report findings from assigned perimeter sweeps. Per the policy, 5. If the patient is not found the Administrator/Assistant Administrator or DON [Director of Nursing] will assume the role of Search Coordinator. Based on the search findings reported by actions already taken by the staff, the Search Coordinator will reactivate a second 15-minute expanded search and recovery, assigning staff members to predetermined specific perimeters in and outside of the building. According to the policy, 7. If the patient is not found within thirty minutes from the initial alert the Search Coordinator will activate a Phase II Extended Search which will include contacting 911/Police, the Attending Physician, the Responsible Party, the Medical Director, the Regional [NAME] President of Operations, and Corporate Compliance Intermediary. 8. The company Missing Patient Profile Extended Search form will be copied and distributed to all search members. 9. The Administrator and his/her designated staff will continue intense search efforts with local authorities until the patient is located. 10. Documentation on the following forms is to be timely completed and submitted as directed: Missing Patient Initial Search . Phase 1 Missing Patient Profile Extended Search . Phase II. An admission Record revealed the facility admitted Resident #127 on 04/22/2025. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness, malignant neoplasm of brain, dementia, seizures, cognitive communication deficit, and difficulty walking. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed Resident #127 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. According to the MDS, the resident did not exhibit any wandering behaviors during the last seven days. Resident #127's Care Plan Report included a focus area created 04/22/2025, that indicated the resident was at risk for elopement related to dementia. Interventions directed staff to complete an elopement risk assessment as needed (initiated 04/22/2025). Resident #127's Elopement Risk Tool - V 4 signed by Licensed Practical Nurse (LPN) #18 and dated 04/22/2025, revealed the resident was at low risk for elopement. The Elopement Risk Tool did indicate the resident had a diagnosis of dementia/cognitive impairment. During an interview on 10/17/2025 at 3:20 PM with the Director of Nursing (DON) and the Staff Development Coordinator/Infection Preventionist (SDC/IP), the DON stated Resident #127's elopement risk assessment dated [DATE] should have been marked to indicate the resident had a diagnosis of dementia. Resident #127's progress note electronically signed by Licensed Practical Nurse (LPN) #34 and dated 04/23/2025 at 3:36 PM, indicated the resident had a history of exit-seeking behavior while at the hospital. The progress note indicated the resident wandered to the other units during the day but could be redirected. Per the progress note, due to safety concerns a wander guard was placed on the resident's left arm. During an interview on 10/22/2025 at 12:04 PM, LPN #34 stated the progress note electronically signed by her and dated 04/23/2025 indicated Resident #127 wandered to the other units in the facility during the day. LPN #34 stated due to the resident's wandering, she notified the provider to get an order for a wander guard for safety reasons. Resident #127's Order Summary Report revealed an order dated 04/23/2025, that directed staff to check the function of the resident's wander bracelet weekly every Wednesday and check the resident's wander guard band on the resident's left arm every shift. During an interview on 10/18/2025 at 6:19 PM, LPN #18 stated Resident #127 had exit-seeking behaviors and that was why a wander guard was placed on the resident. When asked if Resident #127 tried to leave the facility on 05/11/2025, LPN #18 stated around shift change, the resident walked to the door a few times and had to be redirected. Per LPN #18, geriatric psychology came to talk with the resident on 05/11/2205. Resident #127's progress note electronically signed by the Psychologist and dated 05/11/2025 at 1:00 AM, indicated the resident approached the Psychologist and reported they were ready to leave the facility on 05/11/2025 because no one would help them find out what was going on with their treatment. According to the progress note, the nursing staff reported the resident tried to leave the facility a couple of times on 05/11/2025. During an interview on 10/22/2025 at 9:22 PM, the Psychologist stated over the course of the resident's stay in the facility, they tried to leave the facility a couple of times. The Psychologist stated Resident #127 had a brain tumor, bouts of paranoia and did not make connections between their symptoms and reality. The Psychologist stated he thought the best thing for the resident was to speak with the nurse practitioner first thing Monday morning (05/12/2025). The Psychologist stated he tried to settle the resident down in an attempt to convince the resident to hang in until the next morning (05/12/2025). When asked what the resident's demeanor was at the conclusion of his visit, the Psychologist stated, not in good shape and that he told the nurse that the resident needed to be checked on. Resident #127's progress note electronically signed by LPN #20 and dated 05/11/2025, indicated At resume of shift rounds resident was noted to be alert and was seating in [his/her] room watching TV. At 8pm resident still in [his/her] room where [he/she] received [his/her] night medications at 08:09pm. [Resident #127] was cooperative all through. At 08:45pm resident was walking down the hallway and said I have gotten all my medications? Writer said yes, is there anything you need? [he/she] said NO, and [he/she] sat down in the small living room between the 200 and 300 unit, [he/she] was reading a magazine. At 08:55pm writer checked on resident in small living room, [he/she] wasn't there and not in [his/her] room. Writer called the CNA [certified nursing assistant] and a search was done in the 200 unit. Writer informed other units a search was done. DON, Administrator and 911 was called. RP [responsible party] made aware. Resident #127's progress note electronically signed by LPN #20 and dated 05/11/2025 at 11:01 PM, indicated Resident [family member] called the facility informing us that resident called [their spouse], and [he/she] wants us to know this. 911 dispatched informed us that resident was identified in a nearby school compound. Resident returned with 911 officer in a stable condition. [Resident #127] also stated [he/she] took off [his/her] alarm bracelet. During an interview on 10/16/2025 at 12:32 PM, LPN #20 stated Resident #127 was an exit-seeker and on 05/11/2025 around 7:00 PM/8:00 PM, the resident was seated in the community room and she went to attend to a concern in another resident's room and when she returned, she noticed the resident was not in the community room or their room. LPN #20 stated she and another aide searched the resident's room, the bathroom, and the living room and did not find the resident. LPN #20 stated she called a Code Orange and everyone started to look for the resident. LPN #20 stated she did not hear a door alarm sound, so she felt the resident was still in the facility. LPN #20 stated they searched the inside of the facility for about 15 minutes then decided to call the Administrator, DON, and 911. LPN #20 stated when the resident returned to the facility, the resident stated they took off their wander guard. Per LPN #20, the documentation in the resident progress note that specified the resident went missing at 8:55 PM was accurate. During an interview on 10/17/2025 at 3:34 PM, LPN #17 stated she was aware Resident #127 was an elopement risk and recalled the incident when the resident eloped from the facility. According to LPN #17, LPN #20 informed her that she could not find Resident #127. LPN #17 stated they went room to room and the outside perimeter of the facility looking for the resident. LPN #17 stated she did not recall a Code Orange being announced. When asked what time Resident #127 was discovered missing, LPN #17 replied she really did not know, it was late evening after 8:00 PM. LPN #17 stated she was unaware who all LPN #20 had informed or who found the resident, but that a family member of the resident called the facility to inform the staff, Resident #127 was located at a ball field. When asked what time the police was called, LPN #20 stated she did not know. LPN #20 stated she was not sure if she completed the Code Orange paperwork. During a follow-up interview on 10/18/2025 at 4:44 PM, LPN #17 was asked if she heard anyone announce a Code Orange over the facility's intercom/paging system and she replied, no. When asked should a Code Orange have been announced, LPN #17 answered, absolutely. LPN #17 stated she was not aware what all LPN #20 did before she informed her that the resident was missing. According to LPN #17, all the staff that worked in the facility during the time the resident eloped did not participate in the search for the resident. During a follow-up interview on 10/21/2025 at 3:26 PM, LPN #17 stated LPN #20 came and told her that resident was missing and she followed LPN #20 back to Unit 200 where all rooms were searched, then they searched the gym and service hall and outside perimeter of the facility. LPN #17 stated areas that had locked doors were not searched and no one was stationed at all exit doorways. When asked if other units were searched, LPN #17 stated not that she recalled, but should not speak about LPN #20 did before she was notified. LPN #17 stated it was her understanding that the resident had been missing about an hour before LPN #20 notified her the resident was missing. LPN #17 acknowledged no one from the administrative staff talked during the elopement incident investigation. Contained within the facility's investigation was written statement for an incident dated 05/11/2025 by the former Administrator, which indicated I was called at 10:48 pm on Sunday (05/11/2025) night and was notified that resident [Resident #127] was missing. During an interview on 10/17/2025 at 1:42 PM, the former Administrator stated she could not recall the details of the elopement, did not recall the name of the resident, who notified her, or how long the resident was missing but that a nursing staff member called her and she asked if a Code Orange had been called and she was told yes, so she instructed the staff to call the police. When asked why the nurse documented the resident was missing at 8:55 PM and she was not notified until 10:48 PM, the former Administrator stated she did not know why. The former Administrator stated she did recall Resident #127 informed the staff that they cut off their wander guard. The former Administrator stated the staff never found the resident's wander guard. During a follow-up interview on 10/18/2025 at 1:26 PM, the former Administrator she did not know how staff announced the Code Orange but it should have been announced over the facility's intercom system. The former Administrator explained the process for a Code Orange. Per the former Administrator, Code Orange should be announced three times over the facility's intercom system, the search should start in the inside perimeter of the facility and staff had assignments on where they should search. After 15 minutes, staff should search the outside perimeter of the facility and if not found, the search should extend to the community. When asked when the police should be called, the former Administrator stated she did not remember what the policy specified, but she had the staff to call the police immediately. The former Administrator was asked if during the investigation, did the facility determine what door the resident exited out of and she stated she did not recall. The former Administrator was asked if the facility replaced supervision of the resident with a wander guard and she replied, there was no reason to believe Resident #127 needed anything else. The former Administrator acknowledged she was not aware Resident #127 voiced to the Psychologist earlier in the day (on 05/11/2025) that they wanted to leave the facility. During an interview on 10/18/2025 at 10:38 PM, a dispatcher with the local police department stated a nurse named (LPN #20) called the police department on 05/11/2025 at 10:52 PM and reported a resident was missing. During an interview on 10/20/2025 at 10:42 AM, a sergeant with the local police department stated on 05/11/2025 at 11:22 PM, the resident was found by a police officer at the baseball park. Per the sergeant, a family member of the resident called the police department at 11:18 PM and stated they pinged the resident's cell phone and notified the local police. During an interview on 10/17/2025 at 3:13 PM, the Administrator acknowledged she did not work at the facility when Resident #127 eloped. The Administrator stated it was the facility's policy that administration be notified immediately when a resident was noted to be missing. When asked what interventions were in place to prevent the resident from eloping from the facility, the Administrator replied, a wander guard. During a follow-up interview on 10/18/2025 at 3:54 PM, the Administrator stated from a review of the facility's investigation, LPN #20 enacted the Code Orange and no other staff were interviewed during the investigation of Resident #127's elopement from the facility. The Administrator stated possibly more interviews were needed and should have been conducted. Per the Administrator, there was no documentation to indicate LPN #20 announced the Code Orange as specified in the facility's policy. During an interview on 10/21/2025 at 1:37 PM, the Maintenance Director stated a resident could only have exited out of the front door of the facility before 8:00 PM. When asked how a resident could exit out of the front door and the alarm not sound, the Maintenance Director stated only if an identification badge was scanned, otherwise, the alarm would have sounded. The Maintenance Director stated everyone should respond immediately to a Code Orange. The Maintenance Director stated when a Code Orange was activated, staff should start close perimeter of the facility then meet in the lobby after 15 minutes. Per the Maintenance Director, the Administrator would then select who would search the outside of the facility and then after 30 minutes if the resident had not been located, the police should be called. The Maintenance Director stated there was paperwork to complete for each Code Orange that was activated and it should have been completed by the person who announced the Code Orange. The Maintenance Director stated one copy of the paperwork should be placed in the Risk Assessment binder and another copy should be placed in the Master File binder. The Maintenance Director stated he could not locate any paperwork for the Code Orange that took place on 05/11/2025. During an interview on 10/18/2025 at 11:11 AM, CNA #19 was asked if she recalled the elopement that occurred on 05/11/2025. CNA #19 said yes that a resident was found at a ball field. Per CNA #19, prior to the resident elopement, she was on Unit 100 when got a telephone call from someone on the other unit who asked her if she saw the resident as the resident had been trying to leave. CNA #19 stated she then heard an alarm at the front door, went to the front door and was met by another aide, CNA #35. According to CNA #19, she and CNA #35 tried to redirect the resident and two other aides and a nurse arrived and took over the resident's care. CNA #19 stated then about 30-40 minutes later, she answered the facility phone and it was the resident's family member who stated, who stated you can not keep ahold of your residents. CNA #19 stated she asked the family member what they meant and that was when the family member reported the resident was at the ball field. Per CNA #19, a Code Orange had not been announced. CNA #19 stated she went to inform LPN #17 of what the resident's family member stated, but LPN #17 stated she was already aware. CNA #19 stated no one interviewed her or asked what she knew about the resident's elopement. During an interview on 10/18/2025 at 11:48 PM, CNA #31 acknowledged she worked in the facility on 05/11/2025. When asked how she was notified of the Code Orange, CNA #31 stated it was not announced on the facility's intercom system, that someone went around and said Code Orange. During an interview on 10/19/2025 at 8:39 AM, LPN #30 stated she was assigned to work Unit 300 on 05/11/2025. LPN #30 stated during medication administration around 9:00 PM, LPN #20 notified her a resident was missing. When asked how the Code Orange was announced, LPN #30 stated by word of mouth. Resident #127's medical record revealed no evidence of a completed elopement risk tool assessment once the resident displayed exit seeking behaviors or when the resident elopement from the facility without staff knowledge on 05/11/2025. During an interview on 10/17/2025 at 3:20 PM with the DON and the SDC/IP, the surveyor asked should an elopement risk assessment have been completed after the resident eloped from the facility on 05/11/2025, the DON stated yes and both the DON and the SDC/IP stated it was not done. During a telephone interview on 10/22/2025 at 8:33 AM, Resident #133's RP stated the facility was aware the resident was an elopement risk. The RP stated the resident had a wander guard that was supposed to alarm. Per the RP, it was the evening of Mother's Day (05/11/2025) when they were outside with another family member when the resident called the family member around 11:00 PM and stated they were at a baseball game, they were cold and needed to be picked up. The RP stated they thought the resident was having a bad dream. Per the RP, the family member pinged the resident's cell phone to determine the resident's location and saw that the resident was at a baseball field. The RP stated the family member ran into the house and called the facility. The RP stated the person who answered the phone at the facility placed them on hold and they heard a staff member say, it's the [family member], how do we tell [him/her] we don't know where [the resident] is. The RP stated then another person picked the telephone up and stated they were conducting a room search and that was when the family member reported to facility staff that the resident was at a baseball field. The RP stated the resident had gotten into the field and could not figure out how to get back out. The RP stated no one from the facility ever called them to notify them the resident was missing. During a follow-up interview on 10/22/2025 3:44 PM, Resident #133's RP stated they had the resident' cell phone call log for 05/11/2025, which showed the resident called them on 05/11/2025 at 11:08 PM to report they were at the baseball game, cold, and needed to be picked up. Review of Talk activity documentation for the billing period 04/21/2025 - 05/20/2025, provided by Resident #133's RP revealed a call from the resident's cell phone number to RP on 05/11/2025 at 11:08 PM During an interview on 10/20/2025 at 10:26 AM, the Administrator stated her expectation for the investigation was that a root cause analysis was determined so that the facility would know where the break down in the process was not followed. The Administrator stated she expected there should have been interviews with all the staff that worked and everyone who participated in the Code Orange. Per the Administrator, she would expect the resident's elopement risk assessment to be accurate. 2. An admission Record revealed the facility admitted Resident #133 on 08/09/2025. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness, lack of coordination, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2025, revealed Resident #133 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #133's Elopement Risk Tool - V 4 signed by Licensed Practical Nurse (LPN) #9 and dated 08/09/2025, revealed the resident was at low risk for elopement. The Elopement Risk Tool did indicate the resident had a diagnosis of dementia/cognitive impairment. Resident #133's Behavior Note electronically signed by LPN #21 and dated 09/19/2025 at 6:45 AM, indicated the resident tried to exit the door and set off the alarm. Resident #133's Behavior Note electronically signed by LPN #5 and dated 09/22/2025 at 11:50 AM, indicated the resident attempted to get out of the side door on Unit 400. Resident #133's Behavior Note electronically signed by LPN #5 and dated 09/24/2025 at 3:17 PM, indicated the resident attempted to exit the door on Unit 400. Resident #133's medical record revealed no evidence of a completed Elopement Risk Tool Assessment once the resident displayed exit seeking behaviors on 09/19/2025, 09/22/2025, and 09/24/2025. Resident #133's Order Summary Report contained an order dated 10/13/2025, for a wander guard to left ankle, check placement every shift and an order dated 10/16/2025, to begin 10/22/2025, to check wander guard function every Wednesday.Resident #133's Care Plan Report included a focus area initiated 10/14/2025, that indicated the resident was at risk for elopement related to dementia and exit seeking. Interventions directed staff to check wander guard function weekly, placement every shift, and replace elopement band as needed (initiated 10/16/2025) and complete an elopement risk assessment as needed (initiated 10/14/2025).During a concurrent observation of the front desk and interview on 10/19/2025 at 2:25 PM, the Administrator showed the surveyor a binder and stated the binder contained a picture and face sheet (admission record) of all the residents who had a wander guard. The binder did not contain the picture and face sheet for Resident #133. During an interview on 10/19/2025 at 2:43 PM, the Administrator confirmed Resident #133's information was missing from the binder. During an interview on 10/19/2025 at 2:29 PM, Service Ambassador (SA) #24 stated there was an elopement book at the desk that contained pictures of the residents. SA #24 stated if a resident got close to the door and the alarm sounded, he looked in the book to see if the resident's photo was in the book. Per SA #24, if the resident's picture was not in the book, the resident was free to leave the facility. During an interview on 10/20/2025 at 1:16 PM, SA #25 stated she had the responsibility to ensure no resident with a wander guard exited the facility without staff knowledge. SA #25 stated the only way she knew which resident wore a wander guard was the reference binder. Resident #133's Behavior Note electronically signed by LPN #5 and dated 10/17/2025 at 10:52 AM, indicated the resident removed their wander guard from their left ankle and their responsible party (RP) replaced it. During a telephone interview on 10/19/2025, Resident #133's RP stated when they visited the resident on 10/17/2025, the resident was in bed asleep during the entire visit and they found Resident #133's wander guard on the resident's dresser. The RP stated they asked the nurse and was told it was a wander guard and it should be on the resident. The RP stated they did not know how the resident took the wander guard off, but they (RP) placed it back on Resident #133. The RP stated they got the impression that the certified nursing assistants and nurses knew the wander guard was not on the resident. During a telephone interview on 10/20/2025 at 3:57 PM, LPN #5 was asked about what happened with Resident #133's wander guard on 10/17/2025. LPN #5 stated Resident #133's RP came out of the resident's room and asked if the resident was supposed to be wearing the wander guard. LPN #5 stated she replied yes and Resident #133's RP informed her that the resident did not have the wander guard on and that they (RP) placed it back on the resident. LPN #5 acknowledged Resident #133 had exit-seeking behavior and on 09/24/2025, the resident pushed the door on Unit 400 and the alarm sounded. During an interview on 10/19/2025 at 4:39 PM, the Staff Development Coordinator/Infection Preventionist (SDC/IP), who assumed the role of the Director of Nursing (DON) as of 10/16/2025, stated she was not aware Resident #133 removed their wander guard on 10/17/2025 as no one reported it to her. The SDC/IP confirmed the resident's care plan was not updated to include the resident removed their wander guard and there was not increased monitoring of the resident. Per the SDC/IP, the nurse should have used all available resources to ensure the resident's safety and determine what enabled the resident to remove their wander guard. The SDC/IP acknowledged Resident #133's elopement risk assessment dated [DATE] was not accurate as it did not reference the resident's dementia diagnosis. According to the SDC/IP, another elopement risk assessment should have been completed when the resident displayed exit-seeking behavior on 09/19/2025, 09/22/2025, and 09/24/2024. The SDC/IP states she expected the elopement risk assessments to be accurate and that if it could not confidently determine how a wander guard was removed, the event was likely to recur and staff would need to implement different interventions. During an interview on 10/20/2025 at 1:33 PM, LPN #21 stated she was familiar with Resident #133. When asked if Resident #133 displayed exit-seeking behavior, LPN #21 replied yes and stated the resident went around the facility looking for a way out and would state they needed to find a way out. LPN #21 stated on 09/19/2025, Resident #133 pushed on the door and the alarm sounded and the resident kicked her when she attempted to redirect the resident. When asked if she was supposed to do an assessment (elopement risk assessment) of the resident, LPN #21 replied she did not know. During an interview on 10/20/2025 at 10:26 AM, the Administrator stated she expected the staff to notify the DON when a resident's wander guard was removed and/or not on the resident as assessed. Per the Administrator, she expected the elopement risk assessment to be accurate and that the interdisciplinary team meet to discuss when a resident displayed exit-seeking behavior. During a follow interview on 10/23/2025 at 10:07 AM, the SDC/IP stated an elopement risk assessment should be completed when a resident admitted to the resident, quarterly, and as-needed. When asked what was meant by as-needed, the SDC/IP, stated if an assessment was incorrect. During a follow-up interview on 10/23/2025 at 11:56 AM, the Administrator stated she expected staff to complete an elopement risk assessment when the resident admitted to the facility, quarterly, and whenever the resident had exit-seeking behaviors. The facility submitted a removal plan that was accepted by the state survey agency on 10/23/2025 at 11:20 PM. The removal plan indicated the following: F689 Accidents and Hazards Removal Plan1. Plan Corrective Action for those residents found to be affected by the deficient practice:Resident #127 was placed on 1:1 supervision to ensure safety and to not leave the building unattended once returned to the building on 05/11/2025. Resident #127 was evaluated by nursing staff with no new impairments on 05/11/2025 and seen by the nurse practitioner (NP) on 05/12/2025. Resident remained on 1:1 supervision and discharged from the facility on 05/20/2025. Resident #133 was placed on 1:1 supervision as a precaution on 10/20/2025. The [wander guard] was placed back on the resident and secured the same day it was observed to be off on 10/17/2025. admission Record for Resident #133 was placed in the elopement binder at the front desk on 10/19/2025, all other binders on the units were already updated. 2. Corrective Actions taken for residents with potential to be affected by deficient practice:All residents who are at risk of elopement have the potential to be affected by this deficient practice. The facility licensed nursing staff will conduct new elopement assessments on all residents to determine elopement risk on 10/23/2025 with follow-up based on findings. Any newly identified residents will be assessed for a [wander guard] by Director of Nursing, and it will be placed appropriately. The order and

Based on interview, record review, document review, and facility policy review, the facility failed to ensure prompt resolution of grievances voiced by 3 (Residents #72, #80, and #96) of 8 residents who attended the Resident Council meeting.Findings included: A facility policy titled, Service Concerns/Grievances, effective 03/01/2025, indicated, The Administrator is responsible for ensuring that the management staff are trained in appropriately resolving in-house patient/family service concerns and grievances at the point of service as promptly as possible. The management staff of the Health and Rehabilitation Center is charged with listening and responding to questions, needs, problems, or concerns brought to their attention by patients and/or families within the Health and Rehabilitation Center. The patient has the right to voice/file grievances/complaints without fear of discrimination or reprisal. The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process and for receiving and tracking to their conclusion. During the Resident Council meeting on 09/23/2025 at 1:41 PM, Resident #72 stated they have asked over and over again about the stickiness on the floor on the 200 Hall. Resident 372 stated it did not matter when one went to the 200 Hall that the floor was always nasty and sticky. Resident #72 stated they talked about it all time and was told by staff they would look at it. Resident #72 told the surveyor that if they went to the 200 Hall, they would guarantee them that the floor would be sticky. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2025, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #96 stated since they have been in the facility, the floors have not been cleaned. According to Resident #96, they have asked and asked for the floors to be shampooed but nothing has happened. A quarterly MDS, with an ARD of 08/02/2025, revealed Resident #96 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #80 stated the hallway on the 200 Hall was nasty and there were stains everywhere in the carpet that was peeling. A quarterly MDS, with an ARD of 07/28/2025, revealed Resident #80 had a BIMS score of 15, which indicated the resident had intact cognition. The Resident Council minutes for the time frame 03/2025 to 08/2025 revealed the following concerns were reported by the residents during the Resident Council meeting:-On 05/29/2025, the residents voiced the carpets needed to be shampooed more often.-On 06/26/2025, the residents voiced the dining areas were dirty and the carpet in the rooms needed to be shampooed more often.-On 07/31/2025, the residents voiced the dining room floors were sticky.-On 08/28/2025, the residents voiced the carpet needed to vacuumed and shampooed more often. During an interview on 09/24/2025 at 3:35 PM, the Housekeeping Director (HD) stated she did not have anything to show that the concerns expressed by the residents had been followed up on. During a concurrent interview and observation of the 200 Hall on 09/25/2025 at 11:44 AM with the HD, the surveyor noted the floor in the dining room was dirty and had a sticky glaze on the floor. The HD stated the floor stayed that way and the staff tried to mop it regularly. The HD confirmed the carpet was heavily stained and frayed and needed to be replaced. According to the HD, the facility's brushing machine had been broken, and they had not been able to shampoo the carpet. During an interview on 09/26/2025 at 10:40 AM, the Director of Nursing stated she expected a follow-up to all grievances voiced by the residents during the Resident Council meeting. During an interview on 09/26/2025 at 11:08 AM. The Administrator stated grievances voiced during the Resident Council meeting should be addressed.

Based on observation, interview, record review, and facility policy review, the facility failed to promote the dignity of 6 (Residents #7, #8, #41, #47, #97, and #112) of 27 sampled residents. Specifically, staff failed to knock and gain permission before they entered the room of Resident #41 and Resident #112; failed to perform a fingerstick blood sugar reading for Resident #7 in a private area; and failed to serve the lunch meal for Residents #8, #47, and #97, who were all seated at a table together at the same time.Findings included: A facility policy titled, Resident Rights Annual Review, dated 02/2004 revealed, It is the policy at this Healthcare Center that all Residents shall have the following rights and privileges: Per the policy, 12. To be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs. 1. An admission Record revealed the facility admitted Resident #112 on 05/20/2021. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2025, revealed Resident #112 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. During a concurrent interview and observation on 09/22/2025 at 10:02 AM, Licensed Practical Nurse (LPN) #5 walked into Resident #112's room and did not knock at the door or ask permission to enter the resident's room LPN #5 proceeded into the room and handed the resident a medicine cup with pills and a cup of water and did not communicate with the resident until she was exiting the room, when she told the resident that she would be back with the resident's treatment. Resident #112 stated the staff never knocked before they entered their room and always just walked right in. Resident #112 stated, I wish they would knock. During an interview on 09/24/2025 at 9:29 AM, LPN #5 stated the facility process was to knock on the door and tell the resident that she had their medication and tell them who she was because some residents forgot. LPN #5 stated that when knocking at residents' doors, sometimes she waited to be invited in and If the door was closed, she waited, but if the door was opened, she was able to see the resident she would announce herself and then go on in. LPN #5 stated it was oversight on her part, that she was rushing on 09/22/2025 when she did not knock or request permission to enter Resident #112's room. 2. An admission Record revealed the facility admitted Resident #7 on 12/17/2021. According to the admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #7's Care Plan Report included a focus area initiated 07/08/2025, that indicated the resident was at risk for complication and blood glucose fluctuations related to a diagnosis of diabetes mellitus with insulin use. Interventions directed the staff to administer insulin and medications as ordered. During an observation on 09/23/2025 at 12:16 PM, Licensed Practical Nurse (LPN) #3 entered the dining area and performed a fingerstick blood sugar on Resident #7, while the resident was seated at a dining table with other residents. There was a total of 11 residents in the dining area and one visitor. During an observation on 09/23/2025 at 12:52 PM, Certified Nursing Assistant (CNA) #4 approached the dining table and started to feed Resident #7 their lunch meal, while she stood over the resident. At 12:59 PM, CNA #4 left Resident #7 to deliver a meal tray to a resident's room. At 1:02 PM, CNA #4 came back to Resident #7 and continued to feed the resident while she stood over the resident. During an interview on 09/23/2025 at 1:12 PM, LPN #3 confirmed he completed Resident #7's fingerstick blood sugar reading while the resident was at the dining table. During an interview on 09/23/2025 at 1:08 PM, CNA #4 stated she was the person assigned to feed Resident #7 and that she usually would sit down next to the resident and give them a bite of each item on their plate, but on 09/23/2025, she stood up and fed the resident because it was just easier. 3. An admission Record revealed the facility admitted Resident #41 on 02/22/2016. According to the admission Record, the resident had a medical history that included a diagnosis of mild cognitive impairment. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2025, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. During an observation on 09/24/2025 at 9:23 AM, Certified Nursing Assistant (CNA) #2 entered Resident #41's room and did not knock or announce herself before she entered the resident's room. During an interview on 09/24/2025 at 9:26 AM, CNA #2 stated when entering a resident's room, the process was to knock before entering the room, introduce yourself, self, and if the resident was up, to ask them if they needed anything. CNA #2 stated she did not remember knocking before she entered Resident #41's room but did talk to the resident. CNA #2 stated she did not know why she did not knock before she entered the resident's room, and that she was not thinking about it. During an interview on 09/26/2025 at 9:03 AM, the Director of Nursing (DON) stated fingerstick blood sugar checks should happen based on the physician order and should be done in an area of privacy of the resident's choosing. The DON stated she expected the resident be moved to a private area to complete their fingerstick blood sugar check. The DON stated regarding standing to feed residents and interrupted feeding of a dependent resident, residents were to be gathered in the dining room, and those residents who needed assistance were to be seated in close proximity. The DON stated she expected the residents to be served their meals at the same time and the staff should sit down to feed the resident and engage them in conversation. The DON stated she expected the residents to have an uninterrupted meal experience. During an interview 09/26/2025 at 11:20 AM, the Administrator stated that related to dignity while doing medications, the process was that the nurse should ask the resident if they wanted to do it in private, or did they want to do it in an opened area. Per the Administrator, staff should encourage residents to go to another area. The Administrator stated her expectations were that medical procedures should not be done in opened areas. The Administrator stated related to staff standing while feeding residents and uninterrupted feeding of dependent residents, staff should be seated next to the resident and feed one resident at a time. According to the Administrator, the CNA should sit next to the resident for the entire meal, and she expected the staff stay with the resident for the entirety of the meal, seated. 4. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/31/2025, revealed the facility admitted Resident #8 on 11/14/2021. The MDS indicated Resident #8 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with eating. A MDS, with an ARD of 08/16/2025, revealed the facility admitted Resident #47 on 02/07/2025. The MDS indicated the resident had Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident required extensive assistance of one person for eating. A MDS, with an ARD of 09/04/2025, revealed the facility admitted Resident #97 on 04/13/2023. The MDS indicated Resident #97 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for eating. During an observation of the lunch meal on 09/23/2025 at 12:29 PM, the surveyor noted Residents #8, #47, and #97 were seated at a table in the dining room awaiting their lunch meal. At 12:55 PM, Resident # 8 received their meal tray and began to feed themself while Resident #47 and Resident #97 continued to wait for their meal. Resident # 47 received their meal at 1:03 PM and Resident # 97 received their meal tray at 1:06 PM. During an interview on 09/25/2025 at 11:02 AM, CNA #7 stated Residents #8, #47, and #97, were all seated at the table together, should have been served at the same time, but they were not. During an interview on 09/25/2025 at 11:29 AM, the Director of Nursing (DON) stated staff were to serve the residents in the dining room and then those on the floor. Per the DON, all residents in the dining areas were supposed to be served at the same time. During an interview on 09/25/2025 at 11:54 AM, the Administrator stated she expected all residents seated together should be served their meal tray at the same time.

Based on observation, interview, record review, and facility policy review, the facility failed to conduct an ongoing quarterly assessment to determine if a resident could safely administer their medication(s) as directed by the facility policy for 1 (Resident #72) of 2 sampled residents reviewed for choices. The facility further failed to have evidence of a completed assessment to determine if a resident was able to self-administer their albuterol inhaler for 1 (Resident #87) of 2 sampled residents reviewed for choices. Findings included: A facility policy titled, Self-Administration of Medication at Bedside, effective 01/29/2024, revealed, Policy A licensed nurse will assess patient's ability to self-administer medication. Procedure 1. The patient may request to keep medications at bedside for self-administration in a lock box. 2. Complete Medication Self-Administration Safety Screen assessment. 3. The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible. 4. If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record. 5. A licensed nurse will monitor and chart self-administered medications and will monitor for proper storage on each medication pass. 6. The Medication Self-Administration Safety Screen assessment will be reviewed quarterly by the Interdisciplinary Team. 1. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/04/2025, revealed the facility admitted Resident #72 on 03/17/2023. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. According to the MDS, the resident had active diagnoses to include heart failure, hypertension, and diabetes mellitus. Resident #72's Care Plan Report included a focus area initiated 02/20/2024 and revised 09/12/2025 that indicated the resident preferred to self-administer their medications. Interventions directed staff to review self-administration safety screens quarterly and as needed with change of condition (initiated 02/20/2024), provide bedside lockbox (initiated 02/202/2024), and the interdisciplinary team would reassess appropriateness of self-administration as needed (initiated 02/20/2024). Resident #72's Medication Self-Administration Safety Screen – V 1, dated 08/16/2024, revealed, Ongoinf [Ongoing] assessment should occur at a minimum of quarterly. Review of Resident #72's medical record revealed no evidence to indicate staff completed an ongoing assessment at a minimum of quarterly. During a concurrent interview and observation on 09/22/2025 at 11:18 AM, Resident #72 stated they self-administered their medications. The surveyor noted a locked black utility box in the resident's room. Per Resident #72, the locked box contained their medications. During an interview on 09/26/2025 at 7:58 AM, the Director of Nursing (DON) stated if a resident desired to self-administer their medication, the interdisciplinary team assessed the resident and once the resident was approved, a care plan was implemented, and a quarterly assessment should be conducted to determine if the resident was still appropriate to self-administer their medication(s). The DON acknowledged a quarterly assessment had not been completed for Resident #72 since the assessment was completed 08/16/2024. During an interview on 09/26/2025 at 11:33 AM, the Administrator stated she expected a resident to be assessed quarterly to determine if a resident was still able to self-administer their medication(s). 2. An admission Record revealed the facility admitted Resident #87 on 01/23/2025. According to the admission Record, the resident had a medical history that included diagnoses of emphysema, chronic respiratory failure, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/012025, revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #87's Care Plan Report included a focus area initiated 04/30/2025, that indicated the resident preferred to self-administer their inhaled medications. Resident #87's Order Summary Report revealed an order dated 01/24/2025, for Atrovent HFA inhalation aerosol solution 17 micrograms per actuation, inhale two puffs orally four times a day for chronic obstructive pulmonary disease unsupervised self-administration. Resident #87's medical chart revealed no evidence of a medication self-administration safety screen assessment During a concurrent observation and interview on 09/22/2025 at 2:32 PM, Resident #87 was observed with an inhaler in the left breast pocket on their shirt. Resident #87 stated They know I have it and explained they kept their inhaler on them in case of an emergency. Resident #87 stated they got short winded and liked to have their inhaler on them, so they did not have to wait on the staff to bring it to them. Resident #87 stated they did their own breathing treatments. it. During an interview on 09/24/2025 at 12:51 PM, Certified Nursing Assistant #11 stated Resident #87 administered their inhaler and kept it in their pocket or the top drawer in their room. During an interview on 09/24/2025 at 2:57 PM, Registered Nurse (RN) #12 stated Resident #87 kept their albuterol inhaler in their pocket and administered the medication whenever it was needed. RN #12 stated the resident liked to keep it in case of an emergency as it made them feel safe. Per RN #12, the resident should have an assessment to self-administer the medication, but she was not sure the resident did. During an interview on 09/26/2025 at 7:58 AM, the Director of Nursing stated if a resident desired to self-administer their medication, the interdisciplinary team assessed the resident and once the resident was approved, a care plan was implemented, and a quarterly assessment should be conducted to determine if the resident was still appropriate to self-administer their medication(s). During an interview on 09/26/2025 at 11:33 AM, the Administrator stated she expected a resident to be assessed quarterly to determine if a resident was still able to self-administer their medication(s).

Based on interview, record review, and document review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 1 (Resident #127) of 4 sampled residents reviewed for accidents.Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual dated 10/2024, revealed Section E: Behavior Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident themself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. Per the manual, Steps for Assessment 1. Review the medical record and interview staff to determine whether wandering occurred during the 7-day look-back period. Wandering is the act of moving from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to their physical or safety needs. The resident may have a purpose such as searching to find something, but they persist without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas. 2. If wandering occurred, determine the frequency of the wandering during the 7-day look-back period. An admission Record revealed the facility admitted Resident #127 on 04/22/2025. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness, dementia, seizures, cognitive communication deficit, and difficulty walking. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed Resident #127 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. According to the MDS, the resident did not exhibit any wandering behaviors during the last seven days. Resident #127's Care Plan Report included a focus area created 04/22/2025, that indicated the resident was at risk for elopement related to dementia. Resident #127's progress note electronically signed by Licensed Practical Nurse (LPN) #34 and dated 04/23/2025 at 3:36 PM, indicated the resident had a history of exit-seeking behavior while at the hospital. The progress note indicated the resident wandered to the other units during the day but could be redirected. Per the progress note, due to safety concerns a wander guard was placed on the resident's left arm. During an interview on 10/22/2025 at 12:04 PM, LPN #34 stated the progress note electronically signed by her and dated 04/23/2025 indicated Resident #127 wandered to the other units in the facility during the day. LPN #34 stated due to the resident's wandering, she notified the provider to get an order for a wander guard for safety reasons. During an interview on 10/21/2025 at 2:40 PM, the MDS Coordinator stated Resident #127's MDS with an ARD of 04/28/2025 was not completed accurately and should have indicated the presence of wandering in the past one to three days. During an interview on 10/23/2025 at 10:07 AM, the Staff Development Coordinator/Infection Preventionist, who assumed the role of the Director of Nursing as of 10/16/2025, stated Resident #127's MDS was not accurate for wandering and she expected the MDS to be accurate and for staff to follow the RAI manual. During an interview on 10/23/2025 at 11:56 AM, the Administrator stated she expected the MDS to be accurate and for staff to follow the RAI manual.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure ordered medication was available for administration for 1 (Resident #128) of 1 sampled resident reviewed for change of condition. Findings included: A facility policy titled, General Guidelines for Medication Administration, revised 08/2020, indicated The facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Resident #128's Admission/readmission Nursing Collection Tool V15-V2, indicated the facility admitted the resident on 08/01/2021 with a medical history to include a diagnosis of alcoholic cirrhosis. Resident #128's Order Summary Report revealed an order dated 08/01/2025, for gabapentin (a prescription medication used to treat nerve pain) capsule, 100 milligrams by mouth three times a day for alcoholic cirrhosis of liver and an order dated 08/01/2025, for sucralfate (a prescription medication used to treat ulcers) oral tablet, 1 gram give one tablet by mouth two times a day for alcoholic cirrhosis of liver. Resident #128's Care Plan Report, included a focus area initiated 08/01/2025, that indicated the resident was at risk for pain. Interventions directed staff to administer medications as ordered (initiated 08/01/2025) and observe for physical indicators of pain (initiated 08/01/2025). Resident #128's Medication Administration Record [MAR] for the timeframe 08/01/2025 - 08/31/2025, revealed no evidence to indicate the 9:00 PM dose of gabapentin and sucralfate for 08/01/2025 was administered to the resident. Per the MAR, Licensed Practical Nurse (LPN) #15 documented on the MAR a 9 for the administration of the 08/01/2025 9:00 PM dose of gabapentin and sucralfate, which indicated Other / See Progress Notes. Resident #128's progress notes for the timeframe 07/24/2025 to 08/23/2025, revealed no evidence to indicate why the 08/01/2025 9:00 PM dose of gabapentin and sucralfate were not administered to the resident. The pharmacy Delivery Manifest dated 08/02/2025 at 10:18 AM, revealed gabapentin and sucralfate were delivered to the facility from the pharmacy and signed by an LPN on 08/02/2025 at 10:04 AM. On 09/24/2025 at 12:02 PM and 09/25/2025 at 12:16 PM, a telephone interview was attempted with LPN #15, an agency nurse; however, there was no answer, and the surveyor was unable to leave a message. During an interview on 09/24/2025 at 12:06 PM, the Director of Nursing (DON) stated the pharmacy delivered medications to the facility between 11:00 PM and 12:00 midnight and the next delivery time would be the next morning. The DON stated Resident #128 arrived at the facility around 2:00 PM on 08/01/2025 and most of the resident's medications were not due to be administered until 08/02/2025. During an interview on 09/26/2025 at 11:47 AM, LPN #14 stated the facility had an automated medication management system that contained gabapentin; however, a lot of the agency nurses did not have access to the system. During an interview on 09/25/2025 at 2:50 PM, the Regional Director of Clinical Services stated that per her conversation with the pharmacy, no medication was ever pulled for the facility's automated medication management system for Resident #128.

Based on interview and document review, the administrative staff failed to conduct a thorough investigation into the elopement of Resident #127 from the facility on 05/11/2025. This deficient practice affected 1 (Resident #127) of 4 sampled residents reviewed for accidents.Findings included: The Job Description for the Administrator revised 04/2023, indicated The Administrator is directly responsible for the overall successful operations of the healthcare center. The primary role of the Administrator is to plan, direct and lead the day-to-day functions of the facility in accordance with current, federal, state, and local standards, guidelines, and regulations that govern skilled nursing facilities to ensure that residents are consistently receiving care and services in line with the company's vision of Care Beyond Care. The Job Description for the Director of Nursing (DON) revised 05/2023, indicated The Director of Nursing is responsible for the overall management, supervision, and direction of the nursing services department. The DON implements and maintains nursing department goals and objectives, ensures compliance with current standards of nursing practice, company policy and procedure, as well as applicable federal, state, and local guidelines and regulations. On 05/11/2025 at 8:55 PM, Resident #127, identified by the facility as having exit-seeking behaviors, eloped from the facility without staff knowledge. Licensed Practical Nurse (LPN) #20, assigned to the care of the resident, failed to ensure the facility's missing person protocol (Code Orange) was implemented as specified. Per facility documents, the Administrator was not made aware of the resident's elopement until 10:48 PM on 05/11/2025. The facility staff failed to notify the resident's responsible party that the resident was missing. On 05/11/2025 at 11:08 PM, the resident used their cell phone and called a family member and reported they were at a baseball game, cold, and needed to be picked up. The resident's responsible party then notified the facility staff of the resident's whereabouts, and the resident was returned to the facility by the local police and a staff member. The facility's investigation file only contained a statement from LPN #20; there were no other interviews with the staff that were on duty at the time of the resident elopement or interviews with the staff that participated in the search for the resident. Refer to F689. During an interview on 10/18/2025 at 3:54 PM, the Administrator stated from a review of the facility's investigation, LPN #20 enacted the Code Orange and no other staff were interviewed during the investigation of Resident #127's elopement from the facility. The Administrator stated possibly more interviews were needed and should have been conducted. During a follow-up interview on 10/20/2025 at 10:26 AM, the Administrator stated her expectation for the investigation was that a root cause analysis was determined so that the facility would know where the break down in the process was not followed. The Administrator stated she expected there should have been interviews with all the staff that worked and everyone who participated in the Code Orange.

Based on interview, document review, and facility policy review, the facility failed to ensure a resident elopement involving 1 (Resident #127) of 4 sampled residents reviewed for accidents was reviewed by the facility's Quality Assurance and Performance Improvement (QAPI) committee.Findings included:On 05/11/2025 at 8:55 PM, Resident #127, identified by the facility as having exit-seeking behaviors, eloped from the facility without staff knowledge. Licensed Practical Nurse (LPN) #20, assigned to the care of the resident, failed to ensure the facility's missing person protocol (Code Orange) was implemented as specified. Per facility documents, the Administrator was not made aware of the resident's elopement until 10:48 PM on 05/11/2025. The facility staff failed to notify the resident's responsible party that the resident was missing. On 05/11/2025 at 11:08 PM, the resident used their cell phone and called a family member and reported they were at a baseball game, cold, and needed to be picked up. The resident's responsible party then notified the facility staff of the resident's whereabouts, and the resident was returned to the facility by the local police and a staff member. The facility's investigation file only contained a statement from LPN #20; there were no other interviews with the staff that were on duty at the time of the resident elopement or interviews with the staff that participated in the search for the resident. Refer to F689. A facility document titled, Quality Assurance and Performance Improvement Leadership Guide, dated 09/2017, revealed, Quality Assurance and Performance Improvement Committee The management process is vested in the Center's Quality Assurance and Performance Improvement Committee. The QAPI Committee identifies potential markers of quality within their center that may need to be evaluated or investigated. These areas may or may not represent a potential or undesirable outcome. The QAPI Committee collects and analyzes data from various sources. These sources may include, but are not limited to, internal and external audits, surveys, reports, subcommittee reports, or other administrative initiatives. The Center QAPI Committee develops and implements appropriate plans of action to correct any undesirable outcomes and monitors the effect of implemented changes, making revisions to the action plans as needed. The document indicated, At the quarterly meetings the Committee will collect and analyze potential or actual undesirable outcomes from various data sources. The sources include but are not limited to: -Reportable incidents and -Environmental/operational/safety issues related to patient/staff safety from the Safety Management Subcommittee. A facility policy titled, QAPI, effective 09/23/2024, indicated, 5. The Center maintains center specific quality clinical and service indicators that are to be monitored and improved by QAPI Committee if undesirable patterns or trends are established. The Administrator is responsible for overseeing the QAPI Committee's initiatives to sustain and/or improve quality outcomes of problems identified within his/her Center. 6. In addition to Center established indicators and surveys, the Administrator and the QAPI Committee are responsible for targeting and monitoring specific services and/or operational areas of on-going studies within the Center. These are identified as a priority for high risk, high volume, problem prone processes, or value-added care or service relationships and/or opportunities for improving dimensions of performance. Feedback is regularly obtained from multiple parties including but not limited to resident council, patient and family survey responses, and staff feedback. The Center's QAPI committee decides which process to measure and monitor and what approaches are to be implemented. During an interview on 10/18/2025 at 4:40 PM, the Staff Development Coordinator/Infection Preventionist (SDC/IP), who assumed the role of the Director of Nursing (DON) as of 10/16/2025, stated Resident #127's elopement had not been reviewed by the facility's QAPI committee. During an interview on 10/23/2025 at 11:56 AM, the Administrator stated Resident #127's elopement was not reviewed by the facility's QAPI committee. The Administrator stated she did not know why it was not reviewed in QAPI, but it should have been. During a follow-up interview on 10/25/2025 at 10:52 AM, the Administrator stated her expectation was that the QAPI committee should have reviewed Resident #127's elopement. She stated if it had been reviewed by QAPI, they could have conducted a root cause analysis to determine if there were processes that were broken; identified additional steps the facility needed to take, such as staff training; and determined whether a Performance Improvement Plan (PIP) needed to be developed.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure 1 (Resident #5) of 27 sampled residents' rooms was free of pests.Findings included: A facility policy titled, Pest Control, effected 01/01/2019, indicated Policy: The Center environment will be monthly inspected and treated for pests by a corporate-approved contractor. A pest service receipt dated 06/30/2025, revealed pest control maintenance was completed on 06/30/2025. The facility was unable to provide any other documentation of monthly inspections for pest control as specified in their policy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/17/2025, revealed the facility admitted Resident #5 on 05/02/2017. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Per the MDS, Resident #5 had active diagnoses to include stroke, heart failure and hypertension. During a concurrent observation and interview on 09/22/2025 at 3:53 PM, Resident #5 stated they always had to kill stink bugs in their room. The surveyor noted 20 dead stink bugs on the floor that led to the outside area and two stink bugs were noted to crawl on the curtain and ceiling in the resident's room. Resident #5 stated they asked for the area to be sprayed but was told it could not be due to the other residents in the room. During a concurrent observation and interview on 09/23/2025 at 8:30 AM, the surveyor noted dead bugs on the floor of Resident #5's room that led to the patio. Resident #5 stated the bugs on the floor were the same ones from 09/22/2025. Resident #5 stated the bugs were pointed out to the staff, but nobody had done anything. According to Resident #5, the Maintenance Director informed them that he could not spray or do anything about the bugs. During a concurrent observation and interview on 09/23/2025 at 12:22 PM, the surveyor noted 18 dead stink bugs on the floor and four stink bugs that were alive on Resident #5's window and curtains. Resident #5 stated those were new bugs that they killed on 09/23/2025. During a concurrent observation and interview on 09/25/2025 at 10:40 AM, the Maintenance Director stated 09/25/2025 was his second day working in the facility. Per the Maintenance Director, the previous Maintenance Director left about two weeks ago, and the maintenance technician was on vacation. When the surveyor and the Maintenance Director entered Resident #5's room, the Maintenance Director stated he saw why there were stink bugs in the resident's room. The Maintenance Director stated there was a gap in the door around the seal to the wall that allowed the bugs to enter the resident's room. The Maintenance Director stated she would get the area fixed. During an interview on 09/25/2025 at 11:42 AM, the Director of Nursing stated she was not aware of a concern in Resident #5's room with bugs or a gap in the door which allowed bugs to enter the resident's room. During an interview on 09/25/2025 at 11:48 AM, the Administrator stated she was not aware of a concern in Resident #5's room with bugs.

Based on staff interview and facility document review, the facility staff failed to follow abuse prevention policies regarding volunteers for eight of nine volunteer records reviewed.The findings include:On 7/17/25 at 9:04 a.m., the activity director (other staff #5) was interviewed about current volunteers used in the facility and any required screening for volunteers. The activity director stated volunteers assisted at times with provision of activities including games and music. The activity director stated the facility had one pastor that came to the facility weekly, one previous resident that visited residents in the day area and several members from local churches that provided music, visits and assistance with games such as Bingo. The activities director stated prior to providing services, all volunteers were required to complete an application and a self-questionnaire about any past or pending criminal charges. The activities director stated the application and criminal questionnaire were reviewed by the administrator and if approved, human resources then performed a criminal background check. The activities director stated if the criminal background check was clear, she conducted an orientation/training regarding facility rules prior to the volunteer participating in any activities. The activity director stated the receptionist informed her when volunteers were in the facility.The list of current volunteers was requested and reviewed. The list included nine current volunteers. Review of screening documents for these volunteers revealed that eight of the nine volunteers had no criminal background check performed. Seven of the nine volunteers did not have a completed self-questionnaire about past or pending criminal charges.On 7/17/25 at 1:40 p.m., the human resources (HR) manager (other staff #7) was interviewed about any criminal background checks for the current volunteers. The HR manager stated she had worked at the facility since April 2025 and there had been no new volunteer screenings requested or performed since she had been hired. The HR manager stated she would search her portal for prior screenings on the current volunteers.On 7/17/25 at 1:30 p.m., the administrator and regional nurse consultant (administration #3) were interviewed. The administrator stated the HR manager searched the portal and that eight of the current volunteers had no criminal background check performed. The administrator stated the background checks were supposed to be done prior to any volunteer service. The administrator stated there were no self-questionnaires completed for seven of the volunteers that were from a local church. The administrator stated the activity director was responsible for getting volunteers to complete the application and questionnaire and that the HR manager was responsible for criminal background checks. The regional nurse consultant stated there had been no reports of any concerns or complaints regarding volunteers.On 7/17/25 at 1:40 p.m., the activity director was interviewed again about the missing screening documents. The activity director stated the seven volunteers without a self-questionnaire and background check were from a local church and had participated with one Bingo session which was supervised by activity staff. The activity director stated the other volunteer without a background check was a former resident who came periodically to visit/talk with residents in the day area. The activity director stated she should have obtained questionnaires and background checks from HR prior to the volunteers providing services in the facility.The facility's abuse prevention policy regarding volunteer services titled Pre-Screening Requirements (effective 11/1/23) documented, .The Recreation Director [activity director] and staff may utilize the services of volunteers to enhance the quality of life for patients if the volunteers working with patients in the Center have met the established pre-screening requirements .the Recreation Director will ask the potential candidate to complete the Center's Volunteer Application as well as the Center's Criminal Background Self-Questionnaire for Volunteer Applicant Pre-Screening .if the said questionnaire has any offenses marked 'yes' the applicant is automatically disqualified .Upon receiving a completed Volunteer Application and a qualifying Criminal Background Self-Questionnaire for Volunteer Applicant Pre-Screening, The Director will meet with the selected volunteer and the Center HR Manager to initiate a transmittal for a nationwide background check validation .Returned results of the National Background Check will be secured by HR and reviewed promptly with the Recreation Director. Once a qualifying validation is confirmed, the Recreation Director will notify the applicant that the prescreening is complete and their application for volunteer service has been approved .This finding was reviewed with the administrator and regional nurse consultant on 7/17/25 at 1:35 p.m. with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff allowed self-administration of medications without a prior assessment or physician's order for two of eight residents in the survey sample (Residents #5 and #6). The findings include: Resident #5 (R5) was admitted to the facility with diagnoses that included diabetes, asthma, atrial fibrillation, anorexia, depression, neuropathy, chronic kidney disease, anxiety and insomnia. The minimum data set (MDS) dated [DATE] assessed R5 as cognitively intact. Resident #6 (R6) was admitted to the facility with diagnoses that included spinal stenosis, osteoporosis, peripheral vascular disease, gastroesophageal reflux disease, insomnia, depression, anxiety and hypertension. The MDS dated [DATE] assessed R6 as cognitively intact. 1. Oral medications were prepared and left at the bedside on 2/22/25 for R5 and R6 to self-administer when the residents had no prior assessment or physician's order to self-administer medications. Clinical records for R5 and R6 included no physician's order or assessments indicating the residents were deemed safe to self-administer medications. On 6/10/25 at 12:10 p.m., licensed practical nurse (LPN #1) caring for R5 and R6 on the evening of 2/22/25, was interviewed about an allegation that medications had been left at the bedside. LPN #1 stated R5 and R6 liked to be the first residents to get their evening medicines. LPN #1 stated on 2/22/25 around 5:30 or 6:00 p.m., R5 and R6 were in the dining room. LPN #1 stated she told R5 and R6 that she had prepared their bedtime medicines and had put the medicines on their bedside tables for them to take when they returned to their rooms. LPN #1 stated she was in hallway the entire evening passing medications to other residents and R5 and R6 returned to their rooms after dinner. LPN #1 stated R5 reported that she took her medications after she got back to the room, but she did not witness R5 take the medicines. LPN #1 stated later in the evening, R6 asked about her medications, she then accompanied R6 to the room and found the medicines still on the bedside table. LPN #1 stated she witnessed R6 take the prepared medications. LPN #1 stated the medications left for the residents were medicines scheduled for 9:00 p.m. When asked why she left the medications unsecured/unattended, LPN #1 stated she was trying to get them [medications] out of the way and get ahead. On 6/10/25 at 3:09 a.m., the director of nursing (DON) and registered nurse staff development coordinator (RN #1) were interviewed about LPN #1 preparing and leaving medicines for R5 and R6 to self-administer. RN #1 stated R5 and R6 had not been assessed for self-administration of medications. The DON stated nurses were not expected to leave medications at the bedside unattended. The DON stated residents desiring to self-administer medicines required a physician's order to do so and an assessment by the interdisciplinary team indicating the resident was safe to self-administer. The DON stated residents assessed as safe to self-administer medicines were provided a lock box for medication storage in the room. R5's clinical record documented the medications prepared and left for self-administration on 2/22/25 at 9:00 p.m. included montelukast sodium 10 mg (milligrams) and sodium bicarbonate 650 mg. R6's clinical record documented medications administered to R6 on 2/22/25 at 9:00 p.m. included atorvastatin 20 mg, gabapentin 300 mg (2 capsules), melatonin 6 mg, trazodone 400 mg, Tylenol 500 mg (2 tablets) and Cymbalta 30 mg. 2. R5 had the medication Trelegy Ellipta inhaler at the bedside without a prior physician's order or assessment to safely self-administer medications. On 6/10/25 at 10:45 a.m., R5 was observed in her room with a Trelegy Ellipta inhaler device located on the bedside table. R5 was interviewed at this time about the Trelegy Ellipta. R5 stated she was able to self-administer the Trelegy Ellipta and that she took the Trelegy Ellipta once per day. R5 stated she thought a nurse had left the Trelegy Ellipta inhaler in the room, but she did not recall when that occurred or how long the Trelegy Ellipta inhaler had been in her room. R5's clinical record documented a physician's order dated 6/27/24 for Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 micrograms/actuation with instructions to inhale one puff orally once per day with mouth rinse after for treatment of asthma. R5's clinical record documented no physician's order for self-administration and no assessment indicating the resident was deemed safe to self-administer medications. On 6/10/25 at 11:50 a.m., the licensed practical nurse (LPN #2) caring for R5 was interviewed about the Trelegy Ellipta inhaler. LPN #2 stated R5 had not been assessed to self-administer medications and that the Trelegy Ellipta inhaler should not be at the resident's bedside. Accompanied by LPN #2, the Trelegy Ellipta inhaler was observed on the resident's bedside table. LPN #2 stated four doses had been activated from the device. LPN #2 stated she was not aware the device was at the bedside. LPN #2 stated, A nurse must have left it in the room. On 6/10/25 at 3:09 a.m., the director of nursing (DON) and registered nurse staff development coordinator (RN #1) were interviewed about R5 having the Trelegy Ellipta inhaler at the bedside. RN #1 stated R5 had not been assessed for self-administration of medications. The DON stated nurses were not expected to leave medications at the bedside unattended. The DON stated residents desiring to self-administer medicines required a physician's order to do so and an assessment by the interdisciplinary team indicating the resident as safe to self-administer. The DON stated residents assessed as safe to self-administer medicines were provided a lock box for medication storage in the room. The facility's policy titled Self-Administration of Medication at Bedside (effective 1/29/24) documented, .A licensed nurse will assess patient's ability to self-administer medication .Complete Medication Self-Administration Safety Screen assessment .The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible .If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record .The Medication Self-Administration Safety Screen assessment will be reviewed quarterly by the Interdisciplinary Team . These findings were reviewed with the administrator and regional nurse consultant during a meeting on 6/11/25 at 10:30 a.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of quality during medication administration for two of eight residents in the survey sample (Residents #5 and #6). The findings include: On 2/22/25, oral medications were prepared ahead of the scheduled administration time and left unattended/unsecured at the bedside for two residents (Residents #5 and #6). The nurse failed to observe R5 take the prepared medications. Resident #5 (R5) was admitted to the facility with diagnoses that included diabetes, asthma, atrial fibrillation, anorexia, depression, neuropathy, chronic kidney disease, anxiety and insomnia. The minimum data set (MDS) dated [DATE] assessed R5 as cognitively intact. Resident #6 (R6) was admitted to the facility with diagnoses that included spinal stenosis, osteoporosis, peripheral vascular disease, gastroesophageal reflux disease, insomnia, depression, anxiety and hypertension. The MDS dated [DATE] assessed R6 as cognitively intact. On 6/10/25, R5, R6 and LPN #1 were interviewed regarding an allegation that medications were prepared ahead and left unattended in the residents' rooms on the evening of 2/22/25. On 6/10/25 at 10:45 a.m., R5 stated she did not remember a nurse leaving medications in her room during February (2025). On 6/10/25 at 10:50 a.m., R6 stated she did not remember a nurse leaving medications in her room during February (2025). On 6/10/25 at 12:10 p.m., licensed practical nurse (LPN #1) that cared for R5 and R6 on the evening of 2/22/25 was interviewed about an allegation that medications had been left at the bedside. LPN #1 stated R5 and R6 liked to be the first residents to get their evening medicines. LPN #1 stated on 2/22/25 around 5:30 or 6:00 p.m., R5 and R6 were in the dining room. LPN #1 stated she told R5 and R6 that she had prepared their bedtime medicines and had put the medicines on their bedside tables for them to take when they returned to their rooms. LPN #1 stated she was in hallway the entire evening passing medications to other residents. LPN #1 stated after dinner, R5 returned to her room. LPN #1 stated that R5 reported that she took the prepared medications but that she did not witness R5 take the medicines. LPN #1 stated later in the evening, R6 asked about her bedtime medications, that she then accompanied R6 to the room and found the medicines still on the bedside table. LPN #1 stated she witnessed R6 take the prepared medications. LPN #1 stated the medications prepared and left for the residents were medicines scheduled for 9:00 p.m. that evening. LPN #1 stated she was aware that she was not supposed to leave medicines unattended. When asked why she prepared the medicines ahead and left them unattended, LPN #1 stated she was trying to get them [medications] out of the way and get ahead. LPN #1 stated medications were supposed to be administered within an hour before or after the scheduled administration time. On 6/10/25 at 3:09 a.m., the director of nursing (DON) and registered nurse staff development coordinator (RN #1) were interviewed about LPN #1 preparing and leaving medicines for R5 and R6 to self-administer. RN #1 stated R5 and R6 had not been assessed for self-administration of medications. The DON stated nurses were not expected to leave medications at the bedside unattended or unsecured. The DON stated residents desiring to self-administer medicines required a physician's order to do so and an assessment by the interdisciplinary team indicating the resident as safe to self-administer medicines. RN #1 stated nurses were expected to observed residents taking medications to ensure proper administration. R5's clinical record documented the medications administered on 2/22/25 at 9:00 p.m. included montelukast sodium 10 mg (milligrams) and sodium bicarbonate 650 mg. R6's clinical record documented medications administered to R6 on 2/22/25 at 9:00 p.m. included atorvastatin 20 mg, gabapentin 300 mg (2 capsules), melatonin 6 mg, trazodone 400 mg, Tylenol 500 mg (2 tablets) and Cymbalta 30 mg. Clinical records for R5 and R6 included no physician's order or assessment indicating the residents were safe to self-administer medications. The facility's policy titled General Guidelines for Medication Administration (effective 9/2018) documented, Medications are administered as prescribed in accordance with good nursing principles and practices .When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.), medications are administered at the time they are prepared. Medications are not prepoured either in advance of the med pass or for more than one resident at a time .Medications are administered within 60 minutes of the scheduled administration time .Residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications .The resident is always observed after administration to ensure that the dose was completely ingested .The individual who administers the medication dose records the administration on the resident's MAR [medication administration record] directly after the medication is given . These findings were reviewed with the administrator and regional nurse consultant during a meeting on 6/11/25 at 10:30 a.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders for medication administration for one of eight residents in the survey sample (Resident #4). The findings include: Resident #4 (R4) was admitted to the facility with diagnoses that included osteomyelitis, MRSA (methicillin resistant staphylococcus aureus), end stage renal disease, protein-calorie malnutrition, anemia, hypertension and diabetes. The minimum data set (MDS dated [DATE] assessed R4 as cognitively intact. R4's closed clinical record documented a physician's order dated 1/30/25 for Zosyn (piperacillin - tazobactam) intravenous (IV) solution reconstituted 4.5 (4-0.5) grams with instructions to give 4.5 grams intravenously every 12 hours until 3/5/25 for treatment of acute osteomyelitis. R4's medication administration record (MAR) for February 2025 documented Zosyn was scheduled for administration at 6:00 a.m. and 6:00 p.m. each day. The MAR documented Zosyn was not administered on 2/11/25 at 6:00 a.m. as ordered/scheduled. A nursing note dated 2/11/25 at 6:16 a.m. documented, .Informed IV completed. There was no other explanation in the clinical record indicating why the dose was not administered. The clinical record included no order to discontinue or stop the IV Zosyn. Medication administration continued after the 2/11/25 6:00 a.m. dose through 3/5/25 as ordered. On 6/10/25 at 3:09 p.m., the director of nursing (DON) and the registered nurse infection preventionist (RN #1) were interviewed about R4's missed dose of IV Zosyn on 2/11/25. RN #1 and the DON stated the Zosyn order was not discontinued or completed on 2/11/25 as listed in the note. RN #1 stated the medication was ordered every 12 hours through 3/5/25 and no changes were made to the order during the resident's stay. RN #1 and the DON stated they did not understand the note written on 2/11/15 by licensed practical nurse (LPN #3) indicating the IV medicine was complete. On 6/11/25 at 8:20 a.m., the regional nurse consultant (administration #3) was interviewed about R4's missed dose of Zosyn on 2/11/24. The regional nurse consultant stated the 6:00 a.m. dose on 2/11/25 was not given as ordered. The regional nurse consultant stated she was not sure why the medicine was not given. The regional nurse consultant stated the resident's Zosyn order was not completed or discontinued on 2/11/25 as written in the note. On 6/11/25 at 8:53 a.m., the nurse practitioner (other staff #1) caring for R4 was interviewed about the missed dose of IV Zosyn. The NP stated she was aware of the missed dose. The NP stated the resident's labs and vital signs remained stable during the resident's stay and there was no indication to add or extend the IV antibiotic treatment due the missed dose. The NP stated the Zosyn was administered per recommendations from the hospital. The NP stated R4 did not miss a significant number of doses and there was no change to the resident's overall outcome based on the missed dose of Zosyn. LPN #3, responsible for giving the 6:00 a.m. dose of Zosyn on 2/11/25 was not available for interview as she was not working during the survey and attempts to call her were unanswered. The facility's policy titled General Guidelines for Medication Administration (revised 8/2020) documented, .Medications are administered in accordance with written orders of the prescriber . This finding was reviewed with the administrator and regional nurse consultant during a meeting on 6/11/25 at 10:30 a.m. with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure medications remained secured in locked compartments and/or carts for two of eight residents in the survey sample (Residents #5 and #6). The findings include: Resident #5 (R5) was admitted to the facility with diagnoses that included diabetes, asthma, atrial fibrillation, anorexia, depression, neuropathy, chronic kidney disease, anxiety and insomnia. The minimum data set (MDS) dated [DATE] assessed R5 as cognitively intact. Resident #6 (R6) was admitted to the facility with diagnoses that included spinal stenosis, osteoporosis, peripheral vascular disease, gastroesophageal reflux disease, insomnia, depression, anxiety and hypertension. The MDS dated [DATE] assessed R6 as cognitively intact. 1. The medication Trelegy Ellipta inhaler was observed stored unsecured on Resident #5's bedside table. On 6/10/25 at 10:45 a.m., R5 was observed in her room with a Trelegy Ellipta inhaler device located on the bedside table. R5 was interviewed at this time about the Trelegy Ellipta. R5 stated she thought a nurse had left the Trelegy Ellipta inhaler in the room, but she did not recall when that occurred or how long the Trelegy Ellipta inhaler had been in her room. R5's clinical record documented a physician's order dated 6/27/24 for Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 micrograms/actuation with instructions to inhale one puff orally once per day with mouth rinse after for treatment of asthma. R5's clinical record documented no physician's order for self-administration of medications and no assessment indicating the resident was deemed safe to self-administer medications. On 6/10/25 at 11:50 a.m., the licensed practical nurse (LPN #2) caring for R5 was interviewed about the Trelegy Ellipta inhaler. LPN #2 stated R5 had not been assessed to self-administer medications and that the Trelegy Ellipta inhaler should not be at the resident's bedside. Accompanied by LPN #2, the Trelegy Ellipta inhaler was observed on the resident's bedside table. LPN #2 stated she was not aware the device was at the bedside. LPN #2 stated, A nurse must have left it in the room. LPN #2 stated four doses had been activated from the device and LPN #2 located an empty Trelegy Ellipta box in the medication cart labeled for R5. On 6/10/25 at 3:09 p.m., the director of nursing (DON) and registered nurse staff development coordinator (RN #1) were interviewed about the Trelegy Ellipta inhaler left unsecured/unattended in the resident's room. The DON stated medications were not to be left at the bedside. The DON stated residents assessed to self-administer medications were required to keep medications stored in a locked box. RN #1 stated it was not acceptable for nurses to leave medications unsecured and that R5 had no order or assessment for self-administration of medications. The facility's policy titled General Guidelines for Medication Administration (effective 9/2018) documented, .Medications are administered within 60 minutes of the scheduled administration time .During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart .The resident is always observed after administration to ensure that the dose was completely ingested . 2. On the evening of 2/22/25, oral medications for R5 and R6 were prepared and left unsecured in the residents' rooms. On 6/10/25 at 12:10 p.m., licensed practical nurse (LPN #1) that cared for R5 and R6 on the evening of 2/22/25 was interviewed about an allegation that medications had been left at the bedside. LPN #1 stated R5 and R6 liked to be the first residents to get their evening medicines. LPN #1 stated on 2/22/25 around 5:30 or 6:00 p.m., R5 and R6 were in the dining room. LPN #1 stated she told R5 and R6 that she had prepared their bedtime medicines and had put the medicines on their bedside tables for them to take when they returned to their rooms. LPN #1 stated she was in hallway the entire evening passing medications to other residents. LPN #1 stated after dinner, R5 returned to her room. LPN #1 stated R5 reported that she took the prepared medications but that she did not witness R5 take the medicines. LPN #1 stated later in the evening, R6 asked about her bedtime medications, she then accompanied R6 to the room and found the medicines still on the bedside table. LPN #1 stated she witnessed R6 take the prepared medications. LPN #1 stated the medications prepared and left for the residents were medicines scheduled for 9:00 p.m. that evening. LPN #1 stated she was aware that she was not supposed to leave medicines unattended. When asked why she prepared the medicines ahead and left them unattended, LPN #1 stated she was trying to get them [medications] out of the way and get ahead. LPN #1 stated medications were supposed to be administered within an hour before or after the scheduled administration time. On 6/10/25 at 3:09 a.m., the director of nursing (DON) and registered nurse staff development coordinator (RN #1) were interviewed about LPN #1 preparing and leaving medicines for R5 and R6 to self-administer. The DON stated nurses were not expected to leave medications at the bedside unattended or unsecured. The DON stated residents assessed to self-administer medicines were required to keep medicines stored in a locked box in their rooms. The facility's policy titled General Guidelines for Medication Administration (effective 9/2018) documented, .Medications are administered within 60 minutes of the scheduled administration time .During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart .The resident is always observed after administration to ensure that the dose was completely ingested . These findings were reviewed with the administrator and regional nurse consultant during a meeting on 6/11/25 at 10:30 a.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to include insulin administration in the baseline care plan for one of three residents in the survey sample (Resident #11). The findings include: Resident #11's baseline care plan included no goals/interventions regarding insulin administration with use of an insulin pump. Resident #11 (R11) was admitted to the facility with diagnoses that included Parkinson's, diabetes, asthma, hypertension, irritable bowel syndrome, self-imposed factitious disorder, chronic atrial fibrillation, and hyperlipidemia. An admission assessment date 8/1/24 listed R11 as cognitively intact and oriented to person, place, time and situation. R11's clinical record documented the resident was admitted to the facility with use of an insulin pump for insulin administration related to diabetes. R11's hospital discharge summary dated 8/1/24 documented the resident had his own insulin pump and had demonstrated sufficient ability to change/manage the pump on multiple occasions. Hospital discharge recommendations documented instructions to contact R11's endocrinology office if assistance was needed with the insulin pump. R11's baseline care plan was documented as complete on 8/1/24. The baseline care plan documented the resident was at risk of hypoglycemia due to diabetic medications and included interventions for prevention of diabetic complications. The baseline care plan made no mention the resident used an insulin pump and included no immediate goals and/or interventions regarding insulin administration with the pump and the resident's ability to manage/maintain the pump. The nurse practitioner assessed R11 on 8/2/24 and documented the resident had demonstrated ability to manage the pump on multiple occasions while hospitalized . The nurse practitioner documented the resident was deemed ok to use the home insulin pump while in the facility as he did in the hospital. The nurse practitioner documented if the resident was unable to manage the pump on his own, orders for insulin administration would be changed/entered as needed. On 2/4/25 at 11:30 a.m., the regional nurse consultant (administration #3) was interviewed about R11's baseline care plan. The regional consultant stated R11 was admitted with the insulin pump and was approved by the NP as appropriate to manage the device. The regional consultant stated the baseline care plan should have included the resident's use and management of the insulin pump. The facility's policy titled Care Planning (effective 11/1/2019) documented, .A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient . This finding was reviewed with the administrator and regional nurse consultant during a meeting on 2/4/25 at 4:00 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review the facility staff failed to review and revise a comprehensive care plan for one resident, Resident #13 (R13) out of three residents in the survey. The findings included: The facility staff failed to review and revise R13's care plan with weight bearing status. On 2/4/25 at 9:45 a.m. an interview was conducted with the therapy manager. The therapy manager stated that R13 participated in physical therapy. He stated that R13 was non weight bearing to right leg. On 2/4/25 at 9:57 a.m. an interview was conducted with a certified nursing assistant, CNA#3 (CNA3). CNA3 said, if resident is non weight bearing therapy will evaluate and let us know. We don't know weight bearing status until therapy evaluates but sometimes the nurse reports it to us. On 2/4/25 at 10:00 a.m. an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 stated that when she receives report about the patient's weight bearing status that she would give report to the aide. LPN3 stated she would expect weight bearing status to be on the resident's care plan. LPN3 said, that if it is an order it will come up for us to sign off on. On 2/4/25 at 10:10 a.m. an interview was conducted with the interim director of nursing (IDON). The IDON stated that the aides were to get the residents weight bearing status from the nurse. IDON said, the aides had task to help them and that the care plan information generates to the aides task. IDON stated she would expect weight bearing status to be on the resident's care plan. On 2/4/25 at 10:14 a.m. an interview was conducted with the regional nurse consultant. She said, I don't see the weight bearing status on the care plan, but I do expect it to be on the care plan for staff to know. On 2/4/25 at approximately 11:00 a.m. a clinical record review was conducted. R13's care plan was reviewed and the weight bearing status for him was not on his care plan. R13's physician's orders were reviewed. R13 had an order on 8/6/24 that read, NWB [non weight bearing] to right lower extremity (RLE). On 8/26/24 R13 had an order that read, May apply weight to foot with transferring, try using heel. On 2/4/25 at 4:30 p.m. an end of day meeting was held with the administrator, regional nurse consultant and the regional vice president of operations to discuss the above concerns. No additional information was provided.

Based on staff interview and facility document review, the facility staff failed to provide sufficient dietary staff to provide timely meal delivery on four of four units. The findings include: There was an insufficient number of dietary staff working on 6/9/24 to provide preparation and service of breakfast for residents within the facility. Review of the dietary department as-worked schedule for 6/9/24 revealed that no dietary employees worked in the main kitchen, other than the dietary manager. A hand-written employee schedule documented one cook, and five dietary aides were scheduled to work on 6/9/24 from 6:00 a.m. until 2:00 p.m. This schedule documented the cook and the five dietary aides either called out, went home, or were a no-show on 6/9/24. On 11/12/24 at 3:10 p.m., the dietary manager (other staff #8) was interviewed about kitchen staff on 6/9/24. The dietary manager stated that she was newly hired on 6/4/24. The dietary manager stated there were conflicts with the cook working at that time and all the kitchen staff scheduled for the day shift on 6/9/24 did not show for work. The dietary manager stated that she made the decision to provide cereal and milk for a continental breakfast, so she could concentrate on getting help and lunch prepared. The dietary manager stated the standard breakfast was not served on any of the units with the cereal/milk provided to residents around 10:30 a.m. The dietary manager stated a cook and an employee from another facility came in to assist with food prep but did not stay long. The dietary manager stated a dietary aide (other staff #9) came in later that morning to assist with lunch preparation. The dietary manager stated lunch and dinner were served at scheduled times but there was no cooked breakfast served. The dietary manager stated kitchen employees were contracted by the facility to provide food services. The dietary manager stated she contacted her regional director, and she thought they contacted the facility administrator about the lack of staff. The dietary manager stated she that did not anticipate all the employees not showing for work in 6/9/24 and again stated she made the decision to provide cereal/milk so lunch and dinner would be on schedule. The dietary manager stated she typically needed one cook and at least four dietary aides for timely meal service in the facility. On 11/12/24 at 3:30 p.m., the dietary aide (other staff #9) that assisted with meal service on 6/9/24 was interviewed. The dietary aide stated she was not scheduled to work on 6/9/24 but came in because there was no help. The dietary aide stated, Everybody called out that day. The dietary aide stated she did not know why those scheduled did not come to work on 6/9/24. The dietary aide said that call outs happened occasionally, and she frequently volunteered to fill-in. The dietary aide stated most of those employees no longer worked at the facility. The dietary aide stated 6/9/24 was unusual because all those scheduled to work did not show up. The dietary aide stated there was no cooked breakfast, only cereal/milk provided but that lunch was prepared and served on-time. On 11/13/24 at 3:45 p.m., the administrator and director of nursing (DON) were interviewed about no kitchen staff on 6/9/24. The administrator stated that she was new to the facility and was made aware that kitchen staff had called out. The administrator stated that she should have asked more questions about the staffing issue and did not realize at that time the significance of the missing staff. The administrator stated she and the dietary manager were new and there was poor communication about the meal service that day. The administrator stated that she did not realize breakfast was not being prepared. The administrator stated if the dietary manager had fully informed her of the situation and decision not to prepare breakfast, she would have brought in facility staff to assist as needed. The DON stated cereal, milk, and juice were served to residents around 10:30 a.m. and there were no issues experienced by residents due to the modified breakfast. The DON stated lunch and dinner were prepared that day and served on-time. The administrator stated again that there was poor communication concerning the staffing issue. This finding was reviewed with the administrator, DON and regional director of clinical services during a meeting on 11/13/24 at 4:00 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and facility document review, the facility staff failed to provide timely breakfast service on four of four units. The findings include: There was no cooked breakfast provided to residents in the facility on the morning of 6/9/24. Posted breakfast times were 8:00 a.m. on the 200 and 300 units and at 8:30 a.m. on the 100 and 400 units. Posted mealtimes documented dinner was served daily at 5:00 p.m. (200, 300 units) and 5:30 p.m. (100, 400 units). Review of the dietary department as-worked schedule for 6/9/24 revealed no dietary employees worked in the main kitchen. A hand-written employee schedule documented one cook and five dietary aides were scheduled to work on 6/9/24, from 6:00 a.m. until 2:00 p.m. This schedule documented the cook, and the five dietary aides either called out, went home, or were a no show on 6/9/24. On 11/12/24 at 3:10 p.m., the dietary manager (other staff #8) was interviewed about kitchen staff on 6/9/24. The dietary manager stated she was newly hired on 6/4/24. The dietary manager stated there were conflicts with the cook at that time and all the kitchen staff scheduled for the day shift on 6/9/24 did not show for work. The dietary manager stated she made the decision to provide cereal and milk for a continental breakfast so she could concentrate on getting help and lunch prepared. The dietary manager stated the standard breakfast was not served on any of the units, with the cereal/milk provided to residents around 10:30 a.m. The dietary manager stated a cook and an employee from another facility came in to assist with food prep but did not stay long. The dietary manager stated a dietary aide (other staff #9) came in later that morning to assist with lunch preparation. The dietary manager stated lunch and dinner were served at scheduled times but there was no cooked breakfast served. The dietary manager stated kitchen employees were contracted by the facility to provide food services. The dietary manager stated she contacted her regional director, and she thought they contacted the facility administrator about the lack of staff. The dietary manager stated she did not anticipate all the employees not showing for work in 6/9/24 and again stated she made the decision to provide cereal/milk so lunch and dinner would be on schedule. The dietary manager stated she typically needed one cook and at least four dietary aides for timely meal service in the facility. On 11/12/24 at 3:30 p.m., the dietary aide (other staff #9) that assisted with meal service on 6/9/24 was interviewed. The dietary aide stated she was not scheduled to work on 6/9/24 but came in because there was no help. The dietary aide stated, Everybody called out that day. The dietary aide stated she did not know why those scheduled did not come to work on 6/9/24. The dietary aide stated that call outs happened occasionally, and she frequently volunteered to fill-in. The dietary aide stated 6/9/24 was unusual because all those scheduled to work did not show. The dietary aide stated there was no cooked breakfast, only cereal & milk were provided but that lunch was prepared and served on-time. On 11/13/24 at 3:45 p.m., the administrator and director of nursing (DON) were interviewed about no kitchen staff on 6/9/24. The administrator stated she was made aware that kitchen staff had called out. The administrator stated she should have asked more questions about the staffing issue and did not realize at that time the significance of the missing staff. The administrator stated she and the dietary manager were new and there was poor communication about the meal service that day. The administrator stated that she did not realize breakfast was not being prepared and served. The administrator stated that if the dietary manager had fully informed her of the situation and decision not to prepare breakfast, she would have brought in facility staff to assist as needed. The DON stated cereal, milk, and juice were served to residents around 10:30 a.m. and there were no issues experienced by residents due to the modified breakfast. The DON stated lunch and dinner were prepared that day and served on-time. The administrator stated again that there was poor communication concerning the staffing issue. The administrator stated meals were expected to be served in a timely manner according to the posted schedule. The facility's policy titled Frequency of Meals (revised 10/2019) documented, . It is the center policy to provide at least three meals daily, at regular times comparable to normal mealtimes in the community. The time between the a substantial evening meal and breakfast the following day will not exceed 14 hours, except when a nourishing snack is served at bedtime. Up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span and a substantial evening snack is provided . The Dining [NAME] Director [dietary manager] will ensure that each meal is served within the designated time frame unless there is an emergent situation or a resident request . (sic) This finding was reviewed with the administrator, DON, and regional director of clinical services during a meeting on 11/13/24 at 4:00 p.m., with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure a therapeutic diet and provide foods correctly per meal ticket for four of five residents in the survey sample (Residents #1 through #4). The findings include: 1. Resident #2 (R2) was not provided a diabetic diet for lunch and was not provided foods per meal ticket for breakfast. Resident #3 (R3) was not provided a diabetic diet for lunch. Resident #4 (R4) was not provided foods per meal ticket for breakfast. The R2's clinical record indicated that R2 had diagnoses that included Diabetes, anemia, and anorexia. MDS (minimal Data Set) dated 11/5/24 indicated R2 was severely cognitively impaired. The R3's clinical record indicated that R3 had diagnoses that included: Diabetes, gout, and obesity. MDS (minimal Data Set) dated 9/30/24 indicated R3 was severely cognitively impaired. The R4's clinical record indicated that R4 had diagnoses that included: neuropathy and dysphasia. MDS (minimal Data Set) dated 9/1/24 indicated R4 was moderately cognitively impaired. On 11/12/24 at 12:30 p.m., lunch service and dining observations were made on the 100 and 400 units. On the 100 unit, R2's meal ticket was verified against the meal served. The meal ticket indicated R2 was to receive a diabetic diet that included a half a chocolate cup cake, but R2 was served a whole cup cake. The serving line was also observed and did not indicate any cup cakes were pre-cut in half. The 400 unit was then observed, R3 was also to receive a diabetic diet per the meal ticket, but also received a whole cup cake, instead of the noted half cup cake. The serving line was observed and did not indicate any cup cakes were pre-cut in half. The diabetic meal ticket was then compared to a regular diet ticket, which indicated that the only difference of the tickets was the serving size of the cup cake (a half for a diabetic and a whole piece for a regular). On 11/12/24 at 2:45 p.m., the dietary manager (other staff, OS #8) was interviewed regarding the above finding. OS #8 reviewed the meal tickets and verbalized that the software program defaults to what is supposed to be served based on the diet ordered and that the residents are supposed to be receiving what is on the ticket. On 11/13/24 at 8:30 a.m., breakfast was observed on the 100 unit. R2's meal ticket was verified against the meal served. R2 was missing 8 ounces of 2% milk and 3/4 cup of grits. When asked about the missing items, R2 verbalized not knowing where the missing food was. At this time a staff server came to the table, reviewed the meal ticket, and asked R2 if she would like the milk and grits. R2 replied, I want what I'm supposed to get. R4's meal ticket was also compared to the meal served and evidenced that the meal served was missing a sausage patty. R4 verbalized wanting the sausage patty. When asked if there were sausage patties available to be served, the dietary aide serving breakfast (identified as OS #5) indicated that there were. When asked several times the reason for not serving R4 a sausage patty, OS #5 appeared reluctant to answer the question. When asked if she didn't see the sausage patty on the meal ticket, OS #5 responded, Yeah. On 11/13/24 at 3:45 the above finding was presented to the administrator and director of nursing. No other information was presented prior to exit conference on 11/14/24. 21875 2. Resident #1 was not served foods according to the meal ticket. Resident #1's meal ticket inaccurately documented the resident had a 1500 ml (milliliter) per day fluid restriction. Resident #1 (R1) was admitted to the facility with diagnoses that included congestive heart failure, hypertension, arthritis and lymphedema. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. On 11/12/24 at 1:10 p.m., R1 was observed with lunch. The foods served to R1 were compared to the meal ticket provided with the meal. R1 was served two baked chicken breasts, mashed potatoes, mixed vegetables, a roll, chocolate cupcake and yogurt. R1's meal ticket included the baked chicken, yogurt and vegetables but did not list the mashed potatoes, roll or cupcake. The ticket listed a tossed salad with dressing that was not served with the meal and documented the resident was on a 1500 ml per day fluid restriction. R1 was interviewed at this time about foods served. R1 stated he rarely was served meals according to the ticket. R1 stated he frequently was served foods that he was not supposed to have or did not want. R1 stated he did not want the potatoes, roll, cupcake or the mixed vegetables and he did not know why he was served these items as they were not listed on the ticket. R1 stated he wanted the tossed salad and that was not provided with the meal. R1 stated he was on a fluid restriction a long time ago but did not have a current order for a fluid restriction. R1 presented his meal ticket from lunch on 11/10/24. The meal ticket documented a double portion of baked chicken breast, vegetable, tossed salad with dressing and yogurt and listed the resident had a 1500 ml fluid restriction. R1 had marked the ticket indicating he did not receive the yogurt, vegetable or tossed salad. R1 stated a roll was served that was not listed on the ticket and the yogurt, salad and vegetable were not provided. R1's clinical record documented a physician's order dated 8/23/24 for a heart healthy/low salt, regular textured diet with instructions for no pork products, no fried or breaded foods, no high sodium soups, no prepackaged hamburgers, chicken patties, salted frozen meatballs, chicken thighs, canned fruit or cooked vegetables. The order recommended baked chicken, fresh vegetables, fruit and yogurt. The clinical record documented no current physician's order for a 1500 ml fluid restriction. On 11/13/24 at 2:00 p.m., the dietary manager (other staff #8) was interviewed about R1's meal tickets and foods served not matching the tickets. The dietary manager stated she was aware the fluid restriction on the meal ticket was inaccurate but that she did not know how to revise the information in the ticket system. The dietary manager stated she thought there was a software issue regarding the inaccurate ticket information. The dietary manager stated kitchen employees were supposed to serve foods as listed on the ticket that included resident preferences and therapeutic foods. The dietary manager stated the meal tickets for R1's lunch meals were not followed. The dietary manager did not know why R1 was not served a salad as listed. This finding was reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 11/13/24 at 4:00 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in a sanitary manner from the main kitchen and on two of four kitchenettes (200-unit, 300-unit). The findings include: In the main kitchen, multiple food items were stored beyond use-by dates, with no prep dates and/or opened dates and/or were unsealed in the freezer. Bulk condiment storage containers, flour/sugar bins and the manual can opener were dirty. An employee was observed in the kitchen during meal preparation without a hair restraint. Employee food items were stored in the walk-in refrigerator. On the 200 and 300 units, foods were held on the kitchenette steam tables below recommended safe temperatures and served to residents without reheating. a) The main kitchen was inspected on 11/12/24 at 10:50 a.m., accompanied by the dietary manager (other staff #8). Observed stored in the walk-in refrigerator was a plastic bag containing chopped chicken, cheese, and tortillas. The dietary manager stated this bag of food belonged to the cook and should not be stored in the kitchen's refrigerator. There was a pan of leftover macaroni salad in the refrigerator with no label indicating date prepared or a use-by date. There was a large container of leftover rice pudding prepared on 11/2/24. The dietary manager stated the rice pudding had been stored beyond seven days and should have been discarded. There were gallon containers of mustard, mayonnaise, and salad dressing stored on an upper shelf. The outside of each of these containers was smeared with mustard, mayonnaise, and dressing, making it impossible to pick up without getting the product on hands. A bag of frozen chopped carrots and a bag of frozen green peas were stored in the walk-in freezer. These bags were unsealed exposing the peas and carrots to air. During this inspection, a facility employee entered the kitchen without a hair restraint, and had a discussion with the dietary manager. The employee was not instructed to apply a hair net and had entered the kitchen during lunch preparation. The dietary manager identified this person as the speech therapist. The bulk flour bin was observed dirty with yellow/brown drips/stains along the edge of the bin top. There was a mug positioned inside the container nested in the flour. The bulk sugar bin was also dirty with yellow/brown stains/debris on the top. There was a bowl located inside the container nested in the sugar. The bench mounted can opener was dirty with black, brown buildup noted on the blade and on the mounted bracket. The dietary manager stated the can opener was supposed to go through the dishwasher at least once per day. The dietary manager stated kitchen employees knew to label and date foods when prepped and/or opened and that leftovers were supposed to be discarded after seven days. b) On 11/12/24 at 12:20 p.m., the meal service from the 200-unit kitchenette was observed. Temperature of the foods on the steam table was requested. After leaving the kitchenette to find a thermometer, the dietary aide (other staff #6) checked food temperatures, with multiple food items measuring below the required 135 degrees (F). A pan of pureed ham measured 130.4 degrees (F), ground ham measured 123.8 degrees (F); chicken breasts measured 121.8 degrees (F), and pureed vegetables measured at 127.2 degrees (F). The dietary aide did not reheat any of the low temperature foods and continued to serve residents from the steam table. When asked if he usually checked temperatures prior to food service, the dietary aide (other staff #6) stated the temperatures were usually checked in the kitchen. On 11/12/24 at 12:38 p.m., the meal service from the 300-unit kitchenette was observed. Temperature of the foods on the steam table was requested. After leaving the kitchenette to find a thermometer, the dietary aide (other staff #7) checked food temperatures, with multiple food items measuring below the required 135 degrees (F). A large pan of sliced ham/glaze measured 134.2 degrees (F), pureed vegetables measured 111.7 degrees (F), and ground ham measured 123.0 degrees (F). The dietary aide did not reheat any of the food items found below 135 degrees (F) and continued to plate and serve food to the remaining eight residents on the unit. When asked about checking food temperatures at the steam table, the dietary aide stated the temperatures were checked in the kitchen. On 11/13/24 at 2:00 p.m., the dietary manager (other staff #8) was interviewed about the main kitchen observations and low food temps on the 200 and 300-unit steam tables. The dietary manager stated employee food was not supposed to be stored in the kitchen refrigerator. The dietary manager stated she did not have a scoop for the bulk flour and sugar, so employees were using a mug and/or bowl to retrieve the product. The dietary manager stated scoops were not supposed to be stored in the flour/sugar. The dietary manager stated servers in the kitchenettes were supposed to be checking food temperatures at the steam table. The dietary manager stated foods below the 135 degrees (F) were supposed to be removed and reheated prior to serving. The dietary manager state she did not realize the servers were not checking steam table temperatures. The facility policy titled Food Safety FS-[NAME]-SOP (revised 8/13/24) documented regarding employee personal items, .Personal belongings should not be stored in preparation, production, storage, and warewashing areas . The facility's Food Storage Chart (undated) documented leftovers including deli meats, salads, opened canned fruits, and pudding should be stored in the refrigerator for no longer than 7 days, with day 1 considered the date of preparation. The facility's procedure titled TCS Food Labeling Guide (2024) documented, .All TCS [temperature control for safety] food we prepare and keep for over 24 hours must be labeled and used within 7 days . The facility's policy titled Staff Attire (undated) documented, .It is the center policy that all Dining Serivces [Services] employees wear approved attire for the performance of their duties .The Dining Services Director insures all staff members have their hair off the shoulders, confined in a hair net or cap . The kitchen's cleaning schedule (undated) documented daily and weekly cleaning of food containers, bins, and food preparation equipment. The U.S. Food Code 2022 documents on page 3-28 that hot holding temperatures of time/temperature control for safety foods shall be maintained at or above 135 degrees (F). These findings were reviewed with the administrator, director of nursing, and regional nurse consultant during a meeting on 11/13/24 at 4:00 p.m., with no further information provided prior to the end of the survey.

Based on observation, interviews, clinical record, and facility documentation, the facility staff failed to provide treatment and services to prevent a worsening stage three pressure ulcer for one of 12 residents, resulting in harm for Resident #8 (R8), and failed to assess and implement treatment timely for a stage three pressure ulcer for one of 12 residents in the survey sample, Resident #5 (R5). 1. R8 did not have an accurate skin assessment, resulting in a delay in treatment of a worsening stage three pressure ulcer/wound. 2. R5 had a delay in treatment of a stage three pressure ulcer/wound. The findings included: According to the clinical record, R8 was admitted to the facility with diagnoses that included, but not limited to hemiplegia, cerebral vascular accident, muscle weakness and aphasia. R8 had a 5 day minimum data set (MDS - assessment tool) dated 7/25/23 noted that the BIMS (Brief Interview of Mental Status) was unable to be obtained. The MDS coded R8 as requiring extensive assistance on staff for Activities of Daily Living care. Section M Skin Conditions of the MDS documented that R8 had a stage three pressure wound that was present upon admission. R8's clinical record included a skin observation tool dated 7/20/23 that indicated the coccyx had reddness and another one dated 7/27/23 that indicated the coccyx had a pressure area, but did not document the stage of the pressure wound. R8's admission assessment note, dated 7/19/23, documented that no wound was present, while a skilled note, dated 7/19/23, documented that R8 had a stage 3 pressure wound on the coccyx area. Another skilled note, dated 7/20/23, documented that no wound was present. However, none of the nurses notes included any description of the wound. R8's clinical record documented no notifications to the physician/provider about the pressure wound and listed no treatment orders for the pressure wound since admission to the facility on [DATE]. Review of the wound consultant report, dated 7/24/23, documented a Stage 3 coccyx pressure wound was present on admission, with measurments of 1.0 cm x 1.0 cm x 0.2 cm depth (length by width by depth in centimeters). The note documented the coccyx wound had moderate amount of bloody drainage, no odor, and had reddened, fragile wound perimeters. A physician's order was entered on 7/26/23, upon recommendation from the wound consultant for treatment of the pressure wound to the coccyx. R8's treatment administration record (TAR) documented that the treatments were implemented on 7/27/23 as ordered. On 8/1/23, a comprehensive assessment, with a recommended change in treatment, was completed by the wound consultant. The assessment documented that the coccyx wound measured 3.5 cm x 2.0 cm x 2.0 cm, had moderate amount of bloody drainage, had reddened, fragile wound perimeters, and had a wound status that was noted as worsening. The wound consultant recommended cleansing the wound with 0.125% dakins solution, then apply dakins moistened fluffed gauze to wound bed, and cover with bordered foam and zinc barrier cream to reddended area. A physician's order was entered on 8/3/23, per the wound consultant's recommendation for the treatment change. R8's TAR documented that the treatment was implemented on 8/3/23. An interview was conducted with LPN# on 3/5/24 at 9:00 a.m. LPN# verbalized that the process for admission of a resident to the facility would include a head to toe assessment. LPN# verbalized that if a skin impairment was found, the process is to notify the provider, and to implement the orders given by the provider, unless the hospital sent wound treatment orders, which would be implemented. An interview was conducted with the wound consultant nurse practitioner (NP) on 3/5/24 at 12:35 p.m. The NP verbalized that the nurses notes are used for reference on the resident's skin obeservation on admission day. The NP verbalized that if no information is on the nurses notes, then the NP will talk to the resident. The NP verbalized that if the NP has never seen the resident before or anyone from the NP company, then the resident is considered a new patient for the company. An interview was conducted with license practical nurse (LPN#5 ) on 3/5/24 at 3:00 p.m. LPN# 5 verbalized that the process for admission of a resident to the facility would include a head -to-toe assessment. LPN#5 verbalized that if a skin impairment is found, the process is to notify the provider and to implement the orders given by the provider, unless the hospital sent wound orders, which would be implemented. An interview was conducted with a licensed practical nurse ( LPN#4, wound nurse). LPN#4 verbalized that the process for the skin observation tool on admission is that the floor nurse does the initial assessment when the patient comes into the facility and then a second skin assessment is completed after admission. LPN#4 verbalized that if the admission is Monday through Friday that LPN#4 completes the second skin assessment, as the wound consultant comes in twice weekly and completes a skin assessment. LPN#4 reviewed R8's clinical record and verbalized that no treatment was started from admitted [DATE] until 7/27/23, adding that the nurses should have implemented skin care. When asked to identify the initial findings, the LPN#4 verbalized that there was some discrepancy from what the admitting nurse noted on admission skin assessment and what the wound nurse noted on their first skin assessment after admission. A review of the facility documents was conducted on 3/5/24. The facility policy titled, Skin Assessments, read in part, A licensed nurse will ensure that the skin risk assessment is done upon admission, care plan specific interventions will be developed based on skin risk assessment outcomes. The facility policy titled, Pressure Ulcer Monitoring and Documentation, read in part, A licensed nurse will assess patients for the prescence of pressure ulcers/injuries and if a pressure ulcer/injury is present, the nurse will evaluate for complications. Provide pain management prior to treatment of the pressure ulcer. The facility documentation of staff education, with the title of Basic Wound Care for Nurses and Aides, read in part, Documentation for wounds should include wound type, exudate, and the type of dressing that will be used . that all wounds should be correctly assessed and documented weekly in the resident's chart. On 3/5/24 at 5:00 p.m., the director of nursing (DON) verbalized that the process for skin observation on admission is for the nurse to assess, then if something is found the nurse is to notify the physician, to obtain an order, to implement the order, and to notify the wound nurse the following day, so the wound nurse can follow up. The DON stated, Skin assesssments not being conducted has been a pattern that has been identified. The DON verbalized that the same wound nurse makes rounds with the NP weekly for consistancy and that education is being provided to the nursing staff. The DON verbalized that wound orders should be implemented by the nurse that is making rounds with the NP and the orders should be entered while doing the rounds. These findings were reviewed with the director of nursing (DON), Administrator, and the regional clinical nurse during a meeting held on 3/5/24 at 5:00 p.m. On 3/6/24 at 2:08 p.m., the Administrator verbalized that with R8's medical conditions, that even though no treatment had been started, I don't know if there would have been a different outcome for this residen.t On 3/6/24 at 2:30 p.m., these findings were reviewed with the DON, Administrator, and regional clinical nurse and no other information was provided prior to exit conference. 2. R5 did not have a comprehensive assessment completed for 3 days after a pressure ulcer was identified. A treatment order was not implemented for R5's pressure ulcer until eleven days after the ulcer was identified. According to the clinical record, R5 was readmitted to the facility on [DATE], with diagnoses that included, but not limited to, adult failure to thrive, pressure ulcer to sacal region Stage 3, hypertension, and anemia. A discharge return anticipated MDS (Minimum Data Set - assessment tool), dated 1/29/24, assessed R5 with no cognitive impairments. The Section M (Skin Conditions) documented R5 had a stage three pressure ulcer upon discharge to the hospital. Documentation indicated R5 returned to the facility on [DATE] with pressure ulcer. R5's nursing notes were reviewed from 2/4/24 through 2/7/24 and no documentation for the pressure wound was noted. R5's clinical record included a hospital record dated 1/31/24 that documented the Stage 3 pressure injury. On 2/3/24, the admission skin assessment documented that R5 had a stage 1 pressure ulcer on the sacral area. On 2/6/24, the wound consultant documented a Stage 3 to coccyx, with measurements of 0.3 cm x 0.2 cm x 0.6 cm prior to debridement (cutting away of dead tissue) and 0.4 cm x 0.2 cm x 0.2 cm depth post debridement. It was also noted that the wound perimeters were fragile, with a moderate amount of bloody drainage, for which treatment was recommmended. The NP assessed R5 on 2/13/24 for wound debridment without a change in the treatment. The NP followed up with R5 on 2/20/24 and 2/27/24 and documented the wound was improving. On 3/5/24, the NP documented that the occyx wound had resolved. Review of R5's TAR indicated treatments were started on 7/27/23 and were being carried out. Interview was conducted with LPN#4 (wound nurse) on 3/5/24 at 3:20 p.m. LPN#4 verbalized that there is a break in communication with the nurses about staging the wounds. LPN#4 reviewed R5's clinical recorded and verbalized that the treatment ordered was not updated until 2/14/24 by LPN#4 and that the wound should have been treated sooner. Interview was conducted with LPN#6 on 3/5/24 at 3:51 p.m. A review was done with LPN#6 to explain the skin assessment part of the admission note. LPN#6 verbalized that the hospital had documented the wound as a stage 3 in their report. LPN#6 verbalized that a skin assessment was completed, the dressing covering the coccyx wound was removed, and a skin observation was made, but that the wound . had appeared to be a stage 1 to me, not a stage 3 wound. A review of the facility documents was conducted on 3/5/24. The facility policy titled, Skin Assessments, read in part, A licensed nurse will ensure that the skin risk assessment is done upon admission, care plan specific interventions will be developed based on skin risk assessment outcomes. The facility policy titled, Pressure Ulcer Monitoring and Documentation, read in part, A licensed nurse will assess patients for the prescence of pressure ulcers/injuries and if a pressure ulcer/injury is present, the nurse will evaluate for complications. Provide pain management prior to treatment of the pressure ulcer. The facility documentation of staff education, with the title of Basic Wound Care for Nurses and Aides, read in part, Documentation for wounds should include wound type, exudate, and the type of dressing that will be used . that all wounds should be correctly assessed and documented weekly in the resident's chart. On 3/5/24 at 5:00 p.m., the director of nursing (DON) verbalized that the process for skin observation on admission is for the nurse to assess, then if something is found, the nurse is to notify the physician to obtain an order, to implement the order, and to notify the wound nurse the following day, so the wound nurse can follow up. The DON stated, Skin assesssments not being conducted has been a pattern that has been identified. The DON verbalized that the same wound nurse makes rounds with the NP weekly for consistancy and that education is being provided to the nursing staff. The DON verbalized that wound orders should be implemented by the nurse that is making rounds with the NP and the orders should be entered while doing the rounds. On 3/6/24 at 2:30 these findings were reviewed with the DON, Administrator, and regional clinical nurse and no further information was provided prior to exit conference

Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to ensure adequate supervision and/or interventions for the prevention of falls for one of 25 residents (Resident #111), which resulted in actual harm and failed to ensure one of 25 residents (Resident #7) was safe when consuming hot liquids. Findings include: 1.) Resident #111's diagnoses included, but were not limited to: ataxia [impaired coordination] following a non-traumatic intracerebral hemorrhage, [CONDITION(S)] syndrome, pancytopenia, headache, [CONDITION(S)], cognitive communication deficit, abnormalities of gait and mobility, lack of coordination, dysphagia, mild protein calorie malnutrition, high blood pressure, [CONDITION(S)], [CONDITION(S)] [dizziness/off balance feeling] and fracture of right femur. The most recent full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 11, indicating moderate impairment in daily decision making skills. The resident was assessed as requiring extensive assistance of two staff for transfers, bed mobility, dressing, eating and toileting. The resident was assessed as requiring total assistance of two staff for bathing. The resident was coded as incontinent of bowel and bladder A complaint investigation was conducted on Resident #111 on 09/06/22 through 09/08/22. An allegation within the complaint alleged that the resident had multiple falls at the facility, with the last fall (on 08/07/22) resulting in Resident #111 sustaining a right [CONDITION(S)]. Resident #111's clinical records were reviewed and revealed the following: An admission assessment dated [DATE] and timed 2:50 PM documented, .on arrival: cognitively intact .Does the resident exhibit any signs of or complain of .pain? no Admission Narrative note: Resident admitted from [name of hospital] following brain bleed and stroke. No surgical intervention pursued. Vitals are stable and c/o of headache persistently. Able to make all needs known. PT and OT will evaluate. History noted for pancytopenia, [CONDITION(S)], afib, [CONDITION(S)]. Family in to visit. Monitor closely . Nursing notes were then reviewed and revealed that the resident had a fall on the following days: On 7/12/2022 at 6:27 PM, a skilled nursing note documented, .Nursing Focus: Continues skilled nursing care due to intracerebral hemorrhage. A&O (alert and oriented) x 2. Takes medication whole .2 person assist with ADLs. Incontinent to bowel and bladder No other complaints at this time . On 7/13/2022 at 6:00 PM, a nursing noted documented, .Alert Note .Patient found on the floor at 1500 [3:00 PM], fell from w/c [wheelchair], head was resting under the chair, patient indicated that he did hit head. 911 called . patient transported .Daughter .aware .VS [vital signs] stable post fall. A fall risk assessment dated [DATE] documented that the resident was on an antihypertensive and anti-[CONDITION(S)] medication, the resident was chair bound, incontinent and had improper body position. The assessment did not address the areas of unsafe behavior or mobility (those areas were blank). This assessment did not indicate by a score and/or other means that the resident was at risk for fall or was at high risk for falls. A fall investigation dated 07/13/22 and timed 3:00 PM was reviewed and documented that the resident was, on an anti-[CONDITION(S)] medication, was not alert and oriented, was confused and disoriented, was restless and was in the resident's room at the time of the fall, did not call for help and that the call light was not in reach and that the resident was not wearing proper shoes and that the resident had cognitive impairment. The fall on 07/13/22 was unwitnessed and occurred in the resident's room. There were no specific details in the investigation regarding the circumstances around the fall and there were no interviews from staff. The resident's CCP (comprehensive care plan) was then reviewed and documented, .ensure the resident wears shoes when ambulating created on: 07/07/2022, place bed in lowest position while resident is in bed created on: 07/07/2022, place common items within reach of the resident created on: 07/07/2022, remind the resident to use their call light to ask for assistance with ADLS created on: 07/07/2022, reorientation to the room to assist the resident to familiarize created on: 07/07/22, therapy referral created on: 07/07/2022 .ACTUAL FALL: [Name of Resident #111] is at risk for injury from fall/falls. Resident had a fall. Created on: 07/14/2022, The resident will resume usual activities without further incident through the review date. Continue interventions on the at-risk plan Created on: 07/14/2022 . On 07/27/22 at 4:50 PM, a skilled nursing note documented, .weakness. He is alert and oriented to self, cognitive status varies .no complaints of pain .Continues to be a two assist for transfers and ADL's . The resident's physician's orders were reviewed. A bed alarm was ordered on 07/27/22. The resident's July 2022 MARs (medication administration records) were reviewed. The MARs documented the bed alarm order on the MAR and it was signed off that this intervention was in place for the resident from 07/27/22 through 07/31/22. The resident's CCP was updated and documented, .bed alarm to bed created on: 07/28/2022 . On 7/30/2022 at 5:48 PM an SBAR [situation-background-assessment-recommendation] Summary note documented, .The Change In Condition/s reported on this Evaluation are/were: Falls .Code Status: DNR .Recommendations: n/a .New Testing Orders .n/a .New Intervention Orders: Other - n/a . On 7/30/2022 at 5:51 PM a progress note documented, .Health Status Note .Resident found sitting beside his bed, range of motion indicates no injury, assisted up off floor by 2 staff. Resident was belligerent when writer explained to him that he should always ring for assistance if he wants to get out of bed or back to bed. Stated I wanted to get up. Wife .informed. MD made aware. The fall on 07/30/22 was an unwitnessed fall. There was no fall investigation and/or fall risk assessment for the fall on 07/30/22. There was no information regarding the bed alarm, if it was in place and/or sounding. On 08/04/2022 at 7:21 PM, a progress note documented, .Fall Note .Skin tear on right shin. No other injuries noted at this time .What interventions were in place at the time of the fall?: Chair alarm, What are the risk factors that could have contributed to the fall?: Confusion and gait imbalance, What new interventions were implemented in response to the fall?: Education regarding call bell usage, Was the Provider/resident and RP notified at the time of the fall?: Yes . A late entry note documented, .Post Fall Documentation Late Entry: Situation: Date and time the fall occurred: 08/04/2022 4:00 PM .Background: Circumstances of the fall: unknown . Assessment (RN)/Appearance (LPN): Current status of the resident's injuries or reports of pain from the fall: no c/o pain .Recommendations: Interventions currently in place to prevent additional falls: Bed alarm and bed in lowest position .Resident's response to new interventions: no response A fall investigation dated 08/04/22 and timed 7:15 PM documented the resident was on an antihypertensive, was not alert and oriented, was confused and disoriented, was restless, the fall was in resident's room, did not call for help, call bell in reach and was wearing appropriate footwear and contributing factors was cognitive impairment. There was no specific information regarding the circumstances of the fall in this investigation or any interviews from staff. There was no information regarding the bed alarm, if it was in place and/or sounding. A fall risk assessment dated [DATE] documented that the resident was on an antihypertensive medication, tried to stand, transfer, or walk alone unsafely, propels or walks alone in unsafe places, uses assistive devices inconsistently, and that the resident was incontinent. The fall risk assessment did not address the resident's gait and balance [that section was blank] and the assessment did not provide a score or a means to quantify the resident's risk for falls. The fall on 08/04/22 was unwitnessed and occurred in the resident's room. A practitioner note dated 8/4/2022 and timed 1:00 AM documented, .Encounter . Date of Service: 08/04/2022 Visit Type: New Evaluation .This patient is a pleasant [AGE] year-old Caucasian male currently in the skilled nursing setting following a recent hospitalization .Nursing staff reports this patient has been having episodes of increased irritability and agitation and poor safety awareness. The patient's PCP recently started this patient on [MEDICATION(S)] 125 mg twice daily dosing for improved mood stabilizing properties. The patient is also on [MEDICATION(S)] 15 mg nightly for [CONDITION(S)] and depression. The patient appears to be tolerating these medications without any adverse side effects. When the patient is seen today he is noted to be lying down in bed and is in no obvious pain or discomfort. The patient is notably only oriented to person and somewhat to place . This provider assessed the patient's pain on a 0-10 pain scale and the patient reports a pain level of 0 .The patient does report minimal anxiety and depressive symptoms due to being in the skilled nursing setting .Care Plan Recommendations: Continue the medications at current dosages as the patient is stable at this dose and dose reduction would likely cause a deterioration of the patient's psychiatric illnesses/symptoms .Monitor patient for mood changes or behaviors: i.e. agitation/aggressiveness, irritability, sleep disturbances, appetite disturbances, significant change in energy level, paranoia, hallucinations, erratic behaviors, change in LOC, mood lability, anxiety, SI/HI, or potential side effects to current psychiatric medications. If any noted please notify TeamHealth . The resident's CCP was again reviewed. An intervention was added on 08/05/22, .Keep resident in high traffic area for safety Created on: 08/05/22 . On 08/06/2022 at 6:33 PM a skilled note documented, .Observations .BP 133/76 .bowel Status: incontinent .Pain: no .Non Pharmacological interventions provided: [blank] Pharmacological interventions provided: [blank] .Continues skilled nursing care due to intracerebral hemorrhage. A&O x 2 .2 person assist with ADLs .Resident fell this evening. States he slipped out of the bed. No injuries noted. Will continue to monitor for any changes. Vitals are within normal limits. A fall investigation dated 08/06/22 and timed 6:24 PM documented that the resident was on an antihypertensive, was alert and oriented, was not confused/disoriented, was calm, the fall occurred in the resident's room, he did call for help, call light was in reach and was wearing the proper footwear and contributing factors were listed as fatigue/weakness. There was no specific information regarding the circumstances of the fall or any interviews from staff. There was no information regarding the bed alarm, if it was in place and/or sounding. The fall on 08/06/22 was unwitnessed and occurred in the resident's room. On 08/07/22 2:19 PM, a progress note documented, .health Status Note . Resident had a fall after lunch in his room. CNA [certified nursing assistant] found resident at the foot of the bed laying on his left side. Resident states he was trying to get up to go to the bathroom. After examining resident, he presented with right side hip pain that was radiating down his leg. Skin tear was noted to right elbow. Vitals were stable. Resident states he also hit his head. Notified weekend supervisor [also known as LPN #1] and stated nurse was sending him to [name of hospital] ER due to possible fracture. Notified DON. Unable to get MD on the phone. Call and let emergency contact know and they were going to meet resident at the hospital. The fall on 08/07/22 that resulted in the resident sustaining a right hip fracture was unwitnessed and occurred in the resident room. There was no investigation completed on this fall. There was no documentation regarding the resident's bed alarm, whether it was in place and/or functioning. There were no interviews from staff regarding this fall. Resident #111 had the fall with injury on 08/07/22. The resident was sent to the hospital and admitted and returned to the facility on [DATE]. The resident's hospital discharge summary dated 08/10/22 documented, .primary discharge diagnosis: Acute intertrochanteric fracture of the proximal RIGHT femur, closed, presumed pathologic due to [CONDITION(S)] .confusion, presumed not new since stroke .chronic pancytopenia, likely [CONDITION(S)] syndrome variant .He was admitted on [DATE] after a fall out of bed. He was found to have an acute right hip fracture .hospital list: fall, closed right hip fracture . On 09/07/22 at 3:50 PM, LPN#1 [also known as the weekend supervisor] was interviewed regarding Resident #111's fall on 08/07/22 [Sunday]. LPN #1 stated that she remembered the resident and that he would get up and try to self transfer and fell and broke his hip. The LPN stated he would attempt to self transfer and we (staff) continually reminded him not to get up and to use the call bell. The LPN stated that the resident was confused and that this was an unwitnessed fall. The LPN was asked if an investigation was done on this resident for this fall. The LPN stated, As far as I know we did. The LPN then looked in the resident's record and stated that she did not see an investigation for that fall for Resident #111. No further information was provided by LPN #1. On 09/08/22 at 8:48 AM, RN #3 [also known as the corporate nurse] presented information regarding Resident #111. The RN stated that they had an investigation for the resident's falls for 07/13/22, 08/04/22, and 08/06/22 and also did fall risk assessments [documented above], but they did not have an investigation for the unwitnessed falls on 07/30/22 or on 08/07/22 when the resident sustained a femur fracture. The RN stated that the resident was sent out to the hospital on those days. The fall investigations and fall risk assessments were reviewed and RN #3 was made aware that the fall risk assessment did not score the resident for fall risks. The RN stated that she was aware of that and that they (facility) were working on a scoring system to better assess fall risk residents. The RN was made aware that the fall investigations were vague and did not provide any real details surrounding the resident's falls and did not have any staff interviews and/or statements that may provide additional information surrounding the falls. The RN was made aware of the serious concerns regarding the resident repeat falls and the resident's fall on 08/07/22, which resulted in harm. On 09/08/22 09:06 AM, LPN (Licensed Practical Nurse) #7 was interviewed regarding Resident #111. LPN #7 stated that the resident used to be in room 228 and that she normally worked that area and worked with that resident. The LPN stated, Since the resident first came to us, he was ., I wouldn't use the word non-compliant, but he was hard to get to do stuff, he didn't want to eat or drink, he'd raise the bed up and down and he was a big fall risk. We had to keep encouraging him to use the call bell, he would keep attempting to get up. We had an extended bed for him [he was tall] and he had a bed alarm .I think he had a bed alarm, he didn't have a chair alarm. LPN #7 further stated, When he came back from the hospital he was on hospice and they [hospice] ordered fall mats and had them delivered and we put them down, I remember because they were pink. I think he was in the chair some and we'd bring him out in the hall, but that was rare. He was a big sleeper and spent a lot of time in his room and in bed. For the most part while I was here he wanted to stay in the bed and sleep. The day he fell the last time [08/07/22], I did not hear an alarm that day, I'm not sure if it was on or not, but I had heard that in the past and remembered the sound it was really loud and annoying, but I didn't hear it that day. One of the girls working was a TNA (temp nurse aid) she is no longer working here and a CNA I don't recall her name. He (Resident #111) was my patient and I was doing med pass when that happened. Of course, it was an unwitnessed fall and from what I understand the CNA took the [lunch] tray in and left and then went to get his roommates tray and came back and he (Resident #111) was on the floor. He was not a big drinker and didn't eat much and we would have to encourage him. LPN #7 was asked who updates the care plans. The LPN stated that she thought it would be the unit managers or MDS, but she had not done that. The LPN stated that the Unit Manager was LPN #1 when the resident's last fall occurred, I believe it was a Saturday or Sunday and LPN #1 was the supervisor. LPN #7 stated that she went to the resident's room immediately, checked the resident out, checked his vitals, and stated, 'for me to even touch his leg he was screaming in pain.' LPN #7 stated that she went and got LPN #1 and they both went to the resident and both agreed that he needed to be sent out. LPN #7 stated that the resident's wife was there just before the resident fell and stated that his wife did tell the TNA that he had attempted to get up before she left. LPN #7 stated that she did not hear the resident's wife say that, but that is what the TNA told her and reported to her after the fall occurred. LPN #7 stated that 911 was called and when EMS [emergency medical services] got here, he [resident] was in so much pain that they had to medicate him and stated that she believed they gave him IV [intravenous] [MEDICATION(S)] to get him on the gurney because he was in so much pain. LPN #7 stated, He never did use the call bell to my knowledge. The LPN stated that she worked with him frequently and the resident seemed to decline pretty fast and the resident was typically quite most of the time. LPN #7 stated that she did not recall the resident being combative with care or anything like that. LPN #7 stated that was the first time he fell on her shift. LPN #7 stated, I had a feeling that was going to happen with him anyways. The facility's fall policy was presented, Falls Management Program .considers all patients to be at risk for falls and provides and environment as safe as practicable .a fall risk assessment will be completed upon admission, readmission, quarterly, and significant change of condition .incorporate identified interventions into the Comprehensive care plan .discuss risks and interventions .do not move or reposition until a licensed nurse has completed a physical and mental assessment .assess, intervene, and promptly provide the necessary interventions for any patient experiencing a fall .notify physician, responsible party and EMS .post fall include neurological assessment if the fall was unwitnessed .complete post fall assessment to determine, to the extent possible the cause of a patient fall .Investigate the fall, and record findings surrounding the fall .A licensed nurse will review, revise and implement interventions to the care plan based on: post fall assessment findings, review device assessment, review of fall risk assessment .unit manager will review the incident report and any post fall follow up .each fall will be reviewed for causative factors utilizing the post fall assessment, device assessment and incident report .the unit manager verifies care plan revisions, patient monitoring, appropriate referrals . On 09/08/22 at 10:19 AM, the survey team met with the administrator, DON, and corporate nurse. The staff were made aware of serious concerns regarding repeated falls for this resident and specifically the fall 08/07/2, which resulted in [CONDITION(S)]. The facility staff were made aware of the concerns regarding the lack of supervision and/or interventions for the prevention of falls for this resident, who had been identified as known as being at risk. The facility staff stated that they would look for any additional information. On 09/08/22 at approximately 11:10 AM, the DON, administrator and corporate nurse returned and stated that they had additional information. The DON stated that the discharge summary documented that the resident's fracture was pathological and that it could not be proven that this fall (the fall from the bed on 08/07/22) is what caused the resident's fracture. The DON was made aware that the discharge summary documented, that the resident had an Acute intertrochanteric fracture of the proximal RIGHT femur . presumed pathologic due to [CONDITION(S)]. The discharge summary also that the resident had a fall out of bed and was found to have an acute right hip fracture and was then admitted to the hospital. The DON was also made aware according to Resident #111's clinical records, Resident #111 did not have a previous diagnosis of [CONDITION(S)] or a current diagnosis of [CONDITION(S)]. The facility staff were made aware that through the complaint investigation and interviews, the resident was in severe pain after the fall that resulted in the hip fracture and that, according to interviews the resident was screaming out in pain when the nursing staff attempted to touch and assess the resident's leg. It was also reported that the EMS had to medicate the resident to be able to get the resident on the gurney due to the severity of the pain he was experiencing. The DON, administrator and corporate nurse were also made aware that the resident's care plan was not updated with new fall interventions and/or supervision and that there was no investigation completed by the facility of this unwitnessed fall. The DON stated that they had interventions in place, but they weren't on the resident's care plan and they (staff) discussed the falls in their meetings and presented documentation to the survey team. The information documented, .7/13/22 [name of resident] fall ? head injury resident to ED for evaluation/continue interventions.[no new interventions added] 08/4/22 [name of resident] fall skin tear on right shin area resident will be place in a highly trafficked area when up to assist with fall prevention [this intervention was added to the care plan] .08/06/22 [name of resident] fall none [injury] resident will be monitored for adverse effects of medications to assist with fall prevention [this intervention was added to the care plan on 08/08/22 after the fall with injury] .08/07/22 [name of resident] fall right hip pain resident sent to ER for evaluation . No information was presented for the fall on 07/30/22. The facility staff were made aware that these interventions were the same interventions already in place and that the only new intervention for actual fall prevention was putting the resident in a high traffic area which was implemented on 08/05/22. The facility staff were also made aware that the all of the resident's falls occurred in the resident's room (not in a high traffic area) and all of the resident's falls were in unwitnessed. No further information and/or documentation was presented prior to the exit conference on 09/08/22 at 11:45 AM to evidence that adequate supervision and/or interventions were implemented for Resident #111 for the prevention of falls, which subsequently resulted in injury. Resident #111 had a total of five falls between 07/06/22 and 08/07/22. The resident sustained a right hip fracture as result of the last fall on 08/07/22 (the resident's last fall). This is a complaint deficiency. 2. Resident #71 was admitted to the facility with the following diagnoses, including but not limited to: Left femur fracture, dementia, protein-calorie malnutrition, and hypertension. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 08/04/2022 assessed Resident #71 as having problems with both long and short term memory, as well as severely impaired with daily decision making skills. On 09/06/2022 at approximately 12:30 p.m., the lunch time meal was observed, Resident #71 was sitting up in her wheelchair, her lunch tray was on a table in front of her. She was attempting to feed herself. Her napkin was crumpled in the middle of her plate, her cold drink was spilled onto the tray, the plate, the table, her clothes, and the floor. She was asked if she needed any help. She stated, I spilled it. A nurse in the hallway was asked to come to the room. She spoke with Resident #71 and went to get her another tray and drink. On 09/07/2022 at approximately 8:30 a.m., Resident #71 was observed sitting in her bed. Her breakfast was on the bedside table in front of her. The front of her gown was wet. She had her coffee cup in her hand and was attempting to get it to her mouth. The coffee spilled down the front of her gown. CNA (certified nursing assistant) #1 was in the adjacent room. She was called to Resident #71's bedside and told about the spilled coffee. She removed the cup from Resident #71's hand. She was asked if the coffee cup was hot to touch, she nodded her head. She was asked if Resident #71 was hurt. She left the room and spoke with RN (registered nurse) #1. RN #1 came to the room. She and CNA #1 removed Resident #71's gown. Her chest was not red and she denied pain. The MDS (ARD 08/04/2022) was reviewed at approximately 8:45 a.m. Under section G, Functional Status, Resident #71 was assessed as a 1/2 for eating, meaning Supervision-oversight, encouragement, or cueing/One person physical assist. The care plan was reviewed. The Focus area ADL (activities of daily living) . contained the following intervention regarding eating: (Resident name) is able to feed herself after set up. she needs encouragement to complete meals. CNA #1 was interviewed at approximately 9:00 a.m. regarding Resident #71. CNA #1 stated that Resident #71's dementia had gotten worse over the last couple of weeks. She stated, She's been spilling more, her hand motions are more jerky. She was asked if the facility had cups with lids. She stated, The lids we have right now don't really fit the cups. She was asked if the facility had cups with spouts to prevent spills She spoke with LPN (licensed practical nurse) #5 who stated, We have those cups, we'll get her one to use (Name of Resident #71) just came out of isolation for COVID, before that she was up and around the unit. She hasn't gotten her strength back .she also needs to be up in the chair when she's eating not sitting up in the bed, that will help .I will update the care plan. During the lunchtime meal on 09/07/2022 Resident #71 was observed with a plastic cup, with handles on each side, and a spout on the lid. There were no spills observed. The above information was discussed during an end of the day meeting on 09/07/2022. The administrative team was asked if there was an assessment done regarding hot liquid safety. The corporate nurse consultant stated, The company has one, but I don't know if it has been implemented here. I will look. On 09/08/2022 a hot liquid assessment for Resident #71 was presented. It was dated 06/14/2022. The resident was not assessed as being at risk for drinking hot liquids. The corporate nurse consultant was asked if there was a policy on when the hot liquid assessment should be done. During a meeting on 09/08/2022 at approximately 10:30 a.m., the corporate nurse consultant stated that there was no policy regarding the hot liquid assessment, but it should be done quarterly, annually, and if there was a change. No further information was obtained prior to the exit conference on 09/08/2022.

Based on staff interview, document review, clinical record review and complaint investigation, the facility staff failed to promptly notify the physician of a change in condition for one of 6 residents in the survey sample. When Resident #2 was assessed with [REDACTED]. The physician was not informed the resident had refused meals and continued to receive oral antidiabetic medications. The resident was sent to the emergency room and diagnosed with [REDACTED]. The resident was admitted to the hospital intensive care unit and later died due to acute [MEDICAL CONDITION] and lactic acidosis that failed to respond to treatments. [DIAGNOSES REDACTED] is a condition of abnormally low blood sugar (glucose) and is commonly associated with the treatment of [REDACTED]. Immediate treatment of [REDACTED].either with high-sugar foods or medications. (4) The findings include: Resident #2 was admitted to the facility on [DATE] and discharged to the emergency roiagnom on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with moderately impaired cognitive skills. Resident #2's closed clinical record was reviewed on [DATE]. The record documented a physician's order dated [DATE] for the antidiabetic medication [MEDICATION NAME] 500 mg (milligrams) to be administered 3 times per day for the treatment of [REDACTED]. Nursing notes documented the following regarding a change in the resident's condition starting on [DATE]. [DATE] at 12:52 a.m. -Pt (patient) alert, confused. Insisting that she be able to put her feet on floor while being pushed in wheelchair .Appetite poor for dinner. Fluid intake fair .C/O (complained of) urinary frequency, refused to go into bathroom (bathroom). Insisted on using bedpan, but produced no urine .Call to MD (physician) . [DATE] at 4:32 a.m. - resident is in bed noted with some altered mental status, she still verbalizes and is responding to questions appropriately especially when responding to family, v/s (vital signs) 97.9, 100, 20, ,[DATE] (temperature, pulse rate, respiration rate, blood pressure) and oxygen saturation 93% on room air. MD contacted and ordered UA (urinalysis), C&S (culture and sensitivity) catheterized x 1 without any result, at this time, no s/s (signs/symptoms) of pain noted . [DATE] at 6:11 a.m. - [MEDICATION NAME] 50 mg administered for pain, resident noted with agitation [DATE] at 9:46 a.m. - Resident displays altered mental status, increased [MEDICAL CONDITION] of upper extremities, pain, and decreased verbal communication, abnormal movements of the upper extremities, and facial gestures of the mouth .Breath sounds, and vitals (vital signs) monitored. ,[DATE], 95%, 89, 95.4, 20 (blood pressure, oxygen saturation, pulse rate, temperature, respiration rate) .Transfer to (hospital) per family request. The resident's food intake records documented the resident on most days since admission ate from 50% to 100 % of meals until the evening of [DATE]. Intake records documented the resident refused dinner on [DATE] and refused breakfast on [DATE]. The resident continued to receive the antidiabetic medications [MEDICATION NAME] on [DATE] at 9:00 p.m., Glimepiride on [DATE] at 8:00 a.m. and the [MEDICATION NAME] again on [DATE] at 9:00 a.m. There was no notification to the physician concerning the resident's lack of food intake. A change in condition form dated [DATE] at 10:04 a.m. documented Resident #2 was assessed with [REDACTED]. The form listed the resident's vital signs as: blood pressure of ,[DATE], pulse rate of 89, respiration rate of 20 and temperature of 95.4. The form also documented the resident's oxygen saturation rate at 95% on room air. The space for the most recent blood glucose level was blank. The assessment listed the resident had an abrupt change in cognition with increased confusion, [MEDICAL CONDITION] and a decreased level of consciousness. The form listed the physician was notified of the resident's change in condition on [DATE] at 8:15 a.m. The form made no mention the resident had no urine when catheterized or had not eaten since lunch on [DATE]. There was no assessment of the resident's blood sugar level in response to the change in condition. Further review of Resident #2's clinical record documented no routine monitoring of the resident's blood sugar levels since her admission. A lab test performed on [DATE], signed by the physician on [DATE], documented the resident's blood sugar level was low with a reading of 64 mg/dL (milligrams/deciliter) with a normal range listed as 70 to 120. There were no physician orders to check or monitor the resident's blood sugar upon admission, in response to the lab work or at the time her condition changed on [DATE]. The resident's care plan (revised [DATE]) included no problems, goals and/or interventions regarding diabetes. The care plan made no mention the resident was diabetic and included no interventions regarding any possible side effects from her daily oral antidiabetic medications. Hospital notes documented the resident arrived at the emergency roiagnom on [DATE] at 10:45 a.m. and was diagnosed with [REDACTED]. Notes documented, .chief complaint of AMS (altered mental status) .Per EMS (emergency medical services) .they state that pt's (patient's) family checked on pt about 3 hours ago and found her with an altered mental status. They (EMS) note a blood sugar of 14 en route . and notes that she has received [MEDICATION NAME] . [DIAGNOSES REDACTED]. The emergency record dated [DATE] listed the resident's blood glucose (sugar) level was undetectable upon arrival. The hospital history and physical dated [DATE] documented, Fingerstick glucose 14 per EMS. Patient not eating well for a few days prior to admission. Most likely cause of [DIAGNOSES REDACTED] is decreased po (oral) intake combined with oral hypoglycemic medications (glimepiride, [MEDICATION NAME]). The history and physical dated [DATE] defined metabolic disarray as abnormal lab results that included high sodium level of 125, high potassium level of 6.2, high phosphorus level of 6.6 all in a setting of AKI (acute kidney injury) and lactic acidosis. Most likely etiology is acute [MEDICAL CONDITION] . (sic) The resident was admitted to the hospital and died on [DATE] after she failed to respond to treatments. The hospital discharge summary dated [DATE] documented the resident had a history of [REDACTED]. The summary stated the resident was in the nursing facility following surgical repair for a hernia. The summary documented, .A few days ago, she (Resident #2) began to have a decreased appetite. On the morning of admission, patient states that she remembers and (an) aide leaving her room, which normally happens around 7 am. Her daughter came to visit at 8:15 am and found her mother lying in bed moaning but otherwise unresponsive. EMS was called and she was taken into the ambulance. In the ambulance, she was found to have a glucose of 14. She was given [MEDICATION NAME] and taken to the ED (emergency department), where repeated fingerstick was too low to measure .Initial labs in the ED were significant for AKI (acute kidney injury) and metabolic disarray as well as lactic acidosis . The discharge summary dated [DATE] documented the resident was admitted to the medical intensive care unit for treatment and stated, During her (Resident #2's) stay .her lactic acidosis failed to respond and she developed oliguric [MEDICAL CONDITION] despite volume resuscitation .Despite interventions she failed to improve .[MEDICAL TREATMENT] was deferred and on ,[DATE] (2016) at which time (Resident #2) was transitioned to comfort care measures. Cause of death is acute oliguric [MEDICAL CONDITION] and refractory lactic acidosis. The nurse caring for Resident #2 during the early morning hours on [DATE] was on leave and not available for interview. On [DATE] at 9:10 a.m. the director of nursing (DON) was interviewed about Resident #2's change in condition on [DATE]. The DON stated there were no physician orders to monitor or check Resident #2's blood sugar levels during her stay or on [DATE] other than the lab on [DATE]. The DON stated blood sugar checks required a physician's order. The DON stated the physician was called but there was no indication the physician was made aware of the lack of urine output or lack of food intake. On [DATE] at 9:40 a.m. the nurse practitioner (NP) that cared for Resident #2 was interviewed about the resident's blood sugar monitoring and change in condition. The NP stated Resident #2 had been on oral diabetic medicines for a long time. The NP stated she could not speak for the physician about when blood sugar checks should have been ordered. When asked if the oral diabetic medicines ([MEDICATION NAME], Glimepiride) should have continued when the resident was not eating, the NP stated she probably would have held the diabetic medicines if she knew she was not eating. The NP stated she was not made aware the resident was refusing meals. The NP stated, The nurses have to let us know. On [DATE] at 2:45 p.m. the registered nurse consultant (RN #2) was interviewed about any assessment of the resident's blood sugar level or notification concerning the lack of urine output and meal refusals. RN #2 stated on the evening of [DATE] the resident started with poor appetite. RN #2 stated the physician was called and the nurses were pushing fluids. RN #2 stated the physician ordered a urinalysis and the nurse catheterized the resident but was unable to get any urine. RN #2 stated she found nothing in the record indicating the nurse called the physician concerning the lack of urine output. RN #2 presented a copy of the change of condition form dated [DATE]. RN #2 stated the form listed the physician was called on [DATE] at 8:15 a.m. but there were no orders given to check the resident's blood sugar. Concerning notification about the lack of urine output and meal refusal, RN #2 stated, If they (nurses) notified the physician they didn't document it. On [DATE] at 3:15 p.m. Resident #2's physician was interviewed about the change of condition and lack of blood sugar monitoring. After reviewing the clinical record the physician stated, I would have expected her (Resident #2's) sugars to have been checked. The physician stated the resident had severe [MEDICAL CONDITION] and massive [MEDICAL CONDITION] and he felt most of her decline was related to her heart failure. The physician stated the resident's right sided heart failure caused liver congestion which made treatments to correct abnormal blood sugars difficult. When asked about the resident's altered mental status and documented change in condition on [DATE], the physician stated, Acutely I would have expected them (nurses) to assess (blood sugar level). The physician stated, In retrospect we should have been monitoring her (Resident #2's) blood sugars. When asked about any knowledge that the resident was catheterized and had no urine output at 4:32 a.m. on [DATE], the physician stated he did not recall any notification about lack of urine output. Concerning notification about the lack of urine output, the physician stated, I would have thought a change in condition would create a call. The physician was shown the hospital discharge summary and asked to define the [DIAGNOSES REDACTED]. The physician stated refractory [DIAGNOSES REDACTED] was low blood sugar that would not respond to treatments and this was most likely related to the resident's severe heart failure and subsequent organ failure. The physician stated the resident's outcome would not have changed even with earlier treatment of [REDACTED]. When asked why the resident's blood sugar level was not routinely checked especially with her history of heart failure, the physician stated he had no explanation of why Resident #2's blood sugar levels were not monitored. On [DATE] at 4:10 p.m. the DON was interviewed about the expected response from nurses when no urine was obtained when catheterized. The DON stated nurses should have called the physician about not getting any urine. On [DATE] at 9:10 a.m. the DON was asked about any standing orders regarding diabetic care. The DON stated the facility had no standing orders for diabetics. The DON stated all orders for diabetic management were ordered by the physician for each resident. The Lippincott Manual of Nursing Practice 10th edition on page 952 describes diabetes mellitus as a metabolic disorder characterized by [MEDICAL CONDITION] and results from defective insulin production, secretion, or utilization. Page 942 of this reference states type 2 diabetes is formally known as non-insulin-dependent diabetes mellitus or adult-onset diabetes mellitus .caused by a combination of insulin resistance and relative insulin deficiency . This reference stated on page 945, Accurate determination of capillary blood glucose assists patients in the control and daily management of diabetes mellitus. Blood glucose monitoring helps evaluate effectiveness of medication .and assists in the evaluation of episodes of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to determine appropriate treatment. This reference on pages 962 and 963 includes in standards of care for diabetes, Closely monitor blood glucose levels to detect [DIAGNOSES REDACTED] .Treat [DIAGNOSES REDACTED] promptly . (1) The Lippincott Manual of Nursing Practice 10th edition on page 795 defines acute kidney injury (AKI) as a clinical syndrome in which there is a sudden decline in renal function. This results in disturbances in fluid and electrolyte balance, acid-base homeostasis, blood pressure regulation, erythropoiesis (red blood cell production), and mineral metabolism. It is frequently associated with an increase in BUN (blood, urea, nitrogen) and creatinine, oliguria (less than 500 mL (milliliters) urine/24 hours), [MEDICAL CONDITION] (elevated sodium level), and sodium and fluid retention. (1) Lactic acidosis results from a buildup of lactic acid made by the body's cells when they do not have enough oxygen. Significant drops in blood pressure, heart failure, [MEDICAL CONDITION] and an overwhelming infection can cause lactic acidosis. (2) The Drug Information Handbook for Nursing 13th edition on pages 778 and 779 describes the medication [MEDICATION NAME] as an antidiabetic agent used for the management of type 2 non-insulin dependent diabetes when [MEDICAL CONDITION] cannot be managed with diet and exercise. This reference lists a U.S. Boxed Warning for [MEDICATION NAME] stating, Lactic acidosis is a rare, but potentially severe consequence of therapy with [MEDICATION NAME] .Use caution in patients with [MEDICAL CONDITION] requiring pharmacologic management, particularly in patients with unstable or acute [MEDICAL CONDITIONS] . (3) The Drug Information Handbook for Nursing 13th edition on pages 573 and 574 describes Glimepiride as a sulfonylurea antidiabetic agent used for the management of type 2 diabetes (non-insulin dependent) along with diet and exercise. This reference states glimepiride may be used in combination with [MEDICATION NAME] or insulin in patients whose [MEDICAL CONDITION] is not controlled with a single agent. This reference lists under warnings for glimepiride use, All sulfonylurea drugs are capable of producing severe [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is more likely to occur when caloric intake is deficient .or when more than one glucose-lowering drug is used . This reference states glimepiride should be given once daily with the first meal of the day and states, Patients that are NPO (nothing by mouth) or require decreased caloric intake may need doses held to avoid [DIAGNOSES REDACTED] .Monitor glucose as recommended by prescriber . (3) These findings were reviewed with the administrator, director of nursing and corporate nursing consultants on [DATE] at 4:50 p.m. and on [DATE] at 11:00 a.m. This was a complaint deficiency. 1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. 2) What is Metabolic Acidosis? Lactic Acidosis. WebMD. [DATE]. http://www.webmd.com (3) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. (4) [DIAGNOSES REDACTED]. Mayo Clinic. 1998 -2016. Mayo Foundation for Medical Education and Research. [DATE]. <http://www.mayoclinic.org/diseases-conditions/[DIAGNOSES REDACTED]/basics/definition/con- 103>

Based on staff interview, document review, clinical record review and complaint investigation, the facility staff failed to follow professional standards of nursing practice for two of 6 residents in the survey sample. Facility staff failed to assess blood sugar levels in response to an abrupt change in condition resulting in severe [DIAGNOSES REDACTED] (harm) for Resident #2. Facility staff failed to document the administration of a controlled medication dispensed from the emergency drug supply for Resident #3. 1. Resident #2, diagnosed and treated with daily oral medication for diabetes, had no assessment of her blood sugar level after experiencing increased confusion, altered mental status, lack of appetite, worsening [MEDICAL CONDITION] and lack of urinary output. Resident #2 continued to be administered antidiabetic medications after she refused meals and the physician was not notified that no urine was obtained when catheterized for a urine sample. The resident was sent to the emergency room at family request and was assessed as unresponsive upon arrival to the emergency room with severe [DIAGNOSES REDACTED] (low blood sugar). The resident was admitted to the hospital intensive care unit and later died due to acute [MEDICAL CONDITION] and lactic acidosis that failed to respond to treatments. [DIAGNOSES REDACTED] is a condition of abnormally low blood sugar (glucose) and is commonly associated with the treatment of [REDACTED]. Immediate treatment of [REDACTED].either with high-sugar foods or medications. (4) 2. Facility staff failed to document appropriate information (to whom it was given, when it was given, why it was given) in the clinical medical record for the use of [MEDICATION NAME] 5 MG (milligrams) for Resident #3. The findings included: 1. Resident #2, diagnosed and treated with daily oral medication for diabetes, had no assessment of her blood sugar level after experiencing increased confusion, altered mental status, lack of appetite, worsening [MEDICAL CONDITION] and lack of urinary output. Resident #2 continued to be administered antidiabetic medications after she refused meals and the physician was not notified that no urine was obtained when catheterized for a urine sample. The resident was sent to the emergency room at family request and was assessed as unresponsive upon arrival to the emergency room with severe [DIAGNOSES REDACTED] (low blood sugar). The resident was admitted to the hospital intensive care unit and later died due to acute [MEDICAL CONDITION] and lactic acidosis that failed to respond to treatments. Resident #2, diagnosed and treated with daily oral medication for diabetes, had no assessment of her blood sugar level after experiencing increased confusion, altered mental status, lack of appetite, worsening [MEDICAL CONDITION] and lack of urinary output. Resident #2 continued to be administered antidiabetic medications after she refused meals and the physician was not notified that no urine was obtained when catheterized for a urine sample. The resident was sent to the emergency room at family request and was assessed as unresponsive upon arrival to the emergency room with severe [DIAGNOSES REDACTED] (low blood sugar). The resident was admitted to the hospital intensive care unit and later died due to acute [MEDICAL CONDITION] and lactic acidosis that failed to respond to treatments. Facility staff failed to follow physician orders, assess, and provide interventions for pain management for Resident #3. The findings include: 1. Resident #2, diagnosed and treated with daily oral medication for diabetes, had no assessment of her blood sugar level after experiencing increased confusion, altered mental status, lack of appetite, worsening [MEDICAL CONDITION] and lack of urinary output. Resident #2 continued to be administered antidiabetic medications after she refused meals and the physician was not immediately notified that no urine was obtained when catheterized for a urine sample. The resident was sent to the emergency room nine hours after the change of condition at family request and was assessed as unresponsive upon arrival to the emergency room with severe [DIAGNOSES REDACTED] (low blood sugar). The resident was admitted to the hospital intensive care unit and later died due to acute [MEDICAL CONDITION] and lactic acidosis that failed to respond to treatments. Resident #2 was admitted to the facility on [DATE] and discharged to the emergency roiagnom on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with moderately impaired cognitive skills. Resident #2's closed clinical record was reviewed on [DATE]. A physician's order dated [DATE] was documented for the antidiabetic medication [MEDICATION NAME] 500 mg (milligrams) to be administered 3 times per day for the treatment of [REDACTED]. Nursing notes documented the following regarding a change in the resident's condition starting on [DATE]. [DATE] at 12:52 a.m. -Pt (patient) alert, confused. Insisting that she be able to put her feet on floor while being pushed in wheelchair .Appetite poor for dinner. Fluid intake fair .C/O (complained of) urinary frequency, refused to go into bathroom (bathroom). Insisted on using bedpan, but produced no urine .Call to MD (physician) . [DATE] at 4:32 a.m. - resident is in bed noted with some altered mental status, she still verbalizes and is responding to questions appropriately especially when responding to family, v/s (vital signs) 97.9, 100, 20, ,[DATE] (temperature, pulse rate, respiration rate, blood pressure) and oxygen saturation 93% on room air. MD contacted and ordered UA (urinalysis), C&S (culture and sensitivity) catheterized x 1 without any result, at this time, no s/s (signs/symptoms) of pain noted . [DATE] at 6:11 a.m. - [MEDICATION NAME] 50 mg administered for pain, resident noted with agitation [DATE] at 9:46 a.m. - Resident displays altered mental status, increased [MEDICAL CONDITION] of upper extremities, pain, and decreased verbal communication, abnormal movements of the upper extremities, and facial gestures of the mouth .Breath sounds, and vitals (vital signs) monitored. ,[DATE], 95%, 89, 95.4, 20 (blood pressure, oxygen saturation, pulse rate, temperature, respiration rate) .Transfer to (hospital) per family request. The resident's food intake records documented the resident on most days since admission ate from 50% to 100 % of meals until the evening of [DATE]. Intake records documented the resident refused dinner on [DATE] and refused breakfast on [DATE]. The resident continued to receive the antidiabetic medications [MEDICATION NAME] on [DATE] at 9:00 p.m., Glimepiride on [DATE] at 8:00 a.m. and the [MEDICATION NAME] again on [DATE] at 9:00 a.m. There was no notification to the physician concerning the resident's lack of food intake. A change in condition form dated [DATE] at 10:04 a.m. documented Resident #2 was assessed with [REDACTED]. The form listed the resident's vital signs as: blood pressure of ,[DATE], pulse rate of 89, respiration rate of 20 and temperature of 95.4. The form also documented the resident's oxygen saturation rate at 95% on room air. The space for the most recent blood glucose level was blank. The assessment listed the resident had an abrupt change in cognition with increased confusion, [MEDICAL CONDITION] and a decreased level of consciousness. The form listed the physician was notified of the resident's change in condition on [DATE] at 8:15 a.m. The form made no mention the resident had no urine when catheterized or had not eaten since lunch on [DATE]. There was no assessment of the resident's blood sugar level in response to the change in condition. Further review of Resident #2's clinical record documented no routine monitoring of the resident's blood sugar levels since her admission. A lab test performed on [DATE], signed by the physician on [DATE], documented the resident's blood sugar level was low with a reading of 64 mg/dL (milligrams/deciliter) with a normal range listed as 70 to 120. There were no physician orders to check or monitor the resident's blood sugar upon admission, in response to the lab work or at the time her condition changed on [DATE]. The resident's care plan (revised [DATE]) included no problems, goals and/or interventions regarding diabetes. The care plan made no mention the resident was diabetic and included no interventions regarding any possible side effects from her daily oral antidiabetic medications. Hospital notes documented the resident arrived at the emergency roiagnom on [DATE] at 10:45 a.m. and was diagnosed with [REDACTED]. Notes documented, .chief complaint of AMS (altered mental status) .Per EMS (emergency medical services) .they state that pt's (patient's) family checked on pt about 3 hours ago and found her with an altered mental status. They (EMS) note a blood sugar of 14 en route . and notes that she has received [MEDICATION NAME] . [DIAGNOSES REDACTED]. The emergency record dated [DATE] listed the resident's blood glucose (sugar) level was undetectable upon arrival. The hospital history and physical dated [DATE] documented, Fingerstick glucose 14 per EMS. Patient not eating well for a few days prior to admission. Most likely cause of [DIAGNOSES REDACTED] is decreased po (oral) intake combined with oral hypoglycemic medications (Glimepiride, [MEDICATION NAME]). The history and physical dated [DATE] defined metabolic disarray as abnormal lab results that included high sodium level of 125, high potassium level of 6.2, high phosphorus level of 6.6 all in a setting of AKI (acute kidney injury) and lactic acidosis. Most likely etiology is acute [MEDICAL CONDITION] . (sic) The resident was admitted to the hospital and died on [DATE] after she failed to respond to treatments. The hospital discharge summary dated [DATE] documented the resident had a history of [REDACTED]. The summary stated the resident was in the nursing facility following surgical repair for a hernia. The summary documented, .A few days ago, she (Resident #2) began to have a decreased appetite. On the morning of admission, patient states that she remembers and (an) aide leaving her room, which normally happens around 7 am. Her daughter came to visit at 8:15 am and found her mother lying in bed moaning but otherwise unresponsive. EMS was called and she was taken into the ambulance. In the ambulance, she was found to have a glucose of 14. She was given [MEDICATION NAME] and taken to the ED (emergency department), where repeated fingerstick was too low to measure .Initial labs in the ED were significant for AKI (acute kidney injury) and metabolic disarray as well as lactic acidosis . The discharge summary dated [DATE] documented the resident was admitted to the medical intensive care unit for treatment and listed, During her (Resident #2's) stay .her lactic acidosis failed to respond and she developed oliguric [MEDICAL CONDITION] despite volume resuscitation .Despite interventions she failed to improve .[MEDICAL TREATMENT] was deferred and on ,[DATE] (2016) at which time (Resident #2) was transitioned to comfort care measures. Cause of death is acute oliguric [MEDICAL CONDITION] and refractory lactic acidosis. The nurse caring for Resident #2 during the early morning hours on [DATE] was on leave and not available for interview. On [DATE] at 9:10 a.m. the director of nursing (DON) was interviewed about Resident #2's change in condition on [DATE]. The DON stated there were no physician orders to monitor or check Resident #2's blood sugar levels during her stay or on [DATE] other than the lab performed on [DATE]. The DON stated blood sugar checks required a physician's order. The DON stated the physician was called but there was no indication the physician was made aware of the lack of urine output or lack of food intake. On [DATE] at 9:40 a.m. the nurse practitioner (NP) that cared for Resident #2 was interviewed about the resident's blood sugar monitoring and change in condition. The NP stated Resident #2 had been on oral diabetic medicines for a long time. The NP stated she could not speak for the physician about when blood sugar checks should have been ordered. When asked if the oral diabetic medicines ([MEDICATION NAME], Glimepiride) should have continued when the resident was not eating, the NP stated she probably would have held the diabetic medicines if she knew she was not eating. The NP stated she was not made aware the resident was refusing meals. The NP stated, The nurses have to let us know. On [DATE] at 2:45 p.m. the registered nurse consultant (RN #2) was interviewed about any assessment of the resident's blood sugar level or notification concerning the lack of urine output and meal refusals. RN #2 stated on the evening of [DATE] the resident started with poor appetite. RN #2 stated the physician was called and the nurses were pushing fluids. RN #2 stated the physician ordered a urinalysis and the nurse catheterized the resident but was unable to get any urine. RN #2 stated she found nothing in the record indicating the nurse called the physician concerning the lack of urine output. RN #2 presented a copy of the change of condition form dated [DATE]. RN #2 stated the form listed the physician was called on [DATE] at 8:15 a.m. but there were no orders given to check the resident's blood sugar. Concerning notification about the lack of urine output and meal refusal, RN #2 stated, If they (nurses) notified the physician they didn't document it. On [DATE] at 3:15 p.m. Resident #2's physician was interviewed about the change of condition and lack of blood sugar monitoring. After reviewing the clinical record the physician stated, I would have expected her (Resident #2's) sugars to have been checked. The physician stated the resident had severe [MEDICAL CONDITION] and massive [MEDICAL CONDITION] and he felt most of her decline was related to her heart failure. The physician stated the resident's right sided heart failure caused liver congestion which made treatments to correct abnormal blood sugars difficult. When asked about the resident's altered mental status and documented change in condition on [DATE], the physician stated, Acutely I would have expected them (nurses) to assess (blood sugar level). The physician stated, In retrospect we should have been monitoring her (Resident #2's) blood sugars. When asked about any knowledge that the resident was catheterized and had no urine output at 4:32 a.m. on [DATE], the physician stated he did not recall any notification about lack of urine output. Concerning notification about the lack of urine output, the physician stated, I would have thought a change in condition would create a call. The physician was shown the hospital discharge summary and asked to define the [DIAGNOSES REDACTED]. The physician stated refractory [DIAGNOSES REDACTED] was low blood sugar that would not respond to treatments and this was most likely related to the resident's severe heart failure and subsequent organ failure. The physician stated the resident's outcome would not have changed even with earlier treatment of [REDACTED]. When asked why the resident's blood sugar level was not routinely checked especially with her history of heart failure, the physician stated he had no explanation of why Resident #2's blood sugar levels were not monitored. On [DATE] at 4:10 p.m. the DON was interviewed about the expected response from nurses when no urine was obtained when catheterized. The DON stated nurses should have called the physician about not getting any urine. On [DATE] at 9:10 a.m. the DON was asked about any standing orders regarding diabetic care. The DON stated the facility had no standing orders for diabetics. The DON stated all orders for diabetic management were ordered by the physician for each resident. The Lippincott Manual of Nursing Practice 10th edition on page 952 describes diabetes mellitus as a metabolic disorder characterized by [MEDICAL CONDITION] and results from defective insulin production, secretion, or utilization. Page 942 of this reference states type 2 diabetes is formally known as non-insulin-dependent diabetes mellitus or adult-onset diabetes mellitus .caused by a combination of insulin resistance and relative insulin deficiency . This reference stated on page 945, Accurate determination of capillary blood glucose assists patients in the control and daily management of diabetes mellitus. Blood glucose monitoring helps evaluate effectiveness of medication .and assists in the evaluation of episodes of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to determine appropriate treatment. This reference on pages 962 and 963 includes in standards of care for diabetes, Closely monitor blood glucose levels to detect [DIAGNOSES REDACTED] .Treat [DIAGNOSES REDACTED] promptly . (1) The Lippincott Manual of Nursing Practice 10th edition on page 795 defines acute kidney injury (AKI) as a clinical syndrome in which there is a sudden decline in renal function. This results in disturbances in fluid and electrolyte balance, acid-base homeostasis, blood pressure regulation, erythropoiesis (red blood cell production), and mineral metabolism. It is frequently associated with an increase in BUN (blood, urea, nitrogen) and creatinine, oliguria (less than 500 mL (milliliters) urine/24 hours), [MEDICAL CONDITION] (elevated sodium level), and sodium and fluid retention. (1) Lactic acidosis results from a buildup of lactic acid made by the body's cells when they do not have enough oxygen. Significant drops in blood pressure, heart failure, [MEDICAL CONDITION] and an overwhelming infection can cause lactic acidosis. (2) The Drug Information Handbook for Nursing 13th edition on pages 778 and 779 describes the medication [MEDICATION NAME] as an antidiabetic agent used for the management of type 2 non-insulin dependent diabetes when [MEDICAL CONDITION] cannot be managed with diet and exercise. This reference lists a U.S. Boxed Warning for [MEDICATION NAME] stating, Lactic acidosis is a rare, but potentially severe consequence of therapy with [MEDICATION NAME] .Use caution in patients with [MEDICAL CONDITION] requiring pharmacologic management, particularly in patients with unstable or acute [MEDICAL CONDITIONS] . (3) The Drug Information Handbook for Nursing 13th edition on pages 573 and 574 describes Glimepiride as a sulfonylurea antidiabetic agent used for the management of type 2 diabetes (non-insulin dependent) along with diet and exercise. This reference states glimepiride may be used in combination with [MEDICATION NAME] or insulin in patients whose [MEDICAL CONDITION] is not controlled with a single agent. This reference lists under warnings for glimepiride use, All sulfonylurea drugs are capable of producing severe [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is more likely to occur when caloric intake is deficient .or when more than one glucose-lowering drug is used . This reference states glimepiride should be given once daily with the first meal of the day and states, Patients that are NPO (nothing by mouth) or require decreased caloric intake may need doses held to avoid [DIAGNOSES REDACTED] .Monitor glucose as recommended by prescriber . (3) These findings were reviewed with the administrator, director of nursing and corporate nursing consultants on [DATE] at 4:50 p.m. and on [DATE] at 11:00 a.m. This was a complaint deficiency. 1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. 2) What is Metabolic Acidosis? Lactic Acidosis. WebMD. [DATE]. http://www.webmd.com (3) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. (4) [DIAGNOSES REDACTED]. Mayo Clinic. 1998 -2016. Mayo Foundation for Medical Education and Research. [DATE]. <http://www.mayoclinic.org/diseases-conditions/[DIAGNOSES REDACTED]/basics/definition/con- 103> 2. Facility staff failed to document appropriate information (to whom it was given, when it was given, why it was given) in the clinical medical record for the use of [MEDICATION NAME] 5 MG (milligrams) for Resident #3. Resident # 3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A clinical record review was conducted on [DATE] and [DATE]. Resident # 3's Admission Minimum Data Set (MDS- an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #3 with no cognitive impairment as indicated by a BIMS (Brief Interview Mental Status) of 15. In addition, the MDS coded Resident # 3 requiring extensive assistance for Activities of Daily Living care (Ambulating, transferring, dressing, and bathing). Documented ROM (Range of Motion) on the MDS indicated impairment to the lower extremity and confirmed a catheter was in use upon admission. The physicians orders for Resident #3 read, [MEDICATION NAME] tablet 5 MG (milligrams); Give 1 tablet by mouth every 4 hours as needed for pain. The start date on this order was [DATE]. The admitted for Resident # 3 was [DATE] at approximately 1:00 pm. According to the MAR (Medication Administration Record) for [DATE] through [DATE], [MEDICATION NAME] was given for pain on each day except for [DATE], the day Resident #3 was admitted to the facility. No clinical notes documented that Resident #3 asked for pain medication on the day of admission. No clinical notes documented that Resident #3 received any pain medication on [DATE]. On a clinical note dated [DATE] in regards to [MEDICATION NAME] 300 MG for chronic pain and at 14:17 (2:17 p.m.) indicated Resident just got here and med have not arrived from pharmacy yet. According to the MAR (Medication Administration Record), [MEDICATION NAME] 300 MG for chronic pain was given on [DATE] at 1700 (5:00 p.m.) and 2100 (9:00 p.m.). The Physician's Order for [MEDICATION NAME] 300 MG read, Give 300 MG by mouth four times a day related to other chronic pain with order and start date [DATE]. In a phone interview with Resident #3 on [DATE] at 2:06 pm Resident #3 explained that he was in pain on the day he was admitted to the facility. He could not recall when or who he had asked for pain medication from. He referred to all staff as the nursing staff. According to Resident #3 the facility staff did not have the pain medication delivered from the pharmacy when he asked. When asked which pain medication he was referring to he stated, [MEDICATION NAME]. There was no time frame given by Resident #3. Nursing notes do not convey that Resident #3 asked for or received pain medication on [DATE], the day of admission to the facility. During an interview on [DATE] at 12:20 p.m. the DON (Director of Nursing) provided the Stat box contains on the Manifest and stated, [MEDICATION NAME] 5 MG is in the stat box. In an interview with the Pharmacy Consultant (Others #4) on [DATE] at 8:45 am, Resident (#3's) medications were reviewed on [DATE] (Pharmacy Review is always on the second to last or the last week of the month). Others #4 confirmed that [MEDICATION NAME] was available on [DATE] in the facility Stat Box. Additionally, Others #4 stated, usually I look at the MAR and reconcile when and to whom the stat box medications are given .I don't see it on the MAR for [DATE] .I only see it on [DATE]. The Pharmacist (Others #4) explained the process of obtaining the medication from the Stat Box. First the doctor must be notified of a request for medication then a hard copy script must be sent to facility and to the pharmacy. Once the pharmacy receives the script the doctor is authorizing access to the Stat Box so the pharmacy sends an access code to the facility to open the Stat Box. This new prescription negates the previous order (usually for a 30 pill supply) and a new script must be written for the next day. Three documents were presented by the Pharmacist (Others #4) on [DATE] at 9:30 am. First, the Request for Removal of controlled substance Medication from the Contingency Supply authorizing the facility staff to remove [MEDICATION NAME] 5 MG from the stat box on [DATE] at 7:04 p.m. with a fax time of 7:33 p.m. and labeled URGENT. Second, the faxed physicians order dated [DATE] at 8:07 p.m. for Resident #3 for [MEDICATION NAME] 5 MG, 1 every 6 hours for pain with a note MD (doctor) wants 1 out of stat box. Third, the document entitled, Timeliness of Receiving New Admission Medications documented the initial admission order was received by the pharmacy on [DATE] at 1:53 p.m. and the original order was filled and received by the nursing center on [DATE] at 10:52 p.m. with an additional note, Oxy ([MEDICATION NAME]) 5 MG #1 tablet on [DATE] at 7:04 p.m.; Medication procured from the control box. Documentation supported that [MEDICATION NAME] 5 MG was taken from the Stat Box on [DATE] at 7:04 p.m. however, no documentation nor interviews could support if Resident #3 actually received this medication. No one (nursing staff, pharmacist, or DON) could verify or account for where the medication (1 [MEDICATION NAME] 5 MG tablet) taken from the stat box had gone. According to the Pharmacist during an interview on [DATE] at 9:30 a.m., We (Pharmacist and Nursing staff) have to reconcile to know where the medications are. According to the DON on [DATE] at 10:00 a.m. the nurse that pulled the medication from the stat box no longer works at the facility but It is my expectation that we (nursing staff) need to account for each medication. No documentation to support that pain medication was given to Resident #3 on [DATE] was presented nor was a pain assessment performed after admission on [DATE]. The DON noted, There was a pain assessment upon admission for Resident #3. The pain Assessment on [DATE] at 13:39 (1:39 p.m.) confirmed, yes (pain present); right knee, nerve pain and a numerical rating score of 6 (out of 1 though 10, with 10 the most severe pain). No other pain assessments were performed by the staff on [DATE] for Resident #3. The Lippincott Manual of Nursing Practice 10th edition on page 16 states concerning nursing documentation, A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events. This reference on pages 16 and 17 states, Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record, administer medications as ordered . (1) The facility administration was informed of the findings during a briefing on [DATE] at approximately 11:00 am. The facility did not present any further information about the findings. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. Complaint deficiency.